Adult Ranges
Respiration
What is 12-20 breaths per minute
Normal heart sounds
What is S1 and S2 (Lub-dub)
Normal pupillary reflex examination done with a penlight
What is PERRLA: pupils equal round reactive to light and accommodation
Assess normal capillary refill
What is use thumb to gently depress nail bed for approximately one second and release. Normal color should return in less than 2 to 3 seconds
Landmarks used during cardiac assessment
What is the right of the sternum at the 2nd intercostal space: aortic, left of the sternum at the 2nd intercostal space: pulmonic, left sternal border at the 3rd intercostal space: Erb's point, left sternal border at the 4th intercostal space: tricuspid, and at the 4th or 5th intercostal space at the midclavicular line: mitral
Heart rate
What is 60 -100 beats per minute
Loud grumbling bowel sounds
What is borborygmi
Bluish discoloration of the skin or mucous membrane
What is cyanosis
Assess rebound tenderness
What is palpate the abdomen and observe for pain that occurs immediately upon removal of your hand
Questions to ask to ascertain A&O x 4
What is What is your full name? (Person), Where are you? (Place), What day, month, season, or year is it? (Time), and What caused you to come to the hospital? (Situation)
Oxygen saturation
What is 95% - 100%
Abnormal lungs and airway sounds due to fluid accumulation or narrowing
What are adventitious breath sounds
Lateral curvature of the spine
What is scoliosis
Assess normal turgor
What is grasp 0.5 to 1 inch thickness of skin fold on the forearm or over the sternum along the 2nd or 3rd intercostal space and gently pinching the fingertips together and then releasing. Well hydrated skin lifts easily and returns to previous position without delay
Assess equilibrium using the Romberg test
What is have patient stand with feet together and arms at their sides first with eyes open and then with eyes closed, for at least 20 seconds without moving their feet, swaying excessively, or falling. A positive test indicates a problem with mainatining balance
Blood pressure
What is 90 -119 systolic and 60 - 79 diastolic
Swooshing sound heard when an artery is obstructed
What is a bruit
The anteroposterior (AP) depth of the chest is equal to the transverse width of the chest
What is barrel chest
Assess pulses for these characteristics
What are symmetry, rate, intensity, and rhythm
A fully alert, normally responsive client will have the following Glascow Coma Scale score
What is 15: (4 for eye opening response, 5 for verbal response, and 6 for motor response = 15)
Oral temperature in degrees Fahrenheit
What is 97.6 degrees F - 99.6 degrees F
Blowing or swishing sounds heard in systole or diastole at cardiac landmarks
What is cardiac murmurs
Thorough assessment of a wound during a dressing change
What is observe for location of the wound, measure the length, width, and depth. Assess for tunneling and undermining. Observe the wound for redness, ecchymosis, edema, drainage, and approximation (REEDA). Observe the drainage for color, odor, consistency, and amount (COCA)
Assess an arteriovenous (AV) fistula for a thrill
What is place your fingertips lightly over the fistula and feel for the vibration. A healthy fistula will have a thrill, which feels like a steady, vibrating sensation
Landmarks used when assessing the posterior upper lobes of the lungs
What is begin auscultating below the C7 vertebra just above the scapula placing stethoscope between the spine and scapula down to the level of T3