Palpate for distention of bladder and abdominal tenderness.
Ask about last BM, problems with urinating.
Turn to side or sit up.
Auscultate posterior lung fields.
Observe skin on back and coccyx.
Palpate for sacral edema.
Sensory: 1 does not moan, flinch or grasp to 3 cannot always tell of pain
Moisture: 1 constantly moist to 3 extra linen change per day
Activity: 1 confined to bed to 3 walks very short distances or w/ assistance
Mobility: 1 totally immobile to 3 frequent, though slight changes in extremity position
Nutrition: 1 Never eats a complete ,meal to 3 eats over half of most meals
Friction & Shear: 1 spasticity, contractures, agitation leads to constant friction to 3 moves feebly; occasionally slides down
Normal: 90–119 / 60–79
Prehypertension: 120–139 / 80–89
Stage 1 hypertension: 140–159 / 90–99
Stage 2 hypertension: ≥160 / ≥100
Hypertensive Crisis (Malignant Hypertension)
Sys > 200
Dia > 150
Hypotension is generally considered to be systolic blood pressure less than 90 systolic or diastolic less than 60. However in practice, blood pressure is considered too low only if noticeable symptoms are present. The cardinal symptoms of hypotension include lightheadedness or dizziness.
Auscultate S1 and S2 at aortic, pulmonic, tricuspid and mitral areas for rate and rhythm and location of extra sounds.
Listen at apex for full minute.
Ease of respirations and use of accessory muscles
Auscultate the: anterior chest (8 areas), posterior chest (10 areas), lateral chest (5 areas each side). Should hear Bronchial, Bronchovesicular and vesicular, but not rales (crackles), Ronchi (growling), or wheezing.
Anterior Lung Sounds
Posterior Lung Sound Locations
Posterior Lung Sounds
Symmetry, Anteroposterior to Transverse diameter should be 1:2 to 5:7
Level of consciousness: alert, sedate, unconscious