KEY ASSESSMENT

Auscultate all quadrants for bowel sounds.

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

Orientation: person, place and time (AAOx3)

Affect: afraid, irritable, distressed, attentive, ashamed, sad, happy, confident, shy, sleepy, calm

• Inspect legs.
• Palpate dorsalis pedis pulses bilaterally.
• Palpate posterior tibial pulse between medial maleous and achillies tendon
• Palpate legs and feet for edema.
• 0: none
• +1: slight pitting
• +2: Deeper, contours still present
• +3: Deep pitting, puffy appearance
• +4: Deep persistent pitting, frankly swollen
• Check foot presses.
• Check feet for resistance.
• Observe feet for lesions.

• Inspect arms.
• Palpate radial pulses bilaterally and capillary refill;
• assess grip strength and equality.

• Check pupils for equality and reaction to light. (PERRLA - pupils equal, round, reactive to light and accommodation)
• Inspect eyes (position, appearance, conjunctiva, sclera, iris)
• Check oral mucosa for color and moisture.
• Observe for facial symmetry and tracheal deviation.
• Check for neck vein distention at 45 degrees.
• Palpate for tender areas and visible abnormalities.

BP of 130/85 or higher or taking drugs for

HDL 40 mg/dL for men or 50 mg/dL for women or taking drugs for

triglycerides of 150 mg/dL or higher or taking drugs for

BS of 110 mg/dL or higher or taking drugs for

Waist > 40"(102cm) men, or 35"(89cm) women

Inc fibrinogen or plasma activator inhibitor Inc C-reactive protein , a marker for inflammation

• Assess
• location,
• quality,
• severity (0-10 scale),
• radiation,
• duration,
• precipitating and alleviating factors,
• associated symptoms,
• level of sedation.

Normal resting 50-90 BPM

10-20

• Generalized color, color variation, and scars.
• Palpate for texture, temperature, moisture, turgor, and edema.

Facial weakness judges whether the person can smile without their mouth or eyes dropping.

Arm weakness is whether the person can hold up both arms successfully.

Speech difficulty is about whether the person can speak clearly and understand speech.

• Normal oral, resting: 37/98.6
• Range: 35.8 - 37.3 or 96.4 - 99.1
• Treat above 100 or 37.7
• 15 after hot/cold, 2 after smoke

• Check all tubes from origin to insertion.
• Verify correct oxygen flow,
• correct IV solutions and flow rates.
• Verify Foley draining and other equipment functioning appropriately.
• Check dressings if present.

30 mL/hr