NUR 110 Lab Final

• 1. Inspection
• 2. Auscultation
• 3. Palpation

• The abdomen should appear:
• -Smooth
• -Striae (stretch marks)
• -Can be paler d/t lack of sun
• -Umbilicus centrally located
• -Sunken/slightly protruding contour
• -NO bulge with cough
• -NO visible peristalsis/pulsations (if found, DO NOT Palpate, Could be Abdominal Aneurysm)

• -Ascities
• -Assymetric
• -Prominent veins
• -Jaundice
• -Visible peristalsis

• LISTEN before PALPATING so we don't alter the presence or absence of bowel sounds.
• -Press lightly with diaphragm of stethoscope 
• -DO NOT CROSS umbilicus 
• -Right upper, left upper, left lower, right lower quadrants
• -We should hear bowel sounds every 5-15 seconds, could take up to 5 minutes

• Now auscultate for vascular sounds with the bell of the stethoscope
• -We are listening for bruits (broots), this is a continuous whooshing sound
• in 7 places:
• -Aorta:  above the belly button 1 1/2 to 2 inches
• -L and R Renal:  above the belly button and to the left and right
• -R and L Iliac:  below the belly button and to the left and right
• -R and L Femoral:  below the belly button and iliac artery and to the left and right

• -Have patient bend their knees to relax the abdomen
• -Palpate lightly and then fimly for tenderness and muscle tone
• -Palpate and areas of KNOWN PAIN LAST

• 1. Inspection
• 2. Palpate
• 3. Auscultate
• 4. Vital Signs

• Color, contour, symmetry
• -Color: can be paler
• -Contour: curved slightly forward
• -Symmetry: right and left side elevate the same

• -Rib Cage: top of sternum, around the outer edge of the rib cage laterally: 
•    -Tenderness
•    -Masses
•    -Lumps
• -Fremitus Test:  Place hands on anterior chest and ask patient to say 1-2-3

• Using the diaphragm of the stethoscope, Auscultate the 8 locations anteriorly (for 1 inhale-exhale):
• -6 spots above the nipples
• -2 spots below the nipples

• Color, contour, symmetry
• -Color:  can be paler
• -Contour:  curved slightly forward
• -Symmetry:  right and left sides elevate the same

• NOT OVER BONE
• -palpate between the scapula and spinal cord, and then below the scapula and laterally to the sides
• -Fremitus Test:  Place hands on posteriorly on scapula and ask patient to say 1-2-3
• -W Test:  Place hands under the scapula in the shape of a W and observe patient's lung expansion

• Using the diaphragm of the stethoscope, Auscultate the 10 locations posteriorly (for 1 inhale-exhale):
• -6 spots between the scapula and on either side of the spinal column
• -2 spots right below the scapula 
• -2 spots below the scapula and out to the right

• The vital signs that correspond to this assessment are:
• -respirations:  12-20
• -pulse oximetry:  92-100%

• 1. Inspect
• 2. Palpate
• 3. Auscultate
• 4. Vital Signs

• Color, contour, symmetry
• -color: appropriate for race
• -contour: curved slightly outward
• -symmetry: right and left sides match
• -NO pulsations

• -Palpate the same as we would on the respiratory assessment--anteriorly.
• -From the top of the sternum,around the outer edge of the rib cage and out laterally:
•    -Tenderness
•    -Lumps
•    -Masses

5th intercostal space, mid-clavicular line

• Listen for S1 and S2 sounds (lub-dub) in 5 locations:
•    -Aortic
•    -Pulmonic
•    -Erb's Point
•    -Tricuspid 
•    -Apical/Mitral

2nd intercostal space, right sternal border

2nd intercostal space, left sternal border

3rd intercostal space, left sternal border

• 4th intercostal space, left sternal border
•    -Always over breast tissue

• 5th intercostal space, left mid-clavicular line
•    -Below nipple

• The vital signs that correspond to this assessment are:
• -Heart rate:  60-100 bpm
• -Blood pressure:  120/80

• 1. Inspect
• 2. Palpate

• Color, symmetry, and jugular vein
• -Assess for jugular vein distention with the penlight--**bed should be less than 30 degrees!**
• -Inspect color, temperature, skin turgor, and capillary refill (within 3 seconds) 
• -Note any Edema

• -Palpate the each of the temporal pulses for amplitude
• -Palpate the carotid pulses for amplitude 
• -Inspect the jugular vein for distention

• -Inspect and palpate the upper extremities using dorsal hand:
•   -Color
•   -Temperature
•   -Skin integrity
•   -Skin turgor
•   -Edema
•   -Capillary refill

• -Palpate the radial and brachial pulses for amplitude
• -Inspect and palpate the lower extremities for:
•    -color
•    -temperature
•    -skin integrity 
•    -skin turgor
•    -possible edema 
•    -capillary refill

-Palpate the femoral, popiteal, posterior tibial, and dorsalis pedis for amplitude

• -Rhythm:  regular/irregular
• -Amplitude:  0+, 1+, 2+, 3+, 4+
• 0:  no pulse
• 1:  weak
• 2:  normal
• 3:  full volume
• 4:  bounding

• -Person, place, time, and situation
•    -Person:  name and DOB
•    -Place:  Where are you right now?
•    -Time:  What is today's date?/What are the month and year?
•    -Situation:  Can you tell me why you're here?

• There are 6 total--
• Smell
• Smile
• Stick out tongue
• Shrug shoulders and turn head from side to side 
• H-Test/6-point test: draw an H with the penlight and have the patient follow the light
• Swallow

• Tests For Balance
•    Romberg test
•    Stand on one foot, then the other, with eyes closed
•    Heel-to-toe walking
•    Hop on one foot, and then the other
•    Deep knee bend

• Tests for Upper Extremity Coordination
•    Alternately tap hands to thighs
•    With eyes closed and outstretched arms, alternately touch your finger to your nose
•    Touch each finger to thumb in a rapid motion
•    Rapidly move your finger between your nose and my finger

• Tests for Lower Extremity Coordination
•      Lying supine, slide your heels down your opposite shin

• -Make sure to assess for sensation on the peripheral nerves
• -Ask the patient to close their eyes and identify sharp/dull sensations on the upper and lower extremities

• 1. Inspect
• 2. Palpate
• 3. Strength

• -Inspect the patient's axial skeleton and extremities for alignment, contour, symmetry, size, and deformities during ambulation and sitting
• -Observe ROM, pain with movement, gait, symmetry and rhythm

• -TEST muscle strength 
• neck
• shoulders
• elbows
• wrists
• fingers
• hip
• knee
• ankle

Patient performs the exercises to move the joint without and assistance to the muscles surrounding the joint.

The nurse or equipment moves the joint through ROM with no effort from the patient

• 1. Inspect
• 2. Observe
• 3. PERRLA

• -Inspect the head for size, shape, and skin characteristics
• -Inspect the facial features for size, symmetry, movement (symmetric smiling), skin characteristics

• -Observe the eyes using the penlight
• -4 times total

• Heart Rate: 60-100 bpm
• Blood Pressure:  120/80
• Respiratory Rate:  12-20
• Temperature:  96.8-100.4 (axillary is less precise, rectal is most precise)
• Pulse Oximetry:  92-100%
• percent of RBC bound with oxygen
• -can be used on any finger, toe, nose or forehead

• -Distance
• -Patients stand 20ft away and read the smallest line they can see

• -Also used for distance
• -Point to which way the legs are facing

• -Yeager & Rosenbaum 
• -Read a newspaper 14 inches away from face

When ventricles contract

When ventricles fill with blood and relax