NUR 110 Lab Final

The flashcards below were created by user Anonymous on FreezingBlue Flashcards.

  1. Abdominal Assessment (process):
    • 1. Inspection
    • 2. Auscultation
    • 3. Palpation
  2. Abdominal Assessment--Inspection:
    (color, contour, symmetry)
    • 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)
  3. Abdominal Assessment--Inspection
    (Abnormal Findings)
    • -Ascities
    • -Assymetric
    • -Prominent veins
    • -Jaundice
    • -Visible peristalsis
  4. Abdominal Assessment--Auscultation
    • 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
  5. Abdominal Assessment--Auscultation
    • 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
  6. Abdominal Assessment--Palpation
    • -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
  7. Respiratory Assessment (process):
    • 1. Inspection
    • 2. Palpate
    • 3. Auscultate
    • 4. Vital Signs
  8. Respiratory Assessment (anterior)--Inspection
    • Color, contour, symmetry
    • -Color: can be paler
    • -Contour: curved slightly forward
    • -Symmetry: right and left side elevate the same
  9. Respiratory Assessment (anterior)--Palpation
    • -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
  10. Respiratory Assessment (anterior)--Auscultation
    • 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
  11. Respiratory Assessment (posterior)--Inspection
    • Color, contour, symmetry
    • -Color:  can be paler
    • -Contour:  curved slightly forward
    • -Symmetry:  right and left sides elevate the same
  12. Respiratory Assessment (posterior)--Palpation
    • 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
  13. Respiratory Assessment (posterior)--Auscultation
    • 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
  14. Respiratory Assessment--Vital Signs
    • The vital signs that correspond to this assessment are:
    • -respirations:  12-20
    • -pulse oximetry:  92-100%
  15. Cardiovascular Assessment (process):
    • 1. Inspect
    • 2. Palpate
    • 3. Auscultate
    • 4. Vital Signs
  16. Cardiovascular Assessment--Inspection
    • Color, contour, symmetry
    • -color: appropriate for race
    • -contour: curved slightly outward
    • -symmetry: right and left sides match
    • -NO pulsations
  17. Cardiovascular Assessment--Palpation
    • -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
  18. Where is the Apical pulse?
    5th intercostal space, mid-clavicular line
  19. Cardiovascular Assessment--Auscultation
    • Listen for S1 and S2 sounds (lub-dub) in 5 locations:
    •    -Aortic
    •    -Pulmonic
    •    -Erb's Point
    •    -Tricuspid 
    •    -Apical/Mitral
  20. Aortic
    2nd intercostal space, right sternal border
  21. Pulmonic
    2nd intercostal space, left sternal border
  22. Erb's Point
    3rd intercostal space, left sternal border
  23. Tricuspid
    • 4th intercostal space, left sternal border
    •    -Always over breast tissue
  24. Mitral/Apical
    • 5th intercostal space, left mid-clavicular line
    •    -Below nipple
  25. Cardiovascular Assessment--Vital Signs
    • The vital signs that correspond to this assessment are:
    • -Heart rate:  60-100 bpm
    • -Blood pressure:  120/80
  26. Peripheral Vascular Assessment (process):
    • 1. Inspect
    • 2. Palpate
  27. Peripheral Vascular Assessment--Inspection
    • 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
  28. Peripheral Vascular Assessment--
    • -Palpate the each of the temporal pulses for amplitude
    • -Palpate the carotid pulses for amplitude 
    • -Inspect the jugular vein for distention
  29. Peripheral Vascular Assessment--
    • -Inspect and palpate the upper extremities using dorsal hand:
    •   -Color
    •   -Temperature
    •   -Skin integrity
    •   -Skin turgor
    •   -Edema
    •   -Capillary refill
  30. Peripheral Vascular Assessment--
    • -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
  31. Peripheral Vascular Assessment--
    -Palpate the femoral, popiteal, posterior tibial, and dorsalis pedis for amplitude
  32. Pulses:
    • -Rhythm:  regular/irregular
    • -Amplitude:  0+, 1+, 2+, 3+, 4+
    • 0:  no pulse
    • 1:  weak
    • 2:  normal
    • 3:  full volume
    • 4:  bounding
  33. Neurological Assessment (inspect and observe):  LOC
    • -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?
  34. Neurological Assessment (Cranial Nerves)--
    • 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
  35. Neurological Assessment (Balance and Coordination)
    • 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
  36. Neurological Assessment (Balance and Coordination)
    • 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
  37. Neurological Assessment (Balance and Coordination)
    • Tests for Lower Extremity Coordination
    •      Lying supine, slide your heels down your opposite shin
  38. Neurological Assessment (Balance and Coordination)
    • -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
  39. Musculoskeletal Assessment (process):
    • 1. Inspect
    • 2. Palpate
    • 3. Strength
  40. Musculoskeletal Assessment--Inspection
    • -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
  41. Musculoskeletal Assessment--
    • -TEST muscle strength 
    • neck
    • shoulders
    • elbows
    • wrists
    • fingers
    • hip
    • knee
    • ankle
  42. Active ROM:
    Patient performs the exercises to move the joint without and assistance to the muscles surrounding the joint.
  43. Passive ROM:
    The nurse or equipment moves the joint through ROM with no effort from the patient
  44. Head, Eyes, Ears, Nose, and Throat Assessment (process):
    • 1. Inspect
    • 2. Observe
    • 3. PERRLA
  45. Head, Eyes, Ears, Nose, and Throat Assessment--Inspection
    • -Inspect the head for size, shape, and skin characteristics
    • -Inspect the facial features for size, symmetry, movement (symmetric smiling), skin characteristics
  46. Head, Eyes, Ears, Nose, and Throat--Observation
    • -Observe the eyes using the penlight
    • -4 times total
  47. Vital Signs:
    • 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
  48. Snellen chart:
    • -Distance
    • -Patients stand 20ft away and read the smallest line they can see
  49. E chart:
    • -Also used for distance
    • -Point to which way the legs are facing
  50. Near Vision:
    • -Yeager & Rosenbaum 
    • -Read a newspaper 14 inches away from face
  51. Systolic:
    When ventricles contract
  52. Diastolic:
    When ventricles fill with blood and relax
Author
ID
318587
Card Set
NUR 110 Lab Final
Description
NUR 110: Health Assessment Lab Final
Updated
Show Answers