Term
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Definition
level of consciousness
speech
orientation X 3 (person,place,& time)
pain, using pain scale
presence of any equipment |
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Term
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Definition
color
lesions
IV site, presence and condition |
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Term
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Definition
PERRLA, correctly assessed
glasses |
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Term
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Definition
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Term
|
Definition
mucous membranes
dentition |
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Term
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Definition
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Term
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Definition
| JVD (HOB at 45 degree angle) |
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Term
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Definition
capillary refill
skin color
skin temperature
skin turgor
pulses
edema
hand grasps
bony prominences |
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Term
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Definition
breathing pattern
Breath sounds: properly place stethoscope
Anterior-3 locations;
Lateral- 2 locations on each side
Verbalize and describe sounds
Heart sounds:Properly place stethoscope & name 4 positions where heart sounds are heard
aortic,pulmonic,tricuspid,mitral(apical) |
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Term
| Abdomen (client supine,flat,knees slightly bent) |
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Definition
Inspect(contour)
Auscultate all four quad
Palpate(first light palpation, then deeper;
state assessing for tenderness &/or masses |
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Term
| Genitourinary (inspect if appropriate) |
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Definition
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Term
|
Definition
capillary refill
skin color
skin temperature
pulses(dorsalis pedis & posterior tibia)
Homans's sign
edema
plantar flexion
quadriceps strength
hip muscle strength
bony prominences |
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Term
|
Definition
Breath Sounds.properly place stethoscope
Anterior-3 locations;
Lateral- 2 locations on each side
Verbalize and describe sounds
Heart sounds:Properly place stethoscope
Posterior- 4 locations on each side & describe possible sounds)
May listen laterally here(2 positions) instead of anteriorly
bony prominences |
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Term
|
Definition
Assess client position in bed
Level of Consciousness
Eye contact and responsiveness
Short and long term memory
Behavior
level of anxiety
ability to follow commands
signs of discomfort or pain.
orientation X 3(person,time,place)
Assess client's color grooming and hygiene,others and level of independence for performing ADLs
Assess for all suction devices, equipment in specialty beds. |
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Term
|
Definition
General information:establish nurse-client relationship at this time.
Uses pain scale to rate pain.
Have client describe and point to painful area.
Make sure all equipment is functioning properly: All settings are correct and all connections are tight. |
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Term
|
Definition
Color
texture
cleanliness
moisture
hair distribution
lesions
drainage
skin turgor(as appropriate on all body surfaces)
Assess bony prominences for pressure areas.
Observe all I.V. sites,solutions,drip rates,pumps,dressings,drains,tubes. |
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Term
|
Definition
Check for skin turgor on the sternum for elderly clients.
Assess the skin turgor by gently pinching up a small amount of skin between the thumb and index finger. Normally the skin will spring back or have a delayed return.(remains tented) |
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Term
|
Definition
Assess client's
eyelashes
lids
sclera
conjunctiva
iris
use of glasses or contacts
observe for PERRLA |
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Term
|
Definition
Darken room to better observe pupillary reaction to light.
May check PERRL when agency policy does not include accommodation in the assessment data. |
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Term
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Definition
| If on oxygen via nasal cannula or NG/feeding tube assess for irritation/nosebleeds |
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Term
|
Definition
Assess client's lips
buccal mucosa
gums
teeth
dentures
palates
uvula
tongue for moisture,color and presence of lesions |
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Term
|
Definition
Assess client's ability to hear normal conversation.
Note use of hearing aids |
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Term
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Definition
| Inspect for presence of Jugular Venous Distention(JVD) |
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Term
|
Definition
| Make sure bed is at 45 degree angle with client in supine position. |
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Term
|
Definition
nails(clubbing and capillary refill)
Palpate radial and brachial pulses bilaterally
AV Graft and fistulas(if present)
Note temperature, tenderness or edema
Assess ROM
Muscle tone
Bilateral hand grasp for strength and equality)
Listen for vascular flow in AV grafts and fistula is present
Observe skin integrity on elbows |
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Term
|
Definition
Normal capillary refill 2-3 secs
If unable to palpate distal pulse, check proximal pulse sites.
Pulse graded on scale of 0-3
0=absent
1=thready or weak(difficult to feel)
2=normal
3=bounding
Grade Edema as 1+-4+
1+ barely detectable
2+ indentation of <5 mm
3+ indentation of 5-10mm
4+ indentation of >10mm |
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Term
|
Definition
Expose client's chest as needed
Observe for evidence of mastectomy and note location
observe for shape of chest
breathing patterns
respiratory effort
symmetry of chest movement
depth of respiration
palpate chest wall for tenderness and crepitus
Auscultate for vesicular and any adventitious sounds
Inspect PMI and precordium for pulsations
Use bell to auscultate heart sounds,rhythm (S1,S2 4 positions) |
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Term
|
Definition
Uses diaphragm to auscultate lung fields from upper to lower and lateral fields.
Avoid placing stethoscope over bony areas
Compare breath sounds on each side
Aortic (2nd intercostal space, right sternal border)
Pulmonic(2nd intercostal space, left sternal border)
Tricuspid (5th intercostal space, left sternal border)
Mitral(Apical) 5th intercostal space, left midclavical line.
S1 corresponds to carotid pulse. |
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Term
| Abdomen (client supine,flat,knees slightly bent) |
|
Definition
Assess contour pulsations.
Auscultate bowel sounds(BS all 4 quadrants)
Palpate 4 quadrants light 1st. the deeper for tenderness,masses and hernias.
Note presence of tubes/or stool urinary diversions. |
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Term
| Abdomen (client supine,flat,knees slightly bent) |
|
Definition
Auscultate each quadrant in 2 places.
If BS absent auscultate at least 5 min total.
If appropriate measure abdominal girth at largest diameter.(mark abdomen is exact location for consistent measurement.
Palpate bladder if necessary.(based on urine output)
Replace client's if appropriate,
Don non sterile gloves |
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Term
| Abdomen (client supine,flat,knees slightly bent) |
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Definition
Provides privacy and warmth
standard precautions. |
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Term
|
Definition
As clinically indicated
Observe urinary meatus for exudate
If Foley catheter is in place, observe meatus for irritation.
Observe urinary output for color.
Odor,sediment and amount
Females:Assess perineal area for discharge.
Males: check scrotum for alterations in testicles.
Ask about bowel movements
Remove non sterile gloves |
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Term
|
Definition
nails(clubbing,capillary refill)
ROM
Muscle Tone
Bilateral Plantar flexion
Quadriceps
Hip Muscle for strength and equality
Holman's sign
ability to bear weight
note use of assistive devices
palpate dorsalis pedis and posterior tibal pulses bilaterally
Assess temperature.
tenderness
edema
venous distention(varicosities)
observe skin integrity on heels |
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Term
|
Definition
If unable to palpate most distal pulse, check proximal pulse sites.
Pulse graded on scale of 0-3
0=absent
1=thready or weak(difficult to feel)
2=normal
3=bounding
Grade Edema as 1+-4+
1+ barely detectable
2+ indentation of <5 mm
3+ indentation of 5-10mm
4+ indentation of >10mm |
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Term
|
Definition
Position client sitting up or in lateral position as tolerated.
Assess configuration and respiratory effort.
palpate thoracic expansion
chest wall for tenderness and creptitus
Auscultate for vesicular any adventitious sounds.
observe sacral area for edema for skin breakdown if client is not ambulatory.
observe skin integrity on sacrum,trochanter, coccyx and occipital. |
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Term
|
Definition
Liver
Right Kidney
Gallbladder
Colon
Pancreas |
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Term
|
Definition
Stomach
Left Kidney
Spleen
Colon
Pancreas |
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Term
|
Definition
Appendix
Colon
Small Intestine
Ureter
Major Vein and Artery to right leg |
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Term
|
Definition
Colon
Small Intestine
Ureter
Major vein and artery to left leg |
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Term
|
Definition
Aorta
Pancreas
Small intestine
bladder
spine |
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