Term
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Definition
| Gathers exam equipment. (watch,penlight,stethoscope,b/p cuff,note pad and black pen) |
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Term
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Definition
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Term
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Definition
| Obtain Ht and Wt (Verbalize) |
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Term
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Definition
| Place patient in appropriate position. |
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Term
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Definition
| Takes Vital Signs (B/P,Pulse,Temp,Resp) (Verbalize) |
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Term
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Definition
| Do overall view of pt. Any distress or pain? Any O2? How many Liters going? |
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Term
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Definition
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Term
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Definition
| Do they have an IV? Where is it located? Is dressing intact? Is IV heplocked or are fluids infusing? Check infusion rate. |
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Term
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Definition
| Alert and oriented x3 (person,place,& time) |
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Term
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Definition
| PERRLA (Pupils Equal, Round, & Reactive to Light and Accommodation) |
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Term
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Definition
| Check bilateral grips. Are they equal in strength? |
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Term
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Definition
| Any hearing problems? (HOH, hearing aids) |
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Term
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Definition
| Any visual problems? (glasses, contacts) |
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Term
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Definition
| Neck: Is neck sore,stiff, or swollen? |
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Term
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Definition
| Lungs: Auscultate lung sounds. Listen to posterior & anterior chest wall. |
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Term
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Definition
| Heart: Auscultate heart sounds. Listen & count apical heart rate. Note any irregular rhythm or sound. |
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Term
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Definition
| Skin: Is sensation intact? Is skin warm,pink, & dry? |
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Term
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Definition
| Abdomen: Listen in all 4 quadrants. Do you hear bowel sounds? Are they hyperactive or hypoactive? When was last BM(formed or diarrhea)? Colostomy? |
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Term
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Definition
| Urinary: Are they voiding ok? Any burning, urgency, or hematuria? Do they have a foley cath? Note color, amount, or any odor. |
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Term
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Definition
| Leg assessment, ROM; Any swelling in lower extremities? |
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Term
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Definition
| Feet: Check for pedal pulses, capillary refill, & any ulcerations. |
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Term
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Definition
| Posterior of patient: Check for any skin breakdown. |
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Term
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Definition
| Side rails up x2. Call light in reach. Will coninue to monitor closely. |
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