Term
|
Definition
Their formal name
Your name
Reason you're there |
|
|
Term
|
Definition
1. What's your normal BP?
2. BP meds/take?
3. Arm preference? |
|
|
Term
|
Definition
1. Measure and report BP
2. Take P and R (30 seconds + 30 seconds) and report
3. Take temperature and report |
|
|
Term
| 3. Neurological Questions |
|
Definition
1. A&O x3: Full name, date of birth, what month is it?
2. Allergies? Reaction?
3. Do you currently have a headache or blurred or double vision?
4. Have you ever had a TBI, stroke, or TIA?
5. Any trouble walking/getting around?
6. Any assistive devices? |
|
|
Term
|
Definition
PERRLA
Strength: grip and feet |
|
|
Term
|
Definition
1. Dyspnea/SOB?
2. Cough? Productive? Describe sputum?
3. Asthma or allergies?
4. Diagnosis of lung disease/COPD/emphysema?
5. Smoker? ppd? Does anyone around you smoke? |
|
|
Term
| 4. Anterior respiratory actions |
|
Definition
Inspect eyes, nares, mouth, accessory muscles, retractions, AP:T, costal angle
Palpate for masses, crepitus
Auscultate front/sides (14 points) to compare L&R |
|
|
Term
|
Definition
1. Chest pain?
2. Palpitations, racing, skipping beat?
3. Pacemaker?
4. Murmur?
5. History of MI?
6. Diagnosed with heart disease or HTN? |
|
|
Term
|
Definition
Inspect for pulsations, JVD, lifts, heaves
Palpate and auscultate with bell and diaphragm at APETM ("You can breathe normally while I do this") |
|
|
Term
|
Definition
1. Current pain?
2. N/V?
3. Gas?
4. Last BM: description and time?
5. Usual BM's and timing?
6. Do you use anything to help you go?
7. Abdominal surgeries? |
|
|
Term
|
Definition
Inspect contour, symmetry, rise and fall, skin
Auscultate 4 quadrants |
|
|
Term
|
Definition
|
|
Term
| 8. Skin and PVS questions |
|
Definition
1. Notice any skin changes/mole changes?
2. Notice any swelling?
3. Notice any numbness or tingling?
4. Any piercings/tattoos?
5. Any surgeries/scars?
6. Diagnosed with ecsema or psoriasis? |
|
|
Term
|
Definition
1. Assess any wounds: Smelly REEDA
2. Temperature, color, moisture throughout
3. Bruising, scars, acne?
4. Varicosities?
5. Peripheral pulses
6. DVT?
7. Capillary refill? |
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