2) UPPER EXTREMETIES Flashcards
1
Q
UPPER EXTREMETIES
A
5 STEPS
2
Q
1
A
Assess skin - color, temperature, moisture
3
Q
2
A
Assess vascular access; is it a PICC or peripheral line? Is it clear free of pain, redness, and swelling?
4
Q
3
A
Palpate radial pulses bilateral assess for equality of strength. 0= no pulse 1+=weak, 2+=strong 3+=bounding
5
Q
4
A
Assess capillary refill- press nail beds to elicit blanching and remove. Normal color returns <2 seconds. Assess bilateral. *State less than 2 seconds.
6
Q
5
A
Test Arm strength and hand grips - can client grasp your hand firmly with each of his/her hands? Is arm strength equal bilaterally against resistance?
