Assessments Flashcards
Describe skin color
Normal for ethnicity
Describe mucous membranes
moist & pink
Describe hair distribution
evenly distributed
AIDET
Acknowledge patient / introduce yourself / duration / explain / thank
What could cause a thready pulse?
Poor circulation, dehydration, and low blood pressure
What could cause weeping edema?
Low protein
What is the mnemonic device to remember the valves of the heart?
All Patients Take Meds (Aortic, Pulmonic, Tricuspid, Mitral / Apex.)
Where would you find the aortic area?
Second intercostal space, right sternal border
Where would you find the pulmonic area?
Second intercostal space, left sternal border
Where would you find the tricuspid area?
Fourth or fifth intercostal space, left sternal border
Where would you find the mitral area or apex?
Fifth intercostal space, left midclavicular line.
What does PERRLA stand for?
Pupils Equal Round Reactive Light Accomodation
What is considered a normal dilation of the pupil?
2-5mm
How would you chart a pupil that does not meet PERRLA?
__ pupil non-reactive (or other problem) @ (pupil size) mm
What is the highest and lowest score of the Glasgow Coma Scale?
15 / 3
When is a Glasgow Coma Scale indicated?
When pt has neurological problems. Not needed when pt is sitting up and speaking.
What is the highest and lowest score of the Mini Cog tool?
5 / 3 - further assessment needed
If a patient is ‘obtunded,’ they are ___
Between lethargic (drowsy) and comatose
What are the 5 Ps of circulatory assessment?
Pain, pulse, pallor, paresthesia, and paralysis
What is the upper limit of oxygen for COPD patients?
4 L - can cause additional problems if you go over.
_____ is considered a medication and you must get orders from a doctor once you’ve administered it.
Oxygen
