Assessments

Question 1

CNS

Answer 1

General appearance
Behaviour
Level of consciousness, GCS score, orientation x 3
PERRLA
Dizziness, visual disturbances, tremors
Body position/posture/gait
Pain or headache: pqrstu

Question 2

CVS

Answer 2

BP
Distal pulses: rate rhythm, quality (0, 1, 2, 3)(radial)
Heart sounds:s1 & s2’ apical pulse (rate, rhythm, quality)
Extra heart sounds, murmurs
Chest pain: pqrstu

Question 3

Respiratory

Answer 3

Respiration (rate, rhythm, quality)
Work of breathing (sob, resp ease, distress, orthopenea, accessory muscles, tripod)
Oxygen delivery type and concentration
SpO2%, room air or oxygen
Auscultation: air entry, adventitious sounds -anterior and posterior
Cough: frequency, characteristics, productive, sputum
Pain: pqrstua

Question 4

PVS

Answer 4

Cap refill and peripheral pulses (dorsallis pedis, radial)
Colour, warmth, movement, sensation of all extremities
Edema (location, pitting or non-pitting)
Pain to extremities:pqrstu

Question 5

GI

Answer 5

Abdominal contour, soft/firm, distension
Bowel sounds x4 (start RLQ)
N/V/BM (frequency, intensity)
Nutritional status (eating/drinking, current diet, toleration)
Pain to abdomen: pqrstu

Question 6

GU

Answer 6

Urine (amount, appearance, odor, frequency, urgency)
Presence of catheter or drainage
Pain r/t voiding/GU: pqrstu

Question 7

Musculoskeletal

Answer 7

ROM, movement and strength of extremities
Circulation, sensation, warmth of affected extremity
Pain to extremities: pqrstu

Question 8

Integumentary

Answer 8

General skim appearance (colour, hair distribution, redness)
Pressure points
Wounds - assess using REEDA/MEASURE
Pain r/t skin/wounds: pqrstu

Question 9

Environment

Answer 9

Suction - setup and function
Oxygen - verify presence, flow rate, and device
Bed - lifts and lowers
IV - rate, solution, site
Foleys/drains - verify presence