Bedside Mini Health Assessment Flashcards
When assessing the nasal cannula the nurse is going to look in the nose with a pen light, what is the normal findings?
Pink
Moist
Without any crust or drainage
When palpating the IV, a normal finding would be documented how?
Patent and healthy
Noting the arm the IV is in
Define infiltration
Local swelling
Coolness
Pallor
Pain
(IV is leaking through the tissue)
(IV is not inserted properly)
Define phlebitis
Purple vein
Painful
Warm to touch
(Can lead to a clot/ thrombophlebitis)
(Inflammation of the vein)
Abnormal lung sounds can be described as___________ (which means?)
Adventitious - sounds heard in addition to the expected breath sounds)
When listening to lung sounds, what are the abnormal sounds called?
Crackles
Wheezing (Inspiratory and expiratory)
Ronchi
Tightness of chest and bronchioles
Diminished
Described normal breathing sounds
Clear
Regular
Non-shallow
Non-labored
List the different types of retractions
Abdominal
Substernal - indrawing between the breast bone
Intercostal - indrawing between the ribs
Suprasternal - indrawing above the clavicles
Supraclavicular
categorized: mild-moderate-severe
How do you assess the apical pulse? How long?
5th ICS to the left of the sternum at MCL
1 minute
How would a normal radial pulse be documented?
Equal
Symmetrical
Volume (strong, weak, thready)
When assessing capillary refill, what are the two descriptions and the times?
Brisk - less than 3 seconds
Sluggish - over 3 seconds
List the measurements for pitting edema
+1 = 2mm
+2 = 4mm
+3 = 6mm
+4 = 8mm
What is the sequence when assessing the abdomen?
RLQ
RUQ
LUQ
LLQ
List the types of bowel sounds and their frequency
Active / present - 5 seconds - 59 seconds
Hypoactive - 1 min - 5 min
Hyperactive - Less than 5 seconds apart
Absent - no sounds in 5 mins and is an emergency
When palpating the abdomen, a normal finding would be
Soft
Non-distended
Non-tender
