Ch 6 Verbal Responses Flashcards
The head looks normal
Normocephalic
The head looks large
Macrocephalic
The head looks small
Microcephalic
eyes are normal
“Sclera white. Conjunctiva Clear.”
After the light to eyes test
“Pupils equal, round, reactive to light directly and consensually”
Nose is normal
No congestion or drainage
mouth is normal
“mucous membrane moist and pink”. Note if it is pale, jaundice, dry
Trachea is normal
“Trachea is Midline”
Thorax
“normal AP (anterior/ Posterior) Diameter”
normal lung sounds
“lung sounds clear and equal bilaterally”
heart sounds normal, lub dub lub dub
“S1S2, regular, no murmurs or extra heart sounds”
stomach sounds
Judge if they are present or are hypoactive or hyperactive
Abdomen
“Abdomen flat, soft, non-tender. Normoacative bowel sounds.”
Pulse grading? ( checking brachial and radial artery)
3+= "Full, bounding" 2+= "Normal" 1+= "Weak, thready" 0= Absent
give them two fingers to squeeze
“Upper extremities strong”
pinch skin on arm for elasticity
“skin warm and dry with good turgor”
fingers are normal
“no clubbing or deformities. Nail beds pink with prompt capillary refill.”
Perineum
ask about bowel movements and voiding. When’s the last time you used the restroom? Number 1 or number 2? Any pain? (you get the gist)
Edema scale? Press on Tibia
Edema Scale
1+ Mild pitting; slight indentation; no perceptible swelling.
2+ Moderate pitting; indentation subsides rapidly.
3+ Deep pitting; indentation remains for a short time; leg looks swollen.
4+ Very deep pitting; indentation lasts a long time; leg very swollen.
get foot to push, get foot to pull
“lower extremities strong”
