Check Sheet Flashcards
1
Q
Blood pressure
A
- start with palpatory method
- measures arm for cuff size
- arm at heart’s level
- stethoscope over brachial aa
- measure BP bilaterally
- takes ortho’s if on BP meds, lightheaded, syncope, or dehydrated
2
Q
Pulse
A
- determine rate and rhythm
- listen for 15 seconds and time by 4
- listen for full 60 seconds if irregular
- auscultates to determine rate if irregular
3
Q
respirations
A
- comments on assessing while patient is unaware
- notes: rate, effort, depth, rhythm
4
Q
temperature
A
- bladder or rectum measures would be most accurate
- axillary least accurate
- take temperature orally
5
Q
Jugular vein pressure estimation
A
- raise patients head 30 degrees
- use oblique lighting
- inspect both jugular vein pulsations
- measure from apex of pulsation to sternal angle (at 90 degree angle)
- check hepatojugular reflex if
6
Q
Carotid arteries
A
- palpate both carotids independently
- note: amplitude, contour, and thrills
- palpate aa while auscultating to determine S1
- ask patient to hold breath and auscultate both aa
- use bell to assess bruits
- listen with diaphragm for high pitches
7
Q
Inspect pericordum
A
- use tangential lighting
- comments on if PMI is visible
8
Q
Palpates pericordium
A
- aortic area
- pulmonic area
- right ventricle
- left ventricle
- palpates in LLD position
- comments on heaves and thrills
- determines PMI
9
Q
Determines PMI
A
- uses palm to generally assess
- uses fingers to localize
- comments on: duration, diameter, amplitude, and location
- positions pt in LLD if unpalpable supine
10
Q
Auscultation of patient supine
A
- determine rate and rhythm of heart while pt is supine
- listen with diaphragm to:
- listens to 2nd right intercostal space
- listens to 2nd left intercostal space
- listenings to LLSB intercostal spaces 3-5
- listens to apex
- notes findings on aortic and mitral regurgitation, or frictions rubs
- listens with bell to:
- apex
- LLSB
- notes: aortic or mitral stenosis, S3 or S4
11
Q
Auscultations of pt in LLD position
A
- listens with bell over apex
- notes: mitral stenosis, S3 or S4
12
Q
Auscultation of pt leaning forward
A
- asks pt to exhale fully and hold breath
- listens with diaphragm to:
- LLSB
- apex
- notes: aortic regurgitation and friction rub
- listens with bell to:
- LLSB
- notes right sided S3 or S4
- inch stethoscope over auscultatory areas taking time to listen
- if murmur present notes: timing, location of maximal intensity, radiation, intensity, pitch, quality
13
Q
inspects arms
A
- inspects arms bilaterally
- notes: symmetry, swelling, vascular pattern, nail color, skin color, and skin texture
14
Q
Palpates of arms
A
- assess radial aa bilaterally
- assess capillary refill of fingers
- correctly performs allen test
- palpates epitrochlear lymph nodes
15
Q
leg inspection
A
- inspects legs bilaterally
- notes: size, swelling, symmetry, venous patter, nail color, skin color, skin texture, venous enlargement, pigmentation, rashes, scars, ulcers
- assess hair distribution on legs, feet, toes
- assess color of legs dangling
- check for postural changes if indicated
- stand pt and check for varicosities bilaterally
