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3015 Professional Nursing Concepts and Practice > Head to toe - verbage > Flashcards

Head to toe - verbage Flashcards

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1
Q

Vital signs - Temp

A

36.5-37.7 Celsius

96-99.9 F

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2
Q

Vital signs - HR

A

NL 60-100

Regular Rate/Rhythm 2+ amp bilaterally

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3
Q

Vital signs - RR

A

NL 12-20

Regular rate w/ Bilateral rise and fall of the chest and a moderate depth

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4
Q

Vital signs - BP

A

120/80 or below

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5
Q

Vital signs - Pain

A

Are you experiencing any pain? 0-10

Is this normal for you?

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6
Q

Neuro - LOC

A

AVPU/GCS - fully awake and alert

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7
Q

Neuro - Orientation A/O?

A

Person - Full name
Place - Tell me where you are right now?
Time - What is todays date/time?
Situation - What are we doing today?

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8
Q

Head

A

Normocephalic, symmetric, and proportionate head

W/out lesions, soft/boggy spots, or infestations.

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9
Q

CN VII

A

Smile, wrinkle forhead, Close eyes, puff out cheeks

Cranial nerve intact and equal bilaterally.

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10
Q

Eye inspection

A

Are you experiencing any tenderness?

Eye structures are w/out redness, edema, or drainage.

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11
Q

CN III

A

Pupillary rxn to light
Accomodation

PERRLA - eyes converge and pupils constrict bilaterally.
CN III is intact

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12
Q

Ears

A

Please let me know if you experience any tenderness or pain.

No drainage, TTP, or lesions noted.
Ears are symmetrical and inline with outer canthas.

Drainage - color, consistency, odor, or blood?

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13
Q

Nose

A
  • Experiencing any drainage in the last week?
  • Bridge is firm, stable, w/out TTP or masses.
  • Patency is noiseless and easy bilaterally
  • Internal nose is pink/moist w/out drainage or redness.
  • Septum is midline w/out perforation.
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14
Q

Drainage characteristics?

A

Color, consistency, blood?

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15
Q

Mouth exam includes?

A 
Buccal cavity
Teeth
Tongue
Uvula
Tonsils
CN IX and X
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16
Q

Buccal cavity

A

Buccal cavity is pink, moist, w/out lesions.

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17
Q

Teeth

A
  • Have you had any teeth removed?

- Teeth are pearly white w/out decay and are firmly attached to gum line.

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18
Q

Tongue

A

Is moderate in size, pink, moist and without lesions or edema.

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19
Q

Uvula

A

Is pink, moist, without lesions and is midline in the oropharnx.

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20
Q

Tonsils

A

Are 1+ w/out exudate, lesions, or swelling.

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21
Q

CN IX and X

A

Open mouth and say AHH

  • Uvula and soft palate rise and fall symmetrically in the midline.
  • CN IX and X are intact
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22
Q

Neck

A

No bruits present upon auscultation bilaterally.

Carotids regular rate/rhythm w/ 2+ amplitude and no thrills felt upon palpation bilaterally.

23
Q

How to listen to Chest

A

Breath in/out through mouth
Listening during in/exp
Avoiding bone/breast

24
Q

Listen to anterior chest sites

A

Begin above clavicles/2nd ICS
End at the Xiphoid process/6th ICS
— No adventitious sounds heard upon auscultation bilaterally.

25
Q

Listen to lateral chest sites

A

Right - 3 sites and Left 2 sites
Right 2nd ICS MAL, 4th ICS AAL, and 6th ICS PAL
Left 2nd ICS MAL and 6th ICS PAL.
— No adventitious sounds heard upon auscultation bilaterally.

26
Q

Listen to posterior chest sites

A

Begin at C7 and end at T10

— No adventitious sounds heard upon auscultation bilaterally.

27
Q

CV exam includes

A 
Heart sounds
Peripheral pulses at radial and pedal.
Condition/Color of skin
Cap refill - 4 extremities
Peripheral edema - 4 extremities.
28
Q

CV system heart sounds

A

Diaphragm and bell

  • Aortic 2-3 ICS RSB
  • Pulmonic 2-3 ICS LSB - S2 sound.
  • Erbs point 3-4 ICS LSB
  • Tricuspid 4-5 ICS LSB
  • Mitral 4-5 ICS MCL - apical impulse - or S1 sound.
29
Q

Peripheral pulses

A

Bilateral Radial and Pedal pulses are regular rate/rhythm w/ 2+ amplitude

30
Q

Skin condition/color

A

No bruises, rashes, redness are noted.

Skin is even, warm, dry and appropriate for ethnicity.

31
Q

Capillary refill and nail beds

A

Nail beds are appropriate color and cap refill is <2s in upper and lower extremities.

32
Q

Peripheral edema

A

Palpate UE at hands and LE at tibial plateau/ankles.

33
Q

Abdomen exam includes

A

Inspection
Auscultation
Light palpation

34
Q

Abdomen inspection includes

A

Contour
Shape
Pulsations
Skin condition

35
Q

ABD contour

A

Flat or rounded evenly and symmetrically

36
Q

ABD shape

A

Symmetric w/out bulging

37
Q

ABD skin

A

Smooth and even color appropriate for ethnicity w/out bruises, pulsations, or redness.

38
Q

Bowel sounds

A

I will listen for 1 min per quadrant starting in the LRQ for a maximum of 5m in total.
Normoactive bowel sounds are 5-30

39
Q

ABD light palpation

A

Are you experiencing any pain or discomfort in you abdomen,
Palpate lightly starting in LRQ moving clockwise
Upon palpation there was no guarding, masses, TTP or pulsations felt.

40
Q

Musculoskeletal exam includes

A

Muscle size, tone, strength
Joint redness, edema, TTP
Gait/posture
ROM of UE and LE

41
Q

MSK ROM joints to assess

A

UE - shoulder, elbow, wrist, hand/fingers

LE - Hip, Knee, Ankle

42
Q

Muscle size

A

Muscle size is appropriate for person and equal bilaterally.

43
Q

Muscle tone

A

Muscle tone is w/out flaccidity, rigidity, or spasticity.

44
Q

Muscle strength

A

Push/pull hands/feet

Muscle strength is 5+ and equal bilaterally.

45
Q

Joint exam

A

Joints are w/out redness, edema, warmth, or TTP

46
Q

Posture

A

Is erect and symmetric w/out misalignment such as scoliosis, lordosis, or kyphosis

47
Q

Gait

A

Please take a few steps.

Patients gait is smooth and steady w/ toes pointed forward. Posture is erect and arms swing in opposition.

48
Q

ROM - shoulder

A 
Flex/Extend
Hyperextension
Abduction/Adduction
Internal/External rotation
Circumduction
49
Q

ROM - elbow

A

Flex/Extend
Pronation
Supination

50
Q

ROM - wrist

A

Flex/Extend
Hyperextension
Radial deviation
Ulnar deviation

51
Q

ROM - hand/fingers

A

Flex/Extend
Hyperextension
Abduct/Adduct
Opposition

52
Q

ROM - hips

A 
Flex/Extend
Hyperextension
Abduction/Adduction
Internal/External 
Circumduction
53
Q

ROM - knees

A

Flex/Extend

54
Q

ROM - ankles

A

Dorsiflexion
Plantarflexion
Inversion/Eversion
Abduct/Adduct

3015 Professional Nursing Concepts and Practice (12 decks)

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