Lab Final Flashcards
Heath history
Neuro
HEENT
Respiratory
Cardiac
Peripheral
Abdominal
Musculoskeletal
Integument
General survey
Appearance-Alert, appears their age, even skin color, in tact
Body structure
Mobility behavior-no crutches or wheelchair
Obtain vitals
Electronic monitor- temp, radial pulse, respirate rate, oxygen, blood pressure
Any pain???
Mental status
Neuro 1
Patient is alert..
Name?
Where are you?
Why are you here?
Year?
Rate-4
Perrla
Neuro 2
Assess pupils response bilateral
Pupil
Equal
Round
React to light
L
Accommodation
Assess for light reaction (hand between eyes)
Accommodation: (bring pen to and from face) eyes should follow
Sensation
Neuro 3
Cotton ball on face, upper extremities and lower extremities
Hearing
Neuro 4
Whisper behind them with one ear covered..(3 words)
DTRS
Neuro 5
Test knee reflex- rate 1 or 2
Babinski- outline J on foot
(Positive Babinski seen on babies is when toes fan instead of curl)
HEENT 1
Palpate head
No bumps, no tenderness, even hair distribution
Face
HEENT 2
Face is symmetrical, nose midline, structures are aligned
Oral
HEENT 3
Using light to assess mucous membrane
Uvula-midline
Soft palate- rises
Enlarged lymph nodes
HEENT 5
Palpate 2 lymph sites
Assess for symmetry
Respiratory 1
Describe AP to transverse chest configuration 1:2
Chest expansion: feel for C7..down to C10..hold hands flat and have them breathe
Capillary refill
Respiratory 2
Capillary refill: less than 2 seconds
Check for clubbing: 160 or less
Cyanosis: blue coloring in nails, lips, fingers
Breath sound
Respiratory 3
Bronchial-high pitched
Bronchovesicular- moderate pitch
Vesicular-low pitch