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
Auscultate
Respiratory 4
Anterior-6
Lateral-right lobe, 5th rib
Posterior-10
Ladder pattern
Describe lung sounds
Assess chest
Cardiac 1
Explain precordium for lifts/heaves/pulsations
Assess for JVD
Cardiac 2
Lay flat, no pillow, have client face the left..raise bed
30-45 degrees
Assess carotid
Cardiac 3
Palpate bilateral
Auscultate with bell
Auscultate apical pulse
Cardiac 4
5 to 6th intercoastal, mid-clavicle
Listen for 60 seconds
Regular rate
Normal rhythm
Identify and Auscultate heart sounds
Cardiac 5
Z pattern…
Aortic:
Pulmonic:
Erbs:
Tricuspid:
Mitral:
Bell for murmurs
Identify 2 peripheral pulse sites
Peripheral cardio 1
Radial and brachial
Identify 4 lower peripheral pulses
Peripheral cardiac 2
Femoral, popliteal, posterior tibia, dorsalis pedis
Assess radial pulse
Peripheral cardiac 3
Assess radial- bilateral
Grade radial pulse-2 normal rhythm
Assess dorsal is pedis
Peripheral cardiac 4
Assess dorsal is pulse: bilateral
grade: 1 or 2 normal rhythm.
Edema
Peripheral 5
No edema
Abdomen 1
Inspect- convex, distended umbilicus, midline
Auscultate-RLQ, RUQ, LUQ, LLQ
Percussion
Palpate
Abdominal 2
Aortic, iliac, femoral arteries-no bruits (brewes) using the Bell.
Assess gait
Musculoskeletal 1
Get up and go test
Romberg test-balance…stay with client for safety
Upper extremities strength
Muscular 2
Assess and and grade upper extremities bilateral
Grade:
Lower extremities strength
Muscle 3
Assess and grade lower extremities bilateral
Grade:
Assess ROM upper
Muscles 4
Flexion, extension, abduction, adduction, external rotation, internal rotation, circumduction
Elbow: flexion, extension, supination, pronation
Wrist: flexion, extension, inversion, eversion
Assess ROM lower
Muscles 5
Flexion, extension, abduction, adduction, external rotation, interval rotation
Knee: flexion, extension , shallow knee bend, step walking
Ankle: dorsiflexion, plantar flexion, inversion, eversion
Assess skin color
Integumentary 1
Skin color; even skin tone
No bumps, lesions, even hair distribution
Palpate skin upper and lower
Integumentary 2
Warm temperature
Moist skin
Turgors
