Narrative Flashcards
Neuro (9) :
- General appearance
- Lvl consciousness
- Orientation
- Pupils
- Body movement
- Sensory-vision/hear
7.Sensation - Speech
- Glascow coma scale
Neuro: General appearance
-Clean/orderly
>Shuffled, disorganized
Neuro: Level consciousness
-Awake, alert
>Drowsy
Neuro: Orientation
-x4 (place, time, person, event)
> Confused as to___ place…
Neuro: Pupil
-PERRLA 3mm
>Unequal
Neuro: speech
-Clear, fluent
>incoherent, slurred
Neuro: Movement
-All extremities move equally (MAE)
-Tremor, jerking
Neuro: Sensory
- adequate vision/hearing
> Blind, hard of hearing, glasses, hearing aid
Neuro: Sensation
-Sensation intact
> Decreased sensation
Neuro: GCS
Motor response (6)
Verbal response (5)
Eye opening (4)
Cardiovascular (7)
- General Appearance
- Apical rate
- Heart sounds
- Cap refil
- Circulation: color, warmth
- Edema
- Peripheral pulses
Cardio: General App
-Dry, pink, calm
>Diaphoretic, pale, anxious
Cardio: Apical pulse
- 6 -100 BPM
> Less/more Irregular
Cardio: Heart sound
-S1, S2
>Murmur, extra sound
Cardio: Edema
- No edema
> pitting/ non-pitting +1, +2, +3 +4
Cardio: Cap refil
- 1-3 seconds
> more than 3 sec
Cardio: peripheral Circulation
- Pink, warm, nontender
>cyanosis, cool
Cardio: Peripheral pulse
- Regular, symmetrical +1 thread, +2 weak +3 strong +4 bounding
> asymmetrical
Respiratory (5)
- Lung sounds
- Rate
- Chest shape
- Cough/sputum
- Effort
Resp: Lung sounds
-Clear in all lobes
> diminished, absent
(clear upper lobes diminished in bases)
Resp: Rate
-12-20/min regular symmetrical
> irregular <12 >20
Resp: Effort
- Labored
> Unlabored
R/A cannula
Resp: Chest shape
- Symmetrical
-Assymetrical/barrel
Gastrointestinal (4)
- General appearance
- Palpation
- Bowel sounds
- Last BM
Gastro: Appereance
- Flat, round
> Distended, assymetrical
Gastro: Palpation
- Soft, non-tender
> tender, firm
Gastro: Bowel Sounds
- Active
> hypoactive, hyperactive, absent
Gastro: BM
- Every 1-3 days
> less that 3 days
(stool soft, formed, brown)
Nutrition (5)
- General appearance
- Diet type
- Intake of fluid/meals
- Mouth, teeth, gums
- Swallowing
Nutri: General app
-Nourished
>Malnourished
Nutri: Diet type
- Regular
- Soft, puree
Nutri: Intake
-Patient reports 100% intake
> 10 %
Nutri: Mouth, teeth, gums
- no dentures, pink, moist
> pale, lesions
Nutri: Swallowing
-Swallows easily
>Difficulty
Genitourinary (3)
- Urinary output
- Continent/ incontinent
- Bladder
GU: Urinary output
- Voids, +30mL/hr
> difficulty voiding, frequency, burning
(COLOR)
GU: Continent/incontin
- Continent of urine
> Incontinent of urine
GU: Bladder
-Flat, round, soft
> firm, distended, tender
Musculoskeletal (4)
- Gait
- Motor: symmetry, strong
- ROM
- Mobility lvl
MSK: Gait
-Steady
>Unsteady
MSK: Motor symmetry/strong
- Symmetrical, strong 5/5
>Unequal, weakness
MSK: ROM
-Active/full ROM (upper and lower extremities (performs movement w/o assistance )
> Passive: therapist moves the joint
MSK: Mobility
-Ambulates without assistance
>Ambulates w 2 person assist and walker
Integumentary (4)
- Color
- Intactness
- Temperature
- Turgor
Inte: Color
- Normal for ethnicity
> Pale, cyanosis
Inte: temp
-warm cool dry
>Hot, diaphoretic
Inte: intactness
- None
>lesions, wounds
Inte: Turgot
- elastic
>slow to recoil, tented for 4 sec
Equipment: (2)
- Size
- State
Equipment:
IV 20g RT AC no infiltration, clean and intact
Pain:
Scale, location, sharp, relieved with????