Narrative Flashcards

1
Q

Neuro (9) :

A
  1. General appearance
  2. Lvl consciousness
  3. Orientation
  4. Pupils
  5. Body movement
  6. Sensory-vision/hear
    7.Sensation
  7. Speech
  8. Glascow coma scale
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2
Q

Neuro: General appearance

A

-Clean/orderly
>Shuffled, disorganized

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3
Q

Neuro: Level consciousness

A

-Awake, alert
>Drowsy

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4
Q

Neuro: Orientation

A

-x4 (place, time, person, event)
> Confused as to___ place…

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5
Q

Neuro: Pupil

A

-PERRLA 3mm
>Unequal

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6
Q

Neuro: speech

A

-Clear, fluent
>incoherent, slurred

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7
Q

Neuro: Movement

A

-All extremities move equally (MAE)
-Tremor, jerking

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8
Q

Neuro: Sensory

A
  • adequate vision/hearing
    > Blind, hard of hearing, glasses, hearing aid
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9
Q

Neuro: Sensation

A

-Sensation intact
> Decreased sensation

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10
Q

Neuro: GCS

A

Motor response (6)
Verbal response (5)
Eye opening (4)

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11
Q

Cardiovascular (7)

A
  1. General Appearance
  2. Apical rate
  3. Heart sounds
  4. Cap refil
  5. Circulation: color, warmth
  6. Edema
  7. Peripheral pulses
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12
Q

Cardio: General App

A

-Dry, pink, calm
>Diaphoretic, pale, anxious

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13
Q

Cardio: Apical pulse

A
  • 6 -100 BPM
    > Less/more Irregular
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14
Q

Cardio: Heart sound

A

-S1, S2
>Murmur, extra sound

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15
Q

Cardio: Edema

A
  • No edema
    > pitting/ non-pitting +1, +2, +3 +4
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16
Q

Cardio: Cap refil

A
  • 1-3 seconds
    > more than 3 sec
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17
Q

Cardio: peripheral Circulation

A
  • Pink, warm, nontender
    >cyanosis, cool
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18
Q

Cardio: Peripheral pulse

A
  • Regular, symmetrical +1 thread, +2 weak +3 strong +4 bounding
    > asymmetrical
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19
Q

Respiratory (5)

A
  1. Lung sounds
  2. Rate
  3. Chest shape
  4. Cough/sputum
  5. Effort
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20
Q

Resp: Lung sounds

A

-Clear in all lobes
> diminished, absent
(clear upper lobes diminished in bases)

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21
Q

Resp: Rate

A

-12-20/min regular symmetrical
> irregular <12 >20

22
Q

Resp: Effort

A
  • Labored
    > Unlabored

R/A cannula

23
Q

Resp: Chest shape

A
  • Symmetrical
    -Assymetrical/barrel
24
Q

Gastrointestinal (4)

A
  1. General appearance
  2. Palpation
  3. Bowel sounds
  4. Last BM
25
Q

Gastro: Appereance

A
  • Flat, round
    > Distended, assymetrical
26
Q

Gastro: Palpation

A
  • Soft, non-tender
    > tender, firm
27
Q

Gastro: Bowel Sounds

A
  • Active
    > hypoactive, hyperactive, absent
28
Q

Gastro: BM

A
  • Every 1-3 days
    > less that 3 days
    (stool soft, formed, brown)
29
Q

Nutrition (5)

A
  1. General appearance
  2. Diet type
  3. Intake of fluid/meals
  4. Mouth, teeth, gums
  5. Swallowing
30
Q

Nutri: General app

A

-Nourished
>Malnourished

31
Q

Nutri: Diet type

A
  • Regular
  • Soft, puree
32
Q

Nutri: Intake

A

-Patient reports 100% intake
> 10 %

33
Q

Nutri: Mouth, teeth, gums

A
  • no dentures, pink, moist
    > pale, lesions
34
Q

Nutri: Swallowing

A

-Swallows easily
>Difficulty

35
Q

Genitourinary (3)

A
  1. Urinary output
  2. Continent/ incontinent
  3. Bladder
36
Q

GU: Urinary output

A
  • Voids, +30mL/hr
    > difficulty voiding, frequency, burning

(COLOR)

37
Q

GU: Continent/incontin

A
  • Continent of urine
    > Incontinent of urine
38
Q

GU: Bladder

A

-Flat, round, soft
> firm, distended, tender

39
Q

Musculoskeletal (4)

A
  1. Gait
  2. Motor: symmetry, strong
  3. ROM
  4. Mobility lvl
40
Q

MSK: Gait

A

-Steady
>Unsteady

41
Q

MSK: Motor symmetry/strong

A
  • Symmetrical, strong 5/5
    >Unequal, weakness
42
Q

MSK: ROM

A

-Active/full ROM (upper and lower extremities (performs movement w/o assistance )
> Passive: therapist moves the joint

43
Q

MSK: Mobility

A

-Ambulates without assistance
>Ambulates w 2 person assist and walker

44
Q

Integumentary (4)

A
  1. Color
  2. Intactness
  3. Temperature
  4. Turgor
45
Q

Inte: Color

A
  1. Normal for ethnicity
    > Pale, cyanosis
46
Q

Inte: temp

A

-warm cool dry
>Hot, diaphoretic

47
Q

Inte: intactness

A
  • None
    >lesions, wounds
48
Q

Inte: Turgot

A
  • elastic
    >slow to recoil, tented for 4 sec
49
Q

Equipment: (2)

A
  1. Size
  2. State
50
Q

Equipment:

A

IV 20g RT AC no infiltration, clean and intact

51
Q

Pain:

A

Scale, location, sharp, relieved with????