NUR 220 Shift Assessment

Question 1

first 3 things before starting assessment

Answer 1

washes hands
introduces self
explains what they will be doing

Question 2

neuro

Answer 2

• alert and oriented to person, place, time, and why in hospital
• assess pupils: equal, round and reactive to light
• headaches or dizziness
• slurred speech or facial droop VERBALIZE

Question 3

HEENT

Answer 3

• edema or discharge in eyes
• ears and nose for drainage
• oral mucosa
• hearing aids, glasses, dentures
• difficulty swallowing or chewing

Question 4

Respiratory

Answer 4

• breath sounds, under gown, anterior and posterior
• excursion is symmetrical VERBALIZE
• assess for skin tenting
• shortness of breath or difficulty breathing
• cough if so what color and amount

Question 5

Cardiac

Answer 5

• Listens under gown (S1, S2, regular or irregular rhythm)
• chest pain

Question 6

Gastrointestinal

Answer 6

• listens to bowel sounds in all 4 quadrants
• abdomen is soft and non tender and non distended
• check for bladder distension (VERBALIZE)
• normal elimination pattern
• last BM
• passing gas per the rectum
• nausea, vomiting, constipation, diarrhea

Question 7

Anus

Answer 7

• rectal bleeding
• hemorrhoids

Question 8

Genitourinary

Answer 8

• urine color
• urine smell
• control starting and stopping
• burning
• diminished output
• excessive output
• urination at night
• inability to urinate
• increased frequency
• pain
• itching

Question 9

genitalia

Answer 9

• discharge
• swelling
• pain

Question 10

Peripheral vascular

Answer 10

• capillary refill
• radial
• doraslis pedis
• posterior tibial
• edema (VERBALIZE)

Question 11

motor strength

Answer 11

• strength with grips
• move all 4 extremities
• use feet against resistance
• able to walk? gait is steady?

Question 12

integumentary

Answer 12

• assess skin color VERBALIZE
• assess if warm and dry VERBALIZE
• free of lesions, wounds, bruises, abrasions, avulsions, rashes, and other abnormalities