🔹Physical assessment components Flashcards
1
Q
Pain assessment PQRST (subjective)
A
- P roactive/ palliative factors. What works to relieve pain?
- Quality-
- Region/ radiation? (Location)
- Severity? (intensity 1-10 scale)
- Timing ? (onset, frequency, duration)
- How is pain affecting you?
2
Q
Pain (objective)
A
- nonverbal (facial grimacing, guarding)
- nonverbal pain scale
3
Q
Neuro assessment Subjective
A
- alert and oriented to person, place, time?
- swallowing liquids or solids (w/out coughing or choking?)
- memory intact (3 words)
4
Q
Neuro assessment objective
A
- behavior appropriate to situation
- thought process coherent (logical & organized)
- verbalization clear and understandable
- able to hear the spoken word
- pupils equal, round, react briskly to light PERRL
- hand grasps strong and equal
5
Q
Cardio subjective
A
- chest discomfort?
- calf tenderness?
6
Q
cardio objective
A
- apical pulse regular
- S1 and S2 present (name and locate each heart area)
- neck veins flat at 45 deg
- Capillary refill time < 3 seconds all extremities
- peripheral pulses strong , equal, palpable
- no edema
7
Q
respiratory subjective
A
- SOB?
- Sputum COCA
8
Q
respiratory objective
A
- cough strong, dry, non-productive
- respirations are regular, even and unlabored
- lungs clear ( no adventitious sounds) in all lobes bilaterally, anterior & posterior
- nail beds and mucous membranes PINK
9
Q
Gastrointestinal subjective
A
- passing gas?
- tolerates prescribed diet w/out N&V?
- BMs within own normal pattern and consistency…..X day
- last BM ? COCA
- pain?
10
Q
Gastrointestinal objective
A
- oral cavity and teeth healthy
- abdomen flat with no distention ( supine)
- bowel sounds (5-34/min)
- abdomen soft, non-tender with palpation
11
Q
Urinary subjective
A
- continent of urine?
- able to empty bladder w/out: dysuria, urgency, frequency, nocturia
- urine COCA
12
Q
Urinary objective
A
Bladder not distended after voiding
13
Q
Integumentary subjective
A
- skin lesions, bruises, or rashes
14
Q
Integumentary objective
A
- skin color? - pink or normal for individual
- skin warm, dry and intact
- no rashes, bruises , ulcerations
- mucous membranes moist
- hair supple & intact
- nail surface smooth, intact w/out clubbing
- skin turgor < 3 sec
15
Q
Musculoskeletal subjective
A
- painful joints
- painful muscles
- tremors
- tolerates activity