🔹Physical assessment components Flashcards

1
Q

Pain assessment PQRST (subjective)

A
  1. P roactive/ palliative factors. What works to relieve pain?
  2. Quality-
  3. Region/ radiation? (Location)
  4. Severity? (intensity 1-10 scale)
  5. Timing ? (onset, frequency, duration)
  6. How is pain affecting you?
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2
Q

Pain (objective)

A
  • nonverbal (facial grimacing, guarding)

- nonverbal pain scale

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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)
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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
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5
Q

Cardio subjective

A
  • chest discomfort?

- calf tenderness?

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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
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7
Q

respiratory subjective

A
  • SOB?

- Sputum COCA

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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
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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?
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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
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11
Q

Urinary subjective

A
  • continent of urine?
  • able to empty bladder w/out: dysuria, urgency, frequency, nocturia
  • urine COCA
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12
Q

Urinary objective

A

Bladder not distended after voiding

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13
Q

Integumentary subjective

A
  • skin lesions, bruises, or rashes
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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
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15
Q

Musculoskeletal subjective

A
  • painful joints
  • painful muscles
  • tremors
  • tolerates activity
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16
Q

Musculoskeletal objective

A
  • active ROM of all extremities with symmetry of strength
  • major joints: flexion, extension, abduction, adduction
  • steady gait , upright posture
17
Q

Peripheral neurovascular assessment CMS subjective

A

Assess affected extremity:

  • pain
  • numbness
  • tingling
  • describe deficit if present
18
Q

Peripheral neurovascular assessment CMS objective

A
  • circulation intact :
    • pink
    • warm
    • pulse(s) present
    • no edema
    • cap refill <3 sec to affected areas
  • ROM with PTs
  • sensation present in extremity