Practicum Flashcards
Order of Assessment
- Prep
- ID
- Vitals
- General (Mental Status, Appearance, Behavior, Skin)
- Respiratory
- Cardiovascular (Heart, Neck, Peripherals)
- Abdomen
- Close Encounter
Prep
- Intro
- Hand Hygiene
- Provide Privacy
ID
- Name
- DOB
- Allergies
Vitals
- BP 120/80
- HR 60-100
- RR 12-20
- Temp 96.8-100.4
- O2 Sat </= 95 %
- Pain Level 0-10
Mental Status
- LOC - Alertness
- Orientation - Person, Place, Time, Orientation
Appearance
- Overall appearance (Acute distress?)
- Age/Gender
- Posture
- Emotional State
- Face - Expression, Symmetry
- Weight distribution
- Medical devices
Behavior
- Speech
- Thought Process
- Mood and Affect
- Mobility - gait
- Dress, Hygiene, Grooming
Skin
- Color
- Skin integrity
- Temperature and moisture
Respiratory
Insepct
* Respirations at rest - chest symmetry, accessory muscles…
* Chest configuration - AP to transverse ratio
* Skin of thorax
Palpate (Posterior)
* Skin - Temperature, moisture
* Symmetric Expansion
Percuss (Posterior)
* Lung Fields
* Costovertebral angle
Auscultate
* Posterior lung fields
* Anterior lung fields
percussion sounds:
CV Neck
Inspect
* Right External Jugular Vein
Palpate
* Carotid Arteries
Auscultate
* Carotid arteries
CV Precordium
Inspect
* Skin
* Pulsations
Auscultate
* 4 Valve areas
* S1, S2, S3/S4? (extra heart sounds
CV Arms
- Skin
- Size - symmetry/edema
- Nail Bed
- Cap Refill
- Turgor
- Pulses
CV Legs
- Skin (norms + venous pattern, hair distribution)
- Size - symmetry/edema
- Cap Refill
- Pulses
Abdomen
Inspect
* Skin
* Contour and symmetry
* Umbilicus
* Aoritc pulsations
Auscultate
* Bowel sounds
* Aoritc Bruit
Palpate
* Percussion
* Light/Deep Palpation (muscle guarding, rigidity, tenderness, masses)
palpation sounds: tympany
Close Encounter
- Thank Patient
- Anything else?
- Bed in low position
- brakes/fall light is on
- Call light within reach
- Hand hygiene out
