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NUR 114 & 115 > PRIORITY ASSESSMENT RUBRIC > Flashcards

PRIORITY ASSESSMENT RUBRIC Flashcards

1
Q

Introduction - REQUIRED CRITICAL ELEMENTS (8)
HIPPA ICE
HPP IIA EC

A

H.H / ppe / privacy / introd / id / allergies / educate / cover
1. Perform hand hygiene as needed throughout the assessment (includes beginning and end of assessment)
2. Put on appropriate PPE, if indicated
3. Provide privacy as needed
4. Introduce yourself to the client
5. Verify the client identification
6. Determine whether the client has allergies
7. Provide client education
8. Cover the parts of the client’s body that are not being examined.

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2
Q

General Survey – REQUIRED of all client scenarios (8)
MV COP PAM
CO PAMM VP

A

Mobility / vitals / consciousness / orientation / posture / pain / appearance / mood
1. Assess level of consciousness.
2. Determine level of orientation
3. Observe posture and position.
4. Assess overall appearance of the client
5. Determine level of the client’s mobility
6. Observe mood and affect.
7. Measure the client’s temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation level.
8. Ask the client if they are experiencing pain.

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3
Q
  1. Assess level of consciousness. WHAT ARE YOU LOOKING FOR?
A

Is the client responding appropriately to your greeting?

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4
Q
  1. Determine level of orientation WHAT ARE YOU LOOKING FOR?
A

(person, place and time)

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5
Q
  1. Observe posture and position. WHAT ARE YOU LOOKING FOR?
A

→ Is the client’s posture erect, leaning forward (tripod)?
→ Is the client able to change positions independently?

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6
Q
  1. Assess overall appearance of the client WHAT ARE YOU LOOKING FOR?
A

(hygiene, grooming, and dress). Is the client dressed appropriately? Odors?

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7
Q
  1. Determine level of the client’s mobility WHAT ARE YOU LOOKING FOR?
A

(gait, balance, full range of motion of extremities).

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8
Q
  1. Observe mood and affect.WHAT ARE YOU LOOKING FOR?
A

→ What mood does the client appear to be in: pleasant, anxious, depressed, hostile?

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9
Q
  1. Ask the client if they are experiencing pain. WHAT ARE YOU LOOKING FOR?
A

→ If in pain, describe character, location, and intensity (0-10).
→ When did the pain start?
→ Does anything make the pain better (think nonpharmacological)
→ If unable to rate pain, does client appear in pain or distress?

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10
Q

Skin Examination (5)

A
  1. Assess the client’s skin for color temperature, sensation.
  2. Pinch the client’s skin over the clavicle to check skin turgor.
  3. Check the client’s skin for wounds or lesions.
    → Note the size, shape, location, and color of any found.
    → Inspect for drainage or exudate.
    → Check for the presence of bruises, scratches, or cuts.
  4. Inspect for edema. If present, note severity.
  5. Inspect the nails on the feet and hands.
    → Note size, shape, color, and condition of the nail and nail beds.
    → Inspect for clubbing.
    → Check for capillary refill
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11
Q
  1. Assess the client’s skin for color - WHAT COLORS
A

(cyanosis, pallor, jaundice), temperature, sensation.

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12
Q
  1. Pinch the client’s skin over the clavicle to check FOR WHAT
A

skin turgor.

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13
Q
  1. Check the client’s skin for wounds or lesions. WHAT ARE YOU LOOKING FOR?
A

→ Note the size, shape, location, and color of any found.
→ Inspect for drainage or exudate.
→ Check for the presence of bruises, scratches, or cuts.

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14
Q
  1. Inspect for edema. WHAT ARE YOU LOOKING FOR?
A

If present, note severity. WHAT ARE THE RATINGS FOR EDEMA AND PITTING EDEMA (1-4 RIGHT) CONFIRM

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15
Q
  1. Inspect the nails on the feet and hands. WHAT ARE YOU LOOKING FOR?
A

→ Note size, shape, color, and condition of the nail and nail beds.
→ Inspect for clubbing.
→ Check for capillary refill

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16
Q

Neurological Assessment (15)

A
  1. Alert and oriented X 4
  2. Facial symmetry intact
  3. Pupils equal round ractive to light & accommodation
  4. Tongue midline
  5. Vocalization appropriate
  6. Upper extremities equal and strong bilaterally
  7. Lower extremities equal and strong bilaterally
  8. Gait, strength, or balance appropriate
  9. General weakness
  10. Dizziness
  11. Cognitive impairment
  12. Headache
  13. Eye pain
  14. Blurred vision
  15. Double vision
  16. Numbness, tingling/paresis, paralysis/tremors
  17. Seizure activity
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17
Q

Eye Examination (5)

A
  1. Note the distribution of eyebrows and eyelashes.
  2. Look for drooping of the client’s upper eyelids or sagging of the lower lids.
  3. Note the color of the sclera and defects or inflammation of the bulbar conjunctiva (thin layer of membrane that covers the sclera).
  4. Assess cranial nerves II and III by checking for PERRLA.
  5. Assess EOM (six cardinal fields of gaze).
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18
Q

Ears, Nose, and Throat Examination

A
  1. Inspect the client’s ears for shape, placement, and discharge.
  2. Check for tenderness by palpating the pinna and tragus of each ear and percussing over the mastoid process.
  3. Test the client’s hearing.
  4. Check ears for redness, open areas, or foreign objects.
  5. Palpate client’s frontal and maxillary sinuses.
    → Is there tenderness or inflammation?
  6. Check the client’s nose alignment.
  7. Use penlight to check the nasal mucosa for redness, pallor, swelling, or discharge. Note the quality of discharge.
  8. Check the patency of the nares.
    → Have the client occlude each nare one at a time and then sniff through the unoccluded nare.
  9. Assess the client’s lips – dry or moist?
  10. Assess client’s oral mucosa – are the gums inflamed or bleeding?
  11. Assess client’s teeth – missing teeth, dentures present?
  12. Check the client’s tongue, throat, and tonsils – note inflammation, ulcers, lesions, or white patches.
    4
  13. Numbness, tingling/paresis, paralysis/tremors
  14. Seizure activity
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19
Q
  1. Inspect the client’s ears WHAT ARE YOU LOOKING FOR?
A

for shape, placement, and discharge.

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20
Q
  1. Check for tenderness WHAT DO YOU DO
A

by palpating the pinna and tragus of each ear and percussing over the mastoid process.

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21
Q
  1. Test the client’s hearing. WHAT IS THE TEST?
A

→ Perform the whisper test by having the client place a finger on the tragus of one ear. Whisper a two-syllable word

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22
Q
  1. Check ears WHAT ARE YOU LOOKING FOR?
A

for redness, open areas, or foreign objects.

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23
Q
  1. Palpate client’s frontal and maxillary sinuses. WHAT ARE YOU LOOKING FOR?
A

→ Is there tenderness or inflammation?

24
Q
  1. Use penlight to check the nasal mucosa WHAT ARE YOU LOOKING FOR?
A

for redness, pallor, swelling, or discharge. Note the quality of discharge.

25
Q
  1. Check the patency of the nares. WHAT DO YOU DO?
A

→ Have the client occlude each nare one at a time and then sniff through the unoccluded nare.

26
Q
  1. Assess the client’s lips WHAT ARE YOU LOOKING FOR?
A

– dry or moist?

27
Q
  1. Assess client’s oral mucosa WHAT ARE YOU LOOKING FOR?
A

– are the gums inflamed or bleeding?

28
Q
  1. Assess client’s teeth WHAT ARE YOU LOOKING FOR?
A

– missing teeth, dentures present?

29
Q
  1. Check the client’s tongue, throat, and tonsils WHAT ARE YOU LOOKING FOR?
A

– note inflammation, ulcers, lesions, or white patches.

30
Q

Respiratory Assessment

A
  1. Respirations even and unlabored
  2. Bilateral lungs sounds clear, equal and undiminished
  3. Chest expansion symmetrical
  4. Trachea midline
  5. Nailbeds pink without signs of clubbing
  6. Oral mucosa membranes pink and moist
  7. Oxygen therapy
  8. Cough/Sputum
31
Q
  1. Respirations even and unlabored WHAT DO YOU DO?
A

?

32
Q
  1. Bilateral lungs sounds clear, equal and undiminished WHAT DO YOU DO?
A

?

33
Q
  1. Chest expansion symmetrical WHAT DO YOU DO?
A

?

34
Q
  1. Trachea midline WHAT DO YOU DO?
A

?

35
Q
  1. Nailbeds pink without signs of clubbing WHAT DO YOU DO?
A

?

36
Q
  1. Oral mucosa membranes pink and moist WHAT DO YOU DO? WHAT ARE YOU LOOKING FOR
A

?

37
Q
  1. Oxygen therapy WHAT ARE YOU LOOKING FOR
A

?

38
Q
  1. Cough/Sputum WHAT ARE YOU LOOKING FOR
A

?

39
Q

Cardiovascular Assessment (9)

A
  1. Pulse regular
  2. Heart sounds normal (S1, S2)
  3. Palpate and auscultate carotid arteries for rhythm and rate.
  4. Using the bell of stethoscope, listen to the carotid arteries for bruits.
  5. Test for jugular vein distention.
  6. Auscultate over 5 cardiac landmarks:
  7. Auscultate over apex for 1 minute.
  8. Assess and grade the following pulse sites:
  9. Assess BP and MAP.
40
Q
  1. Heart sounds normal. WHAT ARE YOU LOOKING FOR?
A

(S1, S2)

41
Q
  1. Auscultate over 5 cardiac landmarks: WHAT AND WHERE ARE THEY
A

→ Aortic area
→ Pulmonic area
→ Erb point
→ Tricuspid area
→ Mital (apex)

42
Q
  1. Auscultate over apex for 1 minute. WHAT ARE YOU LOOKING FOR
A

→ Is the client’s heart rate regular in rhythm?

43
Q
  1. Assess and grade the following pulse sites: WHAT ARE THE PULSE SITES (6)
A

→ Radial
→ Brachial
→ Femoral
→ Popliteal
→ Posterior Tibial
→ Dorsalis Pedia

44
Q
  1. Assess BP and MAP. WHAT IS THE FORMULA FOR MAP
A

BOTTOM # (DIASTOLE) TIMES 2 PLUS TOP NUMBER (SYSTOLE), THEN DIVIDE BY 3

45
Q

Gastrointestinal Assessment (6)

A
  1. Ausculatate bowel sounds in all 4 quadrants. Describe what you hear.
  2. Palpate all 4 abdominal quadrants. Tender or firm?
  3. Ask the client about their bowel pattern.
  4. Flatus?
  5. Nausea/Vomiting/Dry heaving?
  6. Tubes? Drains?
46
Q
  1. Ausculatate bowel sounds in all 4 quadrants. WHAT DO YOU DO? WHAT ARE YOU LISTENING FOR?
A

Describe what you hear.

47
Q
  1. Palpate all 4 abdominal quadrants. WHAT ARE YOU LOOKING FOR
A

Tender or firm?

48
Q
  1. Ask the client about their bowel pattern. WHAT ARE YOU LOOKING FOR
A

→ Note frequency, character of stools, and recent changes.

49
Q

Musculoskeletal Examiniation (5)

A
  1. Inspect overall appearance and movement.
  2. Observe the client’s gait and balance
  3. Test muscle strength of all limbs.
  4. Test the range of motion of all limbs.
  5. Inspect hair distribution on legs.
50
Q
  1. Observe the client’s gait and balance WHAT ARE YOU LOOKING FOR
A

(tandem, tiptoe, heels).

51
Q
  1. Test muscle strength of all limbs. WHAT DO YOU DO
A

?

52
Q
  1. Test the range of motion of all limbs. WHAT ARE YOU LOOKING FOR
A

→ Does the client experience pain with any movement?

53
Q
  1. Inspect hair distribution on legs. WHY IS THIS IMPORTANT?
A

COULD SHOW CARDIOVASUCLAR DISEASE / ISSUES

54
Q

Female Genitalia (2)

A
  1. Inspect pubic hair.
  2. Inspect vagina.
55
Q

Male Genitalia (2)

A
  1. Inspect penis/scrotum.
  2. Inspect for bulges in inguinal and femoral areas.
56
Q
  1. Inspect for bulges in inguinal and femoral areas. WHERE ARE THESE AREAS
A

?

NUR 114 & 115 (5 decks)

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