Inspection - Answers Findings and observations; watching the patient
Ex. Skin color is consistent with pink undertones and no lesions or incisions
Palpation - Answers Feeling or touching patient
- use dorsal (back of hand) for heat/temp.
- use tips or fingers for apical, checking for edema, checking lymph nodes
Ex. skin is warm, dry and smooth
Percussion - Answers Short, sharp taps
Checking density of underlying organs
Ex. tympany noted in all 4 quadrants of the abdomen
auscultation - Answers listening with stethoscope
listen side to side (left to right)
Ex. Lung sounds clear in all lung fields
Assessment safety - Answers - bed in lowest position when not with patient
- call light by patient
- bed locked
- bed alarm if needed
- yellow band is fall risk
When to wash hands? - Answers All the time
-before and after entering and leaving patients room
, - before and after gloves
- when hands soild
-ect.
General Survey
Physical Appearance - Answers appearance, color of the patient, LOC (alert, confused, sex, age
General Survey
Body Structure - Answers body alignment, stature, BMI, height and weight, waist circumference
General Survey
Mobility - Answers do they need assistive devices, gait (how you walk- smooth and steady or
with a limp)
General Survey
Behavior - Answers Facial expression (maintaining eye contact or appropriate for scenario),
mood and affect (mood- calm, pleasant, cooperative) (affect- benign), speech, dress (dressed
appropriately, personal hygiene
When patient is alert and oriented, what are the possible things a patient can be oriented to? -
Answers Person, place, time, situation
Lethargic - Answers tired but can be woken up verbally
stuporous - Answers painful stimuli, cannot be woken up verbally, woken up by sternal rub
Coma - Answers Unconscious and cannot be woken up, may need to be on a ventilator
Apical HR is counted for how long - Answers 1 minute
irregular respirations and pulses should be counted for how long - Answers 1 minute
Temperature normal ranges
-oral
-axillary
- rectal - Answers Temperature normal ranges
-oral -98.6
-axillary - one degree down