NUR 120 - Exam 4
Full physical exam - answer Typically done by an MD, NP, or PA. a full evaluation on
every system in the body
head to toe assessment - answer done by the nurse at the bedside, an assessment that
looks at the basic information of a patients body
focused assessment - answer assessment conducted to assess a specific problem;
focuses on pertinent history and body regions
concepts of a head to toe assessment that are addressed simultaneously - answer1.
general survey
2. safety
3. psychosocial
4. tissue integrity
what are the components of a general survey? – answer IV access
tubing
use of O2
activity
appearance
orientation
level of consciousness
what are the components of safety? - answerrestraints
mobility
sensory deficits
wristbands
environment
tubing
anything out of the ordinary?
what are the components of psychosocial? - answermood and affect
stress/coping
pain
support system
religious beliefs
what are the components of tissue integrity? - answerintactness of skin
sores
braden scale
incisions
, bruises
dressings
what do we focus on when assessing the head? - answercognition - level of
consciousness
A+O
speech
what do we focus on when assessing intracranial regulation? - answerneuro status
changes in sensation
PERRLA
what do we focus on when assessing tissue perfusion? - answerassess carotid pulse
vital signs
color of mucous membranes
color
apical pulse
is S1-S2 present?
edema (pitting?)
pedal pulse
push/pull on feet: is it equal on both sides?
what do we focus on when assessing fluids and electrolyte balance? - answerare
mouth/eyes moist?
what do we focus on when assessing nutrition? - answerstate of dentition - dentures?
pain/discomfort when eating?
N/V?
what percentage of meal was eaten?
what is their appetite like?
BMI?
nutritional deficits?
Lab data:
albumin
NA
K
Mg
H+H
what do we focus on when assessing sensory perception and sensation? - answerany
hearing or visual deficits?
what do we focus on when assessing upper extremities? - answercapillary refill (<3 sec)
BP
Pulses (whether you can feel them or not)
Full physical exam - answer Typically done by an MD, NP, or PA. a full evaluation on
every system in the body
head to toe assessment - answer done by the nurse at the bedside, an assessment that
looks at the basic information of a patients body
focused assessment - answer assessment conducted to assess a specific problem;
focuses on pertinent history and body regions
concepts of a head to toe assessment that are addressed simultaneously - answer1.
general survey
2. safety
3. psychosocial
4. tissue integrity
what are the components of a general survey? – answer IV access
tubing
use of O2
activity
appearance
orientation
level of consciousness
what are the components of safety? - answerrestraints
mobility
sensory deficits
wristbands
environment
tubing
anything out of the ordinary?
what are the components of psychosocial? - answermood and affect
stress/coping
pain
support system
religious beliefs
what are the components of tissue integrity? - answerintactness of skin
sores
braden scale
incisions
, bruises
dressings
what do we focus on when assessing the head? - answercognition - level of
consciousness
A+O
speech
what do we focus on when assessing intracranial regulation? - answerneuro status
changes in sensation
PERRLA
what do we focus on when assessing tissue perfusion? - answerassess carotid pulse
vital signs
color of mucous membranes
color
apical pulse
is S1-S2 present?
edema (pitting?)
pedal pulse
push/pull on feet: is it equal on both sides?
what do we focus on when assessing fluids and electrolyte balance? - answerare
mouth/eyes moist?
what do we focus on when assessing nutrition? - answerstate of dentition - dentures?
pain/discomfort when eating?
N/V?
what percentage of meal was eaten?
what is their appetite like?
BMI?
nutritional deficits?
Lab data:
albumin
NA
K
Mg
H+H
what do we focus on when assessing sensory perception and sensation? - answerany
hearing or visual deficits?
what do we focus on when assessing upper extremities? - answercapillary refill (<3 sec)
BP
Pulses (whether you can feel them or not)
