NR 509 Week 4 Shadow Health Chest Pain Physical Assessment(COMPLETE)

Appearance (1/1 point) • No visible abnormal findings • Rash or lesion • Cyanosis • Pallor • Redness or flushing • Evidence of trauma (scar, laceration, or bruising) Inspected for jugular venous distension 1 of 1 point Height Of Venous Pressure (1/1 point) • 4 cm or less above the sternal angle • More than 4 cm above the sternal angle Inspected chest 1 of 1 point Symmetry (1/2 point) • Symmetric • Asymmetric Appearance (1/2 point) • No visible abnormal findings • Rash or lesion • AP diameter abnormal • Intercostal retraction while breathing • Excessive use of accessory muscles while breathing • Pectus excavatum • Skin growths (freckles or moles) • Evidence of skin trauma (scar, laceration, or bruising) Inspected hands and fingernails 1 of 1 point Right: Appearance (1/4 point) • No visible abnormal findings • Redness • Moles or skin tags • Masses (warts, cysts, or tumors) • Freckles, birthmark, or other discoloration • Excessive dry or flaking skin • Purpura • Scarring • Laceration, lesion, or wound • Bruising • Rash Left: Appearance (1/4 point) • No visible abnormal findings • Redness • Moles or skin tags • Masses (warts, cysts, or tumors) • Freckles, birthmark, or other discoloration • Excessive dry or flaking skin • Purpura • Scarring • Laceration, lesion, or wound • Bruising • Rash Right: Nail Changes (1/4 point) • No visible abnormal findings • Pallor • Cyanosis • Splinter hemorrhages • Clubbing Left: Nail Changes (1/4 point) • No visible abnormal findings • Pallor • Cyanosis • Splinter hemorrhages • Clubbing Inspected lower extremities and toenails 1 of 1 point Right: Appearance (1/4 point) • No visible abnormal findings • Visible distortion or swelling • Brownish pigmentation • Skin thickening • Ulceration • Varicose veins Right: Nail Changes (1/4 point) • No visible abnormal findings • Pallor • Cyanosis • Splinter hemorrhages • Clubbing Left: Appearance (1/4 point) • No visible abnormal findings • Visible distortion or swelling • Brownish pigmentation • Skin thickening • Ulceration • Varicose veins Left: Nail Changes (1/4 point) • No visible abnormal findings • Pallor • Cyanosis • Splinter hemorrhages • Clubbing Inspect lower extremities for edema 1 of 1 point Right: Edema (1/4 point) • No edema • Pitting • Non-pitting Right: Severity Of Edema (1/4 point) • No edema • 1+ Slight pitting • 2+ Deeper pit, disappears in 10 to 15 seconds • 3+ Noticeably deep pit that lasts more than a minute • 4+ Very deep pit that lasts 2 to 5 minutes Left: Edema (1/4 point) • No edema • Pitting • Non-pitting Left: Severity Of Edema (1/4 point) • No edema • 1+ Slight pitting • 2+ Deeper pit, disappears in 10 to 15 seconds • 3+ Noticeably deep pit that lasts more than a minute • 4+ Very deep pit that lasts 2 to 5 minutes Tested capillary refill time 1 of 1 point Fingers (1/2 point) • Less than 3 seconds • Greater than 3 seconds Toes (1/2 point) • Less than 3 seconds • Greater than 3 seconds Palpated carotid arteries 1 of 1 point Right: Vibration (1/4 point) • No thrill • Thrill Right: Amplitude (1/4 point) • 0 Absent • 1+ Diminished or barely palpable • 2+ Expected • 3+ Increased • 4+ Bounding pulse Left: Vibration (1/4 point) • No thrill • Thrill Left: Amplitude (1/4 point) • 0 Absent • 1+ Diminished or barely palpable • 2+ Expected • 3+ Increased • 4+ Bounding pulse Palpated PMI 1 of 1 point Location (1/3 point) • Present at midclavicular line and 5th intercostal space • Displaced laterally Diameter (1/3 point) • Less than 3 cm • Greater than 3 cm Amplitude (1/3 point) • Brisk and tapping • Increased amplitude (hyperkinetic) Palpated brachial arteries 1 of 1 point Right: Vibration (1/4 point) • No thrill • Thrill Right: Amplitude (1/4 point) • 0 Absent • 1+ Diminished or barely palpable • 2+ Expected • 3+ Increased • 4+ Bounding pulse Left: Vibration (1/4 point) • No thrill • Thrill Left: Amplitude (1/4 point) • 0 Absent • 1+ Diminished or barely palpable • 2+ Expected • 3+ Increased • 4+ Bounding pulse Palpated radial arteries 1 of 1 point Right: Vibration (1/4 point) • No thrill • Thrill Right: Amplitude (1/4 point) • 0 Absent • 1+ Diminished or barely palpable • 2+ Expected • 3+ Increased • 4+ Bounding pulse