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21 Cards in this Set

  • Front
  • Back
What should you do for privacy before assessment?
Pull curtain
What should you ask pt before beginning assessment?
Does pt need to pee?
What do you tell pt before positioning him/her in bed?
I'm going to lay you flat in bed. Can you flex your knees?
What is the only exception for not putting pt flat in bed?
Pt is on O2 or has respiratory problems.
What position should you place O2 pts?
Low fowlers
What should you do BEFORE placing pt in low fowlers?
Invoke CDM and tell CE you don't want to comromise pt's respiratory function, so you will leave pt in low fowlers.
What should you ask pt after positioning flat in bed?
Is pt having pain, and where?
What can you do if pt is extremely fearful of touch around incision site?
Remind pt of importance of assessment to check if tender or rigid, but don't push it! You may invoke CDM and explain why.
BEFORE beginning assessment at all, what should you check on?
Has pt had pain med, or do I need to give it?
When looking at abdomen, what are you looking for?
Distention, contour, size, note incision, dressings, JP or other drains, colostomy/ostomy appliance, g-tube, etc.
What should you chart on?

Size, appearance, color, shape, and condition of skin
Before auscultating or palpating, what should you do?
Put on gloves if at risk of contact with body fluids.
When listening to abdomen, where do you listen?
Listen in all 4 quadrants with navel as intersecting point.
Sounds are hypoactive if ___, Active/Normal if ___, and hyperactive if ___.
1-5/min., 6-30/min., >30/min.
How long should you listen to each quadrant for?
1 minute
How deep should you palpate abdomen?
LIGHTLY 2-3cm in all 4 quadrants.
What if pt c/o pain?
Then invoke CDM and omit that region.
What should you tell pt BEFORE palpating?
Now I'm going to touch your stomach. Let me know if it feels tender when I touch.
What should you measure at the end of assessment?
Girth, but only if assigned.
Where will you measure girth?
Across the navel.
What type of pts should you be careful with when measuring girth?
Abdominal surgery pts, and pts with liver problems or ascites. Compare with baseline, and report to nurse STAT if sudden change.