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12 Cards in this Set
- Front
- Back
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Assess
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Assess the overall appearance of the client:
Once over evaluation |
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Introduce
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Introduce self
Explain procedure Any questions? Provide Privacy |
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Obtain
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Obtain baseline measurements
Ht, Wt, Temp, HR, rythm, Volume, resp. rate and rythm BP, bilaterally |
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Inspect
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Inspect skin color
Nail beds (ring finger) for capillary refill Turgor (under clavical) Edema (on legs) Temperature (w/back of hands) and moisture |
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Palpate
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Palpate: Find the PMI (point of maximum intensity) state how wide the area is.
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Palpate
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feel for thrills, lifts and heaves
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Palpate
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palpate body pulses
:temporal :carotid Use bell and listen over carotids |
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Palpate
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Palpate brachial, radial, ulnar, femoral, popliteal, dorsalis pedis and posterior tibial.
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Identify
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Identify the 5 cardiac areas (give landmarks)
Aortic (2 ICS Pulmonic (2 ICS Erbs Point (3 ICS Tricuspid (4 ICS Mitral (5 ICS Listen w/diaphragm and then bell |
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Listen
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With each ausculatory site say:
Di I hear S1 and S2 |
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Describe
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Describe S3 and S4
(S3 right after S2 - kentucky) (S4 right before S1 - Tenn.) |
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State
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State which murmurs would be reported to primary care provider immediately (continuous or diastole murmurs)
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