Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/20

Click to flip

20 Cards in this Set

  • Front
  • Back
KIWISPLS
8 items
a. Knock on door
b. Introduce self
c. Wash hands and put on gloves
d. Identify patient using 2 sources (ask name, ID band)
e. State your service
f. Provide privacy
g. Check locks on bed
h. Gather needed supplies
General Survey
5 items
a. Overall hygiene, grooming and appearance
b. Signs of distress – e.g. guarding, grimacing
c. Gait and posture – sitting, standing, walking
d. Obvious signs of health or illness – e.g. skin color, breathing pattern
e. Overall condition of skin – color, temperature, moistness, lesions
Assess mental status
5 items
a. Determine patient’s orientation to time, place and person
b. Note client’s affect and mood
c. Note appropriateness of verbal responses – relevance and organization of thoughts
d. Speech quality (amount and pace) and quantity (loudness, clarity and inflection)
e. Vital Signs – Temperature, pulse, respirations, blood pressure, pulse oximetry and pain level using 0 -10 scale
Head
2 items
a. Size and shape of skull
b. Symmetry of facial features and facial movements
Hair and scalp
6 items
a. Texture and oiliness
b. Thickness or thinness
c. Growth pattern over scalp
d. Infections, lesions or
e. Assess behind ears and along hairline at neck
f. Note presence and amount of body hair
Assess the Ears
4 items
a. Auricle for skin integrity, color, symmetry of size and position
b. External canal for cerumen, drainage, lesions
c. Response to normal voice tones – Whisper test, hearing aids
d. Have patient turn head to side to evaluate ROM
Assess the Face
3 items
a. Palpate temporal pulses
b. Palpate frontal and maxillary sinuses
c. Note edema or hollowness around the eyes
Assess the Eyes
5 items
a. Eyebrows movement and hair distribution
b. Eyelids – ability to blink
c. Conjunctive – color, discharge or lesions
d. Pupils – color, shape, symmetry, reaction to light, accommodation to distance
e. Six ocular movements to determine alignment and coordination
Assess the nose
6 items
a. Have patient put head back (checks ROM)
b. Inspect for deviations in shape, size and color
c. Flaring or discharge from nares
d. Patency of both nares
e. Inspect nasal cavities with penlight.
f. Inspect septum. Observe for redness, swelling, growths and discharge
Assess the Mouth
a. Inner and outer lips, gums and mucosa for color, moisture and lesions
b Note presence of dentures, bridges and own teeth.
c. Hard and soft palates for color, shape, texture and bony prominences
d. Tonsils for absence or presence.. Note color, size and any drainage
e. Tongue for moisture, lesions, position (midline)
Assess the Neck
4 items
a. Rotate head ear to shoulder (ROM)
b. Neck muscles for swelling or masses; enlarged lymph nodes
c. Palpate trachea for lateral deviation and enlarged thyroid gland
d. Assess carotid arteries one at a time
Assess the Thorax
2 items
a. Turgor
b. Symmetry from lateral and posterior views
Assess Breasts and Axillae
a. Teach client SBE technique (perform on mannequin, not patient)
b. Inspect breast size, contour, symmetry and shape
c. Inspect skin for localizes discoloration, dimpling, retraction or edema
d. Inspect nipples and areola for shape, symmetry, color surface characteristics, masses, discharge or lesions.
e. Palpate breast tissue for masses and tenderness
Assess the Heart
a. Auscultate heart in all 4 anatomic sites: aortic, pulmonic, tricuspid and mitral) APETME ( Also epigastric area. Erbs optional) )
b. State normal range of heartbeats is 60-100 beats per minute
c. State S1 heard over tricuspid and mitral; S2 heard over pulmonic and aortic
Assess the lungs
4 items
a. Breathing pattern (rate, rhythm, depth, effort) State normal respiratory rate 12-20 breaths per minute.
b. Auscultate posteriorly and anteriorly
c. Posteriorly inspect spinal alignment for deformities and lateral deviation
d. Have client take slow, deep breaths through their mouth. Listen at each point during inspiration and expiration. Note any adventitious sounds
Assess the Abdomen
9 items
a. Any dietary restriction; usual eating pattern
b. Last bowel movement (color, consistency, bleeding, pain) usual bowel habits
c. Inspect contour and symmetry
d. Auscultate for bowel sounds in all 4 quadrants
e. State listen for 4 minutes in each quadrant to determine absence of bowel sounds
f. Light palpation for tenderness and guarding if no complaints of pain
g. Ask about usual voiding pattern. Ask if any frequency, hesitancy, urgency, odor, unusual color.
h. Palpate bladder above symphysis pubis for distention
i. Assess femoral pulse
Asses Genital Area
a. Perineal area for odor, discharge, lesions
b. Note if indwelling catheter present
c. Females: Ask when was LMP. Males: ask if they perform self-testicular exams
d. Note any abnormalities of genitalia
Assess arms
a. Inspect nails noting shape, bed color, angle, any clubbing
b. Inspect surrounding tissue
c. Perform capillary refill (3 seconds or less)
d. Palpate brachial, radial and ulnar pulses bilaterally
e. Assess musculoskeletal system
1. compare muscle strength of one side to the other
2. note contractures or tremors
3. Inspect joints for swelling and tenderness, smoothness of movement, crepitus, and nodules
4. Demonstrate ROM on self (shoulders, elbow, wrist, fingers)
Assess Legs
a. Inspect nails noting shape, bed color, angle, any clubbing
b. Inspect surrounding tissue
c. Perform capillary refill (3 seconds or less)
d. Palpate pulses (popliteal, dorsalis pedis and posterior tibial)
e. Assess calves for pain, swelling, redness, tenderness (may do Homan’s sign if none present)
e. Assess musculoskeletal system
1. compare muscle strength of one side to the other
2. note contractures or tremors
3. Inspect joints for swelling and tenderness, smoothness of movement, crepitus, and nodules
4. Demonstrate ROM on self (hip, knee, ankle)
Turn patient on side and assess lower back and anus
a. Inspect anus and surrounding tissue for color, integrity and lesions
b. Note presence of edema –location, temperature, degree of pitting