Nursing Tips
Health Assessment (18)
Palpating the Carotid Pulse
When palpating the carotid pulse, be sure to only do one side at a time to avoid restricting blood flow to the brain!
Palpating the Carotid Pulse
When palpating the carotid pulse, be sure to only do one side at a time to avoid restricting blood flow to the brain!
Quality of Pain
The "quality" of a patient's pain refers to the words the patient uses to describe it. Examples would be "dull," "aching," "throbbing," "burning," etc.
Quality of Pain
The "quality" of a patient's pain refers to the words the patient uses to describe it. Examples would be "dull," "aching," "throbbing," "burning," etc.
Nociceptive and Neuropathic Pain
Nociceptive pain is caused by tissue damage or inflammation. Neuropathic pain is caused by nerve damage.
Nociceptive and Neuropathic Pain
Nociceptive pain is caused by tissue damage or inflammation. Neuropathic pain is caused by nerve damage.
Taking Blood Pressure
Blood pressure may be taken in either arm except when the patient has an IV infusion running, or has had a mastectomy, PICC line, or AV fistula.
Taking Blood Pressure
Blood pressure may be taken in either arm except when the patient has an IV infusion running, or has had a mastectomy, PICC line, or AV fistula.
Cranial Nerve Assessment: III, IV, and VI
Cranial Nerve III (Oculomotor), IV (Trochlear), and VI (Abducens) can be assessed using the corneal light reflex, the cover test, and/or the six cardinal positions of gaze.
Cranial Nerve Assessment: III, IV, and VI
Cranial Nerve III (Oculomotor), IV (Trochlear), and VI (Abducens) can be assessed using the corneal light reflex, the cover test, and/or the six cardinal positions of gaze.
Edema Scoring
Edema is documented by the depth of the indentation left by pressing a finger over the edematous area. A score of 0 means there is no pitting edema.
Edema Scoring
Edema is documented by the depth of the indentation left by pressing a finger over the edematous area. A score of 0 means there is no pitting edema.
Cranial Nerve VIII Function Assessment
Cranial Nerve VIII (Vestibulocochlear/Acoustic) function can be assessed with the whisper test, Rinne test, and/or Weber test.
Cranial Nerve VIII Function Assessment
Cranial Nerve VIII (Vestibulocochlear/Acoustic) function can be assessed with the whisper test, Rinne test, and/or Weber test.
Lordosis, Kyphosis, and Scoliosis
Lordosis (excessive curvature of the lumbar spine) is a common finding in pregnancy and in toddlers. Kyphosis (excessive curvature of the thoracic spine) is a common finding in the older...
Lordosis, Kyphosis, and Scoliosis
Lordosis (excessive curvature of the lumbar spine) is a common finding in pregnancy and in toddlers. Kyphosis (excessive curvature of the thoracic spine) is a common finding in the older...
Cranial Nerve I (Olfactory) Assessment
Cranial Nerve I (Olfactory) can be assessed by asking the patient to identify a scent (e.g., soap, coffee) while occluding one nostril at a time.
Cranial Nerve I (Olfactory) Assessment
Cranial Nerve I (Olfactory) can be assessed by asking the patient to identify a scent (e.g., soap, coffee) while occluding one nostril at a time.
Assessing Bowel Sounds
Bowel sounds cannot be called "absent" until the nurse has listened for five minutes without hearing bowel activity.
Assessing Bowel Sounds
Bowel sounds cannot be called "absent" until the nurse has listened for five minutes without hearing bowel activity.
Patient Identifiers
All assessments should involve identifying the patient with two patient identifiers (e.g., name, DOB, MRN#). Remember: room number is NOT a valid patient identifier!
Patient Identifiers
All assessments should involve identifying the patient with two patient identifiers (e.g., name, DOB, MRN#). Remember: room number is NOT a valid patient identifier!
Assessing Skin Turgor
Assessing skin turgor should be done by gently pinching/lifting the skin on the sternum. If the skin "tents," (i.e., stays lifted for a prolonged period and doesn't quickly return to...
Assessing Skin Turgor
Assessing skin turgor should be done by gently pinching/lifting the skin on the sternum. If the skin "tents," (i.e., stays lifted for a prolonged period and doesn't quickly return to...
Eye and Ear Assessment
When assessing the eyes, the sclera should be white. The tympanic membrane of the ears, however, should be pearly gray.
Eye and Ear Assessment
When assessing the eyes, the sclera should be white. The tympanic membrane of the ears, however, should be pearly gray.
Assessing Hypoglossal Nerve Function
Asking the patient to stick out their tongue and move it side to side is an effective way to assess the function of Cranial Nerve XII (Hypoglossal).
Assessing Hypoglossal Nerve Function
Asking the patient to stick out their tongue and move it side to side is an effective way to assess the function of Cranial Nerve XII (Hypoglossal).
Assessing for Accommodation
When assessing for "Accommodation," ask the patient to focus their eyes on a distant object, then to a near object. The pupils should constrict when focusing on the near object!
Assessing for Accommodation
When assessing for "Accommodation," ask the patient to focus their eyes on a distant object, then to a near object. The pupils should constrict when focusing on the near object!
Breath Sounds: Vesicular and Adventitious
"Vesicular" breath sounds are a normal finding upon auscultation (i.e., the sound air makes flowing in and out of lungs). "Adventitious" breath sounds are always abnormal!
Breath Sounds: Vesicular and Adventitious
"Vesicular" breath sounds are a normal finding upon auscultation (i.e., the sound air makes flowing in and out of lungs). "Adventitious" breath sounds are always abnormal!
Orthostatic Hypotension
A patient is POSITIVE for orthostatic hypotension if: The SBP decreases more than 20mmHg when changing position AND/OR the DBP decreases more than 10mmHg
Orthostatic Hypotension
A patient is POSITIVE for orthostatic hypotension if: The SBP decreases more than 20mmHg when changing position AND/OR the DBP decreases more than 10mmHg
Physical Assessment Order
Order of physical assessment: Inspect, palpate, percuss, auscultate. EXCEPT for assessing the abdomen: Inspect, auscultate, percuss, palpate (to avoid altering bowel sounds).
Physical Assessment Order
Order of physical assessment: Inspect, palpate, percuss, auscultate. EXCEPT for assessing the abdomen: Inspect, auscultate, percuss, palpate (to avoid altering bowel sounds).
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