focused assessment One body system Tenting A sign of dehydrstion rebound tenderness pain is greater when you release pressure STOP. Don't palpate Abd Bruit dysrhthmia irregular heart beat mitral where to listen for the apical pulse Aortic Listen to right 2nd intercostal space Cap refill Helps to assess adequate circulation Rhonchi Sounds like blowing air through milk with a straw Cyanosis Bluish discoloration (from decreased O2 levels) crackles Sounds like cellophane or dry hair Grips/ Resistance Should be equal and strong Petechiae Purple/red spots on skin caused by small hemorrhages Hypoxemia Decreased O2 in arterial blood sinus bradycardia Regular rhythm but HR <60 bpm 1/2 inch Light palpation Jaundice Yellowing of the skin due to increased bilirubin PERRLA pupils equal round reactive to light and accommodation melanomas asymmetrical, irregular borders, blue/black in color, greater 6 mm diameter bowel sounds should listen for these in each quadrant for 5 mind prior to documenting absent. tender areas Palpate this last Pulses rated 0-3+. Use doppler if you can't find one Neg. Babinski toes curl inward sinus tachycardia Regular rhythm but HR >100 bpm Look listen feel proper abd assessment sequence JVD Can be a sign of Fluid overload Ecchymosis Bruising pleural friction rub Metal on metal, grating wheezes musical sounds focused assessment One body system Tenting A sign of dehydrstion rebound tenderness pain is greater when you release pressure STOP. Don't palpate Abd Bruit dysrhthmia irregular heart beat mitral where to listen for the apical pulse Aortic Listen to right 2nd intercostal space Cap refill Helps to assess adequate circulation Rhonchi Sounds like blowing air through milk with a straw Cyanosis Bluish discoloration (from decreased O2 levels) crackles Sounds like cellophane or dry hair Grips/ Resistance Should be equal and strong Petechiae Purple/red spots on skin caused by small hemorrhages Hypoxemia Decreased O2 in arterial blood sinus bradycardia Regular rhythm but HR <60 bpm 1/2 inch Light palpation Jaundice Yellowing of the skin due to increased bilirubin PERRLA pupils equal round reactive to light and accommodation melanomas asymmetrical, irregular borders, blue/black in color, greater 6 mm diameter bowel sounds should listen for these in each quadrant for 5 mind prior to documenting absent. tender areas Palpate this last Pulses rated 0-3+. Use doppler if you can't find one Neg. Babinski toes curl inward sinus tachycardia Regular rhythm but HR >100 bpm Look listen feel proper abd assessment sequence JVD Can be a sign of Fluid overload Ecchymosis Bruising pleural friction rub Metal on metal, grating wheezes musical sounds
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One body system
A sign of dehydrstion
pain is greater when you release pressure
Abd Bruit
irregular heart beat
where to listen for the apical pulse
Listen to right 2nd intercostal space
Helps to assess adequate circulation
Sounds like blowing air through milk with a straw
Bluish discoloration (from decreased O2 levels)
Sounds like cellophane or dry hair
Should be equal and strong
Purple/red spots on skin caused by small hemorrhages
Decreased O2 in arterial blood
Regular rhythm but HR <60 bpm
Light palpation
Yellowing of the skin due to increased bilirubin
pupils equal round reactive to light and accommodation
asymmetrical, irregular borders, blue/black in color, greater 6 mm diameter
should listen for these in each quadrant for 5 mind prior to documenting absent.
Palpate this last
rated 0-3+. Use doppler if you can't find one
toes curl inward
Regular rhythm but HR >100 bpm
proper abd assessment sequence
Can be a sign of Fluid overload
Bruising
Metal on metal, grating
musical sounds
