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