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