NUR 1510/1520 General Physical Assessment Vocabulary

Vocabulary flashcards created from the Jamestown Community College NUR 1510/NUR 1520 General Physical Assessment evaluation checklist.

P (PQRST Pain Assessment)

Precipitating/palliative factors

Q (PQRST Pain Assessment)

Quality

R (PQRST Pain Assessment)

Radiation/Region

S (PQRST Pain Assessment)

Severity scale ($0\text{ to }10$, or other scale as appropriate)

T (PQRST Pain Assessment)

Timing/Duration

Client Identification Standard

Identifies client with at least $2\,\text{identifiers}$

Orientation Assessment

Assess orientation to time, place, situation

Heart Assessment

Apical pulse $\times 1\,\text{minute}$

Gastrointestinal Quadrant Auscultation

Auscultate all $4\,\text{quadrants}$ (begin in RLQ)

CSM

Circulation, sense of touch, capillary refill, movement

Lower Extremity Pulses

Dorsalis pedis pulse and Posterior tibial pulse

Upper Extremity Pulse

Radial pulse

Lung Assessment

Auscultate lungs bilaterally, anterior/posterior, all lobes; evaluate respiratory effort (free & easy, labored, any accessory muscle use, reg/irreg)

Skin Assessment Criteria

Temperature, Color, Intact, Skin turgor, Lesions, Edema

Head & Neck Assessment Criteria

Facial symmetry/Expression/Affect, PERRLA, ask about hearing aids or dentures, oral cavity, mobility

Genitourinary Assessment Criteria

Bladder distention and voiding assessment (continent/incontinent/normal pattern, Foley/Purewick, color/amount/odor if observed)

Gastrointestinal Assessment Criteria

Inspect abdomen, auscultate all $4\,\text{quadrants}$ (begin in RLQ), palpate, last BM & normal bowel pattern, presence of flatus

Conclusion Protocols

Provide for patient safety & comfort (call bell, bed in lowest position, bathroom), assess if the client has any questions, thank the client, hand hygiene

Bilateral Upper Extremities Assessment

Upper right strength, Upper left strength, Radial pulse, CSM (circulation, sense of touch, capillary refill, movement)

Bilateral Lower Extremities Assessment

Lower right strength, Lower left strength, Dorsalis pedis pulse, Posterior tibial pulse, CSM (circulation, sense of touch, capillary refill, movement)

Incisions, Drains, and Wounds Assessment

Appearance (any signs or symptoms of infection) and Dressings/IV's/drains/tubes