HA Benchmark

Stage 1 Pressure Wound

Non-blanchable redness of intact skin.

Stage 2 Pressure Wound

Partial-thickness skin loss with exposed dermis (blister or shallow open sore).

Stage 3 Pressure Wound

Full-thickness skin loss; may see fat but not bone, muscle, or tendon.

Stage 4 Pressure Wound

Full-thickness skin/tissue loss with exposed bone, tendon, or muscle.

Unstageable Pressure Wound

Covered by slough or eschar, so depth can't be determined.

Deep Tissue Injury

Persistent, non-blanchable deep red/maroon discoloration; skin may be intact or blistered.

Lung Crackles Location for Pneumonia

Heard over the affected lobe, often in lower lobes, typically unilateral and localized.

What causes Lung Crackles in Pneumonia?

Fluid or exudate in alveoli.

Pitting Edema +1 scale

Slight (2 mm); immediate rebound.

Pitting Edema +2 scale

Moderate (4 mm); few seconds to rebound.

Pitting Edema +3 scale

Deep (6 mm); 10–20 seconds rebound.

Pitting Edema +4 scale

Very deep (8 mm); greater than 30 seconds rebound.

Stroke Assessment - FAST

F: Face drooping, A: Arm weakness, S: Speech difficulty, T: Time to call 911.

NIH Stroke Scale

Systematic tool assessing Level of Consciousness, motor, sensory, language, vision, etc.

Delirium Onset

Sudden, acute.

Dementia Onset

Gradual, chronic.

Delirium Duration

Hours to days.

Dementia Duration

Months to years.

Attention in Delirium

Impaired.

Attention in Dementia

Usually normal until late stage.

Is Delirium reversible?

Often reversible if the cause is treated.

Is Dementia reversible?

Not reversible.

Common symptom in Delirium

Hallucinations.

Less common symptom in Dementia

Hallucinations.

Cause of Delirium

Underlying illness, medications, infection.

Cause of Dementia

Alzheimer’s, vascular disease, etc.

Heart Sound S1

'Lub' – closure of mitral/tricuspid valves; start of systole.

Heart Sound S2

'Dub' – closure of aortic/pulmonic valves; end of systole.

Heart Sound S3

Heard after S2 – 'Kentucky' rhythm; sign of fluid overload (CHF).

Heart Sound S4

Heard before S1 – 'Tennessee' rhythm; sign of stiff ventricle (HTN, LVH).

Self-Breast Exam first step

Inspect in a mirror with arms at sides, then raised, and hands on hips.

Key factors to check during SBE

Asymmetry, dimpling, nipple discharge or inversion.

Self-Breast Exam palpation technique

Use pads of 3 fingers, moving in circular or up-and-down pattern.

When should SBE be performed?

Monthly after menstruation.

Pain Assessment significance

Subjective experience; always take patient’s report seriously.

Validated tools for Pain Assessment

Numeric scale, Wong-Baker FACES, verbal descriptor scale.

SOCRATES - Site

Where is the pain?

SOCRATES - Onset

When did it start?

SOCRATES - Character

What does it feel like? (sharp, dull)

SOCRATES - Radiation

Does it move anywhere?

SOCRATES - Associated symptoms

Nausea? Numbness?

SOCRATES - Timing

Constant or intermittent?

SOCRATES - Exacerbating/Relieving factors

What makes it better or worse?

SOCRATES - Severity

Rate pain 0–10.

PQRST - Provocation/Palliation

What causes it? What helps?

PQRST - Quality

What does it feel like?

PQRST - Region/Radiation

Where is it? Does it spread?

PQRST - Severity

0–10 scale.

PQRST - Timing

When does it occur? How long?

Lung Percussion Sound: Resonant

Normal lung.

Lung Percussion Sound: Dull

Consolidation (e.g., pneumonia, tumor).

Lung Percussion Sound: Hyperresonant

Emphysema or pneumothorax.

Lung Percussion Sound: Flat

Over bone or massive effusion.

Lung Percussion Sound: Tympanic

Over air-filled space (e.g., stomach or large pneumothorax).

UTI Symptoms

Dysuria, increased frequency and urgency, cloudy or foul-smelling urine, suprapubic pain.

Chronic Rheumatoid Arthritis key symptoms

Symmetrical joint pain and swelling, morning stiffness >30 min.

Petechiae

Small, pinpoint red/purple spots from capillary bleeding under skin.

Causes of Petechiae

Thrombocytopenia, infection/sepsis, leukemia, Vitamin C deficiency.

Chlamydia symptoms

Often asymptomatic; discharge, dysuria, pelvic pain.

Gonorrhea symptoms

Purulent discharge, burning urination, possible pelvic/testicular pain.

Syphilis symptom

Painless sore (chancre), rash on palms/soles, systemic effects later.

Herpes (HSV-2) symptoms

Painful vesicles/ulcers, itching, burning.

HPV (genital warts) appearance

Flesh-colored, cauliflower-like growths.

Trichomoniasis symptoms

Frothy green/yellow discharge, foul odor, itching.

HIV/AIDS systemic symptoms

Fever, weight loss, genital ulcers possible.