Lab final exam

What to check for neuro assessment

PERRLA

A&O

UE strength

LE strength

Tongue, mouth, ears, nose

Neuro assessment questions

Any dizziness?

Any headaches?

Any weakness?

Do you have any numbness or tingling?

Have you noticed any changes in the way you walk?

Do you use any assistive devices?

Where are we?, Who did you bring with you today?

Any falls?

Do you feel safe at home?

Can you do daily tasks at home such as doing laundry or cooking?

What to check for GI assessment

Inspection, Auscultation x4, Light palpation x4

GI assessment questions

When was your last BM? 

What was the consistency and color?

Do you pass gas?

Any nausea or vomiting? 

Any blood in stool?

Pain (PQRSTU)

What to check for cardiac assessment

Auscultate heart sounds, Aortic 2nd ICS right side, Pulmonic 2nd ICS left side, Second Pulmonic 3rd ICS, Tricuspid 4th ICS, Apical 5th ICS

Capillary refill

Edema on leg

Distal pulse sites for equality, pedal pulses and radial pulses

Cardiac assessment questions

CHF: Any chest pain?

Any SOB?

Any swelling in hands or feet?

Any left arm pain?

Pain (PQRSTU)

What to check for resp assessment

8 sites on front

10 sites on back

Capillary refill

Resp assessment questions

Any SOB?

Any unusual coughing?

Do you smoke?

Do you use oxygen?

Do you have mucus when you cough? If so, what is the color and consistency?

Any falls?

What to check for GU assessment

Inspect, palpate

Bladder scan (retention)

GU assessment questions

When was the last time you peed?

Where is the pain located?

Do you have any lower back pain?

Do you feel a burning sensation when you pee?

What color is your urine? Is there an unusual odor?

Any falls?

PQRSTU

Provokes- What were you doing when the pain started, and what makes it better or worse?

Quality- How would you describe the pain?

Region/radiates- Where is the pain located, and does it spread anywhere else?

Severity- On a scale of 0-10, how would you rate it

Timing- When did it begin, and is it constant or does it come and go?

Understanding- How does the pain affect your ability to perform daily activities or your overall well-being?