HA Benchmark

Stages of Pressure Wound (Injury):

1. Stage 1: Non-blanchable redness of intact skin.

2. Stage 2: Partial-thickness skin loss with exposed dermis (blister or shallow open sore).

3. Stage 3: Full-thickness skin loss; may see fat but not bone, muscle, or tendon.

4. Stage 4: Full-thickness skin/tissue loss with exposed bone, tendon, or muscle.

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

6. Deep Tissue Injury: Persistent, non-blanchable deep red/maroon discoloration; skin may be intact or blistered.

Lung Crackle Location for Pneumonia:

• Crackles (rales) heard over the affected lobe (often in lower lobes).

• More likely to be unilateral and localized.

• Caused by fluid or exudate in alveoli.

Pitting Edema and Edema Stages:

• Press over bony area (e.g., shin or ankle), hold for 5 seconds.

• Grading scale:

  • +1: Slight (2 mm); immediate rebound

  • +2: Moderate (4 mm); few seconds to rebound

  • +3: Deep (6 mm); 10–20 sec rebound

  • +4: Very deep (8 mm); >30 sec rebound

Stroke Assessment (FAST + NIHSS):

• F: Face drooping

• A: Arm weakness

• S: Speech difficulty

• T: Time to call 911

• NIH Stroke Scale: Systematic tool assessing LOC, motor, sensory, language, vision, etc.

Dementia vs. Delirium Symptoms:

Heart Sounds (S1–S4):

• S1: "Lub" – closure of mitral/tricuspid valves; start of systole.

• S2: "Dub" – closure of aortic/pulmonic valves; end of systole.

• S3: Heard after S2 – "Kentucky" rhythm; sign of fluid overload (CHF).

• S4: Heard before S1 – "Tennessee" rhythm; sign of stiff ventricle (HTN, LVH).

How to Perform Self-Breast Exam (SBE):

1. Inspect in mirror: Arms at sides, then raised, then hands on hips.

2. Check for: Asymmetry, dimpling, nipple discharge or inversion.

3. Palpate in shower or lying down:

   • Use pads of 3 fingers.

   • Move in circular or up-and-down (vertical) pattern.

   • Include armpit area.

4. Do monthly after menstruation.

Pain Assessment:

• Subjective experience – always take patient’s report seriously.

• Use validated tools like numeric scale, Wong-Baker FACES, or verbal descriptor scale.

• Include duration, location, intensity, type, and effect on function.

SOCRATES (Pain Assessment Tool):

• S: Site – Where is the pain?

• O: Onset – When did it start?

• C: Character – What does it feel like? (sharp, dull)

• R: Radiation – Does it move anywhere?

• A: Associated symptoms – Nausea? Numbness?

• T: Timing – Constant or intermittent?

• E: Exacerbating/Relieving factors – What makes it better/worse?

• S: Severity – Rate pain 0–10

PQRST (Another Pain Assessment Tool):

• P: Provocation/Palliation – What causes it? What helps?

• Q: Quality – What does it feel like?

• R: Region/Radiation – Where is it? Does it spread?

• S: Severity – 0–10 scale

• T: Timing – When does it occur? How long?

Lung Percussion Sounds:

• Resonant: Normal lung

• Dull: Consolidation (e.g., pneumonia, tumor)

• Hyperresonant: Emphysema or pneumothorax

• Flat: Over bone or massive effusion

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

UTI Symptoms:

• Dysuria (pain/burning when urinating)

• Increased frequency and urgency

• Cloudy or foul-smelling urine

• Suprapubic pain

• Possible fever or flank pain (if progressed to pyelonephritis)

Chronic Rheumatoid Arthritis Symptoms:

• Symmetrical joint pain and swelling

• Morning stiffness >30 min

• Joint deformities (late stage)

• Fatigue, low-grade fever

• Rheumatoid nodules

• Common in hands, wrists, and feet

Petechiae on Mouth/Abdomen:

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

• Causes:

  • Thrombocytopenia

  • Infection/sepsis

  • Leukemia

  • Vitamin C deficiency (scurvy)

  • Monitor for signs of bleeding disorders

STIs and Their Genital Symptoms: