| 1 Intro | Health History | Data gathered about the client's health history, health conditions and diseases, family health history, lifestyle risk appraisal and symptoms (subjective data). |
| 1 | General Suvey | Begins at first contact and is your overall impression of the client. Includes physical apprearance, gait,mental status among other assessments. |
| 1 | Subjective Data | Data gathered from the Health History. Includes what the client says/feels and communicates. |
| 1 | Inspection | An assessment technique that is a visual examination which is deliberate, purposeful and systematic. Not to be hurried. |
| 1 | Critical Thinking | The process of intentional and reflective judgment about a problem where the focus is on clinical decision-making to provide safe and effective care. Answers the question - What if? |
| 1 | CLEAR - Acronym | Holistic Communication Acronym, stands for C=Center yourself, L=Listen wholeheartedly, E= Empathize, A=Attention - Be fully present, R=Respect. |
| 1 | Standard Precautions | Applies to ALL patients. Think barriers. Wear gloves when touching any body fluids or when you anticipate you will be touching body fluids. Wear goggles/gown when ou anticipate splashing of fluids. |
| 2 CV/PV | S1 | The "lub" heart sound and is the start of systole when the mitral & tricuspid valves close |
| 2 | Erb's Point | Located at the left 3rd intercostal space; S1 & S2 are located here |
| 2 | Pulses | Carotid, brachial, radial, femoral, popliteal, dorsalis pedis, & posterior tibial are all types of these… normal findings are for these to be strong and equal bilaterally (Amplitude +2)… +3 Bounding, +1 Diminished; weak, 0 Absent, unable to palpate |
| 2 | S2 | The "dub" heart sound and is caused by the closure of the aortic & pulmonic valves marking the end of systole |
| 2 | Capillary Refill | Assessed by bilaterally & simultaneously using the thumb and forefinger to squeeze the fingernail or toenail until it blanches and release; normal finding for color to return is… less than 3 seconds |
| 2 | Bradycardia | Decreased heart rate, below 60 bpm. |
| 2 | Murmur | Turbulent blood flow with a swooshing or blowing sound when auscultating the heart |
| 3 Respiratory | Resonance | Which sounds is normal to hear when percussing a lung? |
| 3 | Hypercapnia | What is the primary stimulus for breathing? |
| 3 | Left | Which lung has 2 lobes? |
| 3 | Aveoli | Where does gas exchange take place? |
| 3 | Dyspnea | Shortness of breath is also called |
| 3 | Bradypnea | RR <10 breaths per minute |
| 3 | Brochial | This sound is best heard over the trachea and is harsh/high-pitched |
| 4 Skin | Pallor | Abnormal skin finding -- pale skin |
| 4 | Cyanosis | Bluish discoloration of the skin due to poor circulation, cold, or low oxygenated state. |
| 4 | Turgor | Refers to the elasticity of the skin. Genrally checked on sternum or under clavicle |
| 4 | ABCDE | Mole screening for possible melanoma |
| 4 | Braden Scale | Assessment tool to predict pressure sore risk. If any skin breakdown is noted based on the 6 risk factors. |
| 4 | Ecchymosis | Discoloration of the skin resulting from bruising or bleeding under the skin |
| 4 | Macule | Flat, brown, less than 1 cm, non-palpable lesion. Examples inlcude freckles, petechiae, birthmark, Mongolian spot |
| 5 Med Admin | STAT | An abbreviation for an order that is given immediately and only once. |
| 5 | HS | At bedtime |
| 5 | QID | Four times a day |
| 5 | Standing order | Another name for an order that is a protocols |
| 5 | PC | After meals |
| 5 | Enteric coated | Which tablet cannot be crushed? |
| 5 | Buccal | The medication is absorbed in the cheek |
| 6 GI/ GU Male | LUQ | The location of the stomach in the abdomen. |
| 6 | Scaphoid contour | A concave contour of the abdomen noted on inspection. |
| 6 | Hypoactive bowel sounds | An assessment finding on auscultation of the abdoment - decreased bowel sounds defined as < 5 sounds per minute. |
| 6 | Tympany | An assessment finding on percussion of the abdomen that indicates the presence of air or gas. An expected finding unless extremely high-pitched tympanic sounds are heard with distention. |
| 6 | Ileus | A condition in which there is a lack of intestinal activity. Peristalsis is decreased or absent. Common after surgery particularly abdominal surgery. |
| 6 | RLQ, RUQ, LUQ, LLQ | The proper sequence of ausculation, percussion and palpation of the abdomen. This sequence follows the flow of the large intestine. |
| 6 | STI | Sexually transmitted infection. An important focused history question with a male GU assessment. Have you ever had or been treated for a STI? |
| 7 Musculoskeletal | Tendon | Attaches muscle to bone |
| 7 | Ligament | Attaches bone to bone |
| 7 | External Rotation | Turning a bone away from the body |
| 7 | Supination | Turning or facing upward such as your palms |
| 7 | Osteoclasts | These breakdown old and damaged bone |
| 7 | Synarthrotic | This joint is immovable |
| 7 | Synovial | This joint is moveable |