Narrative Flashcards

(51 cards)

1
Q

Neuro (9) :

A
  1. General appearance
  2. Lvl consciousness
  3. Orientation
  4. Pupils
  5. Body movement
  6. Sensory-vision/hear
    7.Sensation
  7. Speech
  8. Glascow coma scale
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2
Q

Neuro: General appearance

A

-Clean/orderly
>Shuffled, disorganized

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3
Q

Neuro: Level consciousness

A

-Awake, alert
>Drowsy

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4
Q

Neuro: Orientation

A

-x4 (place, time, person, event)
> Confused as to___ place…

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5
Q

Neuro: Pupil

A

-PERRLA 3mm
>Unequal

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6
Q

Neuro: speech

A

-Clear, fluent
>incoherent, slurred

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7
Q

Neuro: Movement

A

-All extremities move equally (MAE)
-Tremor, jerking

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8
Q

Neuro: Sensory

A
  • adequate vision/hearing
    > Blind, hard of hearing, glasses, hearing aid
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9
Q

Neuro: Sensation

A

-Sensation intact
> Decreased sensation

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10
Q

Neuro: GCS

A

Motor response (6)
Verbal response (5)
Eye opening (4)

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11
Q

Cardiovascular (7)

A
  1. General Appearance
  2. Apical rate
  3. Heart sounds
  4. Cap refil
  5. Circulation: color, warmth
  6. Edema
  7. Peripheral pulses
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12
Q

Cardio: General App

A

-Dry, pink, calm
>Diaphoretic, pale, anxious

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13
Q

Cardio: Apical pulse

A
  • 6 -100 BPM
    > Less/more Irregular
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14
Q

Cardio: Heart sound

A

-S1, S2
>Murmur, extra sound

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15
Q

Cardio: Edema

A
  • No edema
    > pitting/ non-pitting +1, +2, +3 +4
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16
Q

Cardio: Cap refil

A
  • 1-3 seconds
    > more than 3 sec
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17
Q

Cardio: peripheral Circulation

A
  • Pink, warm, nontender
    >cyanosis, cool
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18
Q

Cardio: Peripheral pulse

A
  • Regular, symmetrical +1 thread, +2 weak +3 strong +4 bounding
    > asymmetrical
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19
Q

Respiratory (5)

A
  1. Lung sounds
  2. Rate
  3. Chest shape
  4. Cough/sputum
  5. Effort
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20
Q

Resp: Lung sounds

A

-Clear in all lobes
> diminished, absent
(clear upper lobes diminished in bases)

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21
Q

Resp: Rate

A

-12-20/min regular symmetrical
> irregular <12 >20

22
Q

Resp: Effort

A
  • Labored
    > Unlabored

R/A cannula

23
Q

Resp: Chest shape

A
  • Symmetrical
    -Assymetrical/barrel
24
Q

Gastrointestinal (4)

A
  1. General appearance
  2. Palpation
  3. Bowel sounds
  4. Last BM
25
Gastro: Appereance
- Flat, round > Distended, assymetrical
26
Gastro: Palpation
- Soft, non-tender > tender, firm
27
Gastro: Bowel Sounds
- Active > hypoactive, hyperactive, absent
28
Gastro: BM
- Every 1-3 days > less that 3 days (stool soft, formed, brown)
29
Nutrition (5)
1. General appearance 2. Diet type 3. Intake of fluid/meals 4. Mouth, teeth, gums 5. Swallowing
30
Nutri: General app
-Nourished >Malnourished
31
Nutri: Diet type
- Regular - Soft, puree
32
Nutri: Intake
-Patient reports 100% intake > 10 %
33
Nutri: Mouth, teeth, gums
- no dentures, pink, moist > pale, lesions
34
Nutri: Swallowing
-Swallows easily >Difficulty
35
Genitourinary (3)
1. Urinary output 2. Continent/ incontinent 3. Bladder
36
GU: Urinary output
- Voids, +30mL/hr > difficulty voiding, frequency, burning (COLOR)
37
GU: Continent/incontin
- Continent of urine > Incontinent of urine
38
GU: Bladder
-Flat, round, soft > firm, distended, tender
39
Musculoskeletal (4)
1. Gait 2. Motor: symmetry, strong 3. ROM 4. Mobility lvl
40
MSK: Gait
-Steady >Unsteady
41
MSK: Motor symmetry/strong
- Symmetrical, strong 5/5 >Unequal, weakness
42
MSK: ROM
-Active/full ROM (upper and lower extremities (performs movement w/o assistance ) > Passive: therapist moves the joint
43
MSK: Mobility
-Ambulates without assistance >Ambulates w 2 person assist and walker
44
Integumentary (4)
1. Color 2. Intactness 3. Temperature 4. Turgor
45
Inte: Color
1. Normal for ethnicity > Pale, cyanosis
46
Inte: temp
-warm cool dry >Hot, diaphoretic
47
Inte: intactness
- None >lesions, wounds
48
Inte: Turgot
- elastic >slow to recoil, tented for 4 sec
49
Equipment: (2)
1. Size 2. State
50
Equipment:
IV 20g RT AC no infiltration, clean and intact
51
Pain:
Scale, location, sharp, relieved with????