Chloe Shared "336 Week 1" - 38 Picmonics
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336 Week 1
Assessment
- Health History
- Objective Data
- Subjective Data
- TEST-TAKING STRATEGY: KEY WORDS
- Identify
- Determine
- Obtain Information
- CONSIDERATIONS
- Assessment Always Done Before Treatments
3 mins
Pain Assessment
- Types of Pain
- Acute Pain
- Chronic Pain
- OPQRST Mnemonic
- Onset
- Provoking or Palliative
- Quality
- Radiation
- Severity
- Timing
- Nursing Considerations
- Subjective Findings
- Objective Findings
- Reassessment of Pain
2 mins
Skin Assessment
- Inspect the skin
- Observe for Abnormal Skin Pigmentation
- Inspect for Cyanosis
- Observe Skin for Pallor
- Observe for Jaundice
- Inspect for Erythema
- Palpate the Skin
- Check the Temperature
- Observe the Skin for Moisture
- Inspect for Diaphoresis or Dehydration
- Check skin for edema
- Imprint Thumb Firmly for 3 to 4 Seconds
- Look for lesions
- Note the Characteristics
- Palpate Lesion
4 mins
Skull, Scalp and Hair Assessment
- Skull
- Inspect Size, Shape and Contour
- Inspect and Palpate Areas for Tenderness or Lesions
- Scalp
- Inspect for Tenderness, Lesions or Rashes
- Inspect for Dandruff
- Inspect for Lice or Nits
- Hair
- Inspect Quality and General Appearance of Hair
- Observe Hair Distribution
2 mins
Nail Assessment
- Observe the Nails
- View Index Finger at its Profile
- Look at Consistency
- Observe Color
- Check Capillary Refill
2 mins
Glasgow Coma Scale
- LOC Assessment
- Score of 3 to 15
- 8 or Less = Coma
- Eye Opening
- Verbal Response
- Motor Response
1 min
Cognitive Abilities Assessment
- Mental Status Examination (MSE)
- Collecting/Organizing Objective Information
- Cognitive assessment tests
- Mini-Mental State Examination (MMSE)
- Montreal Cognitive Assessment Test (MoCA)
- Mini-Cog
2 mins
Cerebellar Assessment
- Coordination
- Observe Rapid Alternating Movements (RAM)
- Touch Thumb to Each Finger
- Finger-Nose-Finger Test
- Heel-to-Shin Test
- Observe Gait
2 mins
Cranial Nerves I and II Assessments
- Cranial Nerve I - Olfactory Nerve
- Use Familiar Attainable Smells
- Note Any Sense of Smell Asymmetry
- Cranial Nerve II - Optic Nerve
- Test Visual Fields
2 mins
Cranial Nerves III, IV and VI Assessments
- Cranial Nerve III - Oculomotor Nerve
- Cranial Nerve IV - Trochlear Nerve
- Cranial Nerve VI - Abducens Nerve
- Assess Extraocular Movements, P.E.R.R.L.A
- Note Any Nystagmus
2 mins
Cranial Nerves V and VII Assessments
- Cranial Nerve V - Trigeminal Nerve
- Assess Temporal and Masseter Muscles
- Assess Light Touch Sensation
- Cranial Nerve VII - Facial Nerve
- Note Mobility and Facial Symmetry
2 mins
Cranial Nerves VIII, IX and X Assessments
- Cranial Nerve VIII - Acoustic (Vestibulocochlear) Nerve
- Test Hearing to Normal Conversation
- Whisper Test
- Cranial Nerve IX - Glossopharyngeal Nerve
- Cranial Nerve X - Vegus Nerve
- Depress the Tongue and Say “Ahh”
- Touch the Posterior Pharyngeal
2 mins
Cranial Nerves XI and XII Assessments
- Cranial Nerves XI - Spinal Accessory Nerve
- Examine Sternocleidomastoid Muscles
- Examine Trapezius Muscles
- Cranial Nerve XII - Hypoglossal Nerve
- Inspect the Tongue
- Note Lingual Speech
2 mins
Reflexes Assessment
- Grading
- Hyperactive
- Hypoactive
- Deep Tendon Reflexes (DTRs)
- Biceps
- Triceps
- Brachioradialis
- Patellar (Quadriceps)
- Achilles Tendon
- Cutaneous (Superficial) Reflexes
- Plantar Reflex (Babinski Sign)
3 mins
Lung Sounds - Wheezes
- Location
- Throughout Lung
- Description
- High Pitched
- Sounds Like
- Musical
- Cause
- Air Moving through Narrowed Airways
38 secs
Lung Sounds - Crackles
- Location
- Lower Lobes
- Description
- Fine/Coarse
- Sounds Like
- Fine: Twisting Hair through Fingers
- Coarse: Velcro
- Cause
- Collapsed Small Airways and Alveoli "Popping Open"
1 min
Lung Sounds - Rhonchi
- Location
- Trachea and Bronchi
- Description
- Low Pitched Rumbling
- Sounds Like
- Gurgling
- Cause
- Narrowed Airway
- Secretions or Bronchospasm
49 secs
Lung Sounds - Pleural Friction Rub
- Location
- Anterior Lateral Lung
- Description
- Dry, Rubbing, or Squeaking
- Sounds Like
- Rubbing a Balloon with Finger
- Cause
- Inflamed Pleura
50 secs
Cardiac and Circulation Assessment
- HEART ASSESSMENT
- Inspect General Appearance
- Inspect Chest
- Note Location of Apical Impulse
- Percuss Chest Wall
- Auscultate Heart Sounds: S1, S2, S3, S4
- Auscultate for Pericardial Friction Rub and Murmurs
- VASCULAR SYSTEM ASSESSMENT
- Assess Skin, Fingernails and Toenails
- Check Carotid Artery and Jugular Vein
- Palpate Skin for Temperature, Texture, Turgor
- Check Capillary Refill Time
- Palpate Arterial Pulses Bilaterally
5 mins
Left Heart Failure Assessment
- Pulmonary Assessment
- Pulmonary Congestion
- Pink Frothy Sputum
- Wheezing or Crackles
- Dyspnea with Exertion
- Cough
- Systemic Assessment
- Fatigue
- Tachycardia
- Weak Peripheral Pulse
- S3, S4 Heart Sounds
1 min
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