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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
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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
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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
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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
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2 mins
Nail Assessment
Observe the Nails
View Index Finger at its Profile
Look at Consistency
Observe Color
Check Capillary Refill
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2 mins
Glasgow Coma Scale
LOC Assessment
Score of 3 to 15
8 or Less = Coma
Eye Opening
Verbal Response
Motor Response
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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
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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
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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
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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
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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
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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
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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
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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)
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3 mins
Lung Sounds - Wheezes
Location
Throughout Lung
Description
High Pitched
Sounds Like
Musical
Cause
Air Moving through Narrowed Airways
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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"
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1 min
Lung Sounds - Rhonchi
Location
Trachea and Bronchi
Description
Low Pitched Rumbling
Sounds Like
Gurgling
Cause
Narrowed Airway
Secretions or Bronchospasm
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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
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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
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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
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1 min

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