Ending the Assessment
Closing Remarks
Safety Checks
Answer
Ending the Assessment
Reassess pain level.
Tell the patient you are done with the exam.
Ask if they have any questions, offer comfort measures.
Ask if there is anything else you can do for them.
Ensure the call bell is within reach, the bed is in the lowest position, and the correct number of side rails are up.
Thank them for their time.
Perform hand hygiene upon exiting.
Card 2
Reflex Assessment
Deep Tendon Reflexes (DTRs)
Babinski Reflex
Answer
Reflex Assessment
Deep Tendon Reflexes (DTRs):
- Check the following locations: biceps, triceps, brachioradialis, patellar/quadriceps, achilles.
- 4+ (brisk, clonus), 3+ (above average), 2+ (normal), 1+ (diminished), 0 (no response).
Babinski Reflex: Superficial plantar reflex. Run instrument/finger up the lateral plantar side of the foot and across the metatarsal pads to the base of the big toe.
- Normal response in infants is for the toes to fan out (i.e., positive Babinski).
- Normal response in adults is downward flexion of the toes (i.e., negative Babinski).
Card 3
Neurologic Tests
Romberg Test
Stereognosis
Graphesthesia
Answer
Neurologic Tests
Romberg Test:
- Have the patient put their feet together, arms at their sides, and ask them to close their eyes. Remain close to the patient in case they sway or fall.
- Normal result is no loss of balance for 20 seconds or more.
- Unexpected finding is loss of balance (e.g., stepping forward or falling).
Stereognosis: Have patient close eyes, place a familiar object (e.g., key, paperclip) in their hand and ask them to identify it.
Graphesthesia: Have the patient close eyes, trace a number on their palm and ask them to identify it.
Card 4
Neurologic Assessment
Assessment Components
Answer
Neurologic Assessment
Assess gait, tandem walk (heel-to-toe walk).
Perform the Romberg test.
Assess coordination with rapid alternating movements (finger → finger, finger → nose, heel→shin).
Assess sensory response to sharp/dull, light touch, vibration.
Assess for stereognosis and graphesthesia.
Assess reflexes.
Card 5
Lower Extremity Assessment
Assessment Components
Answer
Lower Extremity Assessment
Inspect legs for symmetry, edema, color, deformities, varicosities.
Assess hair distribution on the legs.
Assess temperature, tenderness.
Palpate the dorsalis pedis, posterior tibial, popliteal, and femoral pulses.
Palpate inguinal lymph nodes.
Auscultate femoral pulse for bruits.
Assess range of motion and muscle strength.
Card 6
Upper Extremities
Modified Allen Test
Phalen Test
Tinel Test
Answer
Upper Extremity Assessment Tests
Modified Allen Test: Used before radial arterial puncture to assess patency of ulnar collateral flow. Occlude both the radial and ulnar artery and have patient open and close their fist until the palm blanches. Release pressure from ulnar artery and observe to see redness return to the palm indicating a patent ulnar artery.
Phalen Test: Have the patient press the dorsal sides of their hands together for 30 seconds. Normal result is no tingling. Tingling may indicate median nerve compression (i.e., carpal tunnel syndrome).
Tinel Test: Tap over the patient's internal wrist. Normal result is no pain or pins and needles. Pain or pins and needles may indicate median nerve compression (i.e., carpal tunnel syndrome).
Card 7
Upper Extremity Assessment
Assessment Components
Answer
Upper Extremity Assessment
Inspect arms for symmetry, edema, color, deformities, venous patterning.
Assess temperature, tenderness.
Palpate ulnar, radial, brachial pulses.
Palpate epitrochlear lymph nodes.
Check length of capillary refill.
Assess range of motion and muscle strength.
Joint Movements
Flexion: Movement that decreases the angle between two body parts. Think of flexing your arm muscles.
Extension: Movement that increases the angle between two body parts.
Abduction: Movement of an extremity away from the midline.
When someone is abducted they are taken away.
Adduction: Movement of an extremity towards the midline.
Adduction is adding a part to the body.
Circumduction: Circular movement of a body part.
Rotation: External rotation (i.e., rotating a joint outward) and internal rotation (i.e., rotating a joint inward).
Card 9
Spinal Curvatures
Normal Curvatures
Kyphosis
Lordosis
Scoliosis
Answer
Spinal Curvatures
Normal Curvatures: Concave cervical spine, convex thoracic spine, concave lumbar spine, convex sacral spine.
Kyphosis: Excess convex curvature of the thoracic spine (i.e., a "humpback."). Common in older adults.
Lordosis: Excess inward curvature of the lumbar spine (i.e., a "swayback."). Common in toddlers and during pregnancy.
Scoliosis: Abnormal lateral curvature of spine (C or S shaped).
Card 10
Musculoskeletal Assessment
Assessment Components
Answer
Musculoskeletal Assessment
Assess joints for heat, erythema, swelling, masses, deformities.
Assess muscle size, note involuntary muscle movements.
Check for normal curvatures of the spine.
Assess for appropriate joint movements, pain/crepitus with active or passive ROM as appropriate.
Evaluate muscle strength:
- Have the patient resist against your opposing force.
- Assign grade 0 - 5 for muscle strength (5 = full ROM, full resistance). Muscle strength should be equal bilaterally.
Card 11
Additional Assessments
Rebound Tenderness
Murphy's Sign
McBurney's Point
Answer
Abdomen: Additional Assessments
Rebound Tenderness: Also known as Blumberg's sign. Examiner pushes on the abdomen away from source of pain (i.e., on the other side of the abdomen). If the patient experiences more pain when the pressure is relieved, this is positive rebound tenderness, which may indicate acute appendicitis or peritonitis.
Murphy's Sign: Examiner pushes fingers under the right costal margin and asks the patient to inhale. Pain or inspiratory arrest (i.e., patient stops inspiration) is a positive Murphy's sign, which may indicate cholecystitis.
McBurney's Point: Located at ⅔ the distance from the umbilicus to the right iliac crest. Pain at this location may indicate appendicitis.
Card 12
Bowel Sounds
Normal
Hypoactive
Hyperactive
Answer
Bowel Sounds
Normal: High-pitched clicking, gurgling, cascading sounds that occur irregularly (5 - 30 times/min).
Hypoactive: Diminished or absent bowel sounds, which indicates decreased motility. Listen for 5 minutes before determining the patient has absent bowel sounds.
Hyperactive: Loud growling or gurgling sounds (borborygmus), which indicates increased motility.
Card 13
Abdominal Assessment
Assessment Components
Answer
Abdominal Assessment
Assess the contour of the abdomen and umbilicus.
Inspect for lesions, scars, striae, distention, visible pulsations, symmetry.
Auscultate bowel sounds in all four quadrants in the following order: RLQ, RUQ, LUQ, LLQ.
Use the bell to auscultate for bruits over the aorta, both renal arteries, and both iliac arteries.
Percuss the liver for size (expected size: 6 - 12 cm).
Palpate each quadrant and assess for muscle guarding, rigidity, masses, and tenderness. Palpate tender areas last.
Card 14
Heart Assessment
Expected Sounds
Extra Sounds
Answer
Heart Assessment
Expected Sounds:
- S1: Occurs with closure of mitral and tricuspid valves.
- S2: Occurs with closure of aortic and pulmonic valves.
Extra Sounds:
- S3: Caused by rapid filling during early diastole. May be associated with heart failure.
- S4: Caused by poor ventricle compliance. May be the result of a myocardial infarction.
- Murmurs: Auscultation of turbulent blood as it regurgitates through an incompetent valve.
- Pericardial Friction Rub: Loud, grating sound caused by the layers of the pericardium rubbing together.
Card 15
Heart Assessment
Auscultation Sites: Illustration
Answer
Heart: Auscultation Sites
Card 16
Heart Assessment
Auscultation Sites
Answer
Heart: Auscultation Sites
Aortic Valve: 2nd intercostal space, right sternal border.
Pulmonic Valve: 2nd intercostal space, left sternal border.
Erb's Point: 3rd intercostal space, left sternal border.
Tricuspid Valve: 4th intercostal space, left sternal border.
Mitral Valve (Point of Maximum Impulse): 5th intercostal space, left midclavicular line.
All People Enjoy Time Magazine! or
All Physicians Eagerly Take Money.
Card 17
Heart Assessment
Assessment Components
Answer
Heart Assessment
Auscultate with diaphragm and bell.
Use Heavy pressure to listen for High-pitched sounds with the diapHragm. Use Light pressure to listen for Low-pitched sounds with the beLL.
Assess heart rate and regularity.
Identify S1 and S2 sounds.
Listen for extra heart sounds and murmurs at 5 locations.
Additional Lung Assessments
Whispered Pectoriloquy: Have the patient whisper words while auscultating the lungs.
- Expected Finding: Words are muffled, faint.
- Unexpected Finding: Whispered words heard clearly may suggest consolidation (e.g., pneumonia).
Egophony: Have the patient say "Ee" while auscultating the lungs.
- Expected Finding: "Ee" sound heard over the lungs.
- Unexpected Finding: "Ee" sounding like "A" may suggest pleural effusion or consolidation.
Breath Sounds
Finding
Sound Quality
Location
Bronchial
Loud, low-pitched
Over trachea
Bronchovesicular
Medium volume and pitch
Over bronchi
Vesicular
Quiet, low-pitched
Over peripheral lungs
Card 22
Lung Sounds
Posterior Chest: Auscultation Sites
Answer
Posterior Chest: Auscultation Sites
Auscultate all lung sounds using the below "S" pattern with the diaphragm of the stethoscope.
Card 23
Percussion
Findings
Sound Quality
Causes
Answer
Percussion
Finding
Sound Quality
Cause
Resonance
Low-pitched, hollow
Expected when percussing over healthy lungs.
Hyperresonance
Low-pitched, booming
Hyperinflation of lungs (e.g., COPD), air in pleural space (e.g., pneumothorax).
Dullness
Quiet, high-pitched "thud"
Fluid-filled lung (e.g., pneumonia), expected when percussing over solid organs (e.g., liver).
Flatness
Shorter/quieter "thud" than in dullness
Expected when percussing over muscles and bone.
Tympany
High-pitched, drum-like
Expected when percussing over hollow organs (e.g., stomach, bowels).
Card 24
Posterior Chest Assessment
Assessment Components
Answer
Posterior Chest Assessment
Inspect skin for lesions and symmetrical chest expansion.
Check anteroposterior-to-transverse diameter (AP:T) ratio.
- Expected: 1:2 ratio.
Palpate for tenderness or masses.
Test for tactile fremitus by placing the palms of your hands on the patient's back and have the patient say "ninety-nine" each time you move your hands.
- Expected: Vibration intensity gradually decreases as you move your hands lower.
Percuss lungs and for costovertebral angle (CVA) tenderness.
Auscultate breath sounds.
Card 25
Anterior Chest Assessment
Assessment Components
Answer
Anterior Chest Assessment
Assess for symmetrical chest expansion.
Assess for visible pulsations at the point of maximal impulse (PMI) (i.e., the fifth intercostal space at the left midclavicular line).
Inspect for abnormal lifts (i.e., slight movement) and heaves (i.e., strong movement).
Palpate for tenderness or masses.
Percuss anterior chest.
Auscultate breath sounds.
Card 26
Cranial Nerves: CN XI & XII
Type
Function
Assessment
Answer
CN XI (Spinal Accessory) & CN XII (Hypoglossal)
Cranial Nerve XI (Spinal Accessory):
- Type: Motor.
- Function: Sternocleidomastoid and trapezius muscles (controls turning head, shrugging shoulders).
- Assessment:
- Have the patient turn their head against resistance by placing your hand against their cheek.
- Place your hands on their shoulders and ask them to raise their shoulders against the resistance.
Cranial Nerve XII (Hypoglossal):
- Type: Motor.
- Function: Tongue movement.
- Assessment:
- Have the patient stick out their tongue and move it side to side.
Card 27
Cranial Nerves: CN X
Type
Function
Assessment
Answer
CN X (Vagus)
Type: Sensory and motor.
Function: Thoracic and abdominal organ sensation, gag reflex, pharyngeal and laryngeal muscles (e.g., swallowing, speech).
Assessment: Evaluated with CN IX. See previous card.
When you go to Vegas (Vagus), you are out drinking (swallowing) and talking with your friends (speech). You may gag if you get sick from drinking too much!
Card 28
Cranial Nerves: CN IX
Type
Function
Assessment
Answer
CN IX (Glossopharyngeal)
Type: Sensory and motor.
Function: Taste (posterior ⅓ of tongue), gag reflex, pharyngeal muscles (e.g., swallowing, speech), parotid gland.
Assessment:
- Have the patient open their mouth and say "ahhh." The soft palate and uvula should rise symmetrically.
- Test for a gag reflex by touching the posterior pharyngeal wall with a tongue blade.
- Assess swallowing ability.
Card 29
Cranial Nerves: CN VIII
Type
Function
Assessment
Answer
CN VIII (Vestibulocochlear/Acoustic)
Type: Sensory.
Function: Hearing and balance.
Assessment:
- Whisper Test: While shielding your lips, whisper three random letters/numbers from 1 - 2 feet away and ask the patient to repeat them.
- Expected: Patient accurately repeats the letters/numbers.
- Rinne Test: Hold vibrating tuning fork on the mastoid bone until the patient reports they can no longer hear it. Then move the still-vibrating fork in front of the ear canal and ask if the patient can hear it again.
- Expected: Patient can still hear the noise when in front of the ear canal.
Air conduction > bone conduction.
- Weber Test: Hold vibrating tuning fork on top of the patient's head, compare hearing on right vs. left side.
- Expected: Patient can hear the sound equally in both ears.
Card 30
Cranial Nerves: CN VI & VII
Type
Function
Assessment
Answer
CN VI (Abducens) & CN V (Facial)
Cranial Nerve VI (Abducens):
- Type: Motor.
- Function: Controls outward eye movement.
- Assessment: See cranial nerve III.
Cranial Nerve VII (Facial):
- Type: Sensory and motor.
- Function: Taste (anterior ⅔ of tongue), facial movement, salivary and lacrimal gland function.
- Assessment:
- Have the patient smile, frown, puff out their cheeks, and raise their eyebrows. Movements should be symmetrical on both sides of the face.
- Sensory function not tested routinely.
Card 31
Cranial Nerves: CN IV & V
Type
Function
Assessment
Answer
CN IV (Trochlear) & CN V (Trigeminal)
Cranial Nerve IV (Trochlear):
- Type: Motor.
- Function: Controls downward, outward, and inward eye movements.
- Assessment: See cranial nerve III.
Cranial Nerve V (Trigeminal):
- Type: Sensory and motor.
- Function: Facial sensation, chewing.
- Assessment:
- With patient's eyes closed, test sensation over several areas of the face using a cotton wisp.
- Test corneal reflex by lightly touching the cornea using a cotton wisp and observing a blink.
- Palpate for strong and equal contraction of temporal and masseter muscles as patient clenches teeth.
Card 32
Six Cardinal Positions of Gaze
Illustration
Answer
Six Cardinal Positions of Gaze
Card 33
Cranial Nerves: CN III
Type
Function
Assessment
Answer
CN III (Oculomotor)
Type: Motor.
Function: Most eye movements, pupil constriction.
Assessment:
- Corneal Light Reflex: Shine light from ~ 12 inches away, check for reflection in each cornea at the same location.
- Cover Test: Tests for strabismus (deviated alignment). As you cover one eye, look for any movement in the uncovered eye. Normal response is a steady, fixed gaze.
- Six Cardinal Posititions of Gaze: Ask the patient to follow your finger/penlight from ~ 12 inches away. Assess for nystagmus (i.e., involuntary, rhythmic beating of the eyes).
Card 34
Cranial Nerves: CN II
Type
Function
Assessment
Answer
CN II (Optic)
Type: Sensory.
Function: Visual acuity.
Assessment:
- Far Vision: Position patient 20 feet away from Snellen chart while wearing glasses/corrective lenses (if applicable). Have the patient cover one eye at a time and read the letters on each line. Stop when the patient misses > 50% of letters on one line.
- Near Vision: Hold Jaeger card 14" away from patient, with glasses/corrective lenses in place. Have the patient read the smallest block of text possible.
- Color Vision: Assess for color blindness with Ishihara test.
- Peripheral Vision: Assess with confrontation test. Have the patient cover one eye, look at your nose, and state how many fingers you are holding up as you move throughout their peripheral vision. Repeat test with the other eye covered.
Card 35
Cranial Nerves: CN I
Type
Function
Assessment
Answer
CN I (Olfactory)
Type: Sensory.
Function: Sense of smell.
Assessment: With the patient's eyes closed, present a familiar scent (e.g., soap, mint, coffee) to the patient while occluding one nostril at a time, and ask them to identify it.
I can smell that ol' factory (olfactory) down the road!
Card 36
Cranial Nerves
Mnemonics to Remember Names and Types
Answer
Cranial Nerves: Mnemonics
To Remember Cranial Nerve Names:
Only One Of The Two Athletes Feels Very Good, Victorious, & Super Healthy.
To Remember Cranial Nerve Types:
Some Say Marry Money But My Brother Says Big Brains Matter More.
Card 37
Cranial Nerves VII-XII
Overview of Type and Function
Answer
Cranial Nerves
Number/Name
Type
Function
VII: Facial
Both
Taste (anterior ⅔ of tongue) and facial movements.
VIII: Vestibulocochlear
(Acoustic)
Sensory
Hearing and balance.
IX: Glossopharyngeal
Both
Taste (posterior ⅓ of tongue), gag reflex, pharyngeal muscles, parotid gland.
X: Vagus
Both
Thoracic and abdominal organ sensation, gag reflex, pharyngeal muscles.
XI: Spinal Accessory
Motor
Sternocleidomastoid and trapezius muscles.
XII: Hypoglossal
Motor
Tongue movement.
Card 38
Cranial Nerves I-VI
Overview of Type and Function
Answer
Cranial Nerves
Number/Name
Type
Function
I: Olfactory
Sensory
Sense of smell.
II: Optic
Sensory
Visual acuity.
III: Oculomotor
Motor
Most eye movements, pupillary constriction.
IV: Trochlear
Motor
Downward, outward, inward eye movement.
V: Trigeminal
Both
Facial sensation, chewing.
VI: Abducens
Motor
Outward eye movement.
Card 39
Mouth & Throat Assessment
Unexpected Findings
Answer
Mouth & Throat: Unexpected Findings
Mouth:
- Dry, cracked lips/mucosa may indicate dehydration.
- Lesions of the mucosa may indicate viral or bacterial infection or cancer.
Throat:
- Unexpected tonsil sizes:
- 0: Tonsils are not present (may have been surgically removed).
- 3+: Tonsils occupy 50 - 75% of the oropharynx.
- 4+: Tonsils occupy > 75% of the oropharynx and may touch each other. This is a significant threat to the airway!
Card 40
Mouth & Throat Assessment
Assessment Components
Answer
Mouth & Throat Assessment
Mouth:
- Assess lips for color and lesions.
- Assess for missing teeth.
- Inspect the gums, oral/buccal mucosa. Should be pink and moist.
- Assess for lesions on or underneath the tongue.
Throat:
- Assess position and symmetry of tongue and uvula. Both should be midline.
- Assess palate for odor, color, moisture, and lesions.
- Assess for the presence of tonsils and their size.
- 1+ (tonsils occupy
- If indicated, assess cranial nerve IX (glossopharyngeal), cranial nerve X (vagus), and cranial nerve XII (hypoglossal).
Card 41
Nose Assessment
Assessment Components
Answer
Nose Assessment
Assess for position, symmetry, proportion, lesions, and drainage.
Assess bilateral patency.
- Have patient occlude one nostril at a time and breathe through the other (unoccluded) naris. The patient should be able to inhale and exhale through both nares.
Use an otoscope to inspect the septum, internal nares, and turbinates.
If indicated, assess cranial nerve I (olfactory).
Card 42
Ear Assessment
Assessment Components
Answer
Ear Assessment
Assess overall alignment and symmetry. Expected: Top of auricles should be at the same height as the inner canthus of the eyes.
Inspect external ear for swelling, redness, discharge.
Ask about use of hearing aids, exposure to environmental noise.
Using an otoscope, inspect external canal and tympanic membrane for swelling, erythema, lesions, discharge.
- External Canal: Cerumen (i.e., ear wax) is an expected finding.
- Tympanic Membrane: Pearly gray color, intact, no bulging. Light reflex at 5 o'clock on right ear and 7 o'clock on left ear.
5 o'clock is on the right side of a watch face, 7 o'clock is on the left!
If indicated, assess cranial nerve VIII (vestibulocochlear/acoustic).
Card 43
Eye Assessment
Assessment Components
Answer
Eye Assessment
Assess for symmetry, swelling, lesions, discharge, and protrusion or sunken appearance of the eyeballs.
Assess the color of the conjunctiva and sclera. Conjunctiva is normally pink, and the sclera is normally white.
Assess pupillary light reflex and accommodation. Expected Finding: PERRLA (Pupils are Equal, Round, Reactive to Light and Accommodation).
- Pupillary Light Reflex: Have the patient look straight ahead. Advance penlight from the side. Bilateral pupil constriction is expected.
- Accommodation: Have the patient focus on a distant object (pupils dilate) and maintain focus while bringing the object closer (pupils constrict).
If indicated, assess cranial nerve II (optic), cranial nerve III (oculomotor), cranial nerve IV (trochlear), cranial nerve VI (abducens).
Card 44
Neck Assessment
Unexpected Findings
Answer
Neck: Unexpected Findings
If the trachea deviates to one side, this may be due to an injury to the chest, neck, or lungs.
Lymphadenopathy is present when lymph nodes are enlarged, tender, hard, and/or not freely moveable. If present, this can indicate infection, allergies, or neoplasm (i.e., cancer).
Enlargement or nodules of the thyroid may indicate a goiter, which is irregular growth of the thyroid.
Visible pulsations in the neck or signs of JVD may indicate fluid volume overload.
Bruits of the neck vessels may indicate cardiovascular disease.
Card 45
Neck Vessels
Assessment Components
Answer
Neck Vessels
Assess for jugular venous distention (JVD).
- Position the patient at a 30 - 45° angle and inspect the jugular vein.
- Note visible pulsations. A bulging neck vein indicates JVD.
Palpate each carotid pulse (one at a time!).
Use the bell to listen for any bruits (i.e., swishing sounds). Ask the patient to hold their breath while you listen.
Card 46
Lymph Nodes
Lymph Node Locations
Answer
Lymph Node Locations
Card 47
Neck Assessment
Assessment Components
Answer
Neck Assessment
Assess for range of motion, tracheal deviation, and visible pulsations or masses.
Palpate the lymph nodes.
- Assess the following lymph nodes: preauricular, postauricular, occipital, submandibular, submental, jugulodigastric, superficial cervical, posterior cervical, deep cervical, and supraclavicular.
- Normal lymph nodes are moveable, soft, nontender, and
Palpate the thyroid from posterior, ask patient to swallow.
- The thyroid should be symmetrical with no enlargement, tenderness, or nodules.
If indicated, assess cranial nerve XI (spinal accessory).
Card 48
Head & Face Assessment
Assessment Components
Answer
Head & Face Assessment
Head:
- Assess for size and symmetry, lesions, lumps, tenderness, and infestations.
- Palpate temporomandibular joint (TMJ) for range of motion, crepitus, and tenderness.
Face:
- Assess for symmetry and involuntary movements.
- Note if the patient's expression is appropriate for the situation.
- Palpate the frontal and maxillary sinuses, assessing for tenderness.
- If indicated, assess cranial nerve V (trigeminal) and cranial nerve VII (facial).
Card 49
Nail Assessment
Assessment Components
Unexpected Findings
Answer
Nails
Assessment Components:
- Inspect size, shape, thickness, cleanliness.
- Assess the angle between the nail plate and skin (expected ≤ 160°).
- Assess capillary refill (expected ≤ 2 seconds):
- Apply pressure to the nail until it turns white. Then, release pressure and measure how long it takes for the nail to turn pink again.
Unexpected Findings:
- Excessively thick nails may indicate poor blood flow or fungal infections.
- Profile sign (i.e., angle > 160° between the nail plate and skin) is indicative of clubbing, which may indicate chronic hypoxia (e.g., COPD*, cardiovascular disease).
- Capillary refill > 2 seconds may indicate dehydration, shock, hypothermia, or peripheral arterial disease.
*Recent evidence suggests clubbing is not correlated with COPD, however, for testing purposes defer to your instructor, textbook, and/or facility.
Card 50
Lesions
Secondary Lesions
Answer
Secondary Lesions
Lesion
Description
Examples
Crust
Thickened, dried exudate (e.g., blood, serum, pus).
Impetigo, scab
Scale
White/silver flakes of skin (dry or greasy).
Psoriasis, eczema
Fissure
Linear crack that extends into the dermis due to excess moisture or dryness.
Cheilosis, athlete's foot
Erosion
Shallow depression involving only the epidermis.
Ruptured vesicle or bulla
Ulcer
Deep depression, extending into the dermis.
Pressure injury, venous stasis ulcer
Keloid
Overgrowth of scar tissue (i.e., hypertrophy).
Rubbery nodule in area of prior injury
Atrophy
Thinning of epidermis.
Striae (stretch marks)
Card 51
Lesions
Primary Lesions
Answer
Primary Lesions
Flat Area of Discoloration:
- Macule:
- Patch: > 1 cm (e.g., birthmark).
Elevated Solid Lesion:
- Papule:
- Plaque: > 1 cm (e.g., psoriasis).
- Wheal: Superficial, raised, transient, irregular-shaped lesion (e.g., insect bite).
Elevated Fluid-Filled Lesion:
- Vesicle: Elevated, serous filled,
- Pustule: Pus-filled vesicle,
- Bulla: Elevated, serous filled, > 1 cm (e.g., blister).
Vesicles are Very small compared to a Big ol' Bulla, but a Pustule is Pus-filled!
Abnormal Tissue Growth:
- Nodule: Firm, deep, 1 - 2 cm (e.g., lipoma).
- Tumor: Solid mass, deep, > 2 cm (e.g., neoplasm).
Card 52
Edema
Assessment of Pitting Edema
Answer
Edema
May be characterized as non-pitting or pitting (i.e., a "pit" or indentation remains after pressure is applied to the edematous area).
Assessment of Pitting Edema: Use a finger to push down for five seconds over a bony prominence in the edematous area (e.g., tibia, medial malleolus). Document based on the depth of the indentation:
- 0 = No clinical edema.
- 1+ = Slight pitting, 2 mm depth.
- 2+ = Moderate pitting, 4 mm depth.
- 3+ = Deep pitting, 6 mm depth.
- 4+ = Very deep pitting, 8 mm depth.
Divide the pit depth in mm by two to get the pitting level!
Card 53
Color Assessment
Pallor
Cyanosis
Erythema
Jaundice
Brown Discoloration
Answer
Color Assessment
Skin Color
Causes
Pallor (Pale)
Anemia, shock, local arterial insufficiency.
Cyanosis (Blue)
Hypoxia (deoxygenated hemoglobin).
Erythema (Red)
Inflammation, polycythemia, fever, alcohol intake, rash, sunburn.
Jaundice (Yellow)
Hepatic dysfunction, RBC destruction.
Brown Discoloration
Addison's disease (bronzed appearance), venous stasis dermatitis.
Alterations in skin color may be less obvious in patients with black and brown skin. Be sure to assess nail beds, mucus membranes, and the sclera of the eyes.
Card 54
Skin Assessment
Assessment Components
Answer
Skin Assessment
Note skin color.
Assess for edema, lesions, incisions, wounds, or rashes.
Make note of tattoos and piercings.
Palpate for temperature and assess for moisture.
Lift skin on the sternum or forearm to assess skin turgor.
Tenting can indicate dehydration and/or aging.
Card 55
Pain Scales
CRIES
FLACC
FACES
Oucher
Numeric
Answer
Pain Scales
Pain Scale
Age Range
Components
CRIES
≤ 6 months
Crying, Requires O2, Increased vital signs, Expression, Sleeplessness.
FLACC
2 months -
7 years
Face, Legs, Activity, Cry, Consolability.
FACES
("Wong-Baker")
≥ 3 years
Uses diagram of six faces to rate pain on a scale from 0 to 10.
Oucher
3 - 13 years
Uses six photographs to rate pain on a scale of 0 to 10.
Numeric
≥ 8 years
Rate pain on a scale of 0 to 10.
Card 56
Pain Assessment
Components of a Pain Assessment
Answer
Pain Assessment
Remember pain assessment with OLD CARTS!
Onset: When did the pain start?
Location: Where does it hurt?
Duration: Is it constant, or does it come and go?
Characteristics: What does the pain feel like?
- Nociceptive Pain: Described as "aching" or "throbbing".
- Neuropathic Pain: Described as "shooting" or "burning".
Aggravating/Relieving Factors: Does anything make it worse? Does anything make it better?
Radiation: Does the pain move anywhere else?
Treatment: Have you tried anything to treat the pain (e.g., ice, medication)?
Severity: Rate the pain using an appropriate pain scale.
Orthostatic Vital Signs
Orthostatic Hypotension Criteria:
- A drop in SBP ≥ 20 mmHg when changing positions.
- and/or
- A drop in DBP ≥ 10 mmHg when changing positions.
Patient Teaching:
- Change positions slowly.
- Sit on the side of the bed and dangle legs for a few minutes before standing up.
- Increase fluid intake.
- Call for help prior to ambulation.
Card 58
Orthostatic Vital Signs
When to Assess
Assessment Technique
Answer
Orthostatic Vital Signs
When to Assess:
- Take orthostatic vital signs when ordered by the provider.
- Indicated with patient report of fainting/syncope, hypovolemia, certain medications (e.g., ACE inhibitors, beta blockers).
Assessment Technique:
- Have the patient lie supine for at least 5 minutes, then take the patient's BP and pulse.
- Sit the patient upright, wait 2 - 3 minutes, then take their BP/pulse.
- Stand the patient up, wait 2 minutes, then take their BP/pulse.
- Monitor for dizziness or weakness during assessment.
Card 59
Blood Pressure
Expected BP Ranges for Adults, Children, Infants
Levels of Hypertension for Adults
Answer
Blood Pressure
Expected Blood Pressure Ranges:
- Adults: SBP
- Children: SBP = 90 - 110 mmHg, DBP = 55 - 75 mmHg.
- Infants: SBP = 65 - 90 mmHg, DBP = 45 - 65 mmHg.
Systolic is in the Sky (top number).
Diastolic is in the Dirt (bottom number).
Patient Positioning: BP ↑ when lying flat and ↓ in sitting/standing positions.
Levels of Hypertension for Adults:
- Elevated: SBP 120 - 129 mmHg and DBP
- Stage 1 Hypertension: SBP 130 - 139 mmHg or DBP 80 - 89 mmHg.
- Stage 2 Hypertension: SBP ≥ 140 mmHg or DBP ≥ 90 mmHg.
- Hypertensive Crisis: SBP > 180 mmHg and/or DBP > 120 mmHg.
Card 60
Blood Pressure
Assessment Technique
Answer
Blood Pressure
Choose the appropriate arm to take the patient's BP. Avoid using an arm with a running IV infusion, PICC line, AV fistula, or on the same side as a mastectomy.
Position patient's arm relaxed and supported at heart level, with legs uncrossed.
Choose appropriate cuff size and apply snugly 1" above the brachial artery. The BP cuff width should be 40% of arm circumference. Bladder should surround 80% of arm circumference.
If the cuff is too Large, you will get a falsely Low reading. If it is too Small, you will get a Sky high reading.
Palpate the radial pulse while inflating the cuff until the pulse disappears.
Continue inflating the cuff an additional 30 mmHg.
Place the stethoscope over the brachial artery while slowly and steadily releasing air from the cuff.
Note the first sound (SBP) and when the sound disappears (DBP).
Card 61
Oxygen Saturation (SpO2)
Expected Oxygen Saturation Range
Nursing Considerations
Answer
Oxygen Saturation (SpO2)
Non-invasive technique that measures oxygen saturation of the arterial blood using pulse oximetry.
Expected Oxygen Saturation Range: 95 - 100%.
Nursing Considerations:
- Place probe on finger, earlobe, or toe.
- Nail polish, hypotension, peripheral vascular disease, edema, skin pigmentation, and skin temperature may affect accuracy.
- While a ↓ oxygen saturation reading may indicate the patient has ↓ blood oxygen, hypoxemia can only be diagnosed with an ABG.
Oxygen saturation in the low 90s is expected for COPD patients.
Card 62
Respirations
Unexpected Findings
Answer
Respirations: Unexpected Findings
Tachypnea (RR > 20 breaths/min) or bradypnea (RR
Hyperventilation (deep, rapid respirations) or hypoventilation (shallow, slow respirations).
Irregular respirations (e.g., Cheyne-Stokes, Biot's respirations).
Apnea (absence of respirations for > 15 seconds).
Dyspnea (difficulty breathing), including use of accessory muscles, nasal flaring, or retractions.
Respirations
Assessment Components: Rate, depth, rhythm, effort.
Assessment Technique:
- While your fingers are still in place after taking the patient's pulse, observe the rise and fall of the patient's chest without mentioning that you are counting respirations.
- For a regular pattern, count for 30 seconds and multiply by 2.
- For an irregular pattern, count for a full minute.
Card 65
Pulse
Unexpected Findings
Answer
Pulse: Unexpected Findings
Bradycardia (HR 100 bpm).
Athletes may have a below average heart rate, which is an expected finding.
Irregular pulse (i.e., there are irregular pauses in between beats).
Sinus arrhythmia (↑ in HR with inspiration, and ↓ HR with expiration) is a common, harmless irregularity in children and young adults.
Strength: 0 = absent, 1+ = diminished, 3+ = strong, or
4+ = bounding.
Pulsus alternans (i.e., alternating strong and weak beats).
Pulse deficit (i.e., a difference between the apical pulse and a peripheral pulse).
Pulse
Expected Pulse Rate Ranges:
- Adults: 60 - 100 bpm.
- Children: 70 - 120 bpm.
- Infants: 100 - 160 bpm.
Regularity: Pulse should be regular, meaning there are equal length pauses in between beats.
Strength: Pulse strength refers to how forceful the pulse feels against the examiner's fingers. 2+ = normal.
Equality: Pulses should feel equal in strength and frequency bilaterally.
Card 67
Pulse
Assessment Components
How to Take Radial and Apical Pulse
Answer
Pulse
Assess: Rate, regularity, strength, and equality.
- For a regular rhythm, count for 30 seconds and multiply by 2.
- If the pulse is irregular or if the patient is taking cardiac medications, count the apical heart rate for a full minute.
- A peripheral pulse that cannot be felt should be assessed via Doppler to confirm it is absent.
How to Take Pulses:
- Radial: Feel on the wrist proximal to the thumb, using the pads of your first three fingers.
- Apical: Listen with stethoscope at the fifth intercostal space at the left midclavicular line.
Card 68
Temperature
Expected Ranges for Adults, Children, Infants
Nursing Considerations
Answer
Temperature
Expected Temperature Ranges:
- Adults: 96.8 - 100.4°F (36 - 38°C).
- Children: 97.4 - 99.6°F (36.3 - 37.6°C).
- Infants: 97.4 - 99.6°F (36.3 - 37.6°C).
Nursing Considerations:
- A fever is a temperature over 100.4°F for an adult.
- Food/fluid intake can alter temperature. Wait at least 15 minutes after the patient has consumed anything before taking an oral temperature.
- Rectal temperature is considered to be the most accurate.
Card 69
Temperature
Oral
Temporal
Tympanic
Axillary
Rectal
Answer
Temperature
Oral: Place probe beneath patient's tongue in the posterior sublingual pocket. Ask the patient to close lips around probe.
Temporal: Slide probe from the center of the forehead to the hairline behind the ear.
Tympanic: For adults pull the pinna up and back, children
Adults are up high, children are down low.
Axillary: Place probe in center of the axilla. Have patient bring down arm close to the body.
Rectal: Place patient in modified left lateral recumbent position (i.e., Sims'), use lubrication and insert ~ 1" angled towards the umbilicus.
Card 70
Glasgow Coma Scale
Scale Components
Scoring
Answer
Glasgow Coma Scale
Scale used to assess extent of consciousness based on three subcategories. Often used for patients who sustained head trauma.
Eye Opening: (4) spontaneously, (3) in response to voice, (2) in response to pain, (1) no eye opening.
Verbal Response: (5) coherent/oriented, (4) incoherent/disoriented, (3) inappropriate words, (2) sounds, no words, (1) no vocalization.
Motor Response: (6) follows commands, (5) local reaction to pain, (4) general withdrawal to pain, (3) decorticate posture, (2) decerebrate posture, (1) no motor response.
Scoring: Maximum/normal score = 15. Minimum score = 3.
- 13 - 15 = Mild head injury.
- 9 - 12 = Moderate head injury.
- If GCS is less than eight, you're gonna have to intubate.
Card 71
Levels of Orientation
Person
Place
Time
Event/Situation
Answer
Levels of Orientation
Orientation gives insight about the patient's cognitive functioning. A normal finding is for the patient to be oriented x 4 (i.e., to person, place, time, and situation).
Person: "Tell me your name."
Place: "Where are we right now?"
Time: The patient can correctly identify the day, month, year, or season.
Event/Situation: "Who is the president?" or "What brought you to the hospital?"
Card 72
Levels of Consciousness
Alert
Lethargic
Obtunded
Stuporous
Comatose
Answer
Levels of Consciousness
Patient's level of alertness or arousability. A normal finding is for the patient to be alert.
Alert: Awake, opens their eyes spontaneously.
Lethargic: Extremely drowsy. Can be awakened by speaking to them, but they fall back to sleep when not stimulated.
Obtunded: Difficult to arouse. Requires vigorous shaking or shouting. Requires constant stimulation for cooperation.
Stuporous: Responds only to vigorous shaking or painful stimuli.
Comatose: Completely unconscious, unresponsive to pain. Abnormal posturing may be present.
- Decorticate: Arms flexed and rotated inward, legs extended and rotated inward.
- In decorticate posturing, your arms are drawn in towards your core!
- Decerebrate: Head arched back, arms and legs extended.
Card 73
General Survey
Physical Appearance
Body Structure/Mobility
Behavior
Answer
General Survey
Physical Appearance: Assess level of consciousness, orientation, age, sex, facial features, signs of distress.
Body Structure/Mobility: Assess gait, posture, range of motion, use of assistive devices, nutritional status, obvious deformities.
Behavior: Assess mood/affect, eye contact, speech, dress, grooming.
Measurements*: Obtain height, weight, waist circumference, BMI, vital signs.
*Some nursing textbooks/sources do NOT include measurements as part of the general survey. Please defer to your instructor, textbook, or facility.
Card 74
Beginning an Assessment
Key Steps
Answer
Beginning an Assessment
Perform hand hygiene.
Make your presence known (knock on the door).
Introduce yourself and state your job title (e.g., nurse, tech, nursing student).
Provide for privacy.
Tell the patient why you are there, the reason for the assessment, and how long it will take.
Identify the patient using two patient identifiers (e.g., name, date of birth, medical record number, phone number). The patient's room number is not a valid patient identifier.
Physical Assessment Steps
Although each individual and school will follow slightly different steps, below is a general overview of how an assessment should flow.
Introductory explanation, hand hygiene, etc.
General survey
Vital signs
Pain assessment
Skin assessment
Head, neck, eyes, ears, nose, mouth/throat assessment
Anterior and posterior chest assessment
Abdominal assessment
Musculoskeletal assessment
Neurologic assessment
Closing remarks and safety checks
Physical Assessment Components
Inspection: Use sight to assess size, shape, color, symmetry.
Palpation: Use touch to assess temperature, vibration, texture, tenderness, size.
- Use dorsal surface of hand to assess temperature.
- Use palmar surface of the hand to assess vibration.
- Assess most tender areas last.
Percussion: Tap body parts to assess location, size, shape, and tissue density.
Auscultation: Listen for sounds and assess the volume, intensity, duration, frequency, and quality.
Most assessments occur in the following order: inspect, palpate, percuss, auscultate. To avoid altering bowel sounds, abdominal assessment occurs in the following order: inspect, auscultate, percuss, palpate.
Take a look at my belly. I Am Perfect, Pal!