 Methodology

Inspection – visual
examination, general state of
health, apparent age,
physique
 Palpation – touchy feely,
maybe difficult at first due to
cultural beliefs and biases,
warmth, caring,
understanding
 Percussion – gentle beating
using both hands, detects
fluids, air or mass.
 Auscultation – quality of
sounds, intensity, duration of
heart, lungs and intestines.
Sequence
System Flow
The Lungs Inspection (respiration), palpation,
percussion, auscultation
The Heart Inspection (BP, P), palpation,
auscultation
The Abs Inspection, auscultation,
percussion, palpation
The Musculoskeletal Inspection, palpation, ROM,
Strength testing, Deep tendon
reflexes
History
Vital Signs
T ______
P ______
R ______
BP _____
Pain Assessment
______
O2 Saturation
_________
Allergies
Allergies Reaction
1. PCN Anaphylactic
2. Shellfish shock
3. Cat Hives
dander Wheezing
Chronic Conditions
Lung Problems ___________Stomach
Problem_____________
Thyroid Problems _________Neurological
Problems_________
Heart Problems __________Liver Problems
_______________
Vision Problems __________Kidney Problems
_____________
Arthritis _________________Diabetes ___________________
Chronic infection __________Treatment:
__________________
Cancer (where/type) _______Treatment:
_________________
Other Past Medical History or Surgeries:
Family History
 NSF
 Heart disease
 Hypertension
 Diabetes
 Stroke
 Seizures
 Kidney disease
 Liver disease
 Medications
Drug Dose Frequency
Altace 5 mg BID

Lasix 20 mg OD

Digoxin 0.125 mg OD

Alupent 2 puffs QID and prn

SOB
Social History
 Lives alone
 Lives with _________________
_________________

 Stairs at home Yes ___ No___

 Sleep pattern _______________
 Immunization

 Immunizations current?
 Yes ______
 No ______
 Last Tetanus toxoid? _______
 Hepatitis A _______
 Hepatitis B _______
 Flu Vaccine ______
 Smoking/Alcohol/Social
Drug
Nicotine Use:
 No
 Yes – How much? _______ How Long? _____________
 Instructed on “No Smoking” Policy? Yes No
 Do you live in a smoking environment? Yes No
Alcohol Use:
 No
 Yes – How much? _______How Long? _____________
 Last Drink? ______________________________________
Social Drug Use:
 No
 Yes – Type?_______________ Frequency?__________
Disabilities/Impairment
Impaired hearing
 Hearing Aid
Impaired vision
 Glasses
Cane or walking device
______________
Other: ______________
______________
Dietary Habits

Diet restriction:
________________
Special diet:
________________
Supplements:
_________________
Systems Review
Other Assessments
Skin and Fall Assessment
Acuity Level
 EENMT
Eyes:
 NSF
 Blurred Vision Yes __ No __
 Double vision Yes __ No __
 Inflammation Yes __ No __
 Pain Yes __ No __
 Color blind Yes __ No __
 Itching Yes __ No __
 Pupils abnormal Yes __ No __
 Drainage -- Color ________Amount _________
 Other __________________________________
Ears
Ears:
 NSF
 HOH (R) (L) Yes No
 Deaf Yes No
 Tinnitus Yes No
 Dizziness Yes No
 Drainage _______________
 Sense of balance Yes
No
 Pain Yes No
 Other __________________
Nose
Nose:
 NSF Yes No
 Congestion Yes No
 Pain Yes No
 Sinus problems Yes No
 Nasal Flaring Yes No
 Alignment Yes No
 Nosebleeds – frequency _________________
 Drainage – color ______amount ___________
 Other ________________________________
Mouth
Mouth:
 NSF
 Halitosis Yes No
 Pain Yes No
 Bleeding gums Yes No
 Lesions Yes No
 Sense of taste Yes No
 Dental Hygiene ____________
 Last Dental Exam __________
Throat/Neck
Throat/Neck:
 NSF
 Sore throat
Yes No
 Hoarseness
Yes No
 Lumps Yes
No
 Swollen glands Yes
No
 Stiffness Yes
No

Rapid Assessment
Quick Nursing Considerations:
 Patient safety
 VS – including O2 and Pain
 Universal precaution
 Anticipate needs
 Notify MD
PQRST Mnemonics
History of present illness (HPI) - the
chronological order of events of
symptoms.

 Provocative - Palliative factors – what

makes a symptom worse or better.
 Quality – description of the symptom
 Region – which part of the body is
affected
 Severity – what is the intensity of the
symptom; using a scale of 0-10 (10
worst)
Neurological
Assessment
Tools
The following tools will be used during
the neurological exam:
 Reflex hammer
(tomahawk model)
 Penlight
 Tongue blade
 Safety pin
 Cotton swab
 Ophthalmoscope
 Eye chart
 Tuning fork
 Dermatome chart
 NSF
 Cooperative Yes No
 Memory Changes Yes No
 Dizziness Yes No
 Headaches Yes No
 Oriented to: Person __ Place __ Time __
 Deviation: ________________Pupils Size: __________________
 PEARLA Yes No
 Reaction: Brisk __ Sluggish __ No Response __
 LOC: Alert __ Confused __ Sedated __ Somnolent __
Comatose Agitated __ Other ___
 Speech: Clear __ Slurred __ Aphasic __ Dysphasia __ None
 Grips: ________Foot pushes: _________Gag reflex: ___________
Neuro Documentation
Rapid Assessment

Stroke • Cardiac • Comfort

• Pulmona • ECG, cardiac
ry monitor
• Safety • O2 2LPM,
Pulse Ox
• Lab works –
CBC, Coags
 Rapid Assessment
Changes • Neuro • Safety
in • Cardiac • Lab works – CBC,
Mental • Safety lytes, U/A
Status • Following MD
order – sitter or
restraints
• ECG, Cardiac
monitor
• O2 at 2LPM, Pulse
Ox
• Accucheck
 Rapid
Seizure • Assessment
Neuro • Safety
• Safety • Airway
• Lab works – CBC,
lytes, urine
toxicology, ETOH
level
• CT Brain
• Accucheck
• Pulse Ox
• Meds – Ativan
2mg IV
• NPO
Cardiac Assessment
The Heart Chambers and Major
Vessels

http://www.nucleusinc.com/animatio
n2.php
 Patient Positions and Special Techniques for Auscultation

 Position  Use

 supine  general auscultation and most heart sounds

sitting up and leaning 
 aortic stenosis, aortic regurgitation, pericardial 
forward and holding 
rubs
exhalation
 S3, S4, mitral stenosis (using bell of 
 left lateral decubitus
stethoscope)
 increases intensity of mitral valve prolapse and 
 Vasalva manoeuver hypertrophic cardiomyopathy, decreases intensity 
of aortic stenosis
 increases intensity of aortic stenosis, decreases 
 squatting and standing intensity of outflow obstruction in hypertrophic 
cardiomyopathy
1) LV area: apex of the heart at 4th or 5th intercostal space (ICS) along
MCL
2) RV area: 3rd to 5th ICS along the left sternal border (LSB)
3) pulmonic area: 2nd ICS along the LSB
4) aortic area: 2nd ICS along the right sternal border (RSB)
Murmurs
When you encounter a
murmur while
auscultating, it is
important to evaluate
the following
characteristics:

1. systolic vs. diastolic

2. duration
3. pitch: high, medium,
low
4. quality: harsh,
rumbling, blowing
5. intensity: eg
crescendo,
decrescendo,
Distal Pulses
Using a Doppler
Internal Pacemaker
External (Temp)
Pacemaker
ECG Animations
Lead Placement --
http://nobelprize.org/medicine/educational/e
6Second Strips --
http://www.skillstat.com/ECG_Sim_demo.htm
Cardiac Sounds –
http://www.med.ucla.edu/wilkes/Systolic.h
tm
INTERNATIONAL CODES DESCRIBING
PACEMAKERS AND IMPLANTED
DEVICES

Cardiovascular
NSF
 Cardiac Rate: Regular Irregular Irregularly
irregular
 Chest Discomfort Yes No – Where:_______
Intensity (1 -10) _______ Onset _______________
Duration_____________Resolution ____________
 Radial Pulse (R)/(L) Yes No
 Pedal Pulse (R)/(L) Yes No
 JVD (R)/(L)
 Edema – Location __________Pitting __ Non-pitting
__
 Pacemaker – Date Inserted ________________
Type _____________Where: __________________
 Murmur: Yes No
Cardiac Documentation
 Rapid Assessment
Chest • Cardiac • Comfort
Pain • Pulmonar • Lab works –
y CBC, CPK with
• Pain Iso. Troponin
• Stat ECG
• O2 at 2LPM,
Pulse Ox
• Meds – ASA,
NTG, MSO4
Rapid Assessment
Atrial • Cardia • Stat ECG
Fib or • Cardiac
c
A
Flutt monitor
er • Meds
• BR