Tiêu đề NURSING BUNDLE.pdf ✅

Head & Face HEAD • Inspect head/scalp/hair • Palpate head/scalp/hair FACE • Inspect • Check for symmetry • To assess Cranial Nerve 7, check the following: – Raise eyebrows – Smile – Frown – Show teeth – Puff out cheeks – Tightly close eyes EYES • Inspects external eye structures • Inspect color of conjunctiva and sclera • PERRLA – Pupils Equal, Round, Reactive to Light, & Accommodation Neck, Chest (Lungs) & Heart NECK • Inspect and palpate • Palpate carotid pulse • Check skin turgor (under clavicle) POSTERIOR CHEST • Inspect • Auscultate lung sounds in posterior and lateral chest – Note any crackles or diminished breath sounds ANTERIOR CHEST • Inspect: – Use of accessory muscles – AP to transverse diameter – 6WHUQXPFRQILJXUDWLRQ • Palpate: symmetric expansion • Auscultate lung sounds – anterior and lateral – Note any crackles or diminished breath sounds HEART • Auscultate heart sounds (A, P, E, T, M) with diaphragm and bell – Note any murmurs, whooshing, bruits, RUPXIŶHGKHDUWVRXQGV Introduction • Knock • Introduce yourself • Wash hands • Provide privacy • Verify patient ID and DOB • Explain what you are doing (using non-medical language) Orientation • What is your name? • Do you know where you are? • Do you know what month it is? • Who is the current U.S. president? • What are you doing here? • A&O X4 = Oriented to Person, Place, Time, and Situation "Normal" Vital Signs PULSE: 60-100 bpm BLOOD PRESSURE:120/80 mmHg O2 SATURATION: 95-100% TEMPERATURE: 97.8-99.1° F RESPIRATIONS: 12-20 breaths per min INSPECT PALPATE PERCUSS AUSCULTATE HEAD-TO-TOE ASSESSMENT 4