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JH ASSESSMENTS

NURSING ASSESSMENTS

QuestionAnswer
CRACKLES LIGHT CRACKING, POPPING, INTERMITTENT, NONMUSICAL SOUNDS; LIKE HAIRS RUBBED TOGETHER; HEARD ON INSPIRATION OR EXPIRATION
PLEURAL FRICTION RUB LOW-PITCHED, CONTINUAL, SUPERFICIAL, SQUEAKING OR GRATING SOUND; LIKE PIECES OF SANDPAPER BEING RUBBED TOGETHER; HEARD ON INSPIRATION AND EXPIRATION
RHONCHI LOW-PITCHED, SNORING, MONOPHONIC SOUNDS HEARD PRIMARILY ON EXPIRATION; MAY BE HEARD THROUGHOUT THE RESPIRATORY CYCLE
STRIDOR HIGH-PITCHED, MONOPHONIC CROWING SOUND HEARD ON INSPIRATION; LOUDER IN THE NECK THAN CHEST WALL
WHEEZES HIGH-PITCHED, CONTINUAL, MUSICAL OR WHISTLING SOUND HEARD ON EXPIRATION; MAY BE HEARD ON INSPIRATION AND EXPIRATION
CONFUSION *LOSS OF ABILITY TO THINK RAPIDLY AND CLEARLY*IMPAIRED JUDGMENT AND DECISION MAKING
DISORIENTATION *BEGINNING LOSS OF CONSCIOUSNESS *DISORIENTATION TO TIME PROGRESSING TO DISORIENTATION TO PLACE*IMPAIRED MEMORY*LACK OF RECOGNITION OF SELF (LAST SYMPTOM)
LETHARGY *LIMITED SPONTANEOUS MOVEMENT OR SPEECH*EASILY AROUSED BY NORMAL SPEECH OR TOUCH*POSSIBLE DISORIENTATION TO TIME, PLACE, OR PERSON
OBTUNDATION *MILD TO MODERATE REDUCTION IN AROUSAL *LIMITED RESPONSIVENESS TO ENVIRONMENT*ABILITY TO FALL ASLEEP EASILY WITHOUT VERBAL OR TACTILE STIMULATION*MINIMUM RESPONSE TO QUESTIONS
STUPOR *STATE OF DEEP SLEEP OR UNRESPONSIVENESS *AROUSABLE WITH DIFFICULTY (MOTOR OR VERBAL RESPONSE ONLY TO VIGOROUS AND REPEATED STIMULATION)*WITHDRAWAL OR GRABBING RESPONSE TO STIMULATION
COMA *LACK OF MOTOR OR VERBAL RESPONSE TO EXTERNAL ENVIRONMENT OR STIMULI *NO RESPONSE TO NOXIOUS STIMULI SUCH AS DEEP PAIN *CAN'T BE AROUSED BY AND STIMULUS
GLASGOW COMA SCALE - EYE OPENING 4- OPENS EYES SPONTANEOUSLY3- OPENS EYES TO VERBAL COMMAND2- OPENS EYES TO PAINFUL STIMULI1- DOESN'T OPEN EYES IN RESPONSE TO STIMULUS
GLASGOW COMA SCALE - MOTOR RESPONSE 6- OBEYS/REACTS TO VERBAL COMMAND5- LOCALIZES/IDENTIFIES LOCALIZED PAIN4- WITHDRAWS/FLEXES AND WITHDRAWS FROM PAIN3- ABN FLEX/ASSUMES A DECORTICATE POSITION2- ABN EXT/ASSUMES A DECEBRATE POSITION1- NONE/DOESN'T RESPOND/LIES FLACCID
GLASGOW COMA SCALE - VERBAL RESPONSE 5- ORIENTED/ORIENTED AND CONVERSES4- CONFUSED/ DISORIENTED AND CONFUSED3- INAPPROPRIATE WORDS/ REPLIES RANDOMLY2- INCOMPREHENSIBLE/ MOANS OR SCREAMS1- NONE/ DOESN'T RESPOND
5 P's OF MUSCULOSKELETAL INJURY PAIN - LOCATION, SEVERITY, QUALITYPARESTHESIA - ASSESS LOSS OF SENSATIONPARALYSIS - CAN MOVE AFFECTED AREA?PALLOR - PALE, DISCOLORED, AND COOLPULSE - CHECK DISTAL TO INJURY
ABNORMAL BOWEL SOUNDS IN ANY QUADRANTHYPERACTIVE OR HYPOACTIVE; THEN ABSENT HYPERACTIVE - DIARRHEA, LAXATIVE USE, OR EARLY INTESTINAL OBSTRUCTIONHYPOACTIVE - PARALYTIC ILEUS OR PERITONITIS
ABNORMAL BOWEL SOUNDS IN ANY QUADRANTHIGH PITCHED SOUNDS HIGH-PITCHED TINKLING SOUNDS - INTESTINAL FLUID AND AIR UNDER TENSION IN A DILATED BOWELHIGH-PITCHED RUSHING SOUNDS/ABD CRAMPSINTESTINAL OBSTRUCTION
COMPARING HYPOGLYCEMIA, DKA, AND HHNSSYMPTOM ONSET HYPO - RAPID; MIN TO HRSDKA - SLOW; HRS TO DAYSHHNS - SLOW; HRS TO DAYS BUT MORE GRADUAL THAN DKA
COMPARING HYPOGLYCEMIA, DKA, AND HHNSSIGNS AND SYMPTOMS/ BLOOD PRESSURE HYPO - NORMAL OR ABOVE NORMALDKA - SUBNORMALHHNS - SUBNORMAL
COMPARING HYPOGLYCEMIA, DKA, AND HHNSSIGNS AND SYMPTOMS/ BREATH ODOR HYPO - NORMALDKA - FRUITY, ACETONEHHNS - NORMAL
COMPARING HYPOGLYCEMIA, DKA, AND HHNSSIGNS AND SYMPTOMS/ GI HYPO - NONEDKA - ANOREXIA, N/V, DIARRHEA, TENDERNESS/PAINHHNS - NONE
COMPARING HYPOGLYCEMIA, DKA, AND HHNSSIGNS AND SYMPTOMS/ NEUROLOGIC STATUS HYPO - INITIAL/IRRITABILITY, NERVOUSNESS,GIDDINESS, HAND TREMORS, DIFF SPEAKING, CONCENTRATING, PARESTHESIALATE/ HYPERREFLEXIA, DILATED PUPILS, COMADKA - INITIAL/ DULLNESS, CONFUSION, LETHARGY, DIMINISHED REFLEXESLATE/ COMAHHNS - SAME AS DKA
COMPARING HYPOGLYCEMIA, DKA, AND HHNSSIGNS AND SYMPTOMS/ PULSE HYPO - TACHYCARDIA (BRADYCARDIC IN DEEP COMA)DKA - MILDLY TACHYCARDIC, WEAKHHNS - USUALLY RAPID
COMPARING HYPOGLYCEMIA, DKA, AND HHNSSIGNS AND SYMPTOMS/ RESPIRATIONS HYPO - NORMAL TO RAPID PROGR TO SLOWDKA - DEEP FAST PROGR TO KUSSMAULSHHNS - NORMAL PROGR TO RAPID
COMPARING HYPOGLYCEMIA, DKA, AND HHNSSIGNS AND SYMPTOMS/ SKIN AND MUCOUS MEMBRANES HYPO - COLD, CLAMMY SKIN, PALLOR, PROFUSE SWEATING; NORMAL MUCOUS MEMBDKA - WARM, FLUSHED, DRY, LOOSE SKIN; DRY CRUSTY MUCOUS MEMB; SOFT EYEBALLSHHNS - WARM, FLUSHED, DRY EXTREMELY LOOSE SKIN; DRY CRUSTY MUCOUS MEMB, SOFT EYEBALLS
COMPARING HYPOGLYCEMIA, DKA, AND HHNSSIGNS AND SYMPTOMS/ TEMPERATURE HYPO - COMMONLY SUBNORMAL; MAY BE ELEVATED AFTER EPISODEDKA - HYPOTHERMIA; POSS FEVER (FROM DEHYDRATION OR INFECTION)HHNS - POSSIBLE FEVER (FROM DEHYDRATION OR INFECTION)
COMPARING HYPOGLYCEMIA, DKA, AND HHNSSIGNS AND SYMPTOMS/ WEIGHT, FOOD, WATER HYPO - STABLE WEIGHT, HUNGERDKA - DECR WEIGHT, THIRSTHHNS - DECR WEIGHT, THIRST PROGR TO ABSENCE OF THIRST
COMPARING HYPOGLYCEMIA, DKA, AND HHNSDIAGNOSTIC RESULTS/ ABG HYPO - NORMAL OR SLIGHT RESP ACIDOSISDKA - METABOLIC ACIDOSIS WITH COMPENSATORY RESP ALKALOSISHHNS - NORMAL OR SLIGHT METABOLIC ACIDOSIS
COMPARING HYPOGLYCEMIA, DKA, AND HHNSDIAGNOSTIC RESULTS/ BLOOD GLUCOSE HYPO - BELOW NORMAL <50DKA - ABOVE NORMALHHNS - MARKEDLY ABOVE NORMAL >600
COMPARING HYPOGLYCEMIA, DKA, AND HHNSDIAGNOSTIC RESULTS/ HEMATOCRIT HYPO - NORMALDKA - ABOVE NORMALHHNS - ABOVE NORMAL
COMPARING HYPOGLYCEMIA, DKA, AND HHNSDIAGNOSTIC RESULTS/ KETONES (SERUM) HYPO - NEGATIVEDKA - POSITIVE, LARGEHHNS - NEGATIVE, SMALL
COMPARING HYPOGLYCEMIA, DKA, AND HHNSDIAGNOSTIC RESULTS/ SERUM OSMOLARITY HYPO - NORMAL (290-310)DKA - ABOVE NORMAL BUT USUALLY LESS THAN 330HHNS - MARKEDLY ABOVE NORMAL 350 - 450
COMPARING HYPOGLYCEMIA, DKA, AND HHNSDIAGNOSTIC RESULTS/ SERUM POTASSIUM HYPO - NORMALDKA - NORMAL OR ABOVE NORMALHHNS - NORMAL OR BELOW NORMAL
COMPARING HYPOGLYCEMIA, DKA, AND HHNSDIAGNOSTIC RESULTS/ SERUM SODIUM HYPO - NORMALDKA - NORMAL OR SUBNORMALHHNS - ABOVE NORMAL, NORMAL, OR SUBNORMAL
COMPARING HYPOGLYCEMIA, DKA, AND HHNSDIAGNOSTIC RESULTS/ URINE GLUCOSE HYPO - NORMALDKA - ABOVE NORMALHHNS - MARKEDLY ABOVE NORMAL
COMPARING HYPOGLYCEMIA, DKA, AND HHNSDIAGNOSTIC RESULTS/ URINE OUTPUT HYPO - NORMALDKA - POLYURIA PROGR TO OLIGURIAHHNS - MARKED POLYURIA PROGR TO OLIGURIA
Created by: hartjl
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