The Complete Nursing School 2024

The Complete Nursing School 2024

Head-to-Toe Assessment

• Inspect and palpate
• Palpate carotid pulse
• Check skin turgor (under clavicle)
neck

Mitral
Aortic
Pulmonic
Erb’s Point
Tricuspid
All
People
Enjoy
Time
Magazine

5 Areas for Listening
to the Heart

• Auscultate heart sounds (A, P, E, T, M)
with diaphragm and bell
• Note any murmurs, whooshing,
bruits, or muffl ed heart sounds
heart

anterior chest
• Inspect:
• Use of accessory muscles
• AP to transverse diameter
• -ÌiÀÕVw}ÕÀ>Ì
• Palpate: symmetric expansion
• Auscultate lung sounds: anterior and lateral
• Note any crackles or diminished breath sounds

anterior
posterior

effort rhythm
Note if it’s
labored or
unlabored

Note if it’s
regular or
irregular
Assess the depth
of the respirations:

neck, chest (lungs) & heart

• Knock
• Introduce yourself
• Wash hands
• Provide privacy
• Verify patient’s ID using
Ó«>ÌiÌ`iÌwiÀÃ
(name & date of birth)
• Explain what you are doing
(using non-medical language)

• What is your name?
• Do you know where you are?
• Do you know what month it is?
• Who is the current president?
• Do you know what brought you here?
• A&O X4 = oriented to person,
place, time, and situation

Introduction

• heart rate (hr):
60–100 bpm
• Blood Pressure (bp):
£ÓäÉnä}
• oxygen Saturation (spo2):
95–100%
• Temperature (t):
97.8°F–99°F (36.5°C–37.2°C)
• Respiratory rate (rr):
£ÓqÓäLÀi>Ì
ÃÉ
Orientation “normal” vital signs

head & face

• Inspect
i>`ÉÃV>«É
>À

• Palpate
i>`ÉÃV>«É
>À

head

• Inspect external eye structures
• Inspect color of conjunctiva
and sclera
• PERRLA
Pupils
Equal
Round,
Reactive to Light,
& Accommodation
eyes

VII: Facial
• Raise eyebrows
• Smile
• Frown
• Show teeth
• Puff out cheeks
• Tightly close eyes
• Inspect
• Check for symmetry
• To assess Cranial Nerve VII,
check...
face

• -ÞiÌÀÞ]`À>>}iÉ`ÃV
>À}i]

«>]
i>À}`iwVÌÃ
ears

• Symmetry, patency,
`À>>}iÉ`ÃV
>À}i]
presence of deviated septum
nose

• Color of mucous membranes,
ÃÌÉ`ÀÞ]iÃÃ]>LÀ>
`iÌ>w`}Ã]>LÀ>
breath odors
Mouth

posterior chest
• Inspect
• Auscultate lung sounds in posterior and lateral chest
• Note any crackles or diminished breath sounds
• Auscultate in a sequence to compare lungs
(right upper, left upper, right middle, left middle, etc.)

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Head-to-Toe Assessment

Peripherals

lower extremities (hips, knees, ankles)
• Inspect and palpate
• Note any texture, lesions,
temperature, moisture,
tenderness, & swelling
• Palpate radial pulses bilaterally

spine

• Have the client stand up (if able)
• Inspect the skin on the back
• Inspect spinal curvature
­ViÀÛV>ÉÌ
À>VVÉÕL>À®
• Palpate spine
• Note any lesions, lumps,
or abnormalities

upper extremities

• Inspect
• Overall skin coloration
• Lesions
• Hair distribution
• Varicosities
• Edema
• Palpate: check for edema
(pitting or non-pitting)
• Check capillary
ÀiwL>ÌiÀ>Þ
lower extremities

• Inspect and palpate
hips

• Inspect and palpate
knees

INTERPRETATION:
If the skin stays
elevated and does not
return to its original
place quickly, it
indicates the patient
is dehydrated

• Inspect, palpate, assess
shoulder

• Inspect, palpate, assess
elbows

• Inspect
>`ÃÉw}iÀÃÉ>Ã
• Palpate
>`Ã>`w}iÀÌÃ
• Check muscle strength of hands bilaterally
• Does each hand grip evenly?
hands & fingers

abdomen

Absent:
Must listen for at least 5 minutes
to chart absent bowel sounds
Hypoactive:
One bowel sound every 3–5 minutes
Normoactive:
Gurgles 5–30 times per minute
Hyperactive:
Can sometimes be heard without a
stethoscope. Constant bowel sounds
(> 30 sounds per minute)
• Inspect
• Skin color
• Contour
• Scars
• Aortic pulsations
• Auscultate bowel sounds: all 4 quadrants
(start in RLQ and go clockwise)
• Light palpation: all 4 quadrants
Assess in different order:
Inspect
Auscultate
Percuss
Palpate
1
2
3
4

capillary
refill time (CRT)
Time taken for capillary
bed to regain its color
after pressure has
been applied
Normal:
ÌiÌvii`L>VÉÃÌÀÕVÌÃ
• Exhibit professional manner during exam
(treat patient with respect and dignity)
• Be organized and follow a logical sequence
(order of exam should “made sense”)
overall

• Inspect ankles
• Palpate
• Posterior tibial (PT)
& dorsalis pedis (DP) pulse bilaterally
ankles

If we were to
percuss & palpate before
listening (auscultating),
we would alter the bowel
sounds. This would
lead to inaccurate
results.

skin
• Assess skin turgor by
pinching or lifting the skin

0 Pulse is absent
1+ Diminished
2+ Normal
3+ Full
4+ Bounding, strong
pulse scale:

0 Pulse is absent
1+ Diminished
2+ Normal
3+ Full
4+ Bounding, strong
pulse scale:

Dorsalis
Pedis
Artery

Posterior
Tibial
Artery

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Ñøtëß

It’s a beautiful thing
when a career
and a passion
come together.

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Døßågë
Çålçülåtïøñ

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1 Show ALL your work.

5 Most nursing schools do not give partial credit.
This means every step must be done correctly!
2 Leading zeros must be placed before any decimal point.
The decimal point may be missed without the zero
.2 mg should be 0.2 mg
WHY? .2 could appear to be 2
­ä°Ó}vÀ«
iÃ6
,9`vviÀiÌÌ

>Ó}vÀ«
it®

EXAMPLE

EXAMPLE

4 Do not round until you have the final answer!
HOW TO ROUND YOUR FINAL ANSWER:
If the number
in the thousands place
is 5 or greater

→ The # in the hundredth place is rounded up
1.995 mg is rounded to 2 mg
1.985 mg is rounded to 1.99 mg

If the number
in the thousands place
is 4 or less

34.732

tenths
ones
tens
hundredths
thousandths
DECIMAL
REFERENCE GUIDE

→ The # is dropped

0.992 mg is rounded to 0.99 mg
EXAMPLES

EXAMPLES

3 No trailing zeros.
0.7 mL NOT 0.70 mL
1 mg NOT 1.0 mg
WHY? 1.0 could appear to be 10t

Dosage Calc Rules

Medication errors
kill; prevention is
crucial!

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Abbreviations

PO by mouth
IM intramuscularly
PR per rectum
subQ subcutaneously
SL sublingual
ID intradermal
GT gastrostomy tube
IV intravenous
IVP intravenous push
IVPB intravenous piggyback
NGT nasogastric tube
ROUTES OF ADMINISTRATION

tab, tabs tablet
cap, caps capsule
gtt drop
EC enteric coated
CR controlled release
susp suspension
elix elixir
sup, supp suppository
SR sustained release

,É8, iÝÌi`i`Àii>Ãi
DRUG PREPARATION

g (gm, Gm) gram
mg milligram
mcg microgram
kg kilogram
L liter
mL milliliter
mEq milliequivalent

METRIC

gtt drop
min, m, mx minim
tsp teaspoon
pt pint
gal gallon
dr dram
oz ounce
T, tbs, tbsp tablespoon
qt quart
APOTHECARY
& HOUSEHOLD

ac before meals
pc after meals
daily every day
bid two times a day
tid three times a day
qid four times a day
qh every hour
ad lib as desired
stat immediately
q2h every 2 hours
q4h every 4 hours
q6h every 6 hours
prn as needed
hs at bedtime
TIMES OF MEDICATIONS question: A patient is receiving 1 mg tid.
How many mg will they receive in one day?
Remember: tid = 3X a day
Answer: If they are receiving 1 mg for 3X a day,
that’s 1 mg x 3 = 3 mg per day
EXAMPLE

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Conversions

1500 mcg = mg
A mg is larger than a mcg
Therefore you move decimal
3 places to the left
1500. mcg = 1.500 mg (1.5 mg)
Moving to a larger unit?
Move the decimal place to the left
(Ex: mcg → mg)

Båßëd øñ Vølümë

1 mg = 1,000 mcg
1 g = 1,000 mg
1 oz = 30 mL
8 oz = 1 cup
1 tsp = 5 mL
1 dram = 5 mL
1 tbsp = 15 mL
1 tbsp = 3 tsp
1 L = 1,000 mL

Large unit to small unit → move decimal to the right
small unit to Large unit → move decimal to the left
THE METRIC SYSTEM

EXAMPLE

MEMORY
TRICK
larger unit
think left

Båßëd øñ Wëïght

1 kg = 2.2 lbs
1 lb = 16 oz

120 lbs = _____ kg
120 lbsÉ2.2 = 54.545 kg

45.6 kg = ______ lbs
45.6 kg x 2.2 = 100.32 lbs
kg → lb
MULTIPLY by 2.2

lb → kg
divide by 2.2

EXAMPLE

EXAMPLE
3 2 1

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Formula Method

D
H
x V = A
For Volume-Related Dosage Orders:

EXAMPLE 1
Ordered: Drug C 150 mg
Available: Drug C 300 mg/tab
How many tablets should be given?

What’s our desired? Drug C 150mg PO
What do we have? Drug C 300mg/tab
7
>Ì1⁄2ÃÕÀμÕ>ÌÌÞÉÛÕi¶tablets

EXAMPLE 2

150 mg 300 mg x 1 tab = 0.5 tabs
150 300 = 0.5 x 1 = 0.5 tabs

Ordered: Drug C 10,000 units SubQ
Available: Drug C 5,000 units/mL
How many mL should be given?

What’s our desired? Drug C 10,000 SubQ
What do we have? Drug C 5,000 units
7
>Ì1⁄2ÃÕÀμÕ>ÌÌÞÉÛÕi¶1 mL
10,000 units 5,000 units x 1 mL = 2 mL

10,000 5,000 = 2 x 1 = 2 mL
FINAL ANSWER: 0.5 tabs FINAL ANSWER: 2 mL

Some medications like heparin and
insulin are prescribed in units/hour

A= Amount of Medication required for administration

Your answer

D=Desired

H=Dosage of medication available

Example: “The medication is supplied as 100 mgÉx»
Example: “The physician orders 120 mg...”

V= Volume the medication is available in

Example:o/

ii`V>ÌÃÃÕ««i`>ãää}É5 mL”

All answers should be computed per
instructions. This may be per dose, per
shift, per day, etc. Read the instructions
V>ÀivÕÞt­
Ý° ̧
Ü>ÞÌ>LiÌÃÜ

ÞÕ}ÛiÓ{
ÕÀö ̧® ̧

!
!

D
H
x V = A