Clinical Assessment Preparation

CPNE Study Guide

3.3 Abdominal Assessment • Ask the patient if they need to void • Ask if the patient is experiencing any pain • Position the patient supine with knees flexed • Suspend gastric suction prior to auscultation when indicated • Reestablish gastric suction immediately after auscultation • Assess:  Perform assessment techniques in proper sequence  Inspect the abdomen for: 1. Appearance (e.g., drains, incision site, dressing, discoloration) 2. Contour (e.g., flat, round, distended, convex, concave)  Auscultate for bowel sounds in all abdominal quadrants  Perform light palpation in all abdominal quadrants, assessing for: 1. Tenderness or pain 2. Muscle resistance (e.g., soft, firm, rigid) • Document:  Appearance of abdomen  Contour of abdomen  Bowel sounds in all quadrants  Tenderness or pain  Muscle resistance

3.4 Neurological Assessment • LOC: Level of consciousness – person/place/time/familiar objects • Observe a 1 to 3-year-old child or non-communicating child/adult’s ability to recognize familiar people or common objects in the environment • Palpate anterior fontanel when indicated: Assess for child < 1 yr. Upright position, depressed, flat, or bulging • Pupils: equal and round, reaction to light (e.g., brisk, sluggish, fixed) • Determine equality of muscle strength/motor response in upper and lower extremities:  Ask the responsive patient to: 1. Squeeze student’s fingers simultaneously with both hands 2. Dorsiflex both feet simultaneously against resistance 3. Plantarflex both feet simultaneously against resistance • Observe motor response(s) in a child under 3 years of age or a non-communicating child/adult:  Symmetry in the upper extremities  Symmetry in the lower extremities  Movement in the upper extremities  Movement in the lower extremities • Document:  Level of arousal

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