Nursing Charting Examples Flashcards

Questions and Answers

How would you describe gait after inspection/observation?

Steady gait

How would you describe the skin after inspection?

Skin appears pink, well-hydrated, with no obvious lesions

How would you describe a person's nail beds after inspection?

Nail beds appear pink without lines, ridges, clubbing, or cyanosis

How would you grade a pulse that feels 'normal'?

2+ and brisk Signup and view all the answers

How would you describe the head after palpating the head and scalp?

Head is normocephalic with no scars, masses, lesions, or tenderness; good hair distribution and of average texture Signup and view all the answers

How would you describe the alignment and symmetry of the eyes?

Eyes are symmetrical with good alignment; eyebrows and eyelashes with good distribution Signup and view all the answers

How would you describe external eye structures after inspection?

No abnormalities of the eyelids; conjunctiva is pink, sclera is white; no excessive tearing or discharge Signup and view all the answers

What would you say when the patient passes the EOM test (H pattern), convergence, and accommodation?

Extraocular movements for cranial nerves 3, 4, and 6 intact Signup and view all the answers

What would you say when the patient passes the papillary response to light tests?

Pupils constricting with exposure to light; equally reactive to light Signup and view all the answers

How will you describe a normal finding after inspection of the ears?

External ears without lesions, deformities, or tenderness Signup and view all the answers

How will you describe a normal finding after palpation of the external ear?

Pinna and tragus without tenderness Signup and view all the answers

How will you describe the mucosa, septum, and turbinates after inspection of the nose?

Mucosa pink, septum midline, no ulcerations or polyps Signup and view all the answers

How will you describe a normal finding after palpation of the sinuses?

No tenderness of the frontal or maxillary sinuses Signup and view all the answers

How will you describe a normal finding after inspection of the mouth, lips, and gums?

Lips are pink and moist; oral mucosa, gums, pharynx are pink without lesions; good dentition; tongue and uvula midline; tonsils 1+ without crypts or exudate; sublingual area without lesions Signup and view all the answers

What is the tonsillar grading scale?

0=tonsils fit within tonsillar fossa; 1+=tonsils Signup and view all the answers

Study Notes

Gait and Skin Assessment

Gait is described as steady, indicating stability in movement.
Skin assessment reveals a pink appearance, well-hydrated condition, and absence of lesions.

Nail Bed Evaluation

Normal nail beds are pink, lacking lines, ridges, clubbing, or signs of cyanosis.

Pulse Grading

A palpated pulse graded as 2+ signifies a brisk and normal strength.

Head and Scalp Inspection

Normocephalic head is observed with no scars, masses, or tenderness; hair distribution is good with average texture.

Eye Assessment

Eyes appear symmetrical and aligned, with well-distributed eyebrows and eyelashes.
External eye structures show no abnormalities; conjunctiva is pink, and sclera is white with no excessive tearing or discharge.

Extraocular Movements

Extraocular movements assessed via the H pattern indicate intact cranial nerves 3, 4, and 6.

Pupillary Response

Pupils constrict in response to light, and are equally reactive, demonstrating normal neural function.

Ear Examination

External ears are free from lesions, deformities, and tenderness upon inspection.
Both the pinna and tragus are palpated without tenderness, indicating normal findings.

Nasal Examination

Nasal mucosa is pink, septum is midline, and there are no ulcerations or polyps.

Sinus Palpation

No tenderness is noted in the frontal or maxillary sinuses, reflecting normal sinus conditions.

Oral Cavity Inspection

Lips are pink and moist; oral mucosa, gums, and pharynx are pink with no lesions.
Good dentition observed; tongue and uvula are midline, tonsils are rated 1+ with no crypts or exudate, and sublingual area is free from lesions.

Tonsillar Grading Scale

Tonnillar grading is from 0 (fit within fossa) to 1+ (present but not enlarged).

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Description

This quiz focuses on flashcards that provide examples of nursing charting, emphasizing the description of gait, skin, and nail beds. Perfect for nursing students looking to strengthen their observational skills and documentation accuracy.