Chapter 15

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Author:
RosieHernandez
ID:
105701
Filename:
Chapter 15
Updated:
2011-10-03 23:22:01
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Basic Nursing
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Description:
Physical Assessment
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  1. Ptosis
    Drooping of eyelid over the pupil
  2. Alopecia
    Loss of hair
  3. Edema
    Fluid accumliation, swelling
  4. Jaundice
    Yellow orange discoloration
  5. Bruit
    Blowing, swishing sound in blood vessel
  6. Melena
    Black, tarry stools
  7. Kyphosis
    Curvature of the thoracic spine
  8. Petechiae
    Tiny, pinpoint red spots on the skin
  9. Erythema
    Red discoloration
  10. Induration
    A hardening area
  11. Three best positions for a cardiac assessment?
    • Supine
    • Sitting
    • Lateral recumbent
  12. Percussion
    Involves tapping the body with the fingertips to produce a vibration that travels through body tissues.
  13. Auscualtion
    Listening with a stetscope to sounds produced by the body.
  14. Olfaction
    Helps to detect abnormalities not recognized by other means.
  15. Integument
    Consist of skin, hair, scalp, and nails.
  16. Cyanosis
    Blush discoloration of the skin
  17. Pallor
    Unusal paleness
  18. Dorsum
    back of hand
  19. Turgor
    The skins elasticity
  20. Lunula
    Whiteish area at the base line of the nail bed.
  21. Visual Acuity test?
    Snellen chart
  22. Tinnitus:
    Ringing in ears
  23. Vertigo:
    Loss of balance
  24. Cerumen:
    A yellow, waxy subsance in ear.
  25. 3 types of hearing loss:
    • Conduction
    • Sensorineural
    • Mixed
  26. Purpose of physical examination
    • Gather baseline data
    • Supplement, confirm, or refute data
    • Confirm and identify nusring diagnosis
    • Make clinical judgements
    • Evaluate the outcomes of care
  27. Cultural Sensitivity
    Learn to recognize common disorders for those ethnic populations within the community.
  28. Inspection
    the use of vision and hearing to distinguish normal from abnoraml findings
  29. Palpation
    Involves the use of hands to touch body parts to make sensitive assessments.
  30. Should you touch anything pulsating?
    No
  31. Palpation of abdomen
    • Check for tenderess, distention, or masses.
    • 1 cm deep.
    • Palpate after inspection and auscultation
  32. Percussion
    Involves tapping the body with the fingertips to produce a vibration that travels thru body tissues
  33. Ausculation
    Listening with a stethoscope to sounds produced by the body.
  34. Olfaction
    Helps to detect abnormalities not recognized by other means.
  35. General survey
    Begins when you first meet pt and with a review of primary health pattern. Provides info about characteristics of illness, hygiene, skin condition, body image, emotional state, dev status
  36. What is the first part of a physical examination?
    Assessment of vital signs
  37. Vital signs include:
    • BP
    • TPR
    • Height
    • Weight
    • Pain
  38. Integument
    Consists of the skin, hari, scalp, and nails.
  39. What do you use to assess the integument function and integrity?
    • Palpation
    • Olfaction
  40. What does the assessment of skin reveal?
    changes in oxygenation, circulation, nutrition, local tissue damage, and hydration.
  41. What kind of light do you observe the skin?
    Halogen lighting and natural.
  42. The examination of skin includes:
    • Skins color
    • Moisture
    • Temperature
    • Texture
    • Turgor
    • Vascular changes
    • Edema
    • Lesions
  43. Pallor
    Unusual Paleness
  44. Measure lesions in:
    • Height
    • Width
    • Depth
  45. Lunula
    The semilunar whitish area at the base of the nail bed.
  46. Normal nail:
    160 degrees
  47. Clubbing nail:
    • 180 degrees
    • Causes: Chronic lack of oxygen, heart or pulmonary disease.
  48. Beaus nail:
    • Bump in the middle of the nail.
    • Causes: Nail injury
  49. Koilonychia (spoon nail):
    • Concaved nail
    • Anemia
    • Syphillis
  50. Splinter hemorrages:
    • Red or brown streaks on nail
    • Causes: Minor trauma
  51. Paronychia
    • Inflammation of skin at base of nail
    • Causes: Local infection and trauma
  52. Visual acuity test:
    Snellen chart
  53. What do you record if normal pupillary reaction:
    PERRLA
  54. Tinnitus
    ringing of ears
  55. Vertigo
    Loss of balance
  56. Nose bleed:
    Epistaxis
  57. Sites of palpable lymph nodes:
    • Head
    • Neck
  58. What position must a patient be if your orthopnea:
    Upright position
  59. Dyspnea
    Shortness of breath
  60. 4 types of adventitious sounds:
    • Crackles
    • Rhonchi
    • Wheezes
    • Pleural Friction Rub
  61. Heart
    Compare your assessment of heart function with findings from the vascular assessment.
  62. Inspection and palpation of patient with heart disease:
    45 degrees and supine position
  63. Ausculation of heart:
    • Sitting up and leaning forward
    • Supine
    • lateral recumbent
  64. Examining the carotid arteries:
    Patient to sit or lie supine with the head of the bed elavated 30 degrees
  65. Bruit
    Blowing sound
  66. The 2 acessible veins:
    Internal an external jugluar vien
  67. Phlebitis
    Inflammation of a vein
  68. Normal bowel sounds:
    5 to 35 times per minute
  69. Musculosketetal System
    Visualize anatomy of bone, muscle and joint placmeent. Conduct nursing history. Use inspection and palpation (should have no pain). Assess RAM, strength and tone of muscle
  70. Neurological system
    Conduct nursing history. Assess language, intellectual function, cranial nerve function, sensory nerve function, motor functionAlways doing this from time you walk into room
  71. How many cranial nerves is there:
    12
  72. What scale is used for perdiction of recovery potential:
    Glascow Coma Scale
  73. Glascow scale
    Total score between 3 to 15Actions are eyes open, best verbal response, best motor responseResponses range from 1-6 and get a score
  74. What is used for pain assessment:
    • PQRST
    • Pain
    • Quality
    • Radiation
    • Severity
    • Treatment
  75. Sitting position
    Vital signs
  76. Supine
    • laying down
    • for pulse sites
  77. Dorsal recumbent
    • Abdonimal
    • Head and neck
    • Lungs & Breast
  78. Lithotomy
    vagina
  79. Sims
    • Rectum of vagina
    • side with hip and knee bent
  80. Prone
    • laying on stomach
    • Musculoskeletal
  81. Lateral recumbent
    • laying on side
    • heart
  82. Knee - chest
    Rectum

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