Nurs 500 exam 1.txt
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The process of analyzing health data and Drawing conclusions to identify diagnosis
Six phases of the nursing process
- outcome identification
- implementation and
Normal range of findings, posture
Pastor is a rack and position is relaxed
Abnormal findings, posture
Sitting on the edge of the chair crawled into bed, tense muscles, frowning, darling watchful eyes, restless face occurs with anxiety and hypothyroidism. Singing some chair, how slow walking, driving to be occur with depression and some organic brain diseases
Body movements, normal range of findings
Body movements are voluntary deliberate coordinated smooth and even
abnormal findings body movements
- Restless fidgety movements or hyperkinetic parents may occur with anxiety
- At the bar cycle motor slowing occur with depression and dementia
- Abnormal posture and bizarre gestures occur with schizophrenia
- Facial grimaces
￼ Normal range of findings, dress
Dress is appropriate for setting, season, age, gender, and social group. Close fit and are put on appropriately
Abnormal findings: dress
The address can occur with organic brain syndrome. Eccentric dress combinations in bizarre makeup can occur with schizophrenia or manic syndrome
Grooming and hygiene: normal range of findings
The person is clean and well groomed: hair is neat and clean: women have moderate or no make up, men are shaved, or beard or mustache is well groomed. Nails are clean up, (although some jobs leave nails cause they dirty. )
Note: a disheveled. Appearance in a previous Well groomed person is significant. Use care in interpreting clothing that is disheveled, bizarre, or in poor repair, piercings, and tattoos, because sometimes reflect the person's economic status or deliberate fashion trend especially among adolescents
Grooming and hygiene: abnormal findings
- Unilateral neglect, total attention to one side of the body, occurs following some cerebrovascular accidents.
- Inappropriate dress, poor hygiene, and lack of concern with appearance occurs with depression and severe Alzheimer's disease. Meticulously dressed and groomed appearances and fastidious manner make her with obsessive-compulsive disorder
Level of consciousness: normal range findings
A person is awake, alert, and aware of stimuli from the environment within the self and responds appropriately and reasonably soon to stimuli
Level of consciousness: abnormal findings
Loses track of conversation, fall asleep. Lethargic, confused
Facial expressions, normal range of findings
The look is appropriate to situation and changes appropriately with the topic. There's comfortable I contact unless precluded by cultural norm
Facial expressions abnormal findings
Flat masklike expressions occur with Parkinson's and depression
Speech normal range of findings
- Judge the quality of speech by noting the person makes laryngeal sounds effortlessly and shares conversation appropriately.
- the pace of the conversation is moderate and stream of talking is fluid.
- Articulation is clear and understandable.
- Word choice is effortless inappropriate to educational level the person complete sentences occasionally positive think
Speech: abnormal findings
- Dysphonia is abnormal volume, pitch etc.
- Slow monotonous speech with Parkinson's depression and depression rapidfire pressure and loud talking occurs with me and etc.
- Dysarthria Is distorted speech missuses words omits letters, syllables, or words: transposes words: occurs with aphasia
- Iunduly long word finding or failure in WORDsearch occurs with aphasia
Mood and affect ; normal range of findings
Judge this by body language and facial expressions and by asking directly "how do you feel today" or "how do you usually feel" the mood should be appropriate to the person's place in condition and change appropriately with topics person is willing to operate with you
4skills required for physical examination
Level of consciousness: normal range of findings
The person is alert and oriented attends your questions and responds appropriately
Level of consciousness abnormal findings
Confused Drowsy lethargic
Pulse force 3+
Pulse force 1+
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