data about the patient's

objecctive
physical status
data is obtained by patient
report through history taking subjective
and interviewing
what is a visual examination
inspection
of all parts of body
size, shape, color, symmetry, position, abnormalities, compare
what do we inspect for w/ same area on the opposite side of body, and use additional
light if needed and for body cavities
what is the term for touching-
palpation
feeling w/ fingers and hands
how might you encourage advise the client you are to touch him and use a gentle
relaxation beofore you palpate approach
what areas would you palpate
tender areas
last
what does the dorsal
temperature
surfaceof your hand palpate
what does your finger tips
texture, size, consistency, pulsation, form and shape,
palpate
what does your palmer
vibration
surface palpate
what could happen if you
you could reduce circulation to the brain or cause changes in
obstructed blood flow over
heart flow
carotid arteries
what is referred to as tapping
the body w/ fingertips to
percussion
evaluate size, borders, density
air or fluid
when you tap lightly with the
pads of the fingers on the the direct percussion
skin what is that refered to
this is used more frequently
and is requires both hands in indirect percussion
reference to percussion
is listening to sounds auscultation
what is usually performed last auscultation
after inspection, palpation,
and percussion except when
assessing the abdomen
what is direct auscultation is listening w/out using an instrument
what is indirect auscultation is listening w/ the help of a stethoscope
name the 5 major parts of the earpieces, binaurals, tubing, bell chestpiece, and diaphragm
stethoscope chest piece
dual tubes promote sound clarity
what do you listen w/ to listen
diaphragm
to high pitched sounds
what do you listen w/ to listen
to low pitched sounds such as bell
extra heart sounds
when during the physical
assessment would you need if exposure to body fluids is a possibility
to wear gloves
where would you place a on skin, not over the clothes because the clothes will add or
stethoscope obscure sounds and interfere w/ accurate assessment
wash hands, environmental noise, remember to protect the
what are some things you patient's privacy, inform the patient that you are going to do an
would do in order to get ready assessmetn before you start and explain what you are doing
for an assessment throughout the procedure, assess the limitations fo your patient
so that you will know how to assest them, gather equipment

what are the two methods to

use on an assessment
what is the most efficient
method in assessing a client
what is the first step is
assessing a client
what are some things you
would assess under general
appearance and behavior
when you are assessing age
what are looking for
head to toe, and body systems method
head to toe
general survey as soon as you walk in you will be gathering
information about their health status
gender and race, age, are there any signs of distress such as
sob, decreasede alertnes, signs of pain, sweating, abnormal
color, body type, posture, gait, body movements, hygiene and
grooming, dress, body odor, affect adn mood and mental state,
speech, sign of abuse
do they appear their stated age or look oler or younger? this
tells you something about their health status
what are you assessing in the
an unkept appearance may reflect chronic pain, fatigue,
client who is not dressed
depression or low self esteem
normal
are they overweight or underweight. do they have good muscle
what are you assessing in the
tone an dappear physically fit or do they appear out of shape
body type
and debilitated
If daily weights are ordered
at the same time, usually before breakfast on teh same scales
make sure that they are done
w/ the same clothes
when
who would require daily wts. pts. w/ fluid balance due to heart or kidney disease.
What part of the assessment
would provide valuable
information about your client's
growth and development height and weight assessment
nutritional status overall
general health and required
dosages for medication
abnormal skin lesions may
reflect abnormal conditions of the skin or of internal pathological processes
what?
information gained from
circulation, oxygenation, nutrition, hydration and certain
assessment of skin includes
metabolic and endocrine conditions
the status of
what is the term used to
describe a blue gray coloration
cyanosis
of the skin often described as
ashen
in light skinned clients skin
appars whit loss of pink or pallor
yellow tones
a yellow orange cast to the
jaundice
skin
a reddened area erythema
may be related to poor pallor
circulation or a low
hemoglobin level (anemia)
best sites to assess include
the oral mucous membranes,
conjunctiva, nail beds, palms,
and soles of feet
if seen in the lips, mucous
membranes, and facial
features it si known as central
cyanosis and is associated w/
cyanosis
hypoxia may also be seen in
the extremities, especially
hands adn feet, after exposure
to extreme cold
often associated w/ liver
disorders. Best sites to assess
include the sclera, muchouls jaundice
membranes, hard palate of the
mouth, palms and soles
associated w/ rashes, skin
infections, and prolonged erythema
pressure on teh skin
what will you use to assess
the dorsum of the hand or fingers
skin temp.
what may stimulate the
metabolisma nd may also
hyperthyroidism
cause an elevation in skin
temp
erythema accompanied by
infection or inflammatory
warmth may indicate
what is a normal skin moisture
skin is warm and dry
assessment
excessive moisture may result
hyperthermia, thyroid hyperactivity, anxiety or hyperhidrosis
from

dehydration, chronic renal failure, hypothyroidism, excessive

dry skin may result from
exposure, or overzealous hygiene
what is the normal skin texture is smooth and soft
what may be some factors exposure, age, hyperthyroidism and other endocrine
effecting the skin texture disorders, impaired circulation
refers to the elasticity of the
turgor
skin,
skin tenting refers to dehydration in skin tugor
what are white normal raised
areas on the nose chin and
milia
forehead of newborns due to
sebum
how do primary skin lesions
develop as a result of disease or irritation ex pustules of acne
develop
develop from primary lesions as a result of continued illness,
how do secondary lesions
exposure, injory or infection, such as the crusts that form from
develop
ruptured pustules
a is for asymemetry, b border irregularity, c color, d diameter
what is ABCDE
greater than .5 cm, e elevation above the surface
what are due to pigmented
cells in the deeper areas of skin
adn fade as the child matures
mongolian spots
(blue-black areas seen on
lower back and buttocks of
african/asian/native american)
sometimes known as stork
bites are small irregular pink
red areas that are often seen capillary hemangiomas
around the face and neck in
newborns
ecchymosis is a color variation bruised (blue-green-yellow) area may be seen anywhere on
what is the description and teh body. the color will vary based on teh age fo the injury
significance of its meaning may indicate abuse
flat and colored ex. freckle
macule
birthmark, mongolian spot
elevated and raised by
papule
superficial ex. moles psoriasis
a small circumscribed area
distinct from surrounding
patch
surface in character and
appearnce
a patch on the skin or on a
plaque
mucouls surface
elevated solid and firm w/ depth
nodule
into dermis ex. wart
hive/ elevated superficial w/
wheal
localized edema ex. insect bite
palpable fluid filled and
keratogenous cyst
encapsulated
blisters elevated and filled w/
vesicle
serrous fluid ex. blister, herpes,
elevated and filled w/ pus ex.
pustule
acne falliculitis impetigo
What information can you
a change in nail shape may indicate underlying disease
gather by inspecting the nails?
which the nail plate is 180 deg. clubbing is associated w/ long term hypoxic states, such as
or more occurs w/ chronic lung disease
what is the term used that may
result from iron deficiency in ref spoon shaped nails
to nails
level, firm, and similar to the color of the skin, nail is smooth
healthy nail beds are
and uniform in texture w/ a 160deg. nail plate angle

white spots in the nails

may indicate zinc deficiency
represent
black nails are due to blood under the nail, are seen after local trauma
what is referred to as small
hemorrhages under the nail
splinter hemorrhages
bed associated w/ bacterial
endocarditis or trauma
which are transverse white
lines in teh nail bed. seen in
mee's lines
clients who have experienced
sever illnesses
which a distal band of reddish
pink covers 20 to 60% of the
half and half nails
nail occur in clients w/ low
albumin levels or renal disease
what is capillary refill and how
briefly press the tip of the nail w/ firm steady presure then
do you assess it what does an
release and observe for changes in color this test assesses
abnormal capillary refill
circulartory adequacy rather than the nails
indicate?
what is a common complaint w/
pruritis
skin conditions
the scalp is assessed for lesions, lumps, bruises, lice and abnormal hair distribution
what is referred to as
excessive facial or trunk hair
hirsutism
may be due ot endocrine
disorder or steroids
what is referred to hair loss can
be caused by chemotherapy
for the treatment fo cancer or alopecia
by nutritional deficiencies or by
endocrine disorders
what is pediculosis head lice infestation
size, symmetry, and presence fo nodules, masses, and
Inspect head and neck for
bulges, shape
normocephalic normal head
an abnormally small head size is seen in clients w/ certain
microcephaly
types of mental retardation
a disorder associated w/
acromegaly
excess growth hormone
an accumulation of excessive
hydrocephalus
cerebrospinal fluid
disease fo the lymph nodes lymphadenopathy
irregular jaw movement or
TMJ, temperomandibular joint syndrome
cracking of the jaw
do they wear glasses, contact lenses? inspect and palpate the
When assessing the clients
external eye structues, assess vision and examine the internal
eyes what do you inspect
eye structures
double vision is the perception
of two images from a single diplopia
object
associated w/ hyperthyroidism
failure of or both pupils to
exopthalmos
accomadate may reflect a
cranial nerve III
a drooping of the lid ptosis
a white ring encircling the outer
arous senilis
rim of the cornea
lack of coordination between
the eyes as a result the eyes
strabismus
look in different direction and
do not focus on the same time
the medical term for cross eyed strabismus

puffiness of the eye periorbital edema

an inflammation fo the
conjunctivitis
conjunctiva
the medical term for pink eye conjunctivitis
scleral icterus a way of determining jaundice in the sclera of the eye
what is are you inspecting in
reference to the general note irritation, discharge, swelling
appearance of the eye
sob, restlessness, decreased mental alertness, cyanosis, pallor,
what are some signs of
nasal flaring, orthopnea, intercostal retractions, use of accessory
respiratory distress
muscles, increased heart rate
What does barrel ches look used to describe the rounded, barrell shap of the chest that can
like and when would it be occur in people w/ chronic obstructive pulmonary disease
present (COPD) such as emphyema
Which part of the
stethoscope is used to listen diaphragm
to the lungs
what are soft low pitched
breezy sounds w/ a lengthy
vesicular breath sounds
inspiratory phase adn a short
expiratory
which breath sounds are
heard over the 1st and 2nd
ICS adjacent to the sternum
bronchovesicular breath sounds
on teh anterior chest and
between teh scapula on teh
posterior chest
What breath sounds are bronchovesicular breath sounds
medium pitched w/ an equal
inspiratory and expiratory
phase
Auscultation 6 places front
and back what are some of normal, decreased, diminished, absent, increased adventitious
the breath sounds you will voice sounds
hear
if you there are no breathing
absent breathing sounds may be an ex. of a punctured lung,
sounds in that area that may
collapsed or if they removed a portion of the lung
represent what
what is the term to describe
additional sounds that are adventitious
not the normal lung sounds
what do you inspect in ref. to placement, nasal flaring(difficulty breathing), drainage, nasal
nose mucosa, deviated septum
what is the term used to
described difficulty breathing orthopnea
while lying down
what is the 1st sign of lack of
restlessness
oxygen
what are some subjective
cough, chest pain, history of resp. infections, smoking history
data when inspecting the
(pack/years), environmental exposure, self-care behaviors
thorax and lungs
tachypnea rapid respiration
hyperventilation increased respiration
rapid deep breathing w/out
pauses more than 20min in
Kussmaul's respirations
adults labored breathing that
sounds like sighs
slow respiration poor gas
hypoventilation
exchange
slow breathing increase
breath, apnea then slow and cheyne-stokes respirations
increase....
Kyphosis hunch back hump back
Scoliosis S curve back
when observe the ches what
are some ex that you may barrell chest, pectus excavatum, pectus carinatum, scoliosis,
possibly see in ref. to shape kyphosis,
and symmetry
deformities of the chest
pectus excavatum
sternum oun
deformities of the chest
pectus carinatum
sternum in
Plapation of the chest place
masses, tenderness, alignment, retractions of chest or
palms lightly over chest and
intercostal spaces
palpate for
lumps, scars, lesions, ulcerations, temperatures, turgor,
Palpation of the chest using
moisture, subcuaneous crepitus (feels like rice crispies under
fingertips to feel for
the skin some air leakage under the skin)
When you place open palms
on both sides of pt. back and
anterior chest and ask pt. to
say "ninety-nine" loud assessing tactile fremitus
enough for you to feel
vibrations what are you
assessing
what is the interpretation of
vibrations will be more intense in areas of tissue consoliation
tactile fremitus
less intense vibrations in
assessing tactile fremitus presence of empysema, pneumothorax, or pleural effusion
may mean
If vibrations in upper
posterior thorax are faint or bronchial obstruction or a fluid filled pleural sapce
absent, there may be
what are some Percussion
resonance, dull sounds, hyperresonance, and abnormal
sounds you may hear in the
dullness
chest
heard over normal lung
resonance
tissue
heard over heart dull sounds
heard if there is increased air
hyperresonance
in lung or pleural space
found w/ areas of decreased abnormal dullness
air in lungs
punctured lung neumothorax
what is an example of an
crackles, rhonchi, wheezes, stridor, pleural friction rub
adventitious breath sound
what are some normal tracheal breath sounds, bronchial breath sounds,
breath sounds bronchovesicular breath sounds, vesicular
what are the sounds you
hear over teh trachea, harsh,
tracheal breath sounds
high pitched and less during
inspiration (deeper sound)
what are the sounds you
hear next to trachea, loud,
bronchial breath sounds
hight pitched the inspiration
is greater than the expiration
what are the sounds you
heard next to sternum and
between scapulae medium in
bronchovesicular breath sounds
loudness and pitch and the
sound of the inspiration and
expiration are equal
heard in rest of lung
(peripery) soft and low
vesicular
pitched inspiration greater
than expiration
You would listen to this at an
angle also known as fluid in crackles
the lungs
three types of crackles coarse, medium, fine
the frying popping, moist, low
pitched sound here it during
a course crackle
the inspiration and some
expiration is referred to as
where do you find the
found in mid inspiration and its not as loud as course
medium crackle

its a non continuous popping high

pitched and heard at the end of fine crackle
inspiration
its a continuos, low pitched, rattling
sound heard during the expiration,
usually can be cleared by rhonci
coughing caused by fluid partially
blocking large airways
contiunous high pitched sound
during the inspiration or expiration
wheezes
or both caused by constricion of
airway with reultant blockage of air
its like breathing out of a straw
whistling sound trying to breathe wheezes
w/ a constricted airflow
decreased fluid causes pain
pleural friction rub
everytime you breathe
low pitched grating rubbing
inspiration and expiration caused
pleural friction rub
by inflammation of pleura may
have pain where heard
what are bronchophony and
egophony and whispered voice sounds
pectoriloquy

when you have patient repeat bronchophony,

"ninety nine" while you auscultate words will sound muffled over normal lung fields
lung fields what is this representing words will be louder over consolidation

asking the patient to say "E" while egophony

auscultating the lung represents sound is muffled over normal lung fields, will sound like
what letter "A" over consolidation

having the patient whisper "123" whispered pectoriloquy;

while auscultating the lung numbers hard to distinguish over normalo lung fields,
represents numbers will be loud and clear over consolidation
Chest pain, dyspnea, orthopnea,
cough, fatigue, cyanosis or pallor
edema nocturia, past cardiac
subjective data on heart and neck vessels
history, family cardiac history,
personal habits all represent what
kind of data
when assessing the carotid artery palpate medial to sternomastoid muscle and auscultate fro
you would bruits
palpating the medial to
avoid excessive pressure, palpate one at a time, note
sternomastoid muscle for the
contour and amplitude, should be same bilaterally
carotid arter you
how do you auscultate for bruits at use bell of stethoscope, listen for blowing, swishing sound
the carotid artery indicating turbulent blood flow, normally none present
What are the two vessels you
carotid artery and jugular veins
would inspect
appetite, dysphagia, food
intolerance, abdominal pain,
nausea/vomiting bowel habits, past
subjective
abdominal history, medictions
nutritional assessment is what kind
of data
What are the three things you inspect, auscultate, then percuss and palpate
should do upon inspection of an
abdomen (look, listen, and feel)

symmetry, contour, discomort, splinting, guarding, lesions,

when ispecting an abdomen what
scars, brusing, discoloration, swelling, bulges, distention,
do you look for
ostomies, drains, dressings
if a patient appears to have ascites you would get a tape
measure and measure the abdomianl girth. THis would
how would you recognize ascites?
give yo a baseline to go by and future measurements
would indicate if and how fast more fluid is accumulating
what part of the stethoscope is
used for auscultating bowel diaphragm
sounds
what is the normal rate of bowl
5-35 normal
sounds per minute?
what is the term to describe
borborygmus
hunger pains or stomach growling
where do you check for bowel
in all four quadrants
sounds
inspecting the skin on the smooth and even, color, (jaundice, redness, striae, moles,
abdomen what might you find or petehiae, cutaneous angioma) taut, and shiny ascites,
are you looking for lesions rashes
bowel sounds over 35 are loud, hyperactive may be diarrhea
high pitched rushing, tinkiling is
considered to be

hypoactive may be bowl obstruction, after surgery,

bowel sounds less than 5
constipated
if there are no bowel sounds in
listen for 5 minutes
what do you do
when listening to the vascular
sounds in the abdomen what listen w/ bell and listen for bruits over aorta, renal,illiac, adn
are you listening for and what femoral arteries
do you listen w/
size, location, consistency of organs, abnormal masses,
Palpating the abdomen for
tenderndess do last
there are three things to look
for when you are palpating the voluntary guarding, involuntary rigidity, rebound tenderness
abdomen in ref to tenderness
cold, ticklish, tense would be
considered what in ref. to voluntary guarding
abdomen
constant board like hardness
would be considered what in involuntary rigidity
ref to abdomen
pain on release of pressure in
ref to abdom is considered rebound tenderness
what
costovertebral angle tenderness; place one hand over 12th rib
percussing the abdomen where
at CVA on back
what do you do when place one hand over 12th rib at CVA on back thump that hand
percussing the abdomen and w/ ulnar edge of other hand client should feel thud, but no
what are your results pain, sharp pain occurs w/ kidney inflammation
where is the apex of the heart
5th intercostal space at the left midclavicular line
located
what is the structure assessed
mitral valve
in the apex
what is located in the 4th ICS
tricuspid valve
on left sternal border
what is located in the 2nd ICS pulmonic valve
left sternal border
what is located in the 2nd ICS
aoritic valve
right sternal border
in order to thoroughly assess
heart sounds, you would the aortic area
ausculatate where first
what is the mnemonic you may Aunt Polly Takes Meds
use to recall the order of the
heart Aortic, Pulmonic, Tricuspid, Mitral

what is the first heart sound S1 or lub

S1 marks the beginning of
systole
what
S1(lub) is a what kind of sound sow-pitched sound
The S1 may be heard in all
locations on the chest but over the mitral tricuspid
where will it be the loudest
what does the first heart sound
the closure of the valves between the atria and ventricles
result from
what is the second heart sound
S2 or dub
you hear
what does the S2 correspond
closure of the semilunar valves
to
you can hear the S2 in all
at the aortic and pulmonic areas
locations but it is loudest

a third heart sound (S3) is
heard when
when is a S3 normal
when is a S3 abnormal
A fourth heart sound (S4)
heard when
for whom is the S4 normal
immediately after S2 has a gallop cadence that follows the
rhythm of the word KenTUcky
in young children and adolescents when they are sitting or
lying ,but disappears when they stand or sit up. Also a normal
variant in the third trimester of pregnancy
when it does not disappear w/ position change represents
heart failure or volume overload
immediately before S1 has a rhythm FLOrida
trained athletes and some older clients
Both S3 and S4 are best heard at the apical site, w/ the client lying on his left side, and using
where the bell of the stethoscope
S4 is normal w/ trained
athletes and may also be coroanry artery disease, hypertension, and pulmonic stenosis
heard in adults w/ what
what are additonal sounds
produced by turbulent flow murmors
through the heart
what consists of a network of
arteries and veins that
transport oxygen, carbon vascular system
dioxide and nutrients to the
cells of the body
what refers to the contraction
systole
or emptying of the ventricles
what refers to the relaxation or
dystole
filling phase of the ventricles
at an angle on the left side of the chest in the 3rd, 4th, and 5th
where does the heart sit
intercostal spaces.
listen for murmors w/ what the bell of the stethoscope
what is the ausculation begin w/ diaphragm listen to one sonund at a time, note rate
technique for the heart an drhythm, indentify S1 and S2 assess them seperately,
assessment listen for extra heart sounds, and listen for murmous w/ bell
presence of an S3 in adults
ventricular failure (CHF)
over 30 indicate
increased velocity of blood,
decreased viscosity of blood
and structural defects or murmor
unusual openings are all
symptoms of a
this is caused by turbulent
murmurs
blood flow and currents
this is used w/ the bell and best
murmurs
heard at herb's point
its a gentle blowing swooshing
murmor
sound in the heart
when assessing a murmor you the pattern, quality, location, radiation, and posture
assess what
what is the norm for a heart
60 to 100 beats per minute
beat
this occurs normally in young
adults and children, rate
increases w/ inspiration slows sinus arrhthmia
expiration in reference to the
heart
leg pain or cramps, skin
changes on arms or legs,
swelling, lymph node
subjective
enlargement, and medication
are all what kind of data in the
peripheral vascular system
inspect and palpate what for
arms, legs,
the peripheral vascular system
when inspecting the legs what symmetry, pulses, temperature, lesions, measure calf
do you assess circumference if discrepency and palpate lymph nodes

when inspecting the arms

assess symmetry pulses, lesions
what do you assess
temporal, carotid, apical, brachial, radial, femoral, popliteasl,
pulses are located where
pedal
4+ is bounding
3+ is increased
what is the pulse amplitude 2+ is normal
1+ is weak
0 is absent
ck. temp., ck capillary refill but if the refill is slow then use a
if you can't locate the pedal
doppler to validate it get another nurse and then call dr. that is
pulse you would then
considered a significant finding
when assessing for homan's w/ client in supine position dorsiflet food towards tibi, this should
sign how would you position not cause pain calf pain may indicate deep vein thrombosis,
the client phlebitis, tendonitis, muscle injury or lumbosacral disorders
inspecting the umbilicus you
position, color, and if its inverted
would look for
if the color of the umbilical
cord is a bluish color what this occurs with intraabdominal bleeding (cullen's sign)
does this mean
if the umbilicus is everted
ascites, mass, hernia
this could mean what
musculoskeletal system:
when their is pain, stiffness,
swelling, heat and redness, subjective
and limitation of movement
this is what type of data
palpate joints for what warmth, swelling, tenderness, massess
range of motion, and muscle tone and strength compare both
asses the joints for
sides of the body
size and contour, joint deformities, skin color, swelling, observe
inspect the joints for
gait and posture, note lordosis, kyphosis, scoliosis
headache, hgead injury, dizzines/vertigo, seizures, tremors,
what are some ex. of
weakness, incoordination, numbness or tingling, difficulty in
subjective data in the
swallowing, difficulty speaking, significant past history,
neurologic system
environmental occupational hazards
what do you assess in the level of consciousness, orientation, glascow coma scale,
neurological system speech, memory lapses, deficits, coordination and balance
what are the equipment
needed for an exam in penlight, tongue blade, cotton swab, cotton ball, tuning fork,
assessing the neurological percussion hammer, occasionally: familiar aromatic substance
system
cranial nerve II opic
what cranial nerves are you
cranial nerve III, IV, VI occulomotor, trochlear, and abducens
testing for in the neurologic
nerves
system assessment
cranial nerve V trigeminal, and cranial nerve VII facial mobility
what might the nurse use to
snellen chart
scren for visual acuity
if a person has 20/40 vision, that to see lines of print that a person w/ normal vision can read
what does this mean at 40 ft. the client has to stand just 20 ft. from the snellen chart
what does nasal flaring
difficulty breathing
indicate
what would cause pallor a reduced amt. of oxyhemoglobin in skin or mucous membrane a
pale color which can be caused by illness, emotional shock or
 stress, avoiding excessive exposure to sunlight anaemia or
genetics
thick elevated white patches
that do not scrape off may
leukoplakia
be precancerous and called
what
white curdy patches that
scrape off and bleed
leukoplakia
indicate thrush also known
as
thrush is a fungal infection
commonly called yeast
infection or thrush is a
candidiasis
fungal infection of any
candida specias
black hairy tongue an overgrowth of bacteria in the mouth

refers to gingival
inflammation induced by
bacterial biofilms (also called gingivitis
plaque) adherent to tooth
surface
an acute hemorrhage for the
nostril, nasal cavity or
epistaxis
nasopharynx also known as
a nosebleed
during a routine bedside
assessment we are most
radial and the pedal
commonly assessing which
pulses
we usually determine the
rate and regularity of pulses
not only compare it to the opposite side but to also listen to the
using the radial site. If the
apical pulse to determine rate and regularity
pulse is faint or irregular it
would be important to what
if they are present and if they are fainto or strong we are not
when we check pedal pulses
concerned w/ counting the rate of the pedal pulses we want to
we are determining what
know if the pt. has good circulation in the extremeties
there are times when
"neurochecks" are ordered a fall if the pt. hits his head after cranial surgery after head injury
by the physician or the nurse if pt has decreasing LOC or other conditions where brain
this might be after what swelling/compression might be likely to occur
happens
LOC and orientation, PERRLA, ability to follow commands,
neurochecks usually include
ability to move all extremities, muscle strength
inspect the external ears for position, condition of the skin, presence of lesions, and drainage
a specific type of dizziness, is a major symptom of a bal.
vertigo
disorder
tinnitis ringing of the ears
CVA tenderness
(costovertebral angle
tenderness) using the fist or
blunt percussion where the kidney tenderness
end of the rib cage meets
the spine bilaterally to
assess for
what would be the abnormal
associated w/ kidney infection, or musculoskeletal problems
findings for cva tenderness
what are some abnormal
propulsive, scissors, spastic, steppage and waddling
gaits
this is an abnormal gait and
is when a person is leaning propulsive
forward
an abnormal gait when
knees turn in toward each scissors
other
wht is steppage referred to
foot lifted high to clear the toes, no heel strike, toes hit first
in an abnormal gait
waddling is an abnormal gait
feet wide, duck like
what does it look like
spastic is an abnormal gait
stiff leg mvmt while walking
what does it look like
how would you recognize
by the distention of the stomach
ascites
what would you do to assess use a measuring tape to measure the girth. stretch/place
 measuring tape over belly button, the 1 inch mark should be @
ascites the belly button mark on the stomach w/ a pen and this will be
your baseline ck. again later using same techniques
when might sounds be
after abdominal surgery or w/ bowl obstruction infection,or
absent or hypoactive in the
innervation problems
bowel
when might sounds be
w/ diarrhea, early bowl obstruction or gastroenteritis
hyperactive in the bowel
lung sounds will be normal in
48 hrs is what step in the planning
nursing process
ineffective airway clearence
is what step in the nursing nursing diagnosis
process
lung sounds reveal rhonchus
in the upper lobe is what assessment
step in the nursing process

have client deep breathe and cough

every 2 hrs. 4-5 times a day is what implementation
step in the nursing process
lung sounds clear in upper lobes
following coughing. continue deep
evaluation
breathing every 2-4 hr. is what step in
the nursing process