data about the patient's

physical status

objecctive

data is obtained by patient

report through history taking
and interviewing

subjective

what is a visual examination

of all parts of body

inspection

what do we inspect for

size, shape, color, symmetry, position, abnormalities, compare

w/ same area on the opposite side of body, and use additional
light if needed and for body cavities

what is the term for touchingpalpation

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
surfaceof your hand palpate

temperature

what does your finger tips

palpate

texture, size, consistency, pulsation, form and shape,

what does your palmer

surface palpate

vibration

what could happen if you

obstructed blood flow over
carotid arteries

you could reduce circulation to the brain or cause changes in

heart flow

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
to wear gloves

if exposure to body fluids is a possibility

where would you place a

stethoscope

on skin, not over the clothes because the clothes will add or
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

head to toe, and body systems method

what is the most efficient

method in assessing a client

head to toe

what is the first step is

assessing a client

general survey as soon as you walk in you will be gathering

information about their health status

what are some things you

would assess under general
appearance and behavior

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

when you are assessing age

what are looking for

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
assessment of skin includes
the status of

circulation, oxygenation, nutrition, hydration and certain

metabolic and endocrine conditions

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
yellow tones

pallor

a yellow orange cast to the

skin

jaundice

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
pressure on teh skin

erythema

what will you use to assess

skin temp.

the dorsum of the hand or fingers

what may stimulate the

metabolisma nd may also
cause an elevation in skin
temp

hyperthyroidism

erythema accompanied by
warmth may indicate

infection or inflammatory

what is a normal skin moisture

skin is warm and dry
assessment
excessive moisture may result
hyperthermia, thyroid hyperactivity, anxiety or hyperhidrosis
from

dry skin may result from

dehydration, chronic renal failure, hypothyroidism, excessive

exposure, or overzealous hygiene

what is the normal skin texture is smooth and soft

what may be some factors
effecting the skin texture

exposure, age, hyperthyroidism and other endocrine

disorders, impaired circulation

refers to the elasticity of the

skin,

turgor

skin tenting refers to

dehydration in skin tugor

what are white normal raised

areas on the nose chin and
forehead of newborns due to
sebum

milia

how do primary skin lesions

develop

develop as a result of disease or irritation ex pustules of acne

how do secondary lesions

develop

develop from primary lesions as a result of continued illness,

exposure, injory or infection, such as the crusts that form from
ruptured pustules

what is ABCDE

a is for asymemetry, b border irregularity, c color, d diameter

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
around the face and neck in
newborns

capillary hemangiomas

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
birthmark, mongolian spot

macule

elevated and raised by

papule
superficial ex. moles psoriasis
a small circumscribed area
distinct from surrounding
surface in character and
appearnce

patch

a patch on the skin or on a

mucouls surface

plaque

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
encapsulated

keratogenous cyst

blisters elevated and filled w/

vesicle
serrous fluid ex. blister, herpes,
elevated and filled w/ pus ex.
acne falliculitis impetigo

pustule

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
healthy nail beds are

level, firm, and similar to the color of the skin, nail is smooth
and uniform in texture w/ a 160deg. nail plate angle

white spots in the nails

represent

may indicate zinc deficiency

black nails are due to

blood under the nail, are seen after local trauma

what is referred to as small

hemorrhages under the nail
bed associated w/ bacterial
endocarditis or trauma

splinter hemorrhages

which are transverse white

lines in teh nail bed. seen in
clients who have experienced
sever illnesses

mee's lines

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
may be due ot endocrine
disorder or steroids

hirsutism

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

Inspect head and neck for

size, symmetry, and presence fo nodules, masses, and

bulges, shape

normocephalic

normal head

microcephaly

an abnormally small head size is seen in clients w/ certain

types of mental retardation

a disorder associated w/
excess growth hormone

acromegaly

an accumulation of excessive
cerebrospinal fluid

hydrocephalus

disease fo the lymph nodes

lymphadenopathy

irregular jaw movement or

cracking of the jaw

TMJ, temperomandibular joint syndrome

When assessing the clients

eyes what do you inspect

do they wear glasses, contact lenses? inspect and palpate the

external eye structues, assess vision and examine the internal
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
conjunctiva

conjunctivitis

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
what are some signs of
respiratory distress

sob, restlessness, decreased mental alertness, cyanosis, pallor,

nasal flaring, orthopnea, intercostal retractions, use of accessory
muscles, increased heart rate

What does barrel ches look

like and when would it be
present

used to describe the rounded, barrell shap of the chest that can
occur in people w/ chronic obstructive pulmonary disease
(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
the breath sounds you will
hear

normal, decreased, diminished, absent, increased adventitious

voice sounds

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
data when inspecting the
thorax and lungs

cough, chest pain, history of resp. infections, smoking history

(pack/years), environmental exposure, self-care behaviors

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
exchange

hypoventilation

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
sternum oun

pectus excavatum

deformities of the chest

sternum in

pectus carinatum

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
tactile fremitus

vibrations will be more intense in areas of tissue consoliation

less intense vibrations in

assessing tactile fremitus
may mean

presence of empysema, pneumothorax, or pleural effusion

If vibrations in upper
posterior thorax are faint or
absent, there may be

bronchial obstruction or a fluid filled pleural sapce

what are some Percussion

resonance, dull sounds, hyperresonance, and abnormal
sounds you may hear in the
dullness
chest
heard over normal lung
tissue

resonance

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
adventitious breath sound

crackles, rhonchi, wheezes, stridor, pleural friction rub

what are some normal

breath sounds

tracheal breath sounds, bronchial 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
pitched inspiration greater
than expiration

vesicular

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
medium crackle

found in mid inspiration and its not as loud as course

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
w/ a constricted airflow

wheezes

decreased fluid causes pain

everytime you breathe

pleural friction rub

low pitched grating rubbing

inspiration and expiration caused
by inflammation of pleura may
have pain where heard

pleural friction rub

what are bronchophony and

egophony and whispered
pectoriloquy

voice sounds

bronchophony,
when you have patient repeat
"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"
while auscultating the lung
represents

whispered pectoriloquy;
numbers hard to distinguish over normalo lung fields,
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
sternomastoid muscle for the
carotid arter you

avoid excessive pressure, palpate one at a time, note

contour and amplitude, should be same bilaterally

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
would inspect

carotid artery and jugular veins

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
should do upon inspection of an
abdomen

inspect, auscultate, then percuss and palpate

(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
sounds

diaphragm

what is the normal rate of bowl

sounds per minute?

5-35 normal

what is the term to describe

borborygmus
hunger pains or stomach growling
where do you check for bowel
sounds

in all four quadrants

inspecting the skin on the

abdomen what might you find or
are you looking for

smooth and even, color, (jaundice, redness, striae, moles,

petehiae, cutaneous angioma) taut, and shiny ascites,
lesions rashes

bowel sounds over 35 are loud,

hyperactive may be diarrhea

high pitched rushing, tinkiling is

considered to be

bowel sounds less than 5

hypoactive may be bowl obstruction, after surgery,

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
are you listening for and what
do you listen w/

listen w/ bell and listen for bruits over aorta, renal,illiac, adn
femoral arteries

Palpating the abdomen for

size, location, consistency of organs, abnormal masses,

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
abdomen

voluntary guarding

constant board like hardness

would be considered what in
ref to abdomen

involuntary rigidity

pain on release of pressure in

ref to abdom is considered
rebound tenderness
what
percussing the abdomen where

costovertebral angle tenderness; place one hand over 12th rib

at CVA on back

what do you do when

percussing the abdomen and
what are your results

place one hand over 12th rib at CVA on back thump that hand
w/ ulnar edge of other hand client should feel thud, but no
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
on left sternal border

tricuspid valve

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
ausculatate where first

the aortic area

what is the mnemonic you may Aunt Polly Takes Meds

use to recall the order of the
Aortic, Pulmonic, Tricuspid, Mitral
heart
what is the first heart sound

S1 or lub

S1 marks the beginning of

what

systole

S1(lub) is a what kind of sound sow-pitched sound

The S1 may be heard in all
locations on the chest but
where will it be the loudest

over the mitral tricuspid

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
to

closure of the semilunar valves

you can hear the S2 in all

locations but it is loudest

at the aortic and pulmonic areas

a third heart sound (S3) is

heard when

immediately after S2 has a gallop cadence that follows the

rhythm of the word KenTUcky

when is a S3 normal

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 is a S3 abnormal

when it does not disappear w/ position change represents

heart failure or volume overload

A fourth heart sound (S4)

heard when

immediately before S1 has a rhythm FLOrida

for whom is the S4 normal

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
heard in adults w/ what

coroanry artery disease, hypertension, and pulmonic stenosis

what are additonal sounds

produced by turbulent flow
through the heart

murmors

what consists of a network of

arteries and veins that
transport oxygen, carbon
dioxide and nutrients to the
cells of the body

vascular system

what refers to the contraction

or emptying of the ventricles

systole

what refers to the relaxation or

dystole
filling phase of the ventricles
where does the heart sit

at an angle on the left side of the chest in the 3rd, 4th, and 5th
intercostal spaces.

listen for murmors w/ what

the bell of the stethoscope

what is the ausculation

technique for the heart
assessment

begin w/ diaphragm listen to one sonund at a time, note rate

an drhythm, indentify S1 and S2 assess them seperately,
listen for extra heart sounds, and listen for murmous w/ bell

presence of an S3 in adults
over 30 indicate

ventricular failure (CHF)

increased velocity of blood,

decreased viscosity of blood
and structural defects or
unusual openings are all
symptoms of a

murmor

this is caused by turbulent

blood flow and currents

murmurs

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
beat

60 to 100 beats per minute

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
what do you assess

assess symmetry pulses, lesions

pulses are located where

temporal, carotid, apical, brachial, radial, femoral, popliteasl,

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
does this mean

this occurs with intraabdominal bleeding (cullen's sign)

if the umbilicus is everted

this could mean what

ascites, mass, hernia

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

asses the joints for

range of motion, and muscle tone and strength compare both

sides of the body

inspect the joints for

size and contour, joint deformities, skin color, swelling, observe

gait and posture, note lordosis, kyphosis, scoliosis

what are some ex. of

subjective data in the
neurologic system

headache, hgead injury, dizzines/vertigo, seizures, tremors,

weakness, incoordination, numbness or tingling, difficulty in
swallowing, difficulty speaking, significant past history,
environmental occupational hazards

what do you assess in the

neurological system

level of consciousness, orientation, glascow coma scale,

speech, memory lapses, deficits, coordination and balance

what are the equipment

needed for an exam in
assessing the neurological
system

penlight, tongue blade, cotton swab, cotton ball, tuning fork,

percussion hammer, occasionally: familiar aromatic substance
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
indicate
what would cause pallor

difficulty breathing
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 indicate leukoplakia
thrush also known as
thrush is

a fungal infection

commonly called yeast

infection or thrush is a
fungal infection of any
candida specias

candidiasis

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

a fall if the pt. hits his head after cranial surgery after head injury

"neurochecks" are ordered

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
neurochecks usually include

LOC and orientation, PERRLA, ability to follow commands,

ability to move all extremities, muscle strength

inspect the external ears for position, condition of the skin, presence of lesions, and drainage
vertigo

a specific type of dizziness, is a major symptom of a bal.

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
gaits

propulsive, scissors, spastic, steppage and waddling

this is an abnormal gait and

is when a person is leaning propulsive
forward
an abnormal gait when
knees turn in toward each
other

scissors

wht is steppage referred to

in an abnormal gait

foot lifted high to clear the toes, no heel strike, toes hit first

waddling is an abnormal gait

feet wide, duck like
what does it look like
spastic is an abnormal gait
what does it look like

stiff leg mvmt while walking

how would you recognize

ascites

by the distention of the stomach

what would you do to assess use a measuring tape to measure the girth. stretch/place
ascites
measuring tape over belly button, the 1 inch mark should be @

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
absent or hypoactive in the
bowel

after abdominal surgery or w/ bowl obstruction infection,or

innervation problems

when might sounds be

hyperactive in the bowel

w/ diarrhea, early bowl obstruction or gastroenteritis

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
step in the nursing process

implementation

lung sounds clear in upper lobes

following coughing. continue deep
evaluation
breathing every 2-4 hr. is what step in
the nursing process