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114 Cards in this Set
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Chapter 30
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Nursing Health Assessment
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A comprehensive Health Assessment:
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Encompasses the physical, psychological, social and spiritual dimensions of living
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Purpose of the physical examination
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Obtain baseline data
Supplement, confirm, or refute historic data Help establish nursing diagnoses and plans of care |
B/H/D/P
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Purpose of the physical examination 2
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Evaluate physiologic outcomes and progress
Make clinical judgments Identify areas for health promotion and disease prevention |
P/C/HP/DP
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Methods for performing a physical assessment (4)
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Inspection
Palpation Percussion Auscultation |
IPPA
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Inspection
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Deliberate, purposeful, and systematic visual, smell, and hearing examination
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Palpation
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Examination using sense of touch
Texture Temperature Vibration Position, size, consistency, mobility of organs or masses Distention Pulsation Presence of pain upon pressure |
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Palpation
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Light and deep
Light Palpation: Three or four fingers to depress 0.5 to 1 inch Deep Palpation: One, or one hand on top of the other hand, to depress 1.5 to 2 inches |
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Percussion
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Striking body surface to elicit sounds or vibrations
Determine size, shape, borders of internal organs |
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Five sounds of percussion
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Flatness-muscle & bone
Dullness-Liver, spleen, heart Resonance-Lungs Hyperresonance-Emphysematous lung Tympany-Air filled stomach |
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Auscultation
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Listening to sounds produced within the body
Direct-Respiratory wheeze Indirect-Stethoscope |
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Auscultation
For high pitch For low pitch |
Diaphragm: high
Bell: low |
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Four qualities used to describe auscultation
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Pitch, intensity, duration, quality
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Auscultation
Doppler |
ultrasound device used to make sounds louder
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Situation
The client complains of abdominal pain |
Inspect, auscultate, and palpate the abdomen
Assess vital signs |
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Situation
The client is admited with head injuries |
Assess level of consciousness using Glasgow Coma Scale.
Assess pupils for reaction to light and accommodation Assess vital signs |
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Situation
Administering cardiotonic drugs |
Assess apical pulse and compare with baseline
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Situation
Cast applied to LL |
Assess peripheral perfusion, capillary blanch, pedal pulse, vital signs
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Situation
Client fluid intake is minimal |
Assess tissue turgor
Assess Fluid I&O Assess Vital signs |
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Information that comes from the Chart Review:
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Client’s name, age, primary language, health history, current medications, and treatments
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Two types of Data Sources
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Primary Sources: client
Secondary Sources: chart, health care providers |
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The client environment must be:
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Warm, quiet, well-lit room
Privacy Equipment Standard Precautions |
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Appearance and mental status
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Must be assessed in relationship to culture, educational level, SES, and current circumstances
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Vital signs
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Measured to establish baseline data against which to compare future measurements and to detect actual or potential health problems
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Height and weight
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H:W ratio provides a general measure of health
Client self image |
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Skin
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Inspection and palpitation to detect irregularities
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Palor
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Loss of pink tone to skin..
The result of inadequate circulating blood or hem and subsequent reduction in tissue oxy and |
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Cyanosis
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Bluish tinge to skin.
Caused by reduced blood O2 Most evident in nail beds, lips, and buccal mucosa |
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Jaundice
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Yellowish tinge to skin.
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Erythema
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Redness associated with a variety of rashes
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Hyperpigmentation
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Increased pigmentation
Birthmark |
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Hypopigmentation
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Decreased pigmentation
Vitiligi |
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Edema
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The presence of excess interstitial fluid
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Skin Turgor
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Skin fullness or elasticity
When pinched, skin springs back to preious state |
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Describers for skin lesions
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Type primary or secondary
Size, shape, texture Color Distribution over body Configuration in relation to each other |
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Hair
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Aids in determing hair care practices and factors influencing them.
May also hint to other problems such as kwashiorkor |
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Nails
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Inspection of nail plate shape, nail/nail bed angle, texture, color, skin intactness
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Spoon shape nail
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Iron deficiency anemia
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Clubbing nail
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Long term lack of O2
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Beau's line
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Nail injury or severe illness
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Nail blanch test
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Tests capillary refill / peripheral circulation problems
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Nail bluish or purplish tint
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May reflect cyanosis or pallor
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Head
Skull and face |
Assess for normal head shape
Normocephalic |
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Eyes and vision
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Includes the evaluation of
External structures Visual acuity Ocular movement Visual fields |
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Visual acuity
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The degree of detail the eye can discern in a image
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Visual fields
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The area an individual can see when looking straight ahead
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Nystagmus
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Rapid involuntary rhythmic eye movement may indicate neurologic imparement
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Snell chart
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Measures visual acuity
Common eye chart |
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Visual acuity CN
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CN #2
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Extra ocular movement CN
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CN #3, 4, 6
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Peripheral vision CN
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CN #2
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Pupil Consentual response CN
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CN #3
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Ear and hearing
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Direct inspection and palpatation of the external ear and internal inspection with an otoscope
Used to detect conductive and sensorineural hearing loss |
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Normal tympanic membrane color and gloss
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Pearly gray color and semitransparent
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Watch tick test
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Measures ability to hear higher pitches
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Tuning fork test (Webber)
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Measures lateralization of sound and bone conduction
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Tuning fork test (Renee)
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Measures air conduction
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Air conduction should be ___ than bone conduction
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Greater than
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Nose and sinuses
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Includes inspection and palpatation of the external nose and sinuses and inspection of the nasal cavities
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Nose and sinuses
Normal findings external |
Nose is semetric and straight
No discharge or flaring Uniform color No tenderness or lesions |
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Nose and sinuses
Normal findings internal |
Air moves freely
Mucosa is pink and moist No lesions Nasal septum intact and midline Not tender |
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Mouth and oropharynx
Composed of |
Mucosa
Teeth Lips Gums Tongue Tonsils Uvula |
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Mouth and oropharynx
Normal findings |
Mucosa pink, smooth and moist
Tongue centered |
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Neck
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Includes the
Muscles Lymph nodes Trachea Thyroid Carotid arteries Jugular veins |
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Bruits
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Turbulent blood flow through narrowed artery
Use stethoscope bell |
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Neck veins
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Assess for distention
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Jugular venous pressure
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At 30 deg bed angle, height of visible beating should be less than 3 cm above sternal angle
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Skin
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Inspected and palpatated for color, moisture, temperature, texture and hygiene
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Skin normal findings
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Pink or brown, dry, warm, intact
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ABCDE's of Irregular Skin Lesions
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--Size, color, type, location--
Asymmetry Borders Irregular Color changes Diameter Elevation |
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Assessing Wounds
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How-accident, pressure, surgery
Where-Location, color, swelling, approximation, dressing style Drainage-color, character, odor, amount |
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Sanguineous fluid
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Blood
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Serous fluid
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Clear portion of blood. Serum
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Cardiac assessment
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Assessed through inspection, palpation, and auscultation.
In that order |
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Aortic landmark
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2nd ICS, right of sternal border
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Pulmonic landmark
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2nd ICS left of sternal border
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Tricuspid landmark
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5th ICS, left of sternal border
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Mitral/Bicuspid landmark
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5th ICS, midclavicular line
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PMI
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Point of Maximum Impulse
5th ICS, midclavicular line Mitrial valve |
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Abnormal heart findings
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Abnormal Pulsations
Lifts Heavs |
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Heave
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Forceful movements
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Lift
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Anterior movement of the sternum
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S1 sound
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Systole (ventricular contraction)
Occurs when the Atrioventricular valves close Mitrial and tricuspid valves Heard at PMI |
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S2 sounds
What Where |
Diastole (ventricular relaxation)Occurs when the semilunar valves close
Heard at aortic and pulmonic sites |
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Heart abnormal findings
@ Palpation |
Thrills: Vibrations
Abnormal pulsations |
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Cardiac/Heart Auscultation
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Auscultate at PMI for 1min
Rate-60 to 100 Rhythm-regular Quality-+2 |
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Murmor
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Trubulent blood flow through heart and across valves
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Respiratory
4 focus points |
Thorax
Breathing patterns Signs of labored breathing Skin and nails |
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Thorax signs
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Anterior and posterior diameter
Thorax is oval in cross section and elliptical top to bottom |
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Thorax abnormal findings
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Barrel
Kyphosis Scoliosis Kyphoscoliosis |
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Kyphosis
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Excessive convex curvature of the thoracic spine
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Barrel chest
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Anterioposterior to transverse diameter is 1:1
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Scoliosis
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A lateral deviation of the spine
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Emphysema
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Chronic pulmonary condition in which the alveoli are dilated and distended
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Thorax normal findings
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Anteroposterior : Transverse diameter 1:1
Spine vertically aligned All landmarks at same height Skin intact Thorax intact c no tenderness Full and semetrical thorax expansion Excursion semetrical Broncovesicular and Vesicular breath sounds Effortless, quiet, rhythmic respirations |
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Respiratory palpitation
Why? |
To evaluate for painful or abnormal areas
Symmetry of chest expansion-Excursion To detect Tracheal deviation |
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Respiratory palpitation
Tactile (Vocal) Fremitus |
The faintly perceptible vibration felt chrough the chest wall when the client speaks
Should be semetrical |
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Respiratory Auscultation
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Listen for normal and adventitious (Abnormal) breath sounds
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Normal Bronchial sounds
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E>I
Loud and high pitched Heard over the trachea |
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Normal Vesicular sounds
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E<I
Soft and breezy Heard away from major airways |
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Normal Bronchovesicular sounds
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I=E
Breezy and low pitched Heard over main bronchi and between the scapula |
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Adventitious breath sounds
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Occurr when air passes through narrowed airways or airways filled with fluid or mucus, or when pleural linings are inflamed
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Adventitious Crackles (rales)
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Fine, short, interrupted popping sounds
Caused by air passing through fluid or mucus and alveoli popping open |
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Adventitious Ronchi (Gurgles)
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Continuous, low-pitched, coarse gurgling
Caused by ari passing through narrowed air passages Secretions, swelling, tumors |
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Adventitious Wheezes
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Continuous, high pitched, musical sounds
Caused by air passing through constricted broncus Secretions, swelling, tumors |
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Breast assessment
When |
Monthly and after menstrual cycle
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Breast Inspection
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Rounded, symmetrical
Skin smooth, intact Areola darker, round, symmetric Nipple everted w/o discharge |
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Breast Palpation
To Assess for: |
Tenderness
Nodules Masses |
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Abdominal assessment
Normal |
Active bowel sounds
Hypoactive Hyperactive Borborygmi |
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Abdominal assessment
Abnormal |
Absence of bowel sounds
Bruit Pulsations (aneurism) |
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Peripheral assessment
Includes |
Measuring blood pressure
Palpating peripheral pulses Inspecting the skin for perfusion Symmetric and +2 Skin color pink Temperature normal |
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Peripheral palpation
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Assessing the peripheral leg veins for signs of phlebitis
Redness Swelling Tenderness Warmth |
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Horman's Test
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Dorsiflex foot to check for tenderness
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Peripheral pulse sites
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brachial, radial, ulnar, femoral. popliteal, posterior tibial, dorsalis pedis
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