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105 Cards in this Set
- Front
- Back
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Vital signs offer a ???
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Baseline for us to work with for the patient.
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Activity of your patients |
Always know your patients activity tolerance |
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Orthopnea: |
Difficulty breathing lying down |
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Cultural sensitivity during assessment |
Involve patients as much as possible. don't force your views. |
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Other consideration for Assessments |
-Pay attention to infection control
-Developmental stage of clients. (mental Development) |
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When obtaining vitals know.... |
-You need to understand and interpret the values -Communicate findings appropriately -Begin Interventions as needed |
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When to obtain vitals? |
On admission to a health care facility When assessing the client during home care visits Before and after surgical procedure or diagnostics procedure Before, during, and after blood transfusion Before, during, and after certain medications When client’s condition changes Before and after some nursing interventions When the client reports nonspecific symptoms (“feeling funny” or “different” |
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Acceptable VS ranges for adults |
Temp: 96.8-100.4 F Oral/Tympanic 98.6 F Rectal: 99.5 F Axillary: 97.7 F
Pulse: 60-100 BPM Respirations: 12-20 Blood Pressure: Average 120/80 |
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Temp Physiology |
Heat produced-heat lost= body temperature Temp control mechanisms keep the body’s core temp relatively constant despite extremes in environmental conditions & physical activity
Surface temp varies depending on blood flow to the skin and the amount of heat lost due to external environment |
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Body temp measurements |
Surface temp sites: Core Temp sites are reliable indicators -skin -oral -axillae
Core Temp Sites: -Rectum -tympanic -temporal artery -Esophagus -pulmonary Artery
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Temp Regulations |
Body mechanisms maintain the relationship between heat production and heat loss= -Thermoregulation
Regulated by -Neural -Vascular control
Hypothalamus- the "Thermostat" of the body |
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Heat production |
Heat produced by the body is a by-product of metabolism (the chemical reaction in all cells) Activities requiring > chemical reactions increase the metabolic rate Heat production occurs during rest, voluntary movements, and involuntary shivering With exercise= increased metabolism= increased heat production When metabolism decreases, less heat is produced |
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Basal Metabolic Rate (BMR) |
Accounts for heat produced @ absolute rest Dependent on body surface area Affected by thyroid hormones Testosterone influences Muscular activity |
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Heat Loss |
Radiation: The transfer of heat from the surface of one object to the surface of another without direct contact between the two Conduction: The transfer of heat from one object to another with direct contact This accounts for a small amount of heat loss When warm skin touches a cooler object, heat is lost Convection: the transfer of heat away by air movement Evaporation: The transfer of heat energy when a liquid is changed to a gas About 600-900 mL/day is lost from the skin and lungs Diaphoresis (sweating) Breathing |
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Diaphoresis: |
Sweating:
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About how much fluid is lost per day through skin and lungs? |
600-900 Mls |
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Tachypneic/ Tachypnea |
Rapid Breathing:
-Results in more fluid loss throughout the day. |
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Reason for elderly having lower temp |
Less subcu tissue |
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The Skin’s Role in Temp Regulation |
Insulation of the body Body fat
Vasoconstriction
Temperature sensation |
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Factors Affecting Temp: |
Age Newborn Elderly Exercise Hormone Level Circadian Rhythm Stress Environment |
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Pyrexia = |
FEVER
Usually not harmful if below 102.2 F (39 C) Pyrogens Immune system response Defense mechanism Serve diagnostic purposes Fever of unknown origin |
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Phases of a fever |
Phase I- “Pyrexia Phase” Pyrogens trigger the hypothalamus to raise the set point to promote the body’s defense against infection. This triggers a febrile episode
Phase II- “Chill Phase” Client can experience chills, shivers, and can feel cold, even though the body temperature is rising. Chill phase resolves when new set point or higher temp is achieved. |
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Phases Cont. |
Phase III: Febrile Phase If set point exceeded or pyrogens removed, skin becomes warm and flushed because of vasodilation. (plateau) |
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Phase IV- “Afebrile Phase” |
Diaphoresis assists in the evaporative heat loss.
When the fever ‘breaks”, the temperature returns to an acceptable range and the client becomes afebrile. |
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During a Fever… |
Cellular metabolism increases Oxygen consumption rises Heart rate increases Respiratory rate increases
Prolonged fever weakens a client by exhausting energy stores… |
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Hyperthermia |
Results from an overload of the body’s thermoregulatory mechanisms Any disease or trauma to the hypothalamus impairs heat-loss mechanisms
Malignant Hyperthermia Hereditary condition of uncontrolled heat production Occurs when susceptible people receive certain anesthetic drugs |
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Heat Stroke |
S/S: giddiness, confusion, excess thirst, nausea, cramps, visual disturbance, incontinence Temp as high as 113, ^HR & decrease BP Most important sign is hot, dry skin (severe electrolyte loss & hypothalamic malfunction) Can result in unconsciousness with fixed, nonreactive pupils |
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Heat Exhaustion: |
Profuse diaphoresis results in excess H2o & electrolyte loss Show s/s of fluid volume deficit Treat by moving to cooler environment & restore fluid/electrolyte balance |
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Hypothermia |
Unintentional & intentional < 95 F (35 C) Uncontrolled shivering Loss of memory Depression Poor Judgment < 94 F (34.4 C) HR, BP & RR fall Skin cyanotic Cardiac dysrhythmias + loss of consciousness Unresponsiveness to stimuli Assessment of core temp is critical with special thermometer (if < 95 F or 35 C) |
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Thermometers |
Electronic Temporal Artery Tympanic Glass
Disposable
Chemical dot thermometers |
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What are Antipyretics |
Fever reducers |
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Fever in Acute Care… |
Implementations gauged at: Increasing heat loss Decreasing heat production Preventing complications Determining cause of temp Obtaining culture specimens Blood, urine, sputum & wound Administering antibiotics after cultures obtained as ordered Antipyretics- decrease fever Nonpharmacological therapies AVOID: Tepid sponge baths, bathing with ETOH water solutions, ice packs to axillae & groin (SHIVERING) Cooling blankets |
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Hypothermia in Acute Care… |
Priority- Prevent further decrease in body temperature
Interventions: Remove wet clothes and place dry clothes on patient Wrapping pt in blankets Keep head covered Bair hugger |
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Temperature & Older Adults |
Older adults have normal temps which are the low side of normal Very sensitive to slight temp variations in environment Decreased sweat gland reactivity Be aware of other S&S of fever in the older adult population: tachypnea, anorexia, falls, delirium Reduced subcutaneous fat- increased risk of hypothermia (particularly older men) |
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Physiology of Pulse |
The number of pulsing sensations occurring in 1 minute is the PULSE RATE
The volume of blood pumped by the heart in 1 minute is the CARDIAC OUTPUT Stroke volume X Heart rate = CO Normal CO is 5000 ml per minute Mechanical, neural, & chemical factors regulate the strength of contraction & stroke volume As HR increases, there is less time for the heart to fill If HR increases without an increase in SV, then the BP will go down A slow, rapid, or IRREGULAR pulse alters CO |
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Pulse Sites |
Temporal Carotid Apical Brachial Radial Ulnar Femoral Popliteal Posterior Tibial Dorsalis Pedis |
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Character of the Pulse |
Rate Know baseline for patient Postural changes affect the pulse rate due to blood volume & neural activity Irregular peripheral pulse- take apical pulse for 1 min Auscultate (listen) to “lub-dub” Tachycardia: HR >100 Bradycardia: HR < 60 Pulse deficit Rhythm Dysrhythmias |
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Character of the Pulse cont. |
Strength Strong Weak Bounding
Equality Assess all pulses for symmetry EXCEPT the carotid pulse |
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Factors Influencing Pulse Rate |
Exercise Temperature Emotions Drugs Hemorrhage Postural Changes Pulmonary Conditions |
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Respiration |
The mechanism the body uses to exchange gases between the atmosphere and the blood and the blood and cells.
Intake of oxygen (O2)
Output of carbon dioxide (CO2) |
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Respiration cont. |
Includes: Ventilation- the movement of gases in and out of the lungs Resp rate, depth and rhythm
Diffusion- the movement of O2 and CO2 between the alveoli and the red blood cells Atelectasis
Perfusion- the distribution of the red blood cells to and from the pulmonary capillaries Pulmonary embolism |
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Mechanics of Breathing |
Inspiration is an active process Brain sends impulse down phrenic nerve to initiate diaphragm contraction Chest wall moves out with inspiration
Expiration is a passive process |
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Assessment of Ventilation |
Easiest of all VS to be measured Most haphazardly done
Sudden change in character of resps is important Head trauma Abdominal trauma
Be subtle in your assessment of resp rate |
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Assessment of Ventilation cont. |
When assessing resp, keep in mind: Client’s baseline Influence of any disease or illness Relationship b/w resp and cardiac function Influence of any therapies on respirations |
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Alterations in Breathing Pattern |
Bradypnea Tachypnea Apnea Hyperventilation Hypoventilation Cheyne-Stokes Kussmauls |
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Hyperventilation |
Causes: anxiety, infection, drugs: salicylate (ASA), amphetamines, acid-base imbalance. S/S: excessive stimulation of the respiratory center—attempt to blow off CO2. increase anxiety, lightheadedness, restlessness, agitation—unresponsive. Treatment: remove underlying problem, if anxious have them breathing in paper bag. |
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Hypoventilation |
Alveolar ventilation is inadequate to meet O2 demand or to eliminate sufficient CO2. Cause: atelectasis, drugs, inappropriate administration of O2 to COPD pt. S/S: mental status change, dysrhythmias, cardiac arrest. If untreated—convulsion, unconsciousness—death. Treatment: improve oxygenation, restore ventilation, treat underlying cause, achieve acid-base balance. |
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Hypoxia |
Causes: Decreased Hgb & oxygen carrying capacity Diminished concentration of inspired O2;high altitude Inability of tissues to extract O2 from blood; cyanide poisoning Decreased diffusion of O2 from alveoli to blood; pneumonia Poor tissue perfusion; shock Impaired ventilation; multiple rib fx |
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Hypoxemia |
S/S: apprehension, restlessness, inability to concentrate, change in LOC, dizziness. Increased pulse, rate & depth of resp., in early stage increase BP. Cyanosis is late sign. Untreated –cardiac dysrhythmias—death. Treatment: administer O2 & treat underlying cause. |
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Client Teaching r/t Respirations |
Clients who have decreased ventilation will benefit from learning DB & Coughing exercises Instruct caregiver to contact home care nurse or HCP if fluctuations in RR occur Teach client S&S of hypoxemia: Headache, somnolence, confusion, dusky color, SOB, & dyspnea Effect of high-risk behaviors such as smoking on oxygen saturation |
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Older Adults r/t Respirations |
Ossification of costal cartilage and more rigid rib cage; kyphosis & scoliosis Reduction of chest wall expansion and decreased tidal volume (Vt) Depend more on abdominal muscles than on weaker thoracic muscles Sudden events that require an increased demand for O2 create SOB in the older adult Locating pulse ox sites may be difficult d/t PVD, decreased CO, cold-induced vasoconstriction, and anemia |
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Blood Pressure |
The force exerted on the walls of an artery by the pulsing blood under pressure from the heart Systolic pressure-peak maximum pressure, during contraction Diastolic pressure- ventricles relax, minimum pressure exerted at all times Pulse pressure- difference between systolic & diastolic pressure Measured in mm Hg |
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Physiology of Arterial Blood Pressure |
Cardiac Output Peripheral Resistance Blood Volume Viscosity Elasticity |
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Factors Influencing BP |
Age Stress Ethnicity African Americans Higher incidence of HTN at earlier age Gender Daily Variation Medications Activity & Weight Smoking Often asymptomatic Associated with thickening & loss of elasticity of arterial walls |
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Hypertension |
Risk Factors: Family history Obesity Cigarette smoking Heavy ETOH consumption High sodium intake Sedentary lifestyle Continued stress exposure > incidence in diabetics, older adults & African Americans |
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Education Points with Clients: |
Blood pressure values 120-139/80-89 (Prehypertension) > 140/90 (Hypertension) Long term follow up care & therapy Usual lack of symptoms Therapy may control NOT cure Consistently follow tx plan |
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Hypotension |
When SBP < 90 mm Hg Occurs: Dilation of arteries (shock) Loss of a substantial amount of blood volume Failure of the heart muscle to pump adequately (MI) Hypotension associated with pallor, skin mottling, clamminess, confusion, increased HR, or decreased urine output is life-threatening and needs to be reported to the HCP immediately! |
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Orthostatic Hypotension |
Aka- “postural hypotension” Occurs when a normotensive person develops symptoms and low BP when rising to an upright position Distal vessels constrict Already constricted Hypovolemic Prolonged bedrest Medications Measure in supine, sitting, & standing positions |
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Consideration of Older Adults |
The normal range for BP is the same for older adults as in younger people Older adults often have decreased upper arm mass- careful ATTN to cuff size Older adults sometimes have an increase in SBP r/t decreased vessel elasticity The DBP will remain the same which results in wider pulse pressure Instruct older adults to change position slowly and wait after each change to avoid postural hypotension and prevent injuries Difficult to check if elderly dehydrated by checking skin turgor. |
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Purposes of Physical Examination |
Triage for emergency care Routine screening to promote health and wellness To determine eligibility for: Health insurance Military service A new job To admit a patient to a hospital or long-term care facility Use physical examination to: Gather baseline data about patient’s health Support or refute subjective data obtained in the nursing history Identify and confirm nursing diagnoses Make clinical decisions about a patient’s changing health status and management Evaluate the outcomes of care |
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Cultural Sensitivity |
Culture influences a patient’s behavior. Consider health beliefs, use of alternative therapies, nutritional habits, relationships with family, and personal comfort zone. Avoid stereotyping. Avoid gender bias. |
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Preparation for Examination |
Infection control Environment Equipment Physical preparation of patient Positioning Psychological preparation of patient Assessment of age groups |
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Organization of the Examination |
Assessment of each body system Follows the nursing history Systematic and organized Head-to-toe approach |
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General Survey |
Assess appearance and behavior. Assess vital signs. Assess height and weight. |
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Inspection |
Use adequate lighting. Use direct lighting to inspect body cavities. Inspect each area for size, shape, color, symmetry, position, and abnormality. Position and expose body parts as needed so all surfaces can be viewed but privacy can be maintained. When possible, check for symmetry. Validate findings with the patient. |
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Auscultation |
Involves listening to sounds Learn normal sounds first before identifying abnormal sounds or variations. Requires a good stethoscope Requires concentration and practice |
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Percussion |
Tap body with fingertips to produce a vibration. Sound determines location, size, and density of structures. |
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Palpation |
Used to gather information Use different parts of hands to detect different characteristics Hands should be warm, fingernails short. Start with light palpation; end with deep palpation. |
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Skin |
Integument Color Pigmentation Cyanosis Jaundice Erythema Moisture Temperature Texture Turgor |
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Skin (cont’d) |
Vascularity Edema Lesions
ABCD: Asymmetry Border irregularity Color Diameter |
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Head and Neck |
Includes assessment of the head, eyes, ears, nose, mouth, pharynx, neck, carotid arteries, and trachea. Eyes: External eye structure Position and alignment Eyebrows Eyelids Lacrimal apparatus Conjunctivae and sclerae Corneas Pupils and irises PERRLA |
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Ears |
Auricles Texture Tenderness Lesions Color Pain Cerumen
Nose & sinuses |
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Mouth and Pharynx |
Lips Color Texture Hydration Contour Lesions Buccal mucosa Gums Teeth Mouth & pharynx Palate Hard Soft Pharynx
Neck Carotid artery Jugular vein |
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Thorax and Lungs |
Examination Inspection Palpation Auscultation Adventitious sounds Crackles Rhonchi Wheezes Pleural friction rub |
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Thorax and Lungs (cont’d) |
Posterior thorax Inspect for deformities, position of the spine, slope of the ribs, retraction of the intercostal spaces during inspiration, bulging of the intercostal spaces, and rate and rhythm of breathing. Lateral thorax Vesicular sounds Anterior thorax Observe accessory muscles. Palpate muscles and skeleton. Compare right and left sides. Auscultate for bronchial sounds. |
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Heart |
Compare assessment of heart functions with vascular findings. Assess point of maximal impulse (PMI). Locate anatomical landmarks. |
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Vascular System |
Blood pressure Readings tend to be higher in the right arm. Always record the highest reading. Carotid arteries Reflect heart function better than peripheral arteries Commonly auscultated Carotid bruit Narrowed blood vessel creates turbulence, causes blowing/swishing sound. Pronounced “brew-ee” Jugular veins Most accessible Right internal jugular vein follows more direct path to right atrium. Note distention. |
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Vascular System (cont’d) |
Peripheral arteries and veins Blood flow Condition of skin and nails Integrity of venous system Pulses/sufficiency of arterial circulation Pulses 0: absent, not palpable 1+: pulse diminished, barely palpable 2+: expected/normal 3+: full pulse, increased 4+: bounding pulse |
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Peripheral Arteries |
Radial pulse Thumb side of wrist Ulnar pulse Little finger side of wrist Brachial pulse Femoral pulse Popliteal pulse Dorsalis pedis pulse Posterior tibial pulse Ultrasound stethoscopes Tissue perfusion Varicosities Phlebitis |
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Abdomen |
Complex assessment because of organs located in the abdominal cavity Inspection Umbilicus Contour and symmetry Enlarged organs or masses Movements or pulsations Auscultation Bowel motility Peristalsis Palpation Performed last Detects tenderness, distention, or masses May be light or deep, as appropriate Aortic pulsation |
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Musculoskeletal System |
General inspection: Gait Postural abnormalities Age-related changes |
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Musculoskeletal System (cont’d) |
Assess for lordosis, kyphosis, or scoliosis.
Palpation Joints Bones Muscles |
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Neurological System |
Responsible for many functions Full assessment requires time and attention to detail. Many variables must be considered during evaluation: level of consciousness (LOC), physical status, chief complaint. Collect all equipment before beginning.
Motor function Coordination Higher extremity/fine-motor control Lower extremity
Motor function Balance Gross-motor function |
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After the Examination |
Record findings. Give the patient time to dress; assist if needed. If findings are serious, consult health care provider before informing the patient. Delegate cleaning of examination area. Record complete assessment; review for accuracy and thoroughness. Communicate significant findings. |
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Key Points |
Perform a physical examination only after proper preparation of the environment and equipment and the patient has been prepared physically and psychologically. Throughout the examination, keep the patient warm, comfortable, and informed of each step of the process. A competent examiner is systematic while combining simultaneous assessment of different body systems. Information from the history helps to focus on body systems likely to be affected. |
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PE? |
Pulmonary Embolism |
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S/S |
Signs and Symptoms |
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Signs of Hypoxia & Hypoxemia |
First Sign is Restlessness |
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In what order should you Auscultate and Palpate |
Always Auscultate before Palpating |
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Erythema? |
Redness. |
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Turgor??? |
Is Skin Elasticity |
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Carotid Burit |
Narrowed Blood Vessels creates turbulence, causes blowing/ swishing sound. |
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Flubitis |
Inflammation of Vessel wall |
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Accomodation |
When a patient focuses on a distant object and then focuses on a close up object... eg, a penlight |
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Angina is? |
Heart pain/ ie; The heart is not receiving enough 02 |
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Hemoptysis |
Bloody Sputum |
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Rhonchi |
Rattles throughout airway/ Mucus in large airways |
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Cause of Wheezing ??? |
Narrowing of airways |
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Cause of crackles |
Minor fluid accumulation |
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Stridor??? |
Upper airway obstruction |
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Erythropoetin |
Stimulates production of more RBCs |
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Normal platelet count? |
150,000-400,000 mm Normal values
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Units of measurement for Nasal Cannulas and masks |
Nasal Cannulas by Liters and masks measure in % |
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What is Pulse Pressure? |
The difference between the Diastolic and Systolic pressure e.g. 120/80 = a pulse pressure of 40 |
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ISBARR |
I. Identify S. Situation B. Background A. Assess R. Recommendation R. Read Back
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