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277 Cards in this Set
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data about the patient's physical status
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objective
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data is obtained by patient report through history taking and interviewing
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subjective
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what is a visual examination of all parts of body
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inspection
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what do we inspect for
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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
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what is the term for touching- feeling w/ fingers and hands
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palpation
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how might you encourage relaxation beofore you palpate
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advise the client you are to touch him and use a gentle approach
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what areas would you palpate last
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tender areas
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what does the dorsal surfaceof your hand palpate
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temperature
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what does your finger tips palpate
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texture, size, consistency, pulsation, form and shape,
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what does your palmer surface palpate
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vibration
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what could happen if you obstructed blood flow over carotid arteries
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you could reduce circulation to the brain or cause changes in heart flow
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what is referred to as tapping the body w/ fingertips to evaluate size, borders, density air or fluid
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percussion
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when you tap lightly with the pads of the fingers on the the skin what is that refered to
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direct percussion
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this is used more frequently and is requires both hands in reference to percussion
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indirect percussion
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is listening to sounds
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auscultation
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what is usually performed last after inspection, palpation, and percussion except when assessing the abdomen
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auscultation
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what is direct auscultation
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is listening w/out using an instrument
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what is indirect auscultation
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is listening w/ the help of a stethoscope
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name the 5 major parts of the stethoscope
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earpieces, binaurals, tubing, bell chestpiece, and diaphragm chest piece
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dual tubes promote
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sound clarity
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what do you listen w/ to listen to high pitched sounds
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diaphragm
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what do you listen w/ to listen to low pitched sounds such as extra heart sounds
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bell
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when during the physical assessment would you need to wear gloves
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if exposure to body fluids is a possibility
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where would you place a stethoscope
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on skin, not over the clothes because the clothes will add or obscure sounds and interfere w/ accurate assessment
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what are some things you would do in order to get ready for an assessment
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wash hands, environmental noise, remember to protect the patient's privacy, inform the patient that you are going to do an assessmetn before you start and explain what you are doing throughout the procedure, assess the limitations fo your patient so that you will know how to assest them, gather equipment
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what are the two methods to use on an assessment
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head to toe, and body systems method
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what is the most efficient method in assessing a client
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head to toe
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what is the first step is assessing a client
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general survey as soon as you walk in you will be gathering information about their health status
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what are some things you would assess under general appearance and behavior
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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
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when you are assessing age what are looking for
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do they appear their stated age or look oler or younger? this tells you something about their health status
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what are you assessing in the client who is not dressed normal
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an unkept appearance may reflect chronic pain, fatigue, depression or low self esteem
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what are you assessing in the body type
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are they overweight or underweight. do they have good muscle tone an dappear physically fit or do they appear out of shape and debilitated
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If daily weights are ordered make sure that they are done when
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at the same time, usually before breakfast on teh same scales w/ the same clothes
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who would require daily wts.
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pts. w/ fluid balance due to heart or kidney disease.
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What part of the assessment would provide valuable information about your client's growth and development nutritional status overall general health and required dosages for medication
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height and weight assessment
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abnormal skin lesions may reflect abnormal conditions of what?
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the skin or of internal pathological processes
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information gained from assessment of skin includes the status of
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circulation, oxygenation, nutrition, hydration and certain metabolic and endocrine conditions
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what is the term used to describe a blue gray coloration of the skin often described as ashen
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cyanosis
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in light skinned clients skin appars whit loss of pink or yellow tones
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pallor
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a yellow orange cast to the skin
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jaundice
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a reddened area
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erythema
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may be related to poor circulation or a low hemoglobin level (anemia) best sites to assess include the oral mucous membranes, conjunctiva, nail beds, palms, and soles of feet
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pallor
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if seen in the lips, mucous membranes, and facial features it si known as central cyanosis and is associated w/ hypoxia may also be seen in the extremities, especially hands adn feet, after exposure to extreme cold
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cyanosis
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often associated w/ liver disorders. Best sites to assess include the sclera, muchouls membranes, hard palate of the mouth, palms and soles
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jaundice
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associated w/ rashes, skin infections, and prolonged pressure on teh skin
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erythema
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what will you use to assess skin temp.
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the dorsum of the hand or fingers
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what may stimulate the metabolisma nd may also cause an elevation in skin temp
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hyperthyroidism
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erythema accompanied by warmth may indicate
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infection or inflammatory
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what is a normal skin moisture assessment
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skin is warm and dry
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excessive moisture may result from
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hyperthermia, thyroid hyperactivity, anxiety or hyperhidrosis
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dry skin may result from
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dehydration, chronic renal failure, hypothyroidism, excessive exposure, or overzealous hygiene
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what is the normal skin texture
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is smooth and soft
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what may be some factors effecting the skin texture
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exposure, age, hyperthyroidism and other endocrine disorders, impaired circulation
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refers to the elasticity of the skin,
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turgor
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skin tenting refers to
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dehydration in skin tugor
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what are white normal raised areas on the nose chin and forehead of newborns due to sebum
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milia
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how do primary skin lesions develop
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develop as a result of disease or irritation ex pustules of acne
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how do secondary lesions develop
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develop from primary lesions as a result of continued illness, exposure, injory or infection, such as the crusts that form from ruptured pustules
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what is ABCDE
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a is for asymemetry, b border irregularity, c color, d diameter greater than .5 cm, e elevation above the surface
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what are due to pigmented cells in the deeper areas of skin adn fade as the child matures (blue-black areas seen on lower back and buttocks of african/asian/native american)
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mongolian spots
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sometimes known as stork bites are small irregular pink red areas that are often seen around the face and neck in newborns
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capillary hemangiomas
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ecchymosis is a color variation what is the description and significance of its meaning
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bruised (blue-green-yellow) area may be seen anywhere on teh body. the color will vary based on teh age fo the injury may indicate abuse
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flat and colored ex. freckle birthmark, mongolian spot
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macule
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elevated and raised by superficial ex. moles psoriasis
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papule
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a small circumscribed area distinct from surrounding surface in character and appearnce
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patch
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a patch on the skin or on a mucouls surface
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plaque
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elevated solid and firm w/ depth into dermis ex. wart
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nodule
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hive/ elevated superficial w/ localized edema ex. insect bite
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wheal
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palpable fluid filled and encapsulated
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keratogenous cyst
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blisters elevated and filled w/ serrous fluid ex. blister, herpes,
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vesicle
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elevated and filled w/ pus ex. acne falliculitis impetigo
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pustule
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What information can you gather by inspecting the nails?
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a change in nail shape may indicate underlying disease
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which the nail plate is 180 deg. or more
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clubbing is associated w/ long term hypoxic states, such as occurs w/ chronic lung disease
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what is the term used that may result from iron deficiency in ref to nails
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spoon shaped nails
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healthy nail beds are
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level, firm, and similar to the color of the skin, nail is smooth and uniform in texture w/ a 160deg. nail plate angle
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white spots in the nails represent
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may indicate zinc deficiency
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black nails are due to
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blood under the nail, are seen after local trauma
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what is referred to as small hemorrhages under the nail bed associated w/ bacterial endocarditis or trauma
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splinter hemorrhages
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which are transverse white lines in teh nail bed. seen in clients who have experienced sever illnesses
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mee's lines
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which a distal band of reddish pink covers 20 to 60% of the nail occur in clients w/ low albumin levels or renal disease
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half and half nails
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what is capillary refill and how do you assess it what does an abnormal capillary refill indicate?
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briefly press the tip of the nail w/ firm steady presure then release and observe for changes in color this test assesses circulartory adequacy rather than the nails
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what is a common complaint w/ skin conditions
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pruritis
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the scalp is assessed for
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lesions, lumps, bruises, lice and abnormal hair distribution
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what is referred to as excessive facial or trunk hair may be due ot endocrine disorder or steroids
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hirsutism
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what is referred to hair loss can be caused by chemotherapy for the treatment fo cancer or by nutritional deficiencies or by endocrine disorders
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alopecia
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what is pediculosis
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head lice infestation
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Inspect head and neck for
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size, symmetry, and presence fo nodules, masses, and bulges, shape
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normocephalic
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normal head
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microcephaly
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an abnormally small head size is seen in clients w/ certain types of mental retardation
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a disorder associated w/ excess growth hormone
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acromegaly
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an accumulation of excessive cerebrospinal fluid
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hydrocephalus
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disease fo the lymph nodes
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lymphadenopathy
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irregular jaw movement or cracking of the jaw
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TMJ, temperomandibular joint syndrome
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When assessing the clients eyes what do you inspect
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do they wear glasses, contact lenses? inspect and palpate the external eye structues, assess vision and examine the internal eye structures
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double vision is the perception of two images from a single object
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diplopia
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associated w/ hyperthyroidism failure of or both pupils to accomadate may reflect a cranial nerve III
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exopthalmos
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a drooping of the lid
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ptosis
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a white ring encircling the outer rim of the cornea
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arous senilis
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lack of coordination between the eyes as a result the eyes look in different direction and do not focus on the same time
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strabismus
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the medical term for cross eyed
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strabismus
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puffiness of the eye
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periorbital edema
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an inflammation fo the conjunctiva
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conjunctivitis
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the medical term for pink eye
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conjunctivitis
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scleral icterus
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a way of determining jaundice in the sclera of the eye
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what is are you inspecting in reference to the general appearance of the eye
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note irritation, discharge, swelling
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what are some signs of respiratory distress
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sob, restlessness, decreased mental alertness, cyanosis, pallor, nasal flaring, orthopnea, intercostal retractions, use of accessory muscles, increased heart rate
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What does barrel ches look like and when would it be present
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used to describe the rounded, barrell shap of the chest that can occur in people w/ chronic obstructive pulmonary disease (COPD) such as emphyema
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Which part of the stethoscope is used to listen to the lungs
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diaphragm
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what are soft low pitched breezy sounds w/ a lengthy inspiratory phase adn a short expiratory
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vesicular breath sounds
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which breath sounds are heard over the 1st and 2nd ICS adjacent to the sternum on teh anterior chest and between teh scapula on teh posterior chest
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bronchovesicular breath sounds
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What breath sounds are medium pitched w/ an equal inspiratory and expiratory phase
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bronchovesicular breath sounds
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Auscultation 6 places front and back what are some of the breath sounds you will hear
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normal, decreased, diminished, absent, increased adventitious voice sounds
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if you there are no breathing sounds in that area that may represent what
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absent breathing sounds may be an ex. of a punctured lung, collapsed or if they removed a portion of the lung
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what is the term to describe additional sounds that are not the normal lung sounds
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adventitious
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what do you inspect in ref. to nose
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placement, nasal flaring(difficulty breathing), drainage, nasal mucosa, deviated septum
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what is the term used to described difficulty breathing while lying down
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orthopnea
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what is the 1st sign of lack of oxygen
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restlessness
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what are some subjective data when inspecting the thorax and lungs
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cough, chest pain, history of resp. infections, smoking history (pack/years), environmental exposure, self-care behaviors
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tachypnea
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rapid respiration
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hyperventilation
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increased respiration
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rapid deep breathing w/out pauses more than 20min in adults labored breathing that sounds like sighs
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Kussmaul's respirations
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slow respiration poor gas exchange
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hypoventilation
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slow breathing increase breath, apnea then slow and increase....
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cheyne-stokes respirations
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Kyphosis
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hunch back hump back
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Scoliosis
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S curve back
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when observe the ches what are some ex that you may possibly see in ref. to shape and symmetry
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barrell chest, pectus excavatum, pectus carinatum, scoliosis, kyphosis,
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deformities of the chest sternum oun
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pectus excavatum
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deformities of the chest sternum in
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pectus carinatum
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Plapation of the chest place palms lightly over chest and palpate for
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masses, tenderness, alignment, retractions of chest or intercostal spaces
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Palpation of the chest using fingertips to feel for
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lumps, scars, lesions, ulcerations, temperatures, turgor, moisture, subcuaneous crepitus (feels like rice crispies under the skin some air leakage under the skin)
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When you place open palms on both sides of pt. back and anterior chest and ask pt. to say "ninety-nine" loud enough for you to feel vibrations what are you assessing
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assessing tactile fremitus
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what is the interpretation of tactile fremitus
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vibrations will be more intense in areas of tissue consoliation
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less intense vibrations in assessing tactile fremitus may mean
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presence of empysema, pneumothorax, or pleural effusion
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If vibrations in upper posterior thorax are faint or absent, there may be
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bronchial obstruction or a fluid filled pleural sapce
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what are some Percussion sounds you may hear in the chest
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resonance, dull sounds, hyperresonance, and abnormal dullness
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heard over normal lung tissue
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resonance
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heard over heart
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dull sounds
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heard if there is increased air in lung or pleural space
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hyperresonance
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found w/ areas of decreased air in lungs
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abnormal dullness
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punctured lung
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neumothorax
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what is an example of an adventitious breath sound
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crackles, rhonchi, wheezes, stridor, pleural friction rub
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what are some normal breath sounds
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tracheal breath sounds, bronchial breath sounds, bronchovesicular breath sounds, vesicular
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what are the sounds you hear over teh trachea, harsh, high pitched and less during inspiration (deeper sound)
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tracheal breath sounds
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what are the sounds you hear next to trachea, loud, hight pitched the inspiration is greater than the expiration
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bronchial breath sounds
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what are the sounds you heard next to sternum and between scapulae medium in loudness and pitch and the sound of the inspiration and expiration are equal
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bronchovesicular breath sounds
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heard in rest of lung (peripery) soft and low pitched inspiration greater than expiration
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vesicular
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You would listen to this at an angle also known as fluid in the lungs
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crackles
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three types of crackles
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coarse, medium, fine
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the frying popping, moist, low pitched sound here it during the inspiration and some expiration is referred to as
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a course crackle
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where do you find the medium crackle
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found in mid inspiration and its not as loud as course
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its a non continuous popping high pitched and heard at the end of inspiration
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fine crackle
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its a continuos, low pitched, rattling sound heard during the expiration, usually can be cleared by coughing caused by fluid partially blocking large airways
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rhonci
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contiunous high pitched sound during the inspiration or expiration or both caused by constricion of airway with reultant blockage of air
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wheezes
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its like breathing out of a straw whistling sound trying to breathe w/ a constricted airflow
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wheezes
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decreased fluid causes pain everytime you breathe
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pleural friction rub
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low pitched grating rubbing inspiration and expiration caused by inflammation of pleura may have pain where heard
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pleural friction rub
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what are bronchophony and egophony and whispered pectoriloquy
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voice sounds
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when you have patient repeat "ninety nine" while you auscultate lung fields what is this representing
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bronchophony,
words will sound muffled over normal lung fields words will be louder over consolidation |
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asking the patient to say "E" while auscultating the lung represents what
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egophony
sound is muffled over normal lung fields, will sound like letter "A" over consolidation |
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having the patient whisper "123" while auscultating the lung represents
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whispered pectoriloquy;
numbers hard to distinguish over normalo lung fields, numbers will be loud and clear over consolidation |
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Chest pain, dyspnea, orthopnea, cough, fatigue, cyanosis or pallor edema nocturia, past cardiac history, family cardiac history, personal habits all represent what kind of data
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subjective data on heart and neck vessels
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when assessing the carotid artery you would
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palpate medial to sternomastoid muscle and auscultate fro bruits
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palpating the medial to sternomastoid muscle for the carotid arter you
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avoid excessive pressure, palpate one at a time, note contour and amplitude, should be same bilaterally
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how do you auscultate for bruits at the carotid artery
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use bell of stethoscope, listen for blowing, swishing sound indicating turbulent blood flow, normally none present
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What are the two vessels you would inspect
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carotid artery and jugular veins
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appetite, dysphagia, food intolerance, abdominal pain, nausea/vomiting bowel habits, past abdominal history, medictions nutritional assessment is what kind of data
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subjective
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What are the three things you should do upon inspection of an abdomen
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inspect, auscultate, then percuss and palpate
(look, listen, and feel) |
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when ispecting an abdomen what do you look for
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symmetry, contour, discomort, splinting, guarding, lesions, scars, brusing, discoloration, swelling, bulges, distention, ostomies, drains, dressings
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how would you recognize ascites?
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if a patient appears to have ascites you would get a tape measure and measure the abdomianl girth. THis would give yo a baseline to go by and future measurements would indicate if and how fast more fluid is accumulating
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what part of the stethoscope is used for auscultating bowel sounds
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diaphragm
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what is the normal rate of bowl sounds per minute?
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5-35 normal
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what is the term to describe hunger pains or stomach growling
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borborygmus
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where do you check for bowel sounds
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in all four quadrants
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inspecting the skin on the abdomen what might you find or are you looking for
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smooth and even, color, (jaundice, redness, striae, moles, petehiae, cutaneous angioma) taut, and shiny ascites, lesions rashes
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bowel sounds over 35 are loud, high pitched rushing, tinkiling is considered to be
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hyperactive may be diarrhea
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bowel sounds less than 5
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hypoactive may be bowl obstruction, after surgery, constipated
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if there are no bowel sounds in what do you do
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listen for 5 minutes
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when listening to the vascular sounds in the abdomen what are you listening for and what do you listen w/
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listen w/ bell and listen for bruits over aorta, renal,illiac, adn femoral arteries
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Palpating the abdomen for
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size, location, consistency of organs, abnormal masses, tenderndess do last
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there are three things to look for when you are palpating the abdomen in ref to tenderness
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voluntary guarding, involuntary rigidity, rebound tenderness
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cold, ticklish, tense would be considered what in ref. to abdomen
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voluntary guarding
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constant board like hardness would be considered what in ref to abdomen
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involuntary rigidity
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pain on release of pressure in ref to abdom is considered what
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rebound tenderness
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percussing the abdomen where
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costovertebral angle tenderness; place one hand over 12th rib at CVA on back
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what do you do when percussing the abdomen and what are your results
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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
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where is the apex of the heart located
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5th intercostal space at the left midclavicular line
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what is the structure assessed in the apex
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mitral valve
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what is located in the 4th ICS on left sternal border
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tricuspid valve
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what is located in the 2nd ICS left sternal border
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pulmonic valve
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what is located in the 2nd ICS right sternal border
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aoritic valve
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in order to thoroughly assess heart sounds, you would ausculatate where first
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the aortic area
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what is the mnemonic you may use to recall the order of the heart
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Aunt Polly Takes Meds
Aortic, Pulmonic, Tricuspid, Mitral |
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what is the first heart sound
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S1 or lub
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S1 marks the beginning of what
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systole
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S1(lub) is a what kind of sound
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sow-pitched sound
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The S1 may be heard in all locations on the chest but where will it be the loudest
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over the mitral tricuspid
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what does the first heart sound result from
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the closure of the valves between the atria and ventricles
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what is the second heart sound you hear
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S2 or dub
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what does the S2 correspond to
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closure of the semilunar valves
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you can hear the S2 in all locations but it is loudest
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at the aortic and pulmonic areas
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a third heart sound (S3) is heard when
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immediately after S2 has a gallop cadence that follows the rhythm of the word KenTUcky
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when is a S3 normal
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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
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when is a S3 abnormal
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when it does not disappear w/ position change represents heart failure or volume overload
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A fourth heart sound (S4) heard when
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immediately before S1 has a rhythm FLOrida
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for whom is the S4 normal
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trained athletes and some older clients
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Both S3 and S4 are best heard where
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at the apical site, w/ the client lying on his left side, and using the bell of the stethoscope
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S4 is normal w/ trained athletes and may also be heard in adults w/ what
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coroanry artery disease, hypertension, and pulmonic stenosis
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what are additonal sounds produced by turbulent flow through the heart
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murmors
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what consists of a network of arteries and veins that transport oxygen, carbon dioxide and nutrients to the cells of the body
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vascular system
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what refers to the contraction or emptying of the ventricles
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systole
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what refers to the relaxation or filling phase of the ventricles
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dystole
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where does the heart sit
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at an angle on the left side of the chest in the 3rd, 4th, and 5th intercostal spaces.
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listen for murmors w/ what
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the bell of the stethoscope
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what is the ausculation technique for the heart assessment
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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
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presence of an S3 in adults over 30 indicate
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ventricular failure (CHF)
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increased velocity of blood, decreased viscosity of blood and structural defects or unusual openings are all symptoms of a
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murmor
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this is caused by turbulent blood flow and currents
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murmurs
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this is used w/ the bell and best heard at herb's point
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murmurs
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its a gentle blowing swooshing sound in the heart
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murmor
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when assessing a murmor you assess what
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the pattern, quality, location, radiation, and posture
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what is the norm for a heart beat
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60 to 100 beats per minute
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this occurs normally in young adults and children, rate increases w/ inspiration slows expiration in reference to the heart
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sinus arrhthmia
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leg pain or cramps, skin changes on arms or legs, swelling, lymph node enlargement, and medication are all what kind of data in the peripheral vascular system
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subjective
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inspect and palpate what for the peripheral vascular system
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arms, legs,
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when inspecting the legs what do you assess
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symmetry, pulses, temperature, lesions, measure calf circumference if discrepency and palpate lymph nodes
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when inspecting the arms what do you assess
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assess symmetry pulses, lesions
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pulses are located where
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temporal, carotid, apical, brachial, radial, femoral, popliteasl, pedal
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what is the pulse amplitude
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4+ is bounding
3+ is increased 2+ is normal 1+ is weak 0 is absent |
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if you can't locate the pedal pulse you would then
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ck. temp., ck capillary refill but if the refill is slow then use a doppler to validate it get another nurse and then call dr. that is considered a significant finding
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when assessing for homan's sign how would you position the client
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w/ client in supine position dorsiflet food towards tibi, this should not cause pain calf pain may indicate deep vein thrombosis, phlebitis, tendonitis, muscle injury or lumbosacral disorders
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inspecting the umbilicus you would look for
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position, color, and if its inverted
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if the color of the umbilical cord is a bluish color what does this mean
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this occurs with intraabdominal bleeding (cullen's sign)
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if the umbilicus is everted this could mean what
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ascites, mass, hernia
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musculoskeletal system: when their is pain, stiffness, swelling, heat and redness, and limitation of movement this is what type of data
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subjective
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palpate joints for what
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warmth, swelling, tenderness, massess
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asses the joints for
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range of motion, and muscle tone and strength compare both sides of the body
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inspect the joints for
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size and contour, joint deformities, skin color, swelling, observe gait and posture, note lordosis, kyphosis, scoliosis
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what are some ex. of subjective data in the neurologic system
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headache, hgead injury, dizzines/vertigo, seizures, tremors, weakness, incoordination, numbness or tingling, difficulty in swallowing, difficulty speaking, significant past history, environmental occupational hazards
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what do you assess in the neurological system
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level of consciousness, orientation, glascow coma scale, speech, memory lapses, deficits, coordination and balance
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what are the equipment needed for an exam in assessing the neurological system
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penlight, tongue blade, cotton swab, cotton ball, tuning fork, percussion hammer, occasionally: familiar aromatic substance
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what cranial nerves are you testing for in the neurologic system assessment
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cranial nerve II opic
cranial nerve III, IV, VI occulomotor, trochlear, and abducens nerves cranial nerve V trigeminal, and cranial nerve VII facial mobility |
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what might the nurse use to scren for visual acuity
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snellen chart
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if a person has 20/40 vision, what does this mean
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that to see lines of print that a person w/ normal vision can read at 40 ft. the client has to stand just 20 ft. from the snellen chart
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what does nasal flaring indicate
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difficulty breathing
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what would cause pallor
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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
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thick elevated white patches that do not scrape off may be precancerous and called what
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leukoplakia
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white curdy patches that scrape off and bleed indicate thrush also known as
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leukoplakia
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thrush is
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a fungal infection
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commonly called yeast infection or thrush is a fungal infection of any candida specias
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candidiasis
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black hairy tongue
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an overgrowth of bacteria in the mouth
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refers to gingival inflammation induced by bacterial biofilms (also called plaque) adherent to tooth surface
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gingivitis
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an acute hemorrhage for the nostril, nasal cavity or nasopharynx also known as a nosebleed
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epistaxis
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during a routine bedside assessment we are most commonly assessing which pulses
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radial and the pedal
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we usually determine the rate and regularity of pulses using the radial site. If the pulse is faint or irregular it would be important to what
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not only compare it to the opposite side but to also listen to the apical pulse to determine rate and regularity
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when we check pedal pulses we are determining what
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if they are present and if they are fainto or strong we are not concerned w/ counting the rate of the pedal pulses we want to know if the pt. has good circulation in the extremeties
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there are times when "neurochecks" are ordered by the physician or the nurse this might be after what happens
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a fall if the pt. hits his head after cranial surgery after head injury if pt has decreasing LOC or other conditions where brain swelling/compression might be likely to occur
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neurochecks usually include
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LOC and orientation, PERRLA, ability to follow commands, ability to move all extremities, muscle strength
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inspect the external ears for
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position, condition of the skin, presence of lesions, and drainage
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vertigo
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a specific type of dizziness, is a major symptom of a bal. disorder
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tinnitis
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ringing of the ears
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CVA tenderness (costovertebral angle tenderness) using the fist or blunt percussion where the end of the rib cage meets the spine bilaterally to assess for
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kidney tenderness
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what would be the abnormal findings for cva tenderness
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associated w/ kidney infection, or musculoskeletal problems
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what are some abnormal gaits
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propulsive, scissors, spastic, steppage and waddling
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this is an abnormal gait and is when a person is leaning forward
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propulsive
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an abnormal gait when knees turn in toward each other
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scissors
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wht is steppage referred to in an abnormal gait
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foot lifted high to clear the toes, no heel strike, toes hit first
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waddling is an abnormal gait what does it look like
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feet wide, duck like
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spastic is an abnormal gait what does it look like
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stiff leg mvmt while walking
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how would you recognize ascites
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by the distention of the stomach
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what would you do to assess ascites
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use a measuring tape to measure the girth. stretch/place 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
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when might sounds be absent or hypoactive in the bowel
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after abdominal surgery or w/ bowl obstruction infection,or innervation problems
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when might sounds be hyperactive in the bowel
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w/ diarrhea, early bowl obstruction or gastroenteritis
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lung sounds will be normal in 48 hrs is what step in the nursing process
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planning
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ineffective airway clearence is what step in the nursing process
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nursing diagnosis
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lung sounds reveal rhonchus in the upper lobe is what step in the nursing process
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assessment
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have client deep breathe and cough every 2 hrs. 4-5 times a day is what step in the nursing process
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implementation
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lung sounds clear in upper lobes following coughing. continue deep breathing every 2-4 hr. is what step in the nursing process
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evaluation
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