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Ptosis
Drooping of eyelid over the pupil
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Edema
Fluid accumliation, swelling
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Jaundice
Yellow orange discoloration
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Bruit
Blowing, swishing sound in blood vessel
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Melena
Black, tarry stools
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Kyphosis
Curvature of the thoracic spine
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Petechiae
Tiny, pinpoint red spots on the skin
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Erythema
Red discoloration
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Induration
A hardening area
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Three best positions for a cardiac assessment?
- Supine
- Sitting
- Lateral recumbent
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Percussion
Involves tapping the body with the fingertips to produce a vibration that travels through body tissues.
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Auscualtion
Listening with a stetscope to sounds produced by the body.
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Olfaction
Helps to detect abnormalities not recognized by other means.
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Integument
Consist of skin, hair, scalp, and nails.
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Cyanosis
Blush discoloration of the skin
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Turgor
The skins elasticity
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Lunula
Whiteish area at the base line of the nail bed.
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Visual Acuity test?
Snellen chart
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Tinnitus:
Ringing in ears
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Cerumen:
A yellow, waxy subsance in ear.
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3 types of hearing loss:
- Conduction
- Sensorineural
- Mixed
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Purpose of physical examination
- Gather baseline data
- Supplement, confirm, or refute data
- Confirm and identify nusring diagnosis
- Make clinical judgements
- Evaluate the outcomes of care
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Cultural Sensitivity
Learn to recognize common disorders for those ethnic populations within the community.
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Inspection
the use of vision and hearing to distinguish normal from abnoraml findings
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Palpation
Involves the use of hands to touch body parts to make sensitive assessments.
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Should you touch anything pulsating?
No
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Palpation of abdomen
- Check for tenderess, distention, or masses.
- 1 cm deep.
- Palpate after inspection and auscultation
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Percussion
Involves tapping the body with the fingertips to produce a vibration that travels thru body tissues
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Ausculation
Listening with a stethoscope to sounds produced by the body.
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Olfaction
Helps to detect abnormalities not recognized by other means.
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General survey
Begins when you first meet pt and with a review of primary health pattern. Provides info about characteristics of illness, hygiene, skin condition, body image, emotional state, dev status
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What is the first part of a physical examination?
Assessment of vital signs
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Integument
Consists of the skin, hari, scalp, and nails.
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What do you use to assess the integument function and integrity?
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What does the assessment of skin reveal?
changes in oxygenation, circulation, nutrition, local tissue damage, and hydration.
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What kind of light do you observe the skin?
Halogen lighting and natural.
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The examination of skin includes:
- Skins color
- Moisture
- Temperature
- Texture
- Turgor
- Vascular changes
- Edema
- Lesions
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Lunula
The semilunar whitish area at the base of the nail bed.
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Clubbing nail:
- 180 degrees
- Causes: Chronic lack of oxygen, heart or pulmonary disease.
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Beaus nail:
- Bump in the middle of the nail.
- Causes: Nail injury
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Koilonychia (spoon nail):
- Concaved nail
- Anemia
- Syphillis
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Splinter hemorrages:
- Red or brown streaks on nail
- Causes: Minor trauma
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Paronychia
- Inflammation of skin at base of nail
- Causes: Local infection and trauma
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Visual acuity test:
Snellen chart
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What do you record if normal pupillary reaction:
PERRLA
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Sites of palpable lymph nodes:
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What position must a patient be if your orthopnea:
Upright position
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Dyspnea
Shortness of breath
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4 types of adventitious sounds:
- Crackles
- Rhonchi
- Wheezes
- Pleural Friction Rub
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Heart
Compare your assessment of heart function with findings from the vascular assessment.
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Inspection and palpation of patient with heart disease:
45 degrees and supine position
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Ausculation of heart:
- Sitting up and leaning forward
- Supine
- lateral recumbent
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Examining the carotid arteries:
Patient to sit or lie supine with the head of the bed elavated 30 degrees
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The 2 acessible veins:
Internal an external jugluar vien
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Phlebitis
Inflammation of a vein
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Normal bowel sounds:
5 to 35 times per minute
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Musculosketetal System
Visualize anatomy of bone, muscle and joint placmeent. Conduct nursing history. Use inspection and palpation (should have no pain). Assess RAM, strength and tone of muscle
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Neurological system
Conduct nursing history. Assess language, intellectual function, cranial nerve function, sensory nerve function, motor functionAlways doing this from time you walk into room
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How many cranial nerves is there:
12
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What scale is used for perdiction of recovery potential:
Glascow Coma Scale
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Glascow scale
Total score between 3 to 15Actions are eyes open, best verbal response, best motor responseResponses range from 1-6 and get a score
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What is used for pain assessment:
- PQRST
- Pain
- Quality
- Radiation
- Severity
- Treatment
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Sitting position
Vital signs
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Supine
- laying down
- for pulse sites
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Dorsal recumbent
- Abdonimal
- Head and neck
- Lungs & Breast
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Sims
- Rectum of vagina
- side with hip and knee bent
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Prone
- laying on stomach
- Musculoskeletal
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