Exam 1

AD PIE

Assessment, diagnosis, planning, intervention, evaluation

process of collecting, validating, and clustering data.

evaluation of patients condition based on data collected from labs, medical history and patients account of symptoms.

•Determines the client’s: –baseline–normal function–presence of (or risk for) dysfunction–strengths

Goal is to diagnose & treat human response to actual or potential health problems

collected data-> diagnosis

»Pneumonia vs. Ineffective airway clearance     r/t inflammation and presence of secretions

set goals and outcomes

carry out plan

determine effectiveness of plan

identify an occurring health problem

identify high risk health problems that will occur unless take preventative measures.

needs further data to support it

previously diagnosed. Why they are in the hospital. Focus on one system but consider other systems

• evaluate heart lung brain, very rapid
• ABC

screening patters. Recheck

large amount of info, use more tools. Example long term care. (heat to toe to emergency)

Symptoms. Health history, how patient feels, sensations, beliefs, perceptions

• Signs.
• Measurable.
• physical examination, diagnostic studies.

Patient

everyone but the patient (family, friends, old medical records, pcp)

focuses on health promotion and guards against health problems. minimize risk of health problems. PREVENTION

Health fairs, immunizations, nutritional instruction

early detection, prompt intervention, health maintenance for patients with health problems.

monitor condition

rehabilitative or extended care.

skilled nursing facilities, long term care, home care, hospice.

• Activities of daily living
• instrumental activities of daily living (use phone, shopping, travel)
•     AREACTIVITIES NECESSARY TO BE INDEPENDENT IN SOCIETY S

• first impression, overall status
• grooming, gait, appearance of health, affect, level of consciousness, mental health status, posture, mobility, distress

• preparatory
• introductory: introduction, explain purpose, time frame 
• [acknowledge, introduce, duration, explanation and thank you]
• working: data collection
• termination: summarize and state findings, discuss follow up

• inspection
• palpation
• percussion
• auscultation

• subjective and objective should support each other. confirm, clarify, verify.
• sources: patient, family, health care providers, health records, diagnostic tests.

PES

• Problem  (NANDA)
• Etiology (related to)
• symptoms (as evidence by)

• Precipitating/palliative: what doing when problem started, anything make it better/worse
• Quality/Quantity: describe symptom, feel like, sound like, how often
• Radiating/Region: point where, does it spread? other symptoms
• Severity: 0-10
• Timing: when did it start, how often, for how long?

identify familial risks factors at a glance.

• žSkin normal color and turgorž
• Warm and dryž
• No open wounds or lesions
• žHair and scalp without lesion or infestations.ž
• Nail beds pink and smooth
• žNail base angle 160 degrees
• žNail folds without redness or indurationž
• Capillary refill < 3 seconds

1. Frontal•2. Ethmoid•3. Maxillary•Sphenoid lies behind the Ethmoid

children: frontal develop at 7 yrs, maxillary and ethomoid at birth

• look
• general survey
• Direct: directly look at patient
• Indirect: use equipment

• touch
• light: 1/2 inch
• deep: + 1/2 inch

• tapping.
• assess for masses, organs, pulsations, rigidity etc.

• hearing direct or indirect
• use validation (someone else check )

•  temperature, pulse, bp
• why? establish baseline, monitor, evaluate response, identify problems

• Normal 60-100
• force of contraction
• stroke volume: amount of blood ejected
• CO=SV X HR
• tachycardia
• bradycardia

more than 100 bpm

less than 60 bpm

normal 12-20 bpm

• normal respirations
• 12-20

more than 20 bpm

less than 12 bpm

absence breathing for more than 15 seconds

difficulty breathing

• depths of respiration
• 300-500 ml is normal

• 100-120 systolic
• 60-80 diastolic

BP= CO X PVR

felt at site other than the site of origin

pain extends.

• nail base angel greater than 180 degrees
• respiratory, circulatory, cirrhosis, thyroid

• gently pinch skin cause tenting
• decreased turgor means dehydration

on nial, less than 3 seconds is normal

initial alteration of skin (macule, papule, nodule)

arises from change in primary lesion caused by external forces such as trauma, scratching, infection etc.

• 1: nonblacheable erythema of intact skin
• 2: partial thickiness loss in both epidermis and dermis
• 3: full thickess loss involving subcutaneous tissue
• 4: full thickness loss involving muscle, bone, or supporting structure
• 5: covered with eschar, cannot be staged without debridement

• Asymmetry
• Border is irregular
• Color varies
• Diameter is more than 5 mm

• Anterior- 10-18 months
• Posterior- 2 monts

• rushing blood sound due to obstruction
• outside heart

• adult: 32
• child: 20

• cholasma: brown pigmentation on face
• gums: hypertrophy
• thryroid may be palpated due to increased hormone levels.

brown pigmentation during pregnancy

• helix
• maxillary
• tragus

otoscope adult 1/2 inch, child 1/4 inch

• low pitch, low tone
• stand 1-2 ft behind patient and whisper 3-4 unrelated words

vibrating tuning form on mastoid process (behind ear) and in front of ear

• AC:BC
• 2:1

dizzy due to inner ear inbalance

Hearing loss with aging of high pitched sounds

drainage

abnormal skin growth in middle ear behind eardrum

• ringing
• usually with asprin toxicity

earache

test for visual acuity for distance

• for nearsightedness
• 14 inches away, move further is a fail.

• pupils eaqual, round, reactive to light
• accommodation

process by which the vertebrate eye changes optical power to maintain a clear image (focus) on an object as its distance varies

one of six positions to which the normal eye may be turned. This test evaluates the functioning of the six extraocular muscles and cranial nerves III, IV, and VI

constriction of illuminated pupil and consensual opposite pupil restricts

light reflection test (extraocular membrane)

symmetry of light reflection is normal

near sightedness

farsightedness

falling of eyelid

normal finding, otherwise suggest cataracts retinal detachment

located nasally

located on opposite side of optic disc

irregular curvature of lens

above eyelid to naso lacrimal duct (corner- inner canthus)

normal blink, eyes tear

lazy eye test. with corneal light reflex, binocular vision, cover un cover

alignment of eye

cover one nostril at a time

weakness/paralysis of one side of face, usually goes away

• 1: WNL
• 2: enlarge but separate from uvula
• 3: tonsils touch uvula
• 4: tonsils touch eachother

• Inside lining of mouth
• good for assessing skin color on darker skin ppl

• upper, drain saliva from parotid gland
• normal: pink and no lesions

lower, under tongue, drain saliva from submandibular galnds

under tongue

• midline
• prevents food from entering nasal passages

• normal finding
• raised papillae

black papilae

bilateral on buccal mucosa white lace-like erruptions

White plaque on buccal mucosa and gingivae or tongue (HIV)

• skin
• carotid and jugular
• trachea
• thyroid (ask to swallow, should rise)
• carotid (for bruits with bell)

abnormal, asymmetrical health/neck positions

tipped toward shoulder

rotates along logitudal axis

forward flexion

hyperextension of head/neck backwards

lines lungs

line chest and diaphragm

• right-3
• left-2

paleness, due to low hemoglobin

blue color of skin due to low oxygen

low levels of oxygen, causes cyanosis

• normal 1:2, barrel shape is 1:1
• infants are 2:1

upon palpation, subcutaneous air (check around wound sites)

• chest expandability (butterfly)
• diaphragm is 3-5 cm

• "99"-vibrations
• resonance is normal
• increased: fluid in lungs
• decreased: air trappings (asthma etc. )

• (over trachea and larynx)
• loud, hight pitched and hollow I<E

• (over major bronchi/ manybrium) moderate, medium pitched
• I=E

•  (over periphery lung fields) soft, low pitched
• I>E

• over intercostal spaces
• dullness: fluid, tumor, pulmonary edema
• hyperessonance: air
• normal: dullness over bones and organ, otherwise resonance.

• high pitched musical sound 
• continuous
• narrowing of airway

prevents food from entering trachea

• Popping sound
• discontinous

• rattle during expiration in upper large airway resulting from secretions
• low pitched, continuous

• harsh, high pitched during inspiration
• upper airway (trachea or larynx)

high pitched, squeaking sound in pleural layers both inspiration and expiration

abnormal voice sounds, clearer transmission of spoken voice. say 1, 2, 3

abnormal voice sounds ee to aaa

• whisper 1,2,3
• normal: hear indistinct sound
• abnormal: hear clearly

• infants: nose breathers, belly breathers, respirations are faster
• elderly: increase AP- barrel shape

• SA  node
• AV node
• bundle of his
• branches right and left
• purkinje fibers

blood ejected per minute

turbulent sound through chambers/valves hearing in heart

• Apex (mitral)
• LLSB (tricuspid area)
• Base left (pulmonic area)
• Base right (aortic area)
• epigastric

APE T M

First with diaphragm then bell back up

Apical (mitral) for one minute, rythm

•Temp, Pulse, Resp, BP, SaO2, and Pain

• •Surface: oral, axillary, skin, and tympanic
• •Core:  rectal, bladder, and hemodynamic probe

• 95-100% normal
• •SaO2 reflects the percentage of hemoglobin molecules carrying oxygen

100.4-96.8

• I - Olfactory nerve
• II - Optic nerve
• III - Oculomotor nerve
• IV - Trochlear nerve
• V - Trigeminal nerve/dentist nerve
• VI - Abducens nerve
• VII - Facial nerve
• VIII - Vestibulocochlear nerve/Auditory nerve
• IX - Glossopharyngeal nerve
• X - Vagus nerve
• XI - Accessory nerve/Spinal accessory nerve
• XII - Hypoglossal nerve