ch. 34

• S3
• occurs just after S2
• premature rush of blood into a ventricle that is stiff or dilated

continuous palpable sensation, like the purring of a cat

sounds created by vocal cords, send sound waves, vibrations from waves can be externally papated

abnormal drooping of the lid over the pupil

tumorlike growths

involuntary rhythmical oscillation of the eyes

• thick white patches
• heavy smokers and alcoholics

swayback

hunchback

hardened, firm

• increased/decreased tone
• considerable resistance/hangs loosely

protusion of avdominal organs through the muscle wall

bony growth

• skin breakdown
• redness and skin sloughing

• red discoloration
• indicates circulatory changes
• due to localized vasodialation
• sunburn, infalmmation, fever

eye lid margins that turn out/in

• a bulging of the tissues at the nail base
• due to insufficient O2

ruby red papules

a blowing or swishing sound caused by a narrowed section of a blood vessel

certain lung abnormalities cause the whispered voice to become clear and distinct

• fluid is compressing the lung
• vibrations from voice are transmitted to chest wall and become clear

• hyperactive, loud, "growling" sounds
• indicates increased gastrointestinal motility

• reduced in size
• feels soft and boggy when palpated

• a thin white ring along the margin of the iris
• abnormal under age 40

• compare assessment of heart functions with vascular findings
• use inspection and palpation simultaneously
• palpate for PMI
• use auscultation
• locate anatomical landmarks
• identify S1 and S2

• posterior, lateral, anterior
• identify anatomical landmarks
• use inspection, percussion, auscultation
• most common sounds: vesicular, bronchovesicular, bronchial
• adventitious breath sounds: crackles, rhonchi, wheezes, pleural friction rub
• shap and symmetry
• posture
• equality of movement

• pupils- size measured in mm
• equal
• round
• reactive to light
• accommodation- change in pupil size to adjust vision from far to near

• head
• eyes
• nose
• mouth
• pharynx
• neck
• lymph nodes
• carotid arteries
• thyroid gland
• jugular veins
• trachea
• use: inspection, palpatation, ausculation

• condition of nails reflects: general health, state of nutrition, occupation, level of self care
• inspect
• palpate for capillary refill

• assess for type of hair
• color
• distribution
• thickness
• texture

• circumscribed elevation of skin similar to vesicle but filled with pus, varies in size
• eg acne, staph infection

• circumscribed elevation of skin filled with serous fluid, <1 cm
• eg chicken pox, herpes simplex

• elevated solid mass, deeper and firmer than papule, 1-2cm
• eg wart

palpable, circumscribed, solid elevation in skin, <1cm

• flat, nonpalpable change in skin color, <1cm
• eg freckle, petechia

• color
• moisture
• temp
• texture
• turgor
• vascularity
• edema
• lesions and malignancies
• macule
• papule
• vesicle
• pustule

• assess appearance and behavior
• assess VS
• assess height and weight

• infection control
• environment
• equipment
• physical preparation of client
• psychological preparation of client
• assessment of age groups
• assessment of each body system
• follows the nursing history
• systematic and organized
• head to toe approach

• involves listening to sounds
• requires a good stethoscope
• requires concentration and practice

• tap body with fingertips to produce a vibration
• sound determines location, size, and density of structures

• use hands to touch body parts
• use different parts of hands to distinguish texture, temp and movement
• hands should be warm, fingernails should be short
• start with light and end with deep

• uses vision and hearing
• recognizes normal and abnormal
• simplest of assessment skills

• inspection
• palpatation
• percussion
• auscultation
• olfaction

• sitting: head, neck, back, posterior thorax and lungs, anterior thorax and lungs, breasts, axillae, heart, vital signs and upper extremities
• supine: head, neck, anterior thorax and lungs, breasts, axillae, heart, abdomen,extremities, pulses
• dorsal recumbent: (supine with legs bent) head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen
• lithotomy: (legs in stirrups) female genitalia and genital tract
• Sims': (on side,stomach,with flexion of hip and knee) rectum and vagina
• prone: musculoskeletal system
• lateral recumbent: (on side) heart
• knee-chest: rectum

• gather baseline data
• supplement, confirm or refute data obtained in the history
• confirm and identify nursing diagnoses (individualize)
• make clinical judgments about a client's changing health status and managment
• evaluate the outcomes of care (aspect of accountability)