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General Approach
- -Measure height, weight, BP, TPR, vision (if applicable)
- -Provide exam gown (leave room when pt undressing)
- -Wash hand's in front of pt
- -Explain each step
- -Give encouragement as you proceed
- -Organize exam for efficiency and pt comfort
- -Use systematic approach (sequence, top to bottom)
- -Give summary of findings
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General Appearance
(Physical characteristics)
- -Age (appear stated age?)
- -Sex (development appropriate to age?)
- -Skin (pale, red, cyanotic, flushed, lesions, sores)
- -Facial features (symmetrical?)
- -Signs of acute distress (SOB, in pain?)
- -Personal hygiene (look clean, well groomed, oily, BO?)
- -Involuntary movement (twitch, tic)
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General Appearance
(Body structure)
- *WDWN: well developed, well nourished
- -Stature (height w/in standards)
- -Nutrition (well nourished, overweight, obese, thin, cachectic [thin, wasted])
- -Symmetry (atrophy, hypertrophy, swelling
- -Posture (erect, slumped--can indicate depression)
- -Position (relaxed, tense, fetal)
- -Body build (lean muscular)
- -Physical deformities (limp, one leg shorter)
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General Appearance
(mobility)
(& mental status and behavior)
- -Gait (how do they walk--steady, ataxic or ataxia gait [drunk walk])
- -ROM (FROM vs. limited ROM
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Clinical Measurements
- -Essential part of initial data base
- -Analyzed in relation to normal ranges, client's recent values & serial readings, and dx
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Weight
- -Remove shoes, and heavy clothing
- -Serial weights
- -Weight gain
- -Weight loss
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Weight Gain
- -Overeating or decreased activity
- -Fluid vol. excess (2.2 lb weight gain=1L, >2-3lbs/wk is significant)
- -Hypothyroidism (if underactive thyroid dec secretion of TH causes hypermetabl
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