Term
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Definition
| patient tells you (medical surgical histories, allergies, current meds, chief complaint, feeling perceptions symptoms |
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Definition
| info you can directly observe and measure (assessment findings, non verbal cues, labs test results, vital signs, height and weight |
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Term
| purpose of physical examination |
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Definition
| est. baseline data about patients health and make decisions on care, support/refute data from history, identify nursing diagnoses, evaluate the outcomes of care |
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Term
| Organization to the Examination |
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Definition
| Head to Toe assessment, compare moth sides for symmetry, perform painful procedures toward the end, thorough documentation. |
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Definition
| systematic, avoids missing important findings, includes all body systems |
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Definition
| general survey- what to you see, hear, smell? turn lights on, remove clothing/linen. Inspect size, shape, color facial expression odors posture mobility hygiene and symmetry |
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Definition
| touhc- use fingers and palms. Temp, texture, moisture, turgor, tenderness fluid masses pulsation or vibration |
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Definition
| .5 inch identify areas of tenderness |
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Definition
| 2 inches. examine condition of organs |
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Term
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Definition
| tapping skin with fingertips to vibrate underlying tissue and organs. sound produces reflects the density of underlying tissue. air filled? fluid filled? solid? |
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| stethoscope- listen to sounds of fluid or air moving around the body. under clothes, quiet room, directly on skin. |
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Term
| Ausculatating using the diaphragm of scope |
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Definition
| heart lungs and bowels- high pitched |
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Term
| Ausculatating using the bell of scope |
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Definition
| abnormal heart sounds and bruits (low pitched sounds) |
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Term
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Definition
| hand hygeine, introduction, check armband- 2 identifiers. Inspect roo- pt position, side rails, bed pos, call ight. Equipment- steth, bp cuff, therm, pen light. |
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Term
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Definition
| Color- Moisture- Temp- Texture- Turgor- Edema |
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Term
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Definition
1+ = 2mm 2+= 4mm
pitting is when pressure from your fingers leaves an indentation. sign of edema |
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Term
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Definition
hirsutism- hair growth in women- upper lip chin cheeks
alopecia- hair loss (both sexes) |
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Term
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Definition
| change in angle between nail and nail base- greater than 180 degrees, signs of lack of oxygen and heart or pulmonary failure |
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Term
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Definition
| 160 angle between nail and nail base |
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Term
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Definition
| use snellen chart- 20 ft from pt. measure visual acuity. 20/40 this person sees at 20 ft what people see at 40. larger the number worse the vision. |
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Term
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Definition
| pupils equal round reactive to light and acomodation/ assess bilaterally. use pen light. |
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Term
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Definition
| pen light. ask about aids, hard of hearing? medication effecting hearing?> check for drainage. |
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Term
| Face/ Mucous membranes/ Neck |
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Definition
| facial symmetry, teeth- dentures. tongue out and say ahhhh to inspect mucous membranes. any difficulty chewing or swallowing? ROM check of head and neck |
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Term
| Respiratory percussion assessment |
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Definition
normal- hollow resonant sound d/t lung filled with air.
abnormal- dullness, flat d/t mass or fluid |
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| Respiratory Inspection Thorax |
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Definition
| normal dia is 1/2 of the lateral diameter width. deviation can effect lung expansion and breathing- abnormal barrel chest |
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Term
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Definition
| rate, rhythm, quality and depth. Respiratory Excursion |
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Term
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Definition
| symmetry of chest rising and falling |
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Term
| S/S of Respiratory distress |
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Definition
| dyspnea, sluggish or absent capillary refil (under 2 seconds) retraction or use of accessory muscles. |
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Term
| Respiratory Inspection Palpation |
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Definition
| assessing for crepitus, tenderness or masses |
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Term
| Respiratory Inspection Ausculation |
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Definition
| Crackles, Rhonchi, Wheezes, and pleural friction rub |
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