subjective data Vs. Obejective data

• Objective: Can see, can assess by signs
• Subjective: only things patient can tell you

 How does Glascow coma scale measure

• Ranges 3-15
• < 7 = coma
• > 7= more normal functioning
• 15 =normal

What does Glascow coma scale measure

• for head injury
• 3 Parmaters= 
  1. Eye opening
  2. verbal response
  3. best motor responses

acceptable time for capillary refill

Diaphoresis

• persperation (profuslly)
• Assists with heatloss by evaporation

PQRST

• When doing chest evalutation
  • P: Palliative /provoking
  • Q: quality
  • R: radiation
  • S: Severity
  • T: timing

How to auscultate lungs; what pattern?

• Start in back
  • Move 6-7 places- @top Closer to center@ bottom- more toward lateral
• Switch to front- alternate sides 6-7 places
• Aldo lateral sounds

PERRLA

Pupils equil, round, reactive to light and accomidation

Pupil size and reaction

• size: 2-9
• Reaction
  • 1= reacts Briskly
  • 2=Reacts slowly(takes longer to constrict)
  • 0=no reaction

Febrile

Fever

jaundice

Yello color to skin

Means liver complications

How to assess someone with temperature using hand

Use the back of your hand

Whats included in determining someones orientation

Orientation x3 

•  
  • time
  • place
  • person(last one to go)

turgor

Transcultural nursing

• Being open minded, and understand others morals,religion and cultures
• Us this in providing care

Chineses culture

• Health is state of spiritual/physical harmony W/ nature.
• Healthy body= state of balance
• When out of balance=illness
• Bodies given to them by parents/for-bearers
• body not personal property-must be cared for & well maintained
• All things yin(cold) or Yang( hot)-->(qualities)
• Rarly complain- Only know from untouched food tray and silent withdrawl
• Will refuse pain meds
• Need of group more important than induvidual
• Courteious; consider impolite to accept something first time offered
• After havin baby body considered weak
  • Cant excercise/bathe
  • must eat certain food
  • must stay warm
  • boiled water may make baths more acceptable
• Giving blood disrespectful to parents/ancestors
• believe more blood in body -->better

Black culture

• God viewed as source of good health&serious illness
• Believe in healing power of religion
• some practice voodoo
  • Leaders tend to be women( new orleans)
• many muslims
• prayer most common/frequent treatment
• Elderly high esteem-have wisdom/knowledge
• death  -->passing from one realm to another-->passage from evils of this world-->often celebrated with party
• word "boy" offensive when used by caucasian
• use proper name- ms. mrs. etc.

Auscultaion

• listen to sounds within body
• use bell of for(heart/vascular sounds)
• use diaphragm for lung/bowl sounds)

Tympany

• loud
• obtained by percussing surface of large air containg space( distended abdomen)
• ???Ask

symmetry

• same on both sides( size, shape, overall look)

percussion

• taping
• By striking finger on top for other finger on surface
• Determines location, size, density of underlying structures

Borborygmi

• Rumbling noise produced by gas in bowl

exudates

• Accumulation of fluid,pus,serum,matter
  • penetrates through vessel walls

inspection

Look, listen, smell- starts minute you meet patient

rales

Fine crackles

Adeventitious sound

non continuous

tachypnea

• respirations gr8er than 20 per min

lithotomy

• used for vag exam, deliveries, op- of bladder, peri area/vaginal access
• feet in sturups

Initiall assessment

• covers all aspects

Focused assessment

• done most
• R/T specific problem

Emergency assessment

• ID life threatening problems

Time lapsed assessment

• Compares current status to baseline-
• assess same components and compare

Head to toe assessment

system by system- baseline physical

opthalmascope

• used to visualize interior of eye

Otoscope

Used to examine internal ear canal and tympanic membrane

When auscultaing, listen for

• pitch
• loudness
• quality
• duration

Palpation

• Using touch
• light- 1/2 inch deep_(only do as LPN)
• Palpate tender areas last

Percusion sound of bone/muscle

percussion sound of liver

• resonance-loud