Term
| A. General assessment strategies |
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Definition
| 1. Gather supplies before beginning |
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Term
| 2. Adequately explain what is being done, while limiting small talk |
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Definition
| 3. Consider client's anxiety and fears. |
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Term
| 4. consider own facial expression and comments |
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Definition
| 5. Demonstrate confidence, empathy, and gentle manner |
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Term
| Demonstrate confidence, empathy and gentle manner |
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Definition
| 6. Acknowledge and apologize for any discomfort caused |
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Term
| 7. Provide for privacy and warmth at all times |
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Definition
| 8. Determine comfort level, pausing if patient becomes tired |
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Term
| 9. Coordinate procedures to limit position changes for examiner and client |
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Definition
| *10. Wash hands at appropriate times |
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Term
| 11. Briefly summarize findings to client, and thank client for his/her time. |
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Definition
| 12. Use appropriate terminology and correctly pronounces medical terminology with client |
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Term
| 13. Demonstrate skills of inspection, percussion, palpation and auscultation in the correct order for each system with the correct technique |
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Definition
| 14. Demonstrate correct use of instruments, including assembly and manipulation of component parts. |
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Term
| 15, Complete assessment in scheduled time |
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Definition
| 16. Refer to notes minimally. |
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Term
| B. General survey of Client |
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Definition
| 1. gather name, age, sex and occupation |
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Term
| 2. Level of consciousness (arousal, wakefulness) |
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Definition
| 3. Obvious physical deformities |
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Term
| 4. Facial expression: Note distress |
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Definition
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Term
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Definition
| short and long term memory assessed |
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Term
| c. Standing in front of the client, client is sitting. |
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Definition
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Term
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Definition
| *inspect fingernails, note nail bed color |
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Term
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Definition
| d. palpate nails for capillary filling: fingernails |
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Term
| e. inspect skin color and pigmentation. notes cyanosis |
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Definition
| f. palpates skin temperature |
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Term
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Definition
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Term
| *note color of lesion. (must have some type of lesion for students to eval) |
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Definition
| *note pattern or shaw of lesion. |
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Term
| *note any lesions: use ABCDE |
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Definition
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Term
| *Note length, width, and elevation of lesion in centemeters |
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Definition
| *Note location and distribution of lesion |
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Term
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Definition
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Term
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Definition
| *Palpate radial pulses bilaterally. Scale 0-+4 noted |
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Term
| *Palpate brachial pulsees bilaterally |
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Definition
| Palpate arms to shoulders |
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Term
| J. Assess range of motion (ROM) |
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Definition
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Term
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Definition
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Term
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Definition
| L. Assess muscle strength of upper extremities |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
| *n. rapid alternating movements |
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Definition
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Term
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Definition
| q. assess epitrochlear nodes |
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Term
| *r. assess axillary nodes |
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Definition
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Term
| a. Inspect and palpate scalp, hair and cranium |
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Definition
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Term
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Definition
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Term
| C. Palpate and percuss maxillary sinuses, frontal sinuses |
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Definition
| d. auscultate temporal artery for bruits |
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Term
| *e FaceL lightly touch either one or both sides of each of the three divisions of the trigeminal (CN V) |
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Definition
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Term
| a. Hirschberg (corneal light reflex) |
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Definition
| *b. six cardinal fields of gaze (CN III, IV and VI (visual acuity CNII) |
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Term
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Definition
| *Verbalize equal and round |
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Term
| VERBALIZE and demonstrate direct response |
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Definition
| VERBALIZE and demonstrate consensual response |
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Term
| *Accomodation and convergence |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| *g. Fundocopic (verbalize red reflex, retina, vessels, optic disk) |
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Term
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Definition
| *Inspect and palpate external ears |
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Term
| b. gross hearing/whisper test (CN VIII) |
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Definition
| *C. otoscopic ear canals. |
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Term
| know what to note in ear canals |
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Definition
| *e. Weber test (check for lateralization) |
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Term
| *F. Rinne test. (Compares air and bone conduction) |
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Definition
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Term
| a. inspect and palpate external nose. |
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Definition
| b. Patency of nostrils (CN I) |
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Term
| *c. Inspects nasal mucosa |
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Definition
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Term
| *a. Inspect lips and buccal mucosa with light and tongue blade. |
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Definition
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Term
| c. Tongue, CN XII (hypoglossal) |
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Definition
| *Observe tongue at rest in the floor of the mouth |
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Term
| *Observe tongue protruding. (CN IX and X) |
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Definition
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Term
| *Palpate tongue for strength against cheek |
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Definition
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Term
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Definition
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Term
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Definition
| *G. Ask client to say "ah" and observe uvula movement (CN X-vagus) |
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Term
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Definition
| a. Assess skin characteristics |
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Term
| b. Inspect for symmetry, plus palpate for lumps and pulsations. |
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Definition
| c. palpate and verbalize nodes |
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Term
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Definition
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Term
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Definition
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Term
| *superficial cervical nodes |
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Definition
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Term
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Definition
| *Posterior cervical nodes |
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Term
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Definition
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Term
| *Auscultate and palpate carotic pulse. |
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Definition
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Term
| *e. palpate thyroid (front or back approach) |
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Definition
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Term
| *g. shrug shoulders against resistance (CN XI) |
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Definition
| *h. Push chin against examiner's hand bilateral. |
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Term
| D. Move to BACK of CLIENT, SITTING |
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Definition
| CHEST AND LUNGS, POSTERIOR |
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Term
| a. Inspect and VERBALIZE observations: |
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Definition
| Thoracic cage configuration (AP and transverse diameter) |
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Term
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Definition
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Term
| *Retractions, heaves, or dyspnea |
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Definition
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Term
| The following criteria will be evaluated according to the competency map |
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Definition
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Term
| *c. palpate tactile fremitus |
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Definition
| *d. percussion over lung fields |
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Term
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Definition
| f. auscultate breath sounds with diaphragm of stethoscope in: |
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Term
| Organized sequence, side to side. Posterior (6 minimum sites) |
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Definition
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Term
| *g. Lateral breath sounds (5 sites) |
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Definition
| h. describe breath sounds heard. |
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Term
| *j. Assess for CVA tenderness |
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Definition
| E. MOVE TO FRONT OF CLIENT. |
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Term
| 1. CHEST AND LUNGS, Anterior. |
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Definition
| a. inspect and VERBALIZE observations |
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Term
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Definition
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Term
| b. Palpate for lumps or tenderness (4 places, upper/lower) |
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Definition
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Term
| d. osculate breath sounds with diaphragm of stethoscope in organized sequence, side-to-side (4 minimum sites) VERBALIZE FINDINGS |
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Definition
| F. CLIENT SUPINE, STAND AT CLIENT'S RIGHT. |
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Term
| 1. Heart (Pulls out table extension) |
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Definition
| a. Inspect precordium for pulsations and heaves. |
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Term
| b. Palpate precordium with palm. |
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Definition
| *c. Locate, inspect, palpate, and auscultate PMI/apical impulse. |
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Term
| *d. Auscultate apical rate and rhythm. Verbalize findings |
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Definition
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Term
| f. auscultates heart sounds in 5 areas with diphragm |
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Definition
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Term
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Definition
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Term
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Definition
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Term
| g. Auscultate heart sounds in 5 areas with bellL |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| a. Ensures out/pulls out table extension |
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Term
| b. observe abdomen at eye level from client's right |
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Definition
| c. inspect skin characteristics |
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Term
| d. inspect contour, symmetry |
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Definition
| e. inspect umbilicus and pulsations |
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Term
| f. ask client to raise head. |
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Definition
| g. observe face while client has head raised. |
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Term
| h. observe abdomen while client has head raised. |
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Definition
| *auscultate bowel sounds with diaphragm in all four quadrants |
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Term
| *auscultate bowel sounds with diaphragm in all four quadrants |
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Definition
| *auscultate vascular sounds with bell (5 sites) |
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Term
| *j Percuss in all four quadrants. |
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Definition
| *k. light palpation in all 4 quadrants |
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Term
| *l. Deep palpation in all 4 quadrants. |
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Definition
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Term
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Definition
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Term
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Definition
| b. inspect skin characteristics, hair distribution |
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Term
| *palpate and auscultate femoral pulse |
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Definition
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Term
| *f. Posterior tibial pulses VERBALIZE findings on 0- +4 scale |
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Definition
| *g. Dorsalis pedis pulses. VERBALIZE findings on 0-+4 scale |
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Term
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Definition
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Term
| *j. Range of motion, hips |
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Definition
| *k. range of motion, knees |
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Term
| *l. muscle strength, hips |
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Definition
| *m. muscle strength, knees |
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Term
| n. heel down shin bilateral |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| a. walks across room (gait) |
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Term
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Definition
| c. walk on tiptoes, then walk on heels |
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Term
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Definition
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Term
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Definition
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Term
| *curvatures (cervical, thoracic, and lumbar) |
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Definition
| *from behind for lateral curvatures, inequality of scapula, iliac crests and gluteal folds |
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Term
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Definition
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