The Nursing Physical Assessment

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Health/Medical History
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Provides guidence for care; Includes subjective and objective data.
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Nursing Health History
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Biographical information;chief complaint/ reason for seeking care; History of present illness; Perception of health status; Expectations for care; Past medical history
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Nursing Health History
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Family history; Social history; Medications; Complementary therapies; Review of systems; Functional abilities.
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Gordon’s Functional Health Patterns
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Health Perception- Health Promotion; Elimination- Bowel/Bladder; Sleep-Rest; Self perception-Self concept; Sexuality-Reproductive; Nutritional-Metabolic; Activitiy-Exercise; Cognitive-Perceptual; Role-Relationship;Coping-Stress tolerance; Value-Belief
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The nursing physical assessment
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Used to gather data about th epatient; Focuses on functional abilities and rsponses to illness/stressors
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Purposes of Physical Assessment
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Identify nursing diagnoses and collaborative problems; Monitor the status of an identified problem; Screen for health problems; Evaluate nursing care
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Types of Physical Assessments
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Comprehensive, Focused, Ongoing, Emergency
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Preparing for the Assessment
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Develop rapport; explain the procedure; respect cultural differences; use proper positioning and draping; promote comfort; provide privacy; limit noise; enable visualization
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Integration of Assessment
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Integrate exam during routine nursing care: vital signs; bathing; range of motion; activities of daily living
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What is Inspection
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Uses vision to assess data; Recognizes normal and abnormal; USed throughout physical examination
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Percussion
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Tapping on skin to elicit sound (sound determines location, size, and density of structures); Direct and indirect techniques; Useful for assessing abdomen, lungs, underlying structures
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Olfaction
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Using the sense of smewll to gather data; Not typically considered a “formal” assessment skill; Still useful in the clinical setting
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Assessment Parameters for Older Adults
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Basic Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL)
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Basic Activities of Daily Living (ADL)
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Bathing, dressing, grooming, eating, continence, transferring
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Instrumental Activites of Daily Living (IADL)
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Meal preparation, Shopping, medication administration, housework, transportation, accounting, mobility, ambulation, pivoting
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Older Adult
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May need special positioning related to mobility; Adapt examination to vision and hearing changes; Assess for change in physical ability; Assess for ability to perform activities of daily living; Provide periods of rest as needed
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Aspects of the general survey
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Appearance/behavior/affect; body type/posture; Speech; Grooming/hygeine; Vital signs; Height/weight/bmi
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Head to Toe Assessments
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Neurological; Skin; HEENT; Cardiovascular (CV)/Peripheral vascular (PV); Respiratory; Gastrointestinal (GI); Genitourinary (GU); Musculoskeletal; Include safety/environment/needs & concerns
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Basic ssessment responsibilities
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LOC- level of consciousness; Orientation; Emotional/behavioral; PERRLA-Pupil equal round reactive to light & accomodation; Grips/pushes/pulls; intro to cranial nerves`
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Complete Neuro Assessment
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Cerebral function (mental status); Cranial nerves; Reflexes; Sensory function; Motor and cerebellar function
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Cerebral Function
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Level of consciousness (LOS)- Arousal, Orientation; Mental Status; Communication
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Cerebral Function: LOC-Level of Consciousness
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Alert; Lethargic; Obtunded; Stuporous; Coma
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Alert
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Vigilantly attentive, keen
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Lethargic
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Drowsy, sluggish, half asleep
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Obtunded
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Mentally dulled, responds slowly, decreased interest
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Stuporous
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Near unconsciousness, reduced ability to respond
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Coma
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Unconsious, unresponsive
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Cerebral Function: LOC-Glascow Coma Scale (GCS)
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Three parameters of unconsciousness: Eye opening, Verbal response, Motor Response; High score: 15 (fully alert & oreinted); Score of 7 or less reflects coma
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Cerebral Function: Mental Status/Cognitive Function
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Behavior; Mood/affect; Speech; Memory; Thought processes; Judgement
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Assessment of Sensory Function
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Patient keeps eyes closed as you apply various stimuli; Have patient indicate when he/she feels sensation; Vary location and approach; Usually test upper and lower extremities and trunk
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Motor/Cerebellar Function
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Movement/coordination; Tone; Posture; Equilibrium
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Neuro Related Data
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Headache; Head injury; Dizziness/Vertigo; Seizures; Tremors; Uncoordinated; Numbness or tingling; Weakness; Difficulty swallowing; Difficulty speaking; Significant history; Environmental/Occupational hazards
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Abnormal Neuro Findings
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Cerebral Function; Cranial nerves; Relexes; Sensory function; Motor & Cerebellar Function (Gait; Grips/pushes/pulls)
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Skin
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Membrane barrier; Responds to changes; Gives clues about our general state of health; Largest body organ
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Why do a skin assessment
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Can tell us about: local problems and systemic problems; Gives data about: patient’s health, hygeine, and nutrititional habits
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Skin Assessment
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Inspect and Palpate; Note: Color, temperature, moisture, texture, vascularity, lesions, distinguishing marks, turgor, edema
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Skin Assessment:Color
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Expected findings: uniform color. Mucuous membranes and conjunctiva are pink and moist; Abnormal findings: Pallor, Jaundice. Cyanosis, Erythema
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Skin Assessment: Temperature
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Assess with dorsum of hand; Compare right and left sides; Compare temperatures of hands and feet; should be warm but consistent with room temperature and activity level
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Skin Assessment: Moisture
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Normally skin is warm and dry; Excessive moisture: Hyperthermia, Anxiety, Overactive thyroid; Dry skin: dehydration, hypothyroidism
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Skin Assessment: Texture
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Usually smooth and soft; Factors affecting texture : exposure, age, endocrine disorders, impaired circulation
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Skin assessment: vascularity
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Inspect for bleeeding/bruising; May indicate various systemic problems (Cardiovascular, Hematologic, Liver)
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Problems r/t Vascularity: Eccymosis
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Extravasation (leakage) of blood into the skin or mucous membrane; Purple discoloration
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Probelms r/t Vascularity: Petechiae
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Small hemorrhagic spots caused by capillary bleeding; common in blood clotting disorders
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Skin Assessment:: Lesions:Normal variations
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Moles, Freckles, birthmarks, skin tags, striae-stretch marks
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Assessment: Lesions:Abnormal Lesions
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Primary: result of disease or irritation (ex. acne); secondary: develop from primary lesions as a result of continued illness, exposure, or infection (ex. crust that forms from ruptured postules)
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Assess Skin According to
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Size, Shape, Pattern, Color, Distribution, Texture, Exudate, Pain, Itching
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Describe lesions in terms of
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Type, size, elevation, coloring, presence of drainage, itching
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Do nurses diagnose skin lesions?
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Many different skin lesions-Don’t diagnose; just describe
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Abnormal Skin Lesions: Contusion
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Bruise; Caused by blunt force trauma; injury where skin is discolored, but not broken
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Abnormal Skin Lesions: Rash
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Change in skin which affects its color, appearance, or texture; may be localized or may affect all skin; usually itchy; may blister
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Abnormal Skin Lesions: Abrasion
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Superficial damage to skin; generally not deeper than the epidermis; often occurs when exposed skin comes into moving contact with a rough surface
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Skin Assessment: Turgor
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Degree of skin’s resistance to deformation; tested on back of hand or over sternum
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Turgor: Normal Turgor
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Skin rapidly snaps back into position
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Turgor: Tenting
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Skin takes time to return to normal position
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Skin Assessment: Edema
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Swelling caused by excessive amount of fluid in tissues
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Gravitational
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Will develop in dependent areas of the body
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Pitting Edema
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+1 trace- 2mm depression; +2 moderate- 4mm depression; +3 deep-6mm depression; +4 very deep – 8mm depression
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Nails
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Color; Angle of Nail Bed; Texture (smooth, spongy); Capillary refill (measures the amount of blood flow yo tissues-normal is less than 3 seconds)
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AInspect head for
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size, shape, facial features, lesions
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Palpate head for
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Nodules, tenderness, lesions
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Assess hair based on
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Color, Quality (soft, shiny, brittle), quantity (thick, thinned), Texture (coarse, fine), distribution
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Assessing Neck
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Inspect for flexion and extension; inspect and palpate: lymph nodes, thyroid enlargement, carotid pulses, trachea position
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Lymph Nodes
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Inspect and Palpate for: enlargement, warmth, tenderness
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Inspecting the eyes
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Eye lids, conjunctiva, iris, sclera, cornea, pupils
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Gross vision assessed
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With Snellen Chart
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Inspecting the ears
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Inspect and palpate: alignment, auricles; hearing
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Inspecting the nose
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Inspect: shape, symmetry, septum, mucosa; palpate: sinuses
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Nose abnormalities
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Nasal polyp; deviated septum; no septum (associated with drug use)
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Throat and Mouth
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Inspect: breath odor; buccal mucosa, lips, gums, teeth, palate, tonsils, uvulva, and throat; clients ability to move tongue; clients ability to pronounce sounds
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Abnormal Findings for the HEENT
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Tenderness or lesions to head, face, neck, mouth; Asymmetry of facial features; Uneven or abnormally large or small pupils; Sinus tenderness; Hearing or vision loss
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Cardiac Anatomy
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4 Chambers: right and left atria, right and left ventricles; 3 layers: endocardium, myocardium, epicardium; Heart Valves: Atrioventricular Vales (A-V): Tricuspid, Mitral; Semilunar Valves: Pulmonic, aortic
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Blood flow through the cardiac valves
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Tricuspid, pulmonic, mitral, aortic
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Data Collection
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Chest pain/tightness? SOB? Fatigue? Cyanosis or pallor? Cardiac history? Family history? Edema? Medications? Cardiac risk factors?
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Inspection
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Neck: JVD; Extremities: edema, clubbing, cap refill; Chest: apical impulse (pmi)
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Palpation
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Pulses, apical impulse, assess for pulsations, thrills, heaves
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Ausculation
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Heart sounds: use diaphragm and bell of stethoscope, S1 & S2 (Lub-Dub); Carotid artery: use bell of stethoscope
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Patient positioning for ausculation
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Supine, left lateral, sitting up leaning forward
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Where to listen for heart sounds
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All, People, Enjoy, Time, Magazine. Aortic (2 ICS, R), Pulmonic (2 ICS, L), ERB’s Point (-3ICS, L), Tricuspid (-5ICS, L), Mitral (5ICS, LMCL)
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Abnormal Heart Sounds
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Murmurs: blowing or swooshing sound occurring with blood flow in the heart (valve mechanics); Friction rub: high pitched, scratchy, like sandpaper; Prosthetic heart valves: click or ping; S3 and S4
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Pulses
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Carotid, Brachial, Radial, Femoral, Popliteal, Posterior tibial, pedal (dorsalis pedis)
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Peripheral Pulse
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Tell us about arterial blood supply to extremities; Characteristics: Rate, Rhythm, Amplitude, Symmetry
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Assessment of Peripheral Perfusion
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Evaluate: Color, clubbing, capillary refill, JVD, Skin temperature, edema, ulcerations, hair distribution
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Homan’s Sign
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Indicator of deep venous thrombosis (DVT); Present when passive dorsiflexion of the foot produces pain in the calf
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Normal CV/PV Findings
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Heart rate 60-100 beats per minute (adults); S1, S2; Regular rhythm; Peripheral pulses palpable; Capillary refill < 3 seconds; Negative Homan's sign
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Respiratory System Assessment
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Primary purpose = Gas Exchange (transfer of O2 and CO2); 2 Parts: upper respiratory tract, lower respiratory track; Right lung has three lobes; left lung has two lobes
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Normal respiratory system assessment findings
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Chest symmetrical; respiratory rate is 12-20 per minute; respirations regular, even, unlabored; O2 Sats>02% on RA; Lungs clear to ausculation
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Chest and Lung Assessment
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Assess repiratory rate, rhythm, depth, and symmetry; Inspect; Palpate; Percuss; Ausculate Lung Fields
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Inspection of Chest/Lung
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Overall shape of the thorax; chest symmetry; trachea; color and skin condition; respiratory effort; respiratory muscles; presence and color of sputum
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Problems with Chest Shape
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Barrel chest; Kyphosis: humpback; Scoliosis
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Palpation Chest/Lung
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Areas of tenderness; Crepitus; Chest excursion; Tactile fremitus
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Percussion of Chest/Lung
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Percuss over intercostal spaces-not ribs: a resonant sound, air space; Diaphragm and heart produce dull sounds; Hyperresonance: too much air space, specific disease processes
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Ausculation of Chest/Lung
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Use diaphragm of stethoscope; Instruct patient to breathe through mouth; Listen to all lobes (anterior and posterior)
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Ausculation of Breath Sounds
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Pitch, Quality, Duration, Location (visualize)
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Normal Breath Sounds
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Bronchial, Bronchovesicular, Vesicular
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Abnormal Breath Sounds
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Adventitious, diminished
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Normal Lung Sounds: Bronichal
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Sound: high pitched, harsh, hollow, tubular; Heard over trachea; Louder on expiration
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Normal Lung Sounds: Bronchovesicular
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Medium intensity; Heard at 1st and 2nd IC spaces anteriorly; Heard at T4 medial to scapula posteriorly
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Normal Lung Sounds: Vesicular
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Low pitch; soft intensity; over peripheral lung fields; sounds like wind rustling in trees; louder on inspiration

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