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Chapter 12 MSN Health Assesment


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high-pitched, loud, rushing sounds produced by the movement of gass in the liquid contents of the intestine
physical examination tecnique that uses the sense of touch to assess texture, temperature, moisture, organ location and size, vibrations and pulsations, swelling, masses, and tenderness
hight-pitched harsh sound heard on inspiration when the trachea or larynx is obstructed
bluish or dark purple discoloration of the lips, skin, or nail beds
indirect measurement of cardiac output obtained by counting the number of prepheral pulse waves over a pulse point
Pulse rate
low-pitched grating sound on inhalation and exhalation
Pleural Friction Rub
respiratory rate greater than 24 breaths per minute
abnormal, low-pitched breath sound, louder on exhalation
Sonorous Wheeze
abnormal breath sound
Adventitous Breath Sound
abnormal breath sounds that resembles a popping sound, heard in inhalation and exhalation, not cleared by coughing
review of the client's functional health patterns prior to the current contact with the health care agency
Health History
physical examination technique that involves listening to sounds in the body that are created by movement of air or fluid
heart rate less than 60 beats per minute in an adult
physical examination technique that uses short, tapping strokes on the surface of the skin to create vibrations of underlying organs
condition in which the apical pulse rate is greater than the radial pulse rate
Pulse Deficit
regulartity of the heartbeat
Pulse Rhythm
chart containing various-sized letters with standardized numbers at the end of each line of letters
Snellen Chart
brief account of any recent signs or symptoms related to any body system
Review of Systems
medium-pitched and blowing sounds heard equally on inspiration and expiration from air moving through the large airways
Bronchovesicular Sound
easy respirations with a rate of breaths per minute that are age appropriate
outward expression of mood or emotions
respiratory rate of 10 or fewer breaths per minute
physical examination technique thorough visual observation
heart rate in excess of 100 beats per minute in an adult
abnormal breath sound, hight pitched and whistlelike in nature, during inhalation and exhalation
Sibilant Wheeze
breathing characterized by shalow respirations
soft, breezy, low-pitched sound heard longer on inspiration than expiration that results from air moving through the smaller airways over the lung prephery, with the exeption of the scapular area
Vesicular Sound
measurment of the strength or force exerted by the ejected blood against the arterial wall with each contraction
Pulse Amplitude
difficulty breathing as observed by labored or forced respirations through the use of accssory muscles in the chest and neck
loud, tubular, hollow-sounding breath sound normally heard over the sternum
Bronchial Sound
significant decrease in blood pressure that results in dizziness or lightheadedness when a person moves from a lying or sitting (supine) position to a standing position
Orthostatic Hypotension
breathing characterized by deep, rapid respirations
apical pulse
blood pressure
left lower quadrant
level of conciousness
left upper quadrant
pupils equal, round, reacts to light and accomodation
right lower qaudrant
review of systems
right upper quadrant
determine if patient is functioning within the parameters expected for their age group ie. involved with family, involved with their children
Developmental Level
assessment of dimensions such as self-concept and self-esteem as well as usual sources of stress and the patient's ability to cope
Psychosocial History
inquiry about the home environment, family situation, and the client's role in the family. ie caffeine and alcohol intake
aggravating/alleviating factors
Review of systems
demographic info, reason for seeking health care, perception of health status, previous illness, hospitaliations and surgeries, client/family medical history, immunizations/exposure to comunicable diseases, allergies, current meds, developmental level, p
Health History
inspection, palpation, percussion, auscultation
Physical Examination
general survey, vital signs, height and weight, head and neck assessment, mental and neurological status and affect, skin assessmnet, thoracic assessment, abdominal assessment, muskuloskeletal and extremity assessment
Head-to-toe assessment
introduction, general state of health and any signs of distress ie pain, breathing difficulties. Patient's awareness of the surroundings, body type and posture, fascial expressions and mood
General Survey
noraml temperature is between 36.5C - 37.5C
Axillary - under arm
Tympanic - ear
Oral - mouth
Rectal - rectum
Normal temperature and temperature points
normal pulse is 60 -100 BPM
Normal Pulse
normal respirations is 16 - 20 RPM
Normal Respirations
normal blood pressure is 90/60 - 140/90
Normal Blood Pressure
under breast on right side
Apical Pulse Point
inside upper arm
Brachial Pulse Point
outside wrist
Radial Pulse Point
inside wrist
Ulnar Pulse Point
behind knee
Popliteal Pulse Point
behind ankle
Posterior Tibial Pulse Point
front of ankle
Dorsalis Pedis Pulse Point
the force exerted by the blood against the wall of the artery as the heart contracts and relaxes
Arterial pressure
when the ventricals contract and blood is forced into the aorta and pulmonary arteries, first sound heard
Systolic Arterial Pressure
when the heart is in the filling or relaxed stage, last sound heard
Dialostolic Blood Pressure
difference between the systolic and diastolic
Pulse Pressure

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