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19- Assessments -volume 1


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what position allows for full lung expansion? (Ie..if someone is short of breath what posistion should their bed be in?)
when would you use a fowlers or semi fowlers position?
to assess the abdomen, breasts, extremities and pulses.
what is the dorsal recumbant position used fo?
it is supine with knees flexed and its used if the pt is having abdonimal or pelvic pain. It relaxes the stomach muscles.
what position is used for a pelvic exam of a female?
what is the sims position and what is it used for?
flexion of the hip and knees in a side lying position, may be used to examan rectal area or for a female pelvic exam if the pt is not able to assume the lithotomy position.
What position would be used to detect a heart murmer?
lateral recumbant (side lying)--specifically LEFT lateral recumbant because it brings the heart closer to the chest wall. If they cant assume this position then have them seated and bending forward.
what position is used for a neurological assessment?
what is direct and indirect auscultation?
direct is without a stethescope and indirect is with.
what sounds does the bell pick up?
low pitched sounds
what sounds does the diaphragm pick up?
high pitched sounds
which end of the stethescope would you use to auscultate for a heart murmer?
the bell
in what cases would you perform a comprehensive exam?
anual physical, admission to inpatient setting, intitial home health visit. It includes an interview and complete heat to toe assessment of each body system
what would you use a focused assessment?
once an actual problem has been identified
mongolian spots
blue black areas seen on the lower back/butt of african americal, native american or asian babies.
capillary hemangiomas
stork bites on babies
what 3 things should you check with the skin?
temp, turgur, texture
define : pallor, cyanosis, jaundice, flushing, erythema, ecchymosis, petechiae, hyperhidrosis
pallor-may be associated with poor circulation/low Hgb (anemia). Cyanosis is described as ashen, indicates hypoxia. Jaundice-yellow-liver disorders. Flushing-widespread redness-abnormal increase in red blood cells. Erythema-reddened area-rashes, skin infections, prolonged pressure. Ecchymosis-bruise-may indicate physical abuse. Petechiae- tiny pinpoint red or purple spots-leakage of blood vessels into skin.
what might dry skin represent?
hypothyroidis, chronic renal failure, dehydration
what are the sympotms of peripheral arterial insufficiancy?
smooth, thin, shiny skin with little or no hair
what are the sympoms of venous insufficiancy?
thick, rough skin that is hyper pigmented
When assessing for turgor--how do you know if there is tenting? What if skin cannot be pinched?
tending would be if it doesnt return within 3 seconds. it could indicated dehydration or old age. Unable to pinch might be edema or sceroderma (autoimmune disease that hardens your organs--including skin)
what might edema indicate?
congestive heart failure, kidney disease, peripheral vascular disease, low albumin levels.
How do you assess for pitting edema?
the levels, from trace +1 up to +4 are 1/2 of the millimeters of depression. so trace +2 is 4mm in depth.
what are milia, nevi, skin tags, striae?
milia-white heads on newborns, nevi-moles, skin tags and striae you know. all these are normal findings.
how do you classify abnormal skin lesions?
primary and secondary. Primary is something like acne, a direct result of the skin disease. Secondary would be the crusts from the acne- it develops from the primary lesions itself.
what should you assess lesions for?
size, shape, pattern, color, distribution, texture, surface relationship, exudate, tenderness, pain, itching.
what does ABCDE stand for in assessing for malignancies?
assymetry, border irregularity, color variation, diameter greater than 0.5cm, elevation above skin surface.
what is hirsutism?
excessive hair growth
head lice
what should the angle of the nail plate be?
160 degrees.
half and half nails
low albumin levels or renal disease
mees lines
transverse white lines in nail bed, seen in clients whove experianced severe illness
splinter hemorrhages
small hemorages under the nail bed form bacterial endocarditis or trauma
black nails
blood under nails after local trauma
what is clubbing of the nails?
nail place is 180 degrees or more. It indicates long term hypoxia as seen in chronic lung disease
spoon shaped nails
iron deficiancy
thickened nails
poor circulation
brittle nails
hyperthyroidism, malnutrition, calcium or iron deficiancy
soft boggy nails
poor circulation
in a HEENT exam, what assessment techniques do you use?
large head, excessive growth hormone
small head-mental retardation
head growing disproportionately to body. accumulation of excess cerebrospinal fluid
what would an appearance inconsistant with gender/age. or ethnic group indicate?
graves disease, hypothyroidism, myxedema, cushing syndrome
what should the ears look like?
pinna is level with corner of eye and within a 10 degree angle of verticle
otitis externa
outer ear infection
otitis media
inner ear infection
ear wax. can be balck, dark red, gray or brown. can be flaky, hard or soft.
what should the tympanic membrane look like?
shiny, pearly gray, translusent. you should be able to see the structures of the middle ear through the membrane.
in assessing for hearing, how do you assess for low tones?
whisper 1-2 ft behind the person
in assessing for hearign how do you assess for high tones?
watch 5 inches from ear
What is CN VIII and how do you test for it?
its the auditory nerve. It can be assesed using the Webber test, the Rinne test, and the Romberg test.
what is the webber test?
it tests the auditory nerve and you use a tuning fork at the center of the head. The result is POSITIVE if you hear it louder in one ear. This is abnormal , and then you have to preform the Rinne test.
what is the rinne test
tests the auditory nerve, it is only used if the webber test is positive (meaning abnormal). Its the one with the tuning fork at the ear. it tests the difference of air conductino to bone conduction
what is the romberg test?
it tests the auditory nerve-specifically equilibrium. you stand with your feet together and close your eyes and note any swaying. again...abnormal findings are a POSITIVE result for thsi test.
thick elevated white patches that do not scrape off and are precancerous--on tongue. *if they DO scrape off and bleed then it is THRUSH.
how many teeth should an adult have?
28, or 32 if the wisdom teeth are there still.
inflammation of the tongue
what would a dry furry tongue indicate?
black hairy tongue
fungal infections
absence of papillae
allergy, inflammation, infection
smooth red tongue
iron or B12 or B6 deficiancy
vocalization upon which uvula should rise
what muscles form the landmarks of the neck? what are they known as?
sternocleidomastoid and trapezius muscles. They are known as the anterior and posterior triangels
what is found in the anterior triangel of the neck?
trachea, thyroid, anterior cervical lymph nodes, carotid arteries.
what is found in the posterior triangle of the neck?
the posterior cervical nodes.
if the thyroid is palpable, what should you do?
ascultate for bruits
what are the three chains of the cervical lymphnodes?
anterior, posterior, and deep. the deep is under the sternocleidomastoid muscle.
what are normal findings for lymph nodes?
nonpalpable. they are less than 1cm, mobile, soft and nontender.
bronchial breath sounds
loud, high pitched tubular sounds. expiration is longer than inspiration. you will hear best over the trachea on anterior chest, and below the nape of the neck on the posterior chest.
bronchiovesicular sounds
medium pitched, equal inhilation and expiration, best heard over the 1st and 2nd ICS adjacent to the sternum on the anterior chest, and between the scapula on the posterior chest.
vesicular breath sounds
soft low pitched breezy sounds with long inspiratory phase and short expiratory phase. best heard over the lung fields.
when would diminished breath sounds be heard?
in the very muscular or obese, or htose with restricted air flow
what do misplaced breath sounds indicate?
constricted air flow
what are adventitious breath sounds, and what should you do if you hear them?
they are sounds that are heard over normal breath sounds. You shuold have the client cough and listen again.
How do you assess the peripheral vascular system?
take blood pressure, palpate peripheral pulses, inspect and perform tests of adequate perfusion.
when skin is not adequately oxygenated, what does it look like?
pale, cyanotic, cool and shiny. hair growth may be sparce, nails may be clubbed.
what might inadequate oxygenation be a result of?
chronic pulmonary problems, but also inpaired central or peripheral circulation.
where do you draw the lines for the four quadrent method of assessing the abdomen?
vertical line from the xiphoid process to the pubic symphesis, and horizontal line at the level of the umbilicus.
in what order do you assess the abdomen?
inspection, auscultation, percussion, palpation.
what should you have the client do prior to an abdonimal exam?
what do bowel sounds sound like?
irregular, high pitched gurgles or clicks lasting one to several seconds and occuring every 5-15 seconds.
if the client has an NG tube, how do you assess the abdomen?
clamp off the tube or discontinue the suction when listening for bowel sounds.
when assessing the abdomen, what arteries should you listen to, and what are you listening for?
listen to the aorta, renal, iliac and fermoral arteries for the presnece of bruits.
what organ is not palpable in an abdominal assessment?
the spleen
what position should a person be in for abdominal assessment?
dorsal recumbant
what are the basic functions of the nervous system?
cognition, emotion, memory, sensation, perception and regulation of homeostasis
what does cerebral function involve (what are you assessing for?)
it involves the persons intellectual ability and behavioral functioning. You will assess for level of consciousness, mental status and cognitive function and communication.
when assessing the male genitourinary system, what would a complete examination include?
external genitalia, evaluation for hernias, and a rectal exam for prostate screening.
how are the penis and scrotum examened?
by inspection and palpation.
at what point in the exam do you palpate the prostate gland?
during the exam of the rectum and anus.
what is a hernia?
a protrusion of the intestine or other organ.
when would you do an internal genital examination on a female?
on women who are sexually active, have abnormal external findings, or who have abdominal, pelvic or genitourinary complaints, or are on hormone therapy.
during an internal femal exam what do you assess?
palapte the bartholins glands and skenes ducts, assess the vaginal muscle tone and pelvic musculature, do a speculum examination.
what is a papanicolaou test?
pap smear, it screens for cervical and uterine cancer. It should be done every year.
what is a speculum examination?
it is performed to collect specimens and assess the cervix.
what is the very last aspect of a comprehensive examination?
examining the anus and rectum.
how do you examin the rectum and anus for a female client?
it is usually perfomed at the end of a bimanual pelvic exam while they are still in the lithotomy position.
how do you examin the anus and rectum for a male client?
have them assume the sims position. this exam is to be done after the genitalia exam.
what do you inspect the anus and rectum for?
skin condition and hemorrhoids, and palpate for muscle tone, masses and tenderness.
what are Hemorrhoids?
dialated, usually painful anal vessels. They may be seen in clients iwth a history of constipation, or in pregnancy and childbirth.
what might an enlarged prostate mean?
it is common in men over 50 and it may be benign or indicate cancer or prostatitis.

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