Chapter 31

Chapter 31

1. Assess

   • General
     • Vital Signs
       • Height/Weight
         • Integumentary
           • Hair/Scalp
             • Nails
               • Head
                 • Eyes
                   • Visual acuity Rxtraocular mov. visual field external structures
                   • Ears
                     • auricles hearing acuity tests eardrum and canal
                     • Nose
                       • Mouth/Pharynx
                         • Neck
                           • Thorax and Lungs
                             • Heart
                               • Arteries and Veins
                                 • Sexual Organs
                                   • Gi Tract
                                     • Kidneys
                                       • Musculoskeletal
                                         • Neurological
                                           • Mental/Emotional Status
                                             • Nerves
                                               • Reflexes
                                         • Range of motion tests
                                   • palpate and look for abnormalities
                               • PMI: apex heart left 5th intercostal space and mid clavicular line. S1: valve closure, ventricular contraction, lub: (mitral/tricuspid) S2: dub, aortic/pulmonary closure S3: abnormal sound, heart attempt to full a distended ventricle S4: abnormal atria contract to enhance ventricular filling Palpate: aortic area: Right second intercostal space pulmonic area: left second intercostal space 2nd pulmonic area: left 3rd intercostal space tricuspid area: 4/5 intercostal along sternum apical area: left 5th intercostal/midclvicular epigastric: tip sternum
                             • adventitious sounds, abnormal palpitations
                           • Nodes, muscles, thyroid, trachea, carotid/jugular
                     • look for abnormalities, hearing acuity, pain when palpating (ear infections)
                   • Visual Acuity, Musc. Mov, Visual Field, abnormalities in functions or structure, PERRLA (pupils equal, round, reactive to light, and accommodation)
           • Color, edema, elasticity, vascularity, dryness
       • HR, RR, BP, Temp
   • Inspect, Olfaction, Palpatation, Percussion, Ascultation