Chapter 31 (9/6/17)

Chapter 31 (9/6/17)

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
                                           • Nerves
                                             • Reflexes
                                           • Mental/Emotional Status
                                             • Level of Consciousness, Behavior and Appearance, Language
                                             • Mini-Mental State Exam
                                           • Intellectual Function
                                             • Memory, Knowledge, Abstract Thinking, Association, Judgement
                                           • Motor Function
                                             • Coordination, Balance
                                         • Range of motion tests
                                   • palpate and look for abnormalities
                                 • Strength of Pulse
                                   • 0: Absent, not palpable
                                     • 1: Pulse diminished, barely palpable
                                       • 2: Expected
                                         • 3: Full, increased
                                           • 4: Bounding, aneurysmal
                               • 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
                                 • Dysrhythmia: failure of the heart to beat at regular successive intervals
                                 • Ventricular Gallop: premature rush of blood into a ventricule that is stiff or dilates
                                 • Murmurs: sustained swishing or blowing sounds heard at the beginning, middle, or end of the systolic or diastolic phase
                                 • Thrill: continuos palpable sensation that resembles the purring of a cat
                             • adventitious sounds, abnormal palpitations
                               • Vocal/Tactile fremitus: vibrations when you palpate externally
                           • Nodes, muscles, thyroid, trachea, carotid/jugular
                             • Malignancy: an abnormality of superficial lymph nodes
                         • Assess for: dehydration, restricted intake, oral trauma, oral airway obstruction
                         • Inspect:
                           • Lips
                           • Buccal Mucosa, Gums, Teeth
                           • Tongue/Floor of Mouth
                           • Palate
                           • Pharynx
                       • External Nose: observe for shape, size, skin, color, and any deformities or inflammation
                       • Anterior Nares: inspect, mucosa for color, lesions, discharge, swelling, or bleeding
                       • Excoriation: local skin breakdown
                       • Polyps: tumorlike growths
                     • 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)
                     • Ptosis: abnormal drooping of the lid over the pupil
                     • Ectropin: lid turns out
                     • Entropion: lid turns in
                     • Conjuctivitis: redness indicating allergy or infection
                 • Normal: held upright, midline to the trunk
               • Normal: transparent, smooth, well rounded, convex, nail bed angle about 160 degrees
             • Inspect: color, distribution, quantity, thickness, texture and lubrication
           • Color, edema, elasticity, vascularity, dryness
         • Clinical Indications of Abuse
           • Child Abuse
           • Intimate Partner Violence
           • Older-Adult Abuse
       • HR, RR, BP, Temp
   • Inspect, Olfaction, Palpatation, Percussion, Ascultation