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To evaluate the client's current condition, to detect early signs of developing health problems, establishing a baseline and to evaluate client's response to interventions are the purposes of what?
inspection, auscultation, palpitation & percussion
to collect data on bowels sounds you do what 4 things?
this is a brisk, equal & simultaneous constriction of both pupils when one eye then the other is stimulated with light
these are eye movements controlled by several pairs of eye muscles. during the assessment, both eyes should move in a coordinated manner. No movement in one may indicate neurologic pathology.
These normal lung sounds are loud & coarse. They are equal in length during inspiration & expiration and are separated by a brief pause
These normal lung sounds are heard over the upper sternum & between the scapulae, are harsh & loud. they are shorter on inspiration than expiration with a pause between them
These sounds are heard on either side of the central chest or back. These medium-range sounds of equal length during inspiration & expiration have no noticeable pause
these sounds are located in the periphery of all the lung fields. Their soft, rustling quality is longer on inspiration than expiration, with no pause between
AKA rales. High pitched popping sounds heard in distant areas of the lungs. Sound like Rice Crispies!
Whistling or squeaking sounds, like air moving thru a small opening. If this sound suddenly stops, it may mean the air passage is totally occluded.
AKA rhonchi, low pitched, bubbling heard in larger airways. more prominent during expiration. sounds like wet snoring. May clear with deep breathing or coughing.
these sounds are grating, leathery sounds caused by two dry pleural surfaces moving over each other.
Whenever adventitious sounds are heard, the nurse also assesses the characteristics of any cough and the appearance of ______ _______.
1+ Pitting edema
type of edema, slight indentation (2mm), normal contours, associated with interstitial fluid volume 30% above normal is referred to as?
2+ Pitting Edema
type of edema, deeper pit after pressing (4mm), lasts longer with fairly normal contour is referred to as?
3+ Pitting edema
type of edema, deep pit (6mm), remains several seconds after pressing, skin swelling obvious by general inspection, is referred to as?
4+ pitting edema
type of edema, deep pit (8mm), remains for a prolonged time after pressing, possibly minutes, frank swelling, is referred to as?
5+ Brawny edema
type of edema, fluid can no longer be displaced secondary to excessive interstitial fluid accumulation. No pitting, tissue palpates as firm or hard. Skin surface shiny, warm & moist; is referred to as?
striking or tapping on the body to produce vibratory sounds, TO DETERMINE SIZE AND LOCATION OF UNDERLYING STRUCTURES
Lightly touching or applying pressure to the body. USED FOR FEELING SURFACE OF THE SKIN, STRUCTURES THAT LIE JUST BENEATH THE SKIN
This is performed by depressing tissue approximately 1" (2.5cm) with the forefinger of one or both hands, to determine size, shape,consistency and mobility of normal & UNUSUAL masses, SYMMETRY or ASYMMETRY of thyroid gland, skin temp & moisture, TENDERNESS & UNUSUAL vibrations
Resiliency of the skin (hydration). A combination of elastic quality of the skin & pressure exerted on it by fluid within. Older adult: chest. Younger: arm
This is produced when nurse releases tissue and it does not go back to normal quickly, it indicates dehydration.
this is excessive fluid within tissue and signifies abnormal fluid distribution. Clients with cardiovascular, liver & kidney disfuction are prone to this. Signs include, weight gain, tight rings, patterns in skin after removing socks or shoes
HYPERACTIVE (if frequent), HYPOACTIVE (occur after long intervals of silence) and ABSENT (if no sound for 2-5 minutes) are used to describe what?
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