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Nclex Review Guide!
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data about the patient's physical status
objecctive
data is obtained by patient report through history taking and interviewing
subjective
what is a visual examination of all parts of body
inspection
what do we inspect forsize, shape, color, symmetry, position, abnormalities, compare w/ same area on the opposite side of body, and use additional light if needed and for body cavities
what is the term for touching- feeling w/ fingers and hands
palpation
how might you encourage relaxation beofore you palpate
advise the client you are to touch him and use a gentle approach
what areas would you palpate last
tender areas
what does the dorsal surfaceof your hand palpate
temperature
what does your finger tips palpate
texture, size, consistency, pulsation, form and shape,
what does your palmer surface palpate
vibration
what could happen if you obstructed blood flow over carotid arteries
you could reduce circulation to the brain or cause changes in heart flow
what is referred to as tapping the body w/ fingertips to evaluate size, borders, density air or fluid
percussion
when you tap lightly with the pads of the fingers on the the skin what is that refered to
direct percussion
this is used more frequently and is requires both hands in reference to percussion
indirect percussion
is listening to sounds auscultation
what is usually performed last auscultation
after inspection, palpation, and percussion except when assessing the abdomen
what is direct auscultation is listening w/out using an instrument
what is indirect auscultation is listening w/ the help of a stethoscope
name the 5 major parts of the stethoscope
earpieces, binaurals, tubing, bell chestpiece, and diaphragm chest piece
dual tubes promote sound clarity
what do you listen w/ to listen to high pitched sounds
diaphragm
what do you listen w/ to listen to low pitched sounds such as extra heart sounds
bell
when during the physical assessment would you need to wear gloves
if exposure to body fluids is a possibility
where would you place a stethoscope
on skin, not over the clothes because the clothes will add or obscure sounds and interfere w/ accurate assessment
what are some things you would do in order to get ready for an assessment
wash hands, environmental noise, remember to protect the patient's privacy, inform the patient that you are going to do an assessmetn before you start and explain what you are doing throughout the procedure, assess the limitations fo your patient so that you will know how to assest them, gather equipment
what are the two methods to use on an assessment
head to toe, and body systems method
what is the most efficient method in assessing a client
head to toe
what is the first step is assessing a client
general survey as soon as you walk in you will be gathering information about their health status
what are some things you would assess under general appearance and behavior
gender and race, age, are there any signs of distress such as sob, decreasede alertnes, signs of pain, sweating, abnormal color, body type, posture, gait, body movements, hygiene and grooming, dress, body odor, affect adn mood and mental state, speech, sign of abuse
when you are assessing age what are looking for
do they appear their stated age or look oler or younger? this tells you something about their health status
what are you assessing in the client who is not dressed normal
an unkept appearance may reflect chronic pain, fatigue, depression or low self esteem
what are you assessing in the body type
are they overweight or underweight. do they have good muscle tone an dappear physically fit or do they appear out of shape and debilitated
If daily weights are ordered make sure that they are done when
at the same time, usually before breakfast on teh same scales w/ the same clothes
who would require daily wts. pts. w/ fluid balance due to heart or kidney disease.
What part of the assessment would provide valuable information about your client's growth and development nutritional status overall general health and required dosages for medication
height and weight assessment
abnormal skin lesions may reflect abnormal conditions of what?
the skin or of internal pathological processes
information gained from assessment of skin includes the status of
circulation, oxygenation, nutrition, hydration and certain metabolic and endocrine conditions
what is the term used to describe a blue gray coloration of the skin often described as ashen
cyanosis
in light skinned clients skin appars whit loss of pink or yellow tones
pallor
a yellow orange cast to the skin
jaundice
a reddened area erythema
may be related to poor circulation or a low hemoglobin level (anemia)
pallor
best sites to assess include the oral mucous membranes, conjunctiva, nail beds, palms, and soles of feet
if seen in the lips, mucous membranes, and facial features it si known as central cyanosis and is associated w/ hypoxia may also be seen in the extremities, especially hands adn feet, after exposure to extreme cold
cyanosis
often associated w/ liver disorders. Best sites to assess include the sclera, muchouls membranes, hard palate of the mouth, palms and soles
jaundice
associated w/ rashes, skin infections, and prolonged pressure on teh skin
erythema
what will you use to assess skin temp.
the dorsum of the hand or fingers
what may stimulate the metabolisma nd may also cause an elevation in skin temp
hyperthyroidism
erythema accompanied by warmth may indicate
infection or inflammatory
what is a normal skin moisture assessment
skin is warm and dry
excessive moisture may result from
hyperthermia, thyroid hyperactivity, anxiety or hyperhidrosis
dry skin may result fromdehydration, chronic renal failure, hypothyroidism, excessive exposure, or overzealous hygiene
what is the normal skin texture is smooth and soft
what may be some factors effecting the skin texture
exposure, age, hyperthyroidism and other endocrine disorders, impaired circulation
refers to the elasticity of the skin,
turgor
skin tenting refers to dehydration in skin tugor
what are white normal raised areas on the nose chin and forehead of newborns due to sebum
milia
how do primary skin lesions develop
develop as a result of disease or irritation ex pustules of acne
how do secondary lesions develop
develop from primary lesions as a result of continued illness, exposure, injory or infection, such as the crusts that form from ruptured pustules
what is ABCDEa is for asymemetry, b border irregularity, c color, d diameter greater than .5 cm, e elevation above the surface
what are due to pigmented cells in the deeper areas of skin adn fade as the child matures (blue-black areas seen on lower back and buttocks of african/asian/native american)
mongolian spots
sometimes known as stork bites are small irregular pink red areas that are often seen around the face and neck in newborns
capillary hemangiomas
ecchymosis is a color variation what is the description and significance of its meaning
bruised (blue-green-yellow) area may be seen anywhere on teh body. the color will vary based on teh age fo the injury may indicate abuse
flat and colored ex. freckle birthmark, mongolian spot
macule
elevated and raised by superficial ex. moles psoriasis
papule
a small circumscribed area distinct from surrounding surface in character and appearnce
patch
a patch on the skin or on a mucouls surface
plaque
elevated solid and firm w/ depth into dermis ex. wart
nodule
hive/ elevated superficial w/ localized edema ex. insect bite
wheal
palpable fluid filled and encapsulated
keratogenous cyst
blisters elevated and filled w/ serrous fluid ex. blister, herpes,
vesicle
elevated and filled w/ pus ex. acne falliculitis impetigo
pustule
What information can you gather by inspecting the nails?
a change in nail shape may indicate underlying disease
which the nail plate is 180 deg. or more
clubbing is associated w/ long term hypoxic states, such as occurs w/ chronic lung disease
what is the term used that may result from iron deficiency in ref to nails
spoon shaped nails
healthy nail beds arelevel, firm, and similar to the color of the skin, nail is smooth and uniform in texture w/ a 160deg. nail plate angle
white spots in the nails represent
may indicate zinc deficiency
black nails are due to blood under the nail, are seen after local trauma
what is referred to as small hemorrhages under the nail bed associated w/ bacterial endocarditis or trauma
splinter hemorrhages
which are transverse white lines in teh nail bed. seen in clients who have experienced sever illnesses
mee's lines
which a distal band of reddish pink covers 20 to 60% of the nail occur in clients w/ low albumin levels or renal disease
half and half nails
what is capillary refill and how do you assess it what does an
briefly press the tip of the nail w/ firm steady presure then release and observe for changes in color this test assesses
abnormal capillary refill indicate?
circulartory adequacy rather than the nails
what is a common complaint w/ skin conditions
pruritis
the scalp is assessed for lesions, lumps, bruises, lice and abnormal hair distribution
what is referred to as excessive facial or trunk hair may be due ot endocrine disorder or steroids
hirsutism
what is referred to hair loss can be caused by chemotherapy for the treatment fo cancer or by nutritional deficiencies or by endocrine disorders
alopecia
what is pediculosis head lice infestation
Inspect head and neck forsize, symmetry, and presence fo nodules, masses, and bulges, shape
normocephalic normal head
microcephalyan abnormally small head size is seen in clients w/ certain types of mental retardation
a disorder associated w/ excess growth hormone
acromegaly
an accumulation of excessive cerebrospinal fluid
hydrocephalus
disease fo the lymph nodes lymphadenopathy
irregular jaw movement or cracking of the jaw
TMJ, temperomandibular joint syndrome
When assessing the clients eyes what do you inspect
do they wear glasses, contact lenses? inspect and palpate the external eye structues, assess vision and examine the internal eye structures
double vision is the perception of two images from a single object
diplopia
associated w/ hyperthyroidism failure of or both pupils to accomadate may reflect a
exopthalmos
cranial nerve III
a drooping of the lid ptosis
a white ring encircling the outer rim of the cornea
arous senilis
lack of coordination between the eyes as a result the eyes look in different direction and do not focus on the same time
strabismus
the medical term for cross eyed strabismus
puffiness of the eye periorbital edema
an inflammation fo the conjunctiva
conjunctivitis
the medical term for pink eye conjunctivitis
scleral icterus a way of determining jaundice in the sclera of the eye
what is are you inspecting in reference to the general appearance of the eye
note irritation, discharge, swelling
what are some signs of respiratory distress
sob, restlessness, decreased mental alertness, cyanosis, pallor, nasal flaring, orthopnea, intercostal retractions, use of accessory muscles, increased heart rate
What does barrel ches look like and when would it be present
used to describe the rounded, barrell shap of the chest that can occur in people w/ chronic obstructive pulmonary disease (COPD) such as emphyema
Which part of the stethoscope is used to listen to the lungs
diaphragm
what are soft low pitched breezy sounds w/ a lengthy inspiratory phase adn a short expiratory
vesicular breath sounds
which breath sounds are heard over the 1st and 2nd ICS adjacent to the sternum on teh anterior chest and between teh scapula on teh
bronchovesicular breath sounds
posterior chest
What breath sounds are medium pitched w/ an equal inspiratory and expiratory phase
bronchovesicular breath sounds
Auscultation 6 places front and back what are some of the breath sounds you will hear
normal, decreased, diminished, absent, increased adventitious voice sounds
if you there are no breathing sounds in that area that may represent what
absent breathing sounds may be an ex. of a punctured lung, collapsed or if they removed a portion of the lung
what is the term to describe additional sounds that are not the normal lung sounds
adventitious
what do you inspect in ref. to nose
placement, nasal flaring(difficulty breathing), drainage, nasal mucosa, deviated septum
what is the term used to described difficulty breathing while lying down
orthopnea
what is the 1st sign of lack of oxygen
restlessness
what are some subjective data when inspecting the thorax and lungs
cough, chest pain, history of resp. infections, smoking history (pack/years), environmental exposure, self-care behaviors
tachypnea rapid respiration
hyperventilation increased respiration
rapid deep breathing w/out pauses more than 20min in adults labored breathing that sounds like sighs
Kussmaul's respirations
slow respiration poor gas exchange
hypoventilation
slow breathing increase breath, apnea then slow and increase....
cheyne-stokes respirations
Kyphosis hunch back hump back
Scoliosis S curve back
when observe the ches what are some ex that you may possibly see in ref. to shape and symmetry
barrell chest, pectus excavatum, pectus carinatum, scoliosis, kyphosis,
deformities of the chest sternum oun
pectus excavatum
deformities of the chest sternum in
pectus carinatum
Plapation of the chest place palms lightly over chest and palpate for
masses, tenderness, alignment, retractions of chest or intercostal spaces
Palpation of the chest using fingertips to feel for
lumps, scars, lesions, ulcerations, temperatures, turgor, moisture, subcuaneous crepitus (feels like rice crispies under the skin some air leakage under the skin)
When you place open palms on both sides of pt. back and anterior chest and ask pt. to say "ninety-nine" loud enough for you to feel vibrations what are you assessing
assessing tactile fremitus
what is the interpretation of tactile fremitus
vibrations will be more intense in areas of tissue consoliation
less intense vibrations in assessing tactile fremitus may mean
presence of empysema, pneumothorax, or pleural effusion
If vibrations in upper posterior thorax are faint or absent, there may be
bronchial obstruction or a fluid filled pleural sapce
what are some Percussion sounds you may hear in the chest
resonance, dull sounds, hyperresonance, and abnormal dullness
heard over normal lung tissue
resonance
heard over heart dull sounds
heard if there is increased air in lung or pleural space
hyperresonance
found w/ areas of decreased air in lungs
abnormal dullness
punctured lung neumothorax
what is an example of an adventitious breath sound
crackles, rhonchi, wheezes, stridor, pleural friction rub
what are some normal breath sounds
tracheal breath sounds, bronchial breath sounds, bronchovesicular breath sounds, vesicular
what are the sounds you hear over teh trachea, harsh, high pitched and less during inspiration (deeper sound)
tracheal breath sounds
what are the sounds you hear next to trachea, loud, hight pitched the inspiration is greater than the expiration
bronchial breath sounds
what are the sounds you heard next to sternum and between scapulae medium in loudness and pitch and the sound of the inspiration and expiration are equal
bronchovesicular breath sounds
heard in rest of lung (peripery) soft and low pitched inspiration greater than expiration
vesicular
You would listen to this at an angle also known as fluid in the lungs
crackles
three types of crackles coarse, medium, fine
the frying popping, moist, low pitched sound here it during the inspiration and some expiration is referred to as
a course crackle
where do you find the medium crackle
found in mid inspiration and its not as loud as course
its a non continuous popping high pitched and heard at the end of inspiration
fine crackle
its a continuos, low pitched, rattling sound heard during the expiration, usually can be cleared by coughing caused by fluid partially blocking large airways
rhonci
contiunous high pitched sound during the inspiration or expiration or both caused by constricion of airway with reultant blockage of air
wheezes
its like breathing out of a straw whistling sound trying to breathe w/ a constricted airflow
wheezes
decreased fluid causes pain everytime you breathe
pleural friction rub
low pitched grating rubbing inspiration and expiration caused by inflammation of pleura may have pain where heard
pleural friction rub
what are bronchophony and egophony and whispered pectoriloquy
voice sounds
when you have patient repeat "ninety nine" while you auscultate lung fields what is this representing
bronchophony,
words will sound muffled over normal lung fields
words will be louder over consolidation
asking the patient to say "E" while auscultating the lung represents what
egophony
sound is muffled over normal lung fields, will sound like letter "A" over consolidation
having the patient whisper "123" while auscultating the lung represents
whispered pectoriloquy;
numbers hard to distinguish over normalo lung fields, numbers will be loud and clear over consolidation
Chest pain, dyspnea, orthopnea, cough, fatigue, cyanosis or pallor edema nocturia, past cardiac history, family cardiac history, personal habits all represent what
subjective data on heart and neck vessels
kind of data
when assessing the carotid artery you would
palpate medial to sternomastoid muscle and auscultate fro bruits
palpating the medial to sternomastoid muscle for the carotid arter you
avoid excessive pressure, palpate one at a time, note contour and amplitude, should be same bilaterally
how do you auscultate for bruits at the carotid artery
use bell of stethoscope, listen for blowing, swishing sound indicating turbulent blood flow, normally none present
What are the two vessels you would inspect
carotid artery and jugular veins
appetite, dysphagia, food intolerance, abdominal pain, nausea/vomiting bowel habits, past abdominal history, medictions nutritional assessment is what kind of data
subjective
What are the three things you should do upon inspection of an abdomen
inspect, auscultate, then percuss and palpate
(look, listen, and feel)
when ispecting an abdomen what do you look for
symmetry, contour, discomort, splinting, guarding, lesions, scars, brusing, discoloration, swelling, bulges, distention, ostomies, drains, dressings
how would you recognize ascites?
if a patient appears to have ascites you would get a tape measure and measure the abdomianl girth. THis would give yo a baseline to go by and future measurements would indicate if and how fast more fluid is accumulating
what part of the stethoscope is used for auscultating bowel sounds
diaphragm
what is the normal rate of bowl sounds per minute?
5-35 normal
what is the term to describe hunger pains or stomach growling
borborygmus
where do you check for bowel sounds
in all four quadrants
inspecting the skin on the abdomen what might you find or are you looking for
smooth and even, color, (jaundice, redness, striae, moles, petehiae, cutaneous angioma) taut, and shiny ascites, lesions rashes
bowel sounds over 35 are loud, high pitched rushing, tinkiling is considered to be
hyperactive may be diarrhea
bowel sounds less than 5hypoactive may be bowl obstruction, after surgery, constipated
if there are no bowel sounds in what do you do
listen for 5 minutes
when listening to the vascular sounds in the abdomen what are you listening for and what do you listen w/
listen w/ bell and listen for bruits over aorta, renal,illiac, adn femoral arteries
Palpating the abdomen forsize, location, consistency of organs, abnormal masses, tenderndess do last
there are three things to look for when you are palpating the abdomen in ref to tenderness
voluntary guarding, involuntary rigidity, rebound tenderness
cold, ticklish, tense would be considered what in ref. to abdomen
voluntary guarding
constant board like hardness would be considered what in ref to abdomen
involuntary rigidity
pain on release of pressure in ref to abdom is considered what
rebound tenderness
percussing the abdomen wherecostovertebral angle tenderness; place one hand over 12th rib at CVA on back
what do you do when percussing the abdomen and what are your results
place one hand over 12th rib at CVA on back thump that hand w/ ulnar edge of other hand client should feel thud, but no pain, sharp pain occurs w/ kidney inflammation
where is the apex of the heart located
5th intercostal space at the left midclavicular line
what is the structure assessed mitral valve
in the apex
what is located in the 4th ICS on left sternal border
tricuspid valve
what is located in the 2nd ICS left sternal border
pulmonic valve
what is located in the 2nd ICS right sternal border
aoritic valve
in order to thoroughly assess heart sounds, you would ausculatate where first
the aortic area
what is the mnemonic you may use to recall the order of the heart
Aunt Polly Takes Meds
Aortic, Pulmonic, Tricuspid, Mitral
what is the first heart sound S1 or lub
S1 marks the beginning of what
systole
S1(lub) is a what kind of sound sow-pitched sound
The S1 may be heard in all locations on the chest but where will it be the loudest
over the mitral tricuspid
what does the first heart sound result from
the closure of the valves between the atria and ventricles
what is the second heart sound you hear
S2 or dub
what does the S2 correspond to
closure of the semilunar valves
you can hear the S2 in all locations but it is loudest
at the aortic and pulmonic areas
a third heart sound (S3) is heard when
immediately after S2 has a gallop cadence that follows the rhythm of the word KenTUcky
when is a S3 normalin young children and adolescents when they are sitting or lying ,but disappears when they stand or sit up. Also a normal variant in the third trimester of pregnancy
when is a S3 abnormal when it does not disappear w/ position change represents
heart failure or volume overload
A fourth heart sound (S4) heard when
immediately before S1 has a rhythm FLOrida
for whom is the S4 normal trained athletes and some older clients
Both S3 and S4 are best heard where
at the apical site, w/ the client lying on his left side, and using the bell of the stethoscope
S4 is normal w/ trained athletes and may also be heard in adults w/ what
coroanry artery disease, hypertension, and pulmonic stenosis
what are additonal sounds produced by turbulent flow through the heart
murmors
what consists of a network of arteries and veins that transport oxygen, carbon dioxide and nutrients to the cells of the body
vascular system
what refers to the contraction or emptying of the ventricles
systole
what refers to the relaxation or filling phase of the ventricles
dystole
where does the heart sitat an angle on the left side of the chest in the 3rd, 4th, and 5th intercostal spaces.
listen for murmors w/ what the bell of the stethoscope
what is the ausculation technique for the heart assessment
begin w/ diaphragm listen to one sonund at a time, note rate an drhythm, indentify S1 and S2 assess them seperately, listen for extra heart sounds, and listen for murmous w/ bell
presence of an S3 in adults over 30 indicate
ventricular failure (CHF)
increased velocity of blood, decreased viscosity of blood and structural defects or unusual openings are all symptoms of a
murmor
this is caused by turbulent blood flow and currents
murmurs
this is used w/ the bell and best murmurs
heard at herb's point
its a gentle blowing swooshing sound in the heart
murmor
when assessing a murmor you assess what
the pattern, quality, location, radiation, and posture
what is the norm for a heart beat
60 to 100 beats per minute
this occurs normally in young adults and children, rate increases w/ inspiration slows expiration in reference to the heart
sinus arrhthmia
leg pain or cramps, skin changes on arms or legs, swelling, lymph node enlargement, and medication are all what kind of data in the peripheral vascular system
subjective
inspect and palpate what for the peripheral vascular system
arms, legs,
when inspecting the legs what do you assess
symmetry, pulses, temperature, lesions, measure calf circumference if discrepency and palpate lymph nodes
when inspecting the arms what do you assess
assess symmetry pulses, lesions
pulses are located wheretemporal, carotid, apical, brachial, radial, femoral, popliteasl, pedal
what is the pulse amplitude
4+ is bounding
3+ is increased
2+ is normal
1+ is weak
0 is absent
if you can't locate the pedal pulse you would then
ck. temp., ck capillary refill but if the refill is slow then use a doppler to validate it get another nurse and then call dr. that is considered a significant finding
when assessing for homan's w/ client in supine position dorsiflet food towards tibi, this should
sign how would you position the client
not cause pain calf pain may indicate deep vein thrombosis, phlebitis, tendonitis, muscle injury or lumbosacral disorders
inspecting the umbilicus you would look for
position, color, and if its inverted
if the color of the umbilical cord is a bluish color what does this mean
this occurs with intraabdominal bleeding (cullen's sign)
if the umbilicus is everted this could mean what
ascites, mass, hernia
musculoskeletal system: when their is pain, stiffness, swelling, heat and redness, and limitation of movement this is what type of data
subjective
palpate joints for what warmth, swelling, tenderness, massess
asses the joints forrange of motion, and muscle tone and strength compare both sides of the body
inspect the joints forsize and contour, joint deformities, skin color, swelling, observe gait and posture, note lordosis, kyphosis, scoliosis
what are some ex. of subjective data in the neurologic system
headache, hgead injury, dizzines/vertigo, seizures, tremors, weakness, incoordination, numbness or tingling, difficulty in swallowing, difficulty speaking, significant past history, environmental occupational hazards
what do you assess in the neurological system
level of consciousness, orientation, glascow coma scale, speech, memory lapses, deficits, coordination and balance
what are the equipment needed for an exam in assessing the neurological system
penlight, tongue blade, cotton swab, cotton ball, tuning fork, percussion hammer, occasionally: familiar aromatic substance
what cranial nerves are you testing for in the neurologic system assessment
cranial nerve II opic
cranial nerve III, IV, VI occulomotor, trochlear, and abducens nerves
cranial nerve V trigeminal, and cranial nerve VII facial mobility
what might the nurse use to scren for visual acuity
snellen chart
if a person has 20/40 vision, what does this mean
that to see lines of print that a person w/ normal vision can read at 40 ft. the client has to stand just 20 ft. from the snellen chart
what does nasal flaring indicate
difficulty breathing
what would cause pallor
a reduced amt. of oxyhemoglobin in skin or mucous membrane a pale color which can be caused by illness, emotional shock or stress, avoiding excessive exposure to sunlight anaemia or genetics
thick elevated white patches that do not scrape off may be precancerous and called what
leukoplakia
white curdy patches that scrape off and bleed indicate thrush also known as
leukoplakia
thrush is a fungal infection
commonly called yeast infection or thrush is a fungal infection of any candida specias
candidiasis
black hairy tongue an overgrowth of bacteria in the mouth
refers to gingival inflammation induced by bacterial biofilms (also called plaque) adherent to tooth surface
gingivitis
an acute hemorrhage for the nostril, nasal cavity or nasopharynx also known as a nosebleed
epistaxis
during a routine bedside assessment we are most commonly assessing which pulses
radial and the pedal
we usually determine the rate and regularity of pulses using the radial site. If the pulse is faint or irregular it
not only compare it to the opposite side but to also listen to the apical pulse to determine rate and regularity
would be important to what
when we check pedal pulses we are determining what
if they are present and if they are fainto or strong we are not concerned w/ counting the rate of the pedal pulses we want to know if the pt. has good circulation in the extremeties
there are times when "neurochecks" are ordered by the physician or the nurse this might be after what happens
a fall if the pt. hits his head after cranial surgery after head injury if pt has decreasing LOC or other conditions where brain swelling/compression might be likely to occur
neurochecks usually includeLOC and orientation, PERRLA, ability to follow commands, ability to move all extremities, muscle strength
inspect the external ears for position, condition of the skin, presence of lesions, and drainage
vertigoa specific type of dizziness, is a major symptom of a bal. disorder
tinnitis ringing of the ears
CVA tenderness (costovertebral angle tenderness) using the fist or blunt percussion where the end of the rib cage meets the spine bilaterally to assess for
kidney tenderness
what would be the abnormal findings for cva tenderness
associated w/ kidney infection, or musculoskeletal problems
what are some abnormal gaits
propulsive, scissors, spastic, steppage and waddling
this is an abnormal gait and is when a person is leaning forward
propulsive
an abnormal gait when knees turn in toward each other
scissors
wht is steppage referred to in an abnormal gait
foot lifted high to clear the toes, no heel strike, toes hit first
waddling is an abnormal gait what does it look like
feet wide, duck like
spastic is an abnormal gait stiff leg mvmt while walking
what does it look like
how would you recognize ascites
by the distention of the stomach
what would you do to assess ascites
use a measuring tape to measure the girth. stretch/place measuring tape over belly button, the 1 inch mark should be @ the belly button mark on the stomach w/ a pen and this will be your baseline ck. again later using same techniques
when might sounds be absent or hypoactive in the bowel
after abdominal surgery or w/ bowl obstruction infection,or innervation problems
when might sounds be hyperactive in the bowel
w/ diarrhea, early bowl obstruction or gastroenteritis
lung sounds will be normal in 48 hrs is what step in the nursing process
planning
ineffective airway clearence is what step in the nursing process
nursing diagnosis
lung sounds reveal rhonchus in the upper lobe is what step in the nursing process
assessment
have client deep breathe and cough every 2 hrs. 4-5 times a day is what step in the nursing process
implementation
lung sounds clear in upper lobes following coughing. continue deep breathing every 2-4 hr. is what step in the nursing process
evaluation
