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HCC
HCC 2008 Class 3
| Question | Answer |
|---|---|
| ecchymosis | bruising, bleeding under the skin |
| erythema | redness of the skin often seen in face and neck associated with sunburn trama fever and allegic reactions |
| inspection | look with eyes |
| palpation | feeling |
| percussion | striking one object against another (usualy hand) to produce vibration |
| auscultation | listening |
| jaundice | yellowish skin |
| petechiae | small hemorrhagic spots caused by capillary bleeding |
| turgor | fullness of elasticity of the skin and is usually assessed on the sternum or under the clavicle; measure of hydration status |
| Rank the systems in which you perform physical assessments? | neuro, respiratory, cardiac, GI, GU, pulses, musculoskeletal, skin |
| cyanosis | bluish of grayish discoloration of the skin in response to inadequate oxygenation |
| objective data | can be verified by another person |
| subjective data | perceived only by the affected person ; what the patient says it is |
| redness and swelling are noticed at the site of an incision is an example of what kind of data | objective |
| patient complains of pain in his left arm is an example of what kind of data | subjective |
| patient recovering from knee surgery favors his impaired leg when walking | objective |
| patient is nauseated at the sight of food | subjective |
| patient worries about her children during her hospital stay | subjective |
| sources of data | client- #1, significant support people, client record, other health care pros., nursing and other health care lit. |
| clubbing | sign of chronic hypoxia, dark and blue |
| PERRLA | pupils equal round react to light and accommodating |
| bronchial | harsh, high pitched, over trachea , I is shorter than E |
| Bronchovesicular | blowing quality, medium-pitched, over mainstream bronchi, I=E |
| Vesicular | soft, low pitched sounds , over base of lung , I longer and louder then E |
| examples of abnormal breath sounds | crackles, wheezes , Rhonchi, pleural friction rub, dyspnea, Dyspnea on Exertion, Cheyenne-Stokes |
| Crackles | fine and course popping, air moves over wet secretions |
| wheezes | continuous high pitched musical or squeaky sounds as smaller airways narrow |
| Rhonchi | mucus plugs , may be cleared during coughing , continuous low pitched sound usually in large airway |
| Pleura friction rub | grating sound , grating of pleura against the lung |
| Dyspnea | difficulty breathing |
| dyspnea on exertion | difficulty breathing with activity |
| cheyenne-stokes | period of apnea followed by hyperventilation |
| Heart assessment landmarks | Aortic, Palmonic, Tricuspid, Mitral |
| S1 | "Lub", mitral and tricupid valve closing, loudest at apex, systole |
| S2 | "Dub", aortic and pulmonic valve close, diastole |
| S3 | heard after S2, "lub dub dee" |
| S4 | heard before S1, "dee lub dub" |
| murmurs | "swooshing" sound caused by disruption of blood flow |
| Bruits | similar sound as murmur, heard over blood vessels |
| Order for Assessment of Abdomen | lower right, upper right, upper left, lower left |
| when inspecting the abdomen look for... | skin color, striae, scars |
| what comes first when assessing the GI auscultation or palpation? why? | auscultation because you do not want to move stuff around and distort sounds by palpating |
| what are you listening for when auscultating the abdomen | bowel sounds--gurgling, high pitched irregular sounds occuring about every 5-20 seconds |
| how long do you auscultate before charting that the bowel sounds are absent | 5 minutes per quad |
| musculoskeletal system assess.... | gait and posture, inspect for deformities, inspect and palpate bones, joints and muscle groups, assess resistance, full range of motion |
| neurological system assess... | appearance, do they have poor hygiene, appropriate behavior, clear speech, though process logical, assess mood and affect |
| assess orientation | is the client oriented to person place and time? x1, x2, x3? |
| awake and alert | responds to stimuli and verbal commands |
| Lethargic | drowsy or asleep most of the time but is aroused by gentle shaking, spontaneous movement |
| Stuporous | unconscious,most of the time, has no spontaneous movement but response to painful stimuli such as a pinch |
| Comatose | cannot be aroused, even to painful stimuli, may have some reflex activity |
| flatness | flat over dense tissue, bone or muscle |
| dullness | thud-like over solid tissue, spleen, heart |
| resonance | hollow over normal lungs |
| hyper-resonance | booming over air, over inflated lung (emphysema) |
| Tympany | loud drum-like, over air filled structure/organ |
Created by:
jaed008
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