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Chapter 2 Nursing

Chapter 2 Nursing History and Physical Exam

How should you ask the questions to the client? Questions should be unbiased and not intended to lead the client toward a particular answer. Asking a question in an unbiased fashion forces the client to think. Sometimes questions should be asked 2 or 3 times to make sure the owner understood.
What is important in the history taking process? Active listening skills are important. Paraphrasing what the client has said will help determine whether you understood them correctly.
What is the signalment of an animal? Signalment of the animal is the age, breed, and sex, including reproductive status of the animal.
What is the chief compliant? It is the reason the animal has been brought to the clinic for evaluation.
What is the history of the present illness? Detailed information about the chief complaint and any relative problems is obtained. Duration severity, progression, frequency, trigger situations, time of day and character of the problem must be addressed if applicable.
What is the environmental history? The type of environment in which the pet lives often helps narrows the list of possible causes of a particular problem. Examples would be indoor, outdoor, or a combination of both.
What is the medication history? Information on any medication the animal is receiving is important for reasons that include prioritization of differential diagnosis, potential drug side effects, and possible drug interactions when additional drugs are prescribed.
What is the Dietary history? It is important to know what type of food and how much food a patient is consuming, especially when dealing with problems of weight loss or obesity, vomiting, diarrhea, and anorexia.
Why is the system review important? The systems review is necessary to ensure that a complete history is taken. A system review requires that 1 or 2 questions be asked about each body system to identify other problems that the owner may have overlooked.
What are the components of a complete physical exam? It begins with a general impression of the dog or cat, including its attitude, awareness of its surroundings, gait, general appearance (body weight, condition, appearance of coat).
What are the normal temperature ranges of a dog? 99.5 to 102.5.
What is the normal temp for cats? 100.5 to 102.5.
Where should the pulse rate be taken? From the femoral artery on the medial aspect of the hind leg.
Normal heartrate for a dog? 60 to 180 bpm.
Normal heartrate for a cat? 140 to 220 bpm.
Normal respiratory rate for a dog? 10 to 30 breathes per minute.
Normal respiratory rate for a cat? 24 to 42 breathe per minute.
Integument (Skin)? Brush the coat with the hand in the opposite direction whtat the hair is growing, observe the skin for redness or lesions such as macules, papules, pustules or crusts. Also check the skin on the extremeties.
Respiratory System? Examination begins with the nose and throat, including the pharyngeal area. In the oral cavity, examine the pharynx, tonsils, and if possible the edge of the soft palate. Observe the animal breathing and make note the respiratory rate and pattern.
Cardiovascular System? Begin with the mucous membrane color and capillary refill time, look for blanching, or loss of color of the mucous membrane. Palpate the femoral artery while listening to the heart.
Gastrointestinal System? Begins with the oral cavity, and pharyngeal area. Palpate the neck for masses. Asculate the abdomen and note the presence or absence of gut sounds. The perineal area should be examined for evidence of diarrhea or inflammation of the surroundign skin.
Urogential System? The Kidneys are readily palpated in the normal cat. The urinary bladder can usually be palpated in the caudal ventral abdomen, depending on its degree of fullness.
What shape should the bladder be in the cat and dog? It should be pear shaped in the dog and spherical in a cat.
Musculoskeletal System? Palpate the muscles of the head and limbs and note any pain or asymmetry. Beginning with the toes, palpate the bones and joints of each limb.
Nervous System? The general appearance of the animal including mental attitude and ability to ambulate, can provide information regarding the need for a complete neurologic exam.
How is the central nervous system divided? Its divided into the brain and spinal cord for ease of examination and locialization of lesions.
What are reflexes assessed by? By a gentle but firm tapping of a tendon to determine the degree of response (contraction) of the muscle.
What is the most commonly used test for reflexes is? The most commonly performed test is the reaction of conscious proprioception, in which the foot is gently turned so that the animal is standing on the top of its foot.
What is a panniculus reflex? Is a simple test that aids in the localization of a spinal cord lesions. It is performed by gently pinching the skin of the back just lateral to the midline and watching for a reflex contraction of the skin.
Peripheral Lymph Nodes? The peripheral lymph nodes that can be palpated in the normal animal includethe submandibular, prescapular and popliteal. The axillary and inguinal can only be palpated when enlarged.
Ears? Common abnormalities of the ear flaps include hair loss, crusting margins as with manage or flea bite dermatis, hematomas, and skin tumors. The external ear should be free of exudate and debris.
Some characteristics of exudate are: Dark brown and flaky as occurs with ear mites, dark brown and malodorus as occurs with yeast infections, and purulent as occurs with bacterial otitis.
Eyes? A good ocular examination includes an examination of the external eye (eyelids, sclera, cornea, third eyelid) as well as the internal eye structures (anterior chamber, iris, lens)
What does entropion mean? Means the eyelids seem to roll inward so that the lashes rub on the cornea.
What does ectropion mean? It means that the eyelids appear to be loose and not in contact with the eye.
What is Jaundice? Yellow sclera.
Inflammed eye? Red sclera.
Created by: BananaGirl05



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