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Patient Evaluation

Assessment by Palpation/ What You Feel

Assessment by Palpation Pulse/Heart Rate how fast the heart is beating per minute.
Assessment by Palpation Pulse/Normal 60-100 bpm
Assessment by Palpation Pulse/Tachycardia > greater than 100bpm indicates: hypoxemia, anxiety, stress
Assessment by Palpation Pulse/Bradycardia <less than 60bpm indicates: heart failure, shock, code or emergency
Assessment by Palpation Pulse/ Increased during treatments > greater than 20 bpm is an adverse reaction STOP therapy NOTIFY nurse and doctor
Assessment by Palpation Pulse/Rhythm/Force Pulse = regular or irregular any change in rhythm is indication for further monitoring Pulse force = strong or weak/thread
Assessment by Palpation Pulse/Paradoxical pulse/Pulsus Paradoxus pulse/blood pressure varies with respiration. indicates: severe air trapping. - status asthmaticus - cardiac tamponade
Assessment by Palpation Tracheal Deviation/Determines may be used to determine tracheal position
Assessment by Palpation Tracheal Deviation/ Procedure a)place index finger into the supra- sternal notch b)compare the space between the left clavicle and left border of the trachea
Assessment by Palpation Tracheal Deviation causes:( PULLED ) to Inside the lung: - pulmonary atelectasis - pulmonary fibrosis - pneumonectomy - diaphragmatic paralysis
Assessment by Palpation Tracheal Deviation causes (PUSHED) away Outside the lung -massive pleural effusion - tension pneumothorax - neck or thyroid tumors - large mediastinal mass
Assessment by Palpation Tactile Fremitus vibrations that are felt by the hand on the chest wall.
Assessment by Palpation Tactile Fremitus/Vocal Fremitus voice vibrations on the chest wall
Assessment by Palpation Tactile Fremitus/ Pleural Rub Fremitus a grating sensations felt on the chest wall due to roughened pleural surfaces rubbing together.
Assessment by Palpation Rhonchial Fremitus (palpable rhonchi) secretions in the airway
Assessment by Palpation Tenderness Patient skin may be tender around sutures, chest tubes, bruises, fractured bones, and burns.
Assessment by Palpation Crepitus Bubbles of air under the skin that can be palpated and indicates the presence of subcutaneous emphysema.
Assessment by Palpation Chest Motion Symmetry examiners hands are placed on the patients chest and the distance that the hands move during inspiration is noted.Under normal condition both hands move the same distanceindicating symmetrical chest expansion. If one hand more than the other, asymmetrical
Created by: sukar