nursing review Essay

Assessment:
Pallor: unnatural paleness or absence of color on the skin. Assess for pallor in areas not exposed to the sun such as palm of hands. Note if the skin is unusually dark or pale. Color hue is most evident in palms, soles of feet, lips, tongue and nail beds. Best site to inspect for jaundice is patients scelera (eye)
Skin Lesions:
Abdominal assessment: inspect, auscultate for 5 mins, percussion if needed, than palpation.
Older adults
Respiratory assessment:
Crackles: most common in dependent lobes right and left lung bases. Caused by sudden reinflation of groups of alveoli; disruptive passage of air through small airways. Popping, crackling, bubbling moist sounds on inspiration. Problems include pneumonia edema, pulmonary fibrosis
Rhonci: rumbling sound on expiration: caused by muscular spasm, fluid or mucus in larger airways, new growth or external pressure causing turbulence. Is a loud low pitch rumbling coarse sound heard either during inspiration or expiration . problems include pneumonia, emphesema, bronchitis, bronchiectasis
Wheezes: high pitched musical sound during both inspiration and expiration. Is a high velocity airflow through severely narrowed or obstructed airway. Problems include emphysema, asthma, foreign bodies.
Pleural Friction Rub: Dry grating sound on both inspiration and expiration. Is heard over anterior lateral lund field. Caused by inflamed pleura; parietal pleura rubbing against visceral pleura. Problems include pleurisy, pneumonia, pleural infarct
Bronchial breath sounds are loud harsh and high pitched. Heard over trachea, bronchi, between clavicles and midsternum and over main bronchus.
Bronchovesicular breath sound. Blowing sounds moderate intensity and pitch. Heard over large airways, either side of sternum and the angle of Louis, and between scapulae
Vesicular breath sounds: Soft breezy quality, low pitched. Heard over the peripheral lung area, heard best at the base of the lungs
Kussmaul vs Cheyne Stokes. Kussmaul respiration are abnormally deep, regular, and increased in rate. Is typically seen in pts with ketoacidosis such as diabetics.
Cheyne stokes are both respiratory and depth are irregular. Characterized by alternating periods of apnea and hyperventilation. Cheyne stokes results from any condition that slows the blood flow to the brain stem.
PERRLA: pupils equal round reactive to light and accommodation. Perrla is test to see if both pupils react to penlight. Should be 3 down to 1 than back up to 3
Cataracts is an increased in opacity of the lens, which blocks light rays from entering the eye. Cataracts sometimes develop slowly and progressively after age 35 or sudden trauma. Cataracts are the most common eye disorders. Most older adults have some evidence of visual impairment from cataracts.
Temperature: normal temperature is 36-38 degrees C or 96.8-100.4 F. Elevated temperature is anything above 100.5 degrees
Blood pressure: 2 step because estimating systolic pressure prevents false low reading and used on new patients with no known baseline blood pressure reading. Patients with irregular heart rate, pehipheral vascular obstruction, shivering, seizures, excessive tremors, inability to cooperate, and blood pressure less than 90 should not use electronic blood pressure monitoring.
Limb pressures should be the same in arms and legs. If one is lower than the other than possible obstruction such as clot could be causing lower blood pressure.
Vascular insufficiency is inadequate peripheral blood flow. Decreases hair growth on legs and feet, absent or decreased pulses, infection in the foot, poor wound healing, thickened nails, shiny appearance of the skin, and blanching of the skin on elevation.
Cardiac insufficiency is the inability to pump enough blood throughout body.
Positioning during an assessment is important. To decrease number of position changes, organize the assessment so that techniques

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