NEO 111 Melanie Jorgenson, RN, BSN

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1 NEO 111 Melanie Jorgenson, RN, BSN

2 Inspection: performing deliberate, purposeful observations in a systematic manner Palpation: using the sense of touch Percussion: striking one object against another to produce sound Auscultation: listening with a stethoscope to sounds produced in the body

3 Biographical data Reason for seeking care History of present health concern Past medical history Family history Lifestyle

4 Sitting (to examine head, back, lungs, breast, heart, extremities) Supine (to examine head, neck, lungs, breast, abdomen, heart, extremities) Sims (to examine rectum and vagina) Knee-chest (to examine rectum) Dorsal recumbent (to examine head, neck, lungs, breast, heart) Prone (to examine posterior thorax, lungs, hip) Lithotomy (to examine female genitalia, rectum, genital tract)

5 Temperature Turgor Texture Moisture Pulsations Vibrations Shape and masses Organs

6 Location Shape Size of organs Density of other underlying structures or tissues

7 Assessments Blood pressure Heart sounds Lung sounds Bowel sounds Characteristics of sounds Pitch Loudness Quality

8 General survey Height and weight Vital signs

9 The Head & Neck The Eyes & Ears The Nose & Sinuses The Mouth & Throat Chest and back The Posterior and Lateral Thorax The Anterior Thorax The Heart

10 As important as assessing the client s vital signs. Routinely taken on admission to acute care facilities and on visits to physicians offices, clinics, and other health care settings.

11 Facial structures Eyes, ears, nose, mouth, and throat Anterior neck structures Trachea, esophagus, thyroid glad, arteries, veins, and lymph nodes Posterior neck areas Upper portion of the spine

12 Focuses on: Cardiovascular status. Respiratory status. Wounds, scars, drains, tubes, dressings. Breasts.

13 Bronchial (loud and high-pitched with a hollow quality) Bronchovesicular (medium-pitched and blowing) Vesicular (soft, breezy, and low-pitched)

14 Adventitious breath sounds (abnormal) Sibilant wheezes (high-pitched, whistling) Sonorous wheezes (low-pitched snoring) Crackles (popping sounds heard on inhalation or exhalation Pleural friction rub (low-pitched grating sound heard on inhalation or exhalation) Stridor (high-pitched, harsh sound heard on inspiration while trachea or larynx is obstructed)

15 Respiratory system Recognizing and identifying normal and abnormal breath sounds Components of the thorax Lungs, rib cage, cartilage, and intercostal muscles Assessment techniques Inspection, palpation, percussion, and auscultation

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17 Functions of the system Transports oxygen, nutrients, and other substances to the body tissues Removes metabolic waste products to the kidneys and lungs Assessment techniques Careful auscultation is important to identify heart sounds

18 Any symptoms patient is experiencing Vital signs Color and temperature of skin; capillary refill of nails Inspection findings related to carotid arteries, jugular veins, and anterior chest wall Palpation findings related to sternoclavicular area and anterior chest wall Auscultation findings, including rate, rhythm, pitch, and location of sounds

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21 NEO 111 Melanie Jorgenson, RN, BSN

22 Neurological Skin Musculoskeletal Upper and lower extremities Abdomen

23 Neurologic system Assesses cognitive function Evaluates sensation in the body, cranial nerves, and DTR Musculoskeletal examination Provides information on muscles and joints Peripheral vascular system Identifies condition of arteries and veins in the extremities

24 Focuses on: Level of consciousness Pupil response Hand grasps Foot pushes

25 Components of the integumentary system Skin, hair, nails, sweat glands, and sebaceous glands Findings Nutrition and hydration Overall health status Information associated with certain systemic diseases, infection, immobility, sun exposure, and allergies

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27 Through observation of client gait and overall range of movement, the nurse is able to obtain some knowledge of the symmetry and strength of muscles

28 Focuses on gastrointestinal and genitourinary status Includes use of inspection, auscultation, percussion, and palpation within the four quadrants of the abdomen to establish bowel function and status

29 Components of the abdominal cavity Men and women: stomach, small and large intestines, liver, gallbladder, pancreas, spleen, kidneys, urinary bladder, adrenal gland, and major blood vessels Women: uterus, fallopian tubes, and ovaries Assessment techniques Order: inspection, auscultation, percussion, and palpation Not all organs can be assessed

30 The nurse must maintain accurate documentation of the amount of drainage, color, or other changes

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