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Components of the Medication Order
  • Client's Full Name
  • Date & Time
  • Name of Medication
  • Dosage of Medication
  • Route of Administration
  • Frequency of Administration
  • Signature of the person writing order
Written medication orders
1.  Name of the drug

2.  The dosage (abbreviations/symbols)

3.  Route

4.  Frequency
Reconstitution
  • Process of adding a solvent or diluent to a medication in powder form to dissolve it
  • Necessary for medications that come in powdered form
  • Can be oral or parenteral use
Types of Health Assessments
  • Comprehensive
  • Ongoing partial
  • Focused
  • Emergency
Major Components of Health Assessment
  • Health history
  • Physical Assessment
  • Be sure to prepare (client, environment)
Complete Health History

*Family Health History

     - Genetic Predisposition 

     -  Genogram

     -  Summary
Assessment Process Tools
  • Stethoscope
  • B/P Cuff
  • Pulse Ox
  • Hands
  • Eyes
  • Ears
  • Nose
  • Penlight
Purpose of Physical Examination
  • Obtain baseline
  • Supplement, confirm, or refute data from the history
  • Help establish nursing diagnoses and plans of care
  • Evaluate physiologic outcomes/progress
  • Make clinical judgments
  • Identify areas for health promotion and disease prevention
Methods Used in Physical Examination
  • Inspection - eyes
  • Palpation - press with hands
  • Percussion - tap with hands
  • Auscultation - listen
Inspection
  • Deliberate, purposeful, & systemic visual examination
  • Moisture, color, texture of body surfaces
  • Shape, position, size, symmetry of the body
Palpation
  • Examination using touch
  • texture, temp, vibration, position, size, consistency, mobility of organs/masses, distention, pulsation, presence of pain under pressure
  • Light and deep
  • Flatness, dullness, resonance, hyperresonance, tympathy
Percussion
  • Striking body surface to elicit sounds/vibrations
  • Direct (striking body directly) and indirect (striking of an object held against the body
  • Determine sizr, shape, borders of internal organs
Auscultation
  • Listening to sounds produced with the body
  • Direct (ear only) and indirect (stethoscope)
  • Pitch, intensity, duration, quality
Steps in Examination Procedures
  • Planning
  • Obtaining appropriate equipment
  • Preparing the client
  • Implementation of the procedures
  • Evaluation of findings
Sequence for Physical Exam
  • General Survey
  • Vital Signs
  • Head to Toe 
Assessment of Head
  • Hair, scalp, cranium, face
  • Eyes and vision
  • Ears and hearing
  • Nose and sinuses
  • Mouth and ororpharynx
  • Cranial Nerves
     
Assessment of Neck
  • Muscles
  • Lymph Nodes
  • Trachea
  • Thyroid gland
  • Carotid arteries
  • Neck veins
Assessment of Upper Extremities
  • skin and nails
  • muscle strength and tone
  • range of motion
  • brachial and radial pulses
  • birceps and triceps reflexes
  • sensation
Assessment of Chest and Back
  • Skin
  • Chest shape and size
  • Lungs
  • Heart
  • Spinal Column
  • Breasts and axilla
Subjective Data - Health History Questions

     Thorax and lungs
  • Cough
  • Shortness of breath
  • Chest pain with breathing
  • Past history of respiratory infections
  • Environmental exposure
  • Smoking history
  • Self-care behaviors
Inspection

      Thorax and lungs
  • Respiratory Rate, Rhythm, Pattern, Depth
  •       - normal 10-20 breaths/min
  • Normally, breathing is relaxed, regular, automatic & silent
Inspection
      Thorax and lungs
  • Normal or labored breathing?
  • Use of accessory muscles?
  • Pursed Lip Breathing?
Anteroposterior (A/P) Ratio
  • Inspect anterior & posterior thorax
  • Compare A/P diameter w/ lateral diameter
  • Normal A/P Ratio - 1-2
  • Barrel Chest A/P Ratio - 1:1
Palpation
     Thorax and lungs
  • Assess for lumps, pain, tenderness
  • Measures depth of breathing, symmetry of breathing
Percussion
      Thorax and lungs
  • Determines if underlying lung tissue is filled with air or fluid or is solid
  • Use pad of finger on dominany hand to tap
  •     - Resonant, Hyperresonant (increased air),
  •       Dull (consolidation)
Auscultation

    Thorax and lungs
  • Assess air movement through the airways
  • Detect mucus or obstructed airways
  • Ausculate the anterior, posterior, & lateral chest
Auscultation
Thorax and lungs
  • Use the diaphragm of the stethoscope
  • Ask patient to breathe through slowly through mouth
  • Auscultate from side-to-side & top to bottom
  • Assess for asymmetry
  • Note location & quality of the breath sounds
Breath Sounds
  • Location
  • Intensity
  • Pitch
  • Duration (during respiratory cycle)
Normal Breath Sounds
  • Bronchial
  • Bronchovesicular
  • Vesicular
Bronchial
  • Loud High Pitched with hollow quality
  • Heard best over trachea
Bronchovesicular
*  Blowing Sound of medium pitch and intensity

*  Best heard over the branching bronchi
Vesicular
*  Soft breezy, low pitched sounds

*  Heard best over bronchioles or lung's periphery
Adventitious Sounds
     * Crackles
  • fine, medium, course.
  • Heard in lower lobes.
  • Disruptive passage of air
Adventitious Sounds

      *  Wheezing
  • high pitched, continuous musical sounds like a squeak
  • Heard in all lung fields
  • High velocity airflow through severely narrowed bronchi
Adventitious Sounds

     *  Rhonchi
  • loud, low-pitched, rumbling
  • Heard over trachea/bronchi
  • Fluid or mucus in larger airways
Adventitious Sounds

     *  Stridor 

  • high-pitched harsh sound heard during inspiration
  • Caused by obstruction of the upper airway
     
Abnormal Findings:

     *Common Respiratory
       Conditions
  • Atelectasis
  • Lobar Pneumonia
  • Bronchitis
  • Emphysema
  • Asthma
  • Pleural effusion thickening
  • Congestive heart failure
  • phneumothorax
  • PCP: Pneumocystis carinii pneumonia
  • tuberculosis
  • pulmonary emblism
  • acute respiratpry distress syndrome
Objective Documentation
  • Inspection
  • Papation
  • Percussion
  • Auscultation
Auscultation Goals

       Thorax and lungs
  • APTM
  • Aortic valve
  • Pulmonic Valve
  • Tricuspid Valve
  • Mitral Valve
Aortic Valve
  • S2 heard here
  • "dub" sound
Pulmonic Valve
  • S2 heard here too
Tricuspid Valve
  • Soft S1 sound
  • "lub"
Mitral Valves
  • S1 heard most clearly
  • Apex of the heart
Apical Pulse
  • 5th intercostal space
  • At or just medial to the left midclavivular line (MCL)
Heart sounds
  • S1 - "lub"
  •      - closure of atrioventricular valves
  •      - mitral & tricuspid
  •      - onset of systole
  • S2 - "dub"
  •      - closure of semilunar valves
  •      - Aortic & pulmonic
  •      - onset of diastole
Heart Murmurs
Sounds that occur during systole or diastole as a result of turbulent blood flow
Auscultation

     Thorax and lungs
  • Note rate, rhythm, & amplitude
  • Indentify S1 & S2
  • Listen to S1 & S2
  • Listen for extra heart sounds
  • Listen for murmurs
  • Listen for bruits in the carotid arteries
Abdominal Inspection
  • Four quadrants for contour, symmetry, bumps, bulges, masses
  • Skin color
  • Condition - scars, stretch marks
  • Umbilicus
  • Hair distribution
  • Pulsations
Abdominal Inspection Concerns
  • Bulge
  • Midline Umbilicus
  • Abdominal Movements
  • Asymmetric contour
  • Prominent pulsations
  • edema
  • rashes
  • Steadily increasing size of girth
Aortic Bruit
  • Use bell of stethoscope
  • Note any vascular sounds heard as bruits
  • Normally should not be heard
  • Swishing or buzzing sound and indicates turbulent blood flow
     
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