CEPHALOCAUDAL ASSESSMENT Fundamentals of Nursing 1/22/2013 Submitted to: Ms. Azenith Lupig RN.‚ MAN. Submitted by: Apryll Rose Mayo SKIN Assessment Procedure Normal Findings Actual Finding Significance Inspection Inspect general skin coloration Inspect for color variations Check for skin integrity Inspect for lesions Palpation Assess texture Assess thickness Assess moisture Assess mobility and turgor Detect edema Evenly
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Clinical History Comprehensive: Nursing Home‚ dementia‚ diarrhea DOB: 3-17-13 March 14‚ 1995 ANNUAL H&P DICTATION – Completed/Dictated 3-9-95 CODE STATUS: DNR/DNI This resident is an 81-year-old gentleman who is pleasant and cooperative but not a good historian due to his dementia. Chief complaint: Resident has been having diarrhea according to his records for the past week‚ since the 24th of February. He has been having two to three large loose brown stools per day primarily
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(supraventricular tachycardia or SVT). The course is a series of video segments then skills. The course materials well prepare you for the exam. ▪ AED – infant – if pediatric pads are unavailable it is acceptable to use adult pads ▪ AED – no pulse‚ CPR initiated – use AED when it arrives ▪ Airway – Intubated‚ oxygen saturation decreases. Breath sounds only on right – verify tube placement. ▪ BP – 2 year old 55/40 – hypotensive ▪ Bradycardia – vagal maneuver for infant – ice to
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the bed with their trunk at 45degrees‚ they should be exposed from the waist up. 3. Begin by observing the patient from the end of the bed. You should note whether the patient looks comfortable. Are they cyanosed or flushed? Is their respiration rate normal? Are there any clues around the bed such as PCA machines‚ GTN sprays or an oxygen mask? Comments should be provided to the examiner on each of these areas. Observe the patient from the end of the bed 4. Inspect the patient’s hands. Initially
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Abnormal 9. Carotid bruit Systolic sound heard of the carotid artery Heart Abnormal 10. Pedal edema Swelling in the feet or lower legs Lower extremities Abnormal 11. Hepatosplenomegaly Enlargement of liver and spleen Abdomen Abnormal 12. Pulse 80 Pulse rate Heart Normal 13. Alopecia Hair loss Whole body Abnormal 14. Fundus not visualized The base of anything Eye‚ gall bladder‚ stomach‚ etc. Normal 15. Reflexes 2+ Tendon Reflex Knees‚ elbow‚ feet‚ or hands Normal 16. Hemoccult negative No blood
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Unit 2 Study Guide Understand about health‚ illness‚ and wellness: (CHP 17 p. 295 & PP Health Promotion and Disease Prevention) Health - is the state of complete physical‚ mental (emotional)‚ and social (including spiritual) well-being‚ not merely the absence of disease. Health is holistic in nature; it’s the full expression of a person’s physical‚ emotional‚ social and spiritual potential. It’s a dynamic state in which the person continuously adapts to changes in the internal and external environments
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Case Study #5 Heart & Neck Vessels‚ Lungs & Thorax Mrs. Lee‚ 80 year old Asian American female Admitted to the medical-surgical unit with a chief complaint of “breathing problems”. She speaks broken English & requests that her daughter be allowed to stay with her. She is on nasal cannula oxygen & sitting up in bed. At this time‚ she seems slightly short of breath‚ but is not in acute distress. You note that she is pale & has a petite frame. Her ankles are swollen. Her daughter tells you
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Each subject’s pulse was taken by counting the number of beats felt in fifteen second intervals. When that number had been acquired‚ it was multiplied by four to obtain the number of beats per minute‚ known as the heart rate. The next step was to take blood pressure of each subject in the group. This was done by wrapping the sphygmomanometer (blood pressure cuff) around
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Diagnosis: T/C Cerebrovascular Disorder‚ Hpn II Vital Signs Temperature: 36.7o C Height: 5’6” Pulse: 62 bpm Weight:170 lbs. ( 77.27) Respiration: 22 cpm Observation: Received patient lying on bed‚ lethargic‚ oriented to person‚ place‚ Blood Pressure:160/110 mmHg and time‚ with #1 PNSS 1L regulated @ KVO rate‚hooked @ Left hand‚ with 950 cc left‚ infusing
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Cardio Pulmonary Practical The main aim of the practical was to assess‚ what affects did light exercise have on the systolic and diastolic blood pressure‚ heart and respiration rate‚ tidal volume‚ minute volume and percentage of gas. The readings were taken before exercise‚ during exercise and after exercise. Blood pressure is defined as the amount of pressure exerted on the vessels walls‚ during blood flow. Blood pressure can be measured using a sphygmomanometer. The upper value indicates the
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