NURN 155 - Final Exam

e. Braden scale Assessment

(more commonly used) sensory, moisture, activity, mobility, nutrition, friction and shear.

Assessment of the Pulse

* RATE 30 seconds X 2 = one full minute pulse. If irregular or if the patient has a cardiac diagnosis, check full-minute apical pulse - Bradycardia < 60 beats/minute - Tachycardia > 100 beats/minute * RHYTHM - should be regular and steady - A regular rhythm has an equal distance between each beat - Abnormal - arrhythmia - the pulsation or length of pulses occur without a predictable pattern. - Dysrhythmia is an irregular pattern of heartbeats that could lead to decreased cardiac output. - Pulse deficit- the difference between the apical and radial pulse. A slow, rapid or irregular pulse can indicate the hearts inability to meet the demands of the tissues and organs for oxygenated blood.

Immunity labs & Health Promotion

*Immunity Labs and Diagnostics: WBC count and differential. Bone marrow biopsy. Humoral and cellular immunity tests. Phagocytic cell function test. Complement component tests. Hypersensitivity tests. Specific antigen-antibody test. HIV infection tests. *Health Promotion of Immunity: Goal: reduce the risk of infection in healthy people - Use of vaccines. - Health counseling- decrease stress, good nutrition, adequate rest.

h. Coordination and balance- Romberg's test

- A nurse will check a patient's coordination by using the finger-nose-finger test. - Balance - a nurse will test the patient's gait and do the Romberg's test.

Pulse factors

- Age. - Gender. - Autonomic nervous system. - Fever. - Emotions. - Poor oxygenation. - Medications. - Albuterol - asthma medicine. - Atropine - given when the heart rate is low. - Digoxin -given if there are problems with the heart.

Health History

- Bio Data - Historian - Usually the source of history is the patient (primary source), but can be a family member or friend, a letter of referral, or the medical record (secondary source). - Reason for Seeking Care - chief complaint. - Present Health/Illness. - PQRSTU: The mnemonic ''PQRSTU'' is used to illicit information about the HPI. Provoking Factors. Quality/ quantity. Region and Radiation. Severity scale. Timing. Understanding. - PMH: All of the patient's past medical history. - Family History - The health history of family members. ROS - The nurse evaluates each body system's past and present state of health. - Medication Reconciliation. - ADL - The patient's ability to provide self care-bathing, toileting, walking, etc.

j. Labs - Blood sugar, HBA1c, Protein, albumin, Hemoglobin/Hematocrit

- Blood sugar - less than 5.6% - HBA1c (glycated hemoglobin) - a blood test that measures your average blood sugar levels over the past three months. - Fasting blood sugar is 70-100. - Protein - 6.0 - 8.3g/dL. - Hemoglobin: men - 14-17.3g/dL. women - 11.7-15.5g/dL. - Hematocrit: men - 42%-52%. women - 36%-48%. - Albumin - 3.4 to 5.4 g/dL.

c. LOC- GCS 15 max, 3 min. Know what the 3 components that are included in GCS

- Examine best eye-opening: normal is spontaneous opening with verbal stimulation. - Evaluate verbal response: normal is oriented to person, place, and time (in video inappropriate words [3] are recorded as words. Incomprehensible [2] is recorded as sounds. - Evaluate motor response: normal is the patient's ability to obey verbal command.

c. Palpation- Fremitus

- Fremitus is a palpable vibration. - "99" = you're supposed to feel vibrations. That's proper gas exchange. - If it's too loud, there's something in there.

Auscultation

- Listening to the body sounds using a stethoscope. - The Bell of the stethoscope will allow the nurse to hear soft, low pitched sounds. - The Diaphragm of the stethoscope will allow the nurse to hear high pitched sounds.

c. Risk factors for breakdown down

- Moisture. - Mobility status. - Circulation. - Sensation. - Infection. - Disease. - Nutritional Status.

a. Temperature- Sources, Factors, Nursing considerations

- Oral - the most common temperature. check in the mouth with a probe. Check to see if they had something cold or hot to drink. - Check if they had oral surgery, unconscious if they had an infection in the mouth. - Rectal- left lateral position, lubricate probe, insert 2-3 cm the into rectum (most accurate temperature) (lubricate the rectum first). - Temporal - forehead. - Tympanic - ear. - Axillary - armpit. Hold it in place. This source of temperature takes longer to read. Factors Affecting Temperature: - Age. - Exercise. - Hormone levels. - Circadian Rhythm - time of day affects body temp, lowest temp between 0100-0400, highest temp at 1600 for healthy people. - Stress. - Environment - infants and elderly affected more.

e. Sensory

- Pain - pinprick test. - Touch - light touch, is used with a stretched cotton ball on the patient's arms, forearms, legs, hands, thighs, etc. - Vibration - the nurse uses a tuning fork on the patient. - Tactile Discrimination - fine touch. - Stereognosis - the ability to perceive and recognize the form of an object in the absence of visual and auditory information. - Graphesthesia - is the ability to "read" a number by having it traced on the skin.

b. Eyes- Vision check - Snellen chart, PERRLA, EOM

- Snellen chart - patient stands 20 feet from the chart; reads the various lines with one eye covered. Note the number at the smallest line patient can read. •20/20 would be that the patient stood 20 feet away and read the line identified as "20". •A patient that read 20/200 would be considered legally blind. - PERRLA - Pupils Equal, Round, Reactive to Light and Accommodation. - Extraocular Movements - this may be assessed when testing all the cranial nerves but is not routinely done. Check the 6 cardinal fields of movement by having the patient "follow your finger" while having the eyes track up, down, and side-to-side.

d. Pressure ulcer- staging

- Stage 1 - Non-Blanchable Erythema: intact skin is red but unbroken. - Stage 2 - Partial-Thickness Skin Loss: loss of epidermis and exposed dermis. No visible fat or deeper tissue. - Stage 3 - Full-Thickness Skin Loss: see subcutaneous fat, granulation tissue, and rolled edges, but not muscle, bone, or tendon. - Stage 4 - Full-Thickness Skin/Tissue Loss: exposes muscle, tendon, or bone, and may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue), rolled edges, and tunneling. - Deep Tissue Pressure Injury (DTPI): localized, non-blanch-able color change to deep red, maroon, or purple in intact or non-intact skin. - Unstageable Pressure Injury - full-thickness ulcers with a wound base that is covered with slough or eschar.

d. Blood Pressure- Systolic, Diastolic, Mean Arterial Pressure, Factors, Hyper/Hypotension, Precautions

- Systolic - the pressure measured during ventricular contraction. It is the maximum pressure on the arteries with the ejection of blood into the aorta. - Diastolic - the pressure measured during relaxation of the ventricles. This lower pressure is present at all times in the arteries. - Mean Arterial Pressure - the average pressure in a patient's arteries during one cardiac cycle.

Percussion

- The nurse taps the client's skin with his/her fingers to assess underlying organs and structures. - Elicits a characteristic sound or vibration based on the area being assessed. - Can assist with determining location, size, and density of an organ. - Descriptions of sounds heard with percussion: 1. Flatness 2. Dullness 3. Tympany 4. Resonance

c. Ears- Hearing check, Whisper test, Tinnie test, Weber test

- Whisper test - a tester stands behind and to the side of the patient, at arm's length from the patient's non-test ear, and whispers sets of either three digits or a combination of digits and letters. - Rinne test - place the base of a struck tuning fork on the mastoid bone behind the ear. Have the patient indicate when sound is no longer heard. Move the fork (held at base) beside ear and ask if now audible. - Weber test - place the base of a struck tuning fork on the bridge of the forehead, nose, or teeth. In a normal test, there is no lateralization of sound.

Preparation of physical assessment

1. After completion of the interview begins the physical assessment. 2. Always begins with vital signs. 3. The nurse evaluates these values based on the age and history of the patient. 4. During the assessment, the nurse is continually evaluating the findings.

Physical Appearance

1. Age- appears stated age. 2. Sex - sexual development is appropriate for sex and age. 3. Level of consciousness. 4. Skin Color - color tone is even, pigmentation varying with genetic background. 5. Facial Features - are symmetric with movement. 6. Overall appearance - no signs of acute distress are present.

f. Comprehensive physical Assessment- System wise assessment

1. Cellular regulation (Lymphatic and Immune systems). 2. Cognition (Neurological System). 3. Comfort (Pain/Neurological System). 4. Elimination (Genitourinary and Gastrointestinal Systems). 5. Homeostasis (Fluid and body system balance). 6. Immunity (Lymphatic System). 7. Infection control (Immune System). 8. Metabolism (Endocrine System). 9. Mobility (Musculoskeletal System). 10. Neural regulation (Neurological System). 11. Nutrition (Digestive System). 12. Gas exchange (Respiratory System). 13. Perfusion (Cardiovascular System). 14. Sensory/perception (Neurological System).

Purpose of physical assessment

1. Collection of baseline data. 2. Compare data with norms. 3. Analyze findings- support or refute subjective data obtained in the nursing history. 4. Identify or confirm the nursing diagnoses. 5. Prioritize nursing diagnosis'. 6. Make clinical decisions about the patient's health care and management. 7. Evaluate outcomes of care.

Secondary Lesions

1. Crust - a solidified hard layer formed by drying body exudates such as the crusts formed in eczema or impetigo, a scab. 2. Scale - the flakes of the exfoliated dermis, e.g. dandruff. 3. Fissure - a deep linear crack extending to the dermis, e.g., athlete's foot. 4. Erosion - Scooped out but shallow depression. Superficial; epidermis lost; moist but no bleeding. 5. Ulcer - deeper depression extending into the dermis, irregular shape; may bleed. Examples: pressure injuries. 6. Excoriation - self-inflicted abrasion; scratches from intense itching. Examples: insect bites, scabies, dermatitis, varicella. 7. Scar - after a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). 8. Atrophic scar - the resulting skin level is depressed with the loss of tissue. 9. Lichenification - thick, leathery skin, usually the result of constant scratching and rubbing. 10. Keloid - a benign excess scar tissue beyond the sites of the original injury.

Behavior

1. Facial expression - the client maintains eye contact. 2. Mood and Affect - the client is comfortable and cooperative with the nurse and interacts pleasantly. 3. Speech- Articulation clear. 4. Speech pattern - the stream of talking is fluent with an even pace. 5. Dress - clothing is appropriate to the climate, looks clean, fits the body, and is appropriate to the client's culture and age group. 6. Personal hygiene - the client appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group.

Mobility

1. Gait - Descriptors of normal gait include: smooth, well-balanced with symmetrical arm swings. The base of the gait should be as wide as the shoulder width. 2. Range of Motion - note full mobility for each joint and that movement is deliberate, accurate, smooth, and coordinated .

Types of Physical Assessment

1. Initial Assessment - comprehensive nursing assessment resulting in baseline data that enable the nurse to make a judgment about a patient's health status, ability to manage one's own health care, and need for nursing, and to plan individualized, holistic health care for the patient. 2. Focused Assessment - assessment is conducted to assess a specific problem; focuses on pertinent history and body regions but may also be used to address the immediate and highest priority concerns for an individual patient. 3. Emergency Assessment - type of rapid focused assessment conducted when addressing a life-threatening or unstable situation. 4. Time-Lapsed Assessment - an assessment that is scheduled to compare a patient's current status to baseline data obtained earlier. 5. Patient-Centered Assessment method - tool for assessing patient complexity using the social determinants of health that often explain why patients with the same or similar health conditions differ in their ability to manage their health and in their outcomes.

Primary Lesion

1. Macule - solely a color change, flat and circumscribed of less than 1 cm. Examples: freckles, measles, scarlet fever, hypopigmentation, and flat nevi. 2. Papule - something you can feel (i.e., solid, elevated, etc) caused by superficial thickening in the epidermis. Examples: wart, elevated moles, lichen planus. 3. Plaque - a plateau-like, disk-shaped lesion. Examples: psoriasis, lichen planus. 4. Patch - macules that are larger than 1 cm. Examples: vitiligo, cafe au lait spot, measles rash. 5. Nodule - solid, elevated, hard or soft, larger than 1 cm. Examples: xanthoma, fibroma, etc. 6. Tumor - larger than a few centimeters in diameter, firm or soft, deeper into the dermis. Examples: lipoma, hemangioma. 7. Wheal - superficial, raised, transient, and erythematous. Examples: mosquito bite, allergic reaction, dermographism. 8. Urticaria (Hives) - wheals coalesce to form extensive reaction, intensely pruritic. 9. Vesicle - elevated cavity containing free fluid, up to 1 cm; blister. Examples: herpes simplex, chickenpox, shingles, and contact dermatitis. 10. Bulla - larger than 1 cm in diameter; usually single-chambered. Examples: friction blister, burns, or contact dermatitis.

Body Structure

1. Stature - the height appears within the normal range for age and genetic heritage. 2. Nutritional Status - the weight appears within the normal range for height and body build. 3. Symmetry - body parts are equal bilaterally and are in relative proportion. 4. Posture - the client stands comfortably erect as appropriate for their age. 5. Position/Deformities - posture and how the patient holds him/or herself is surveyed.

Palpation

1. This method uses the nurse's sense of touch as part of the assessment. 2. Palpation also identifies pain, pulsations, and masses. 3. Palpate lightly at first, then deeper if necessary. Always palpate tender areas last because the patient will "tighten up" making palpation more difficult and increase the patient's pain.

b. Assessment- ABCD, Height, Weight, BMI, skin tenting

ABCD: A - Anthropometric Measurements. B - Biochemical Analysis. C - Clinical Examination. D - Dietary Evaluation. Waist-hip ratio: Ø Ratio shows the increased risk for obesity § Male 1.0 and greater § Female 0.8 and greater § Waist circumference >35 inches in female and >40 in male risk for DM, heart disease, other illnesses. - Height and weight are obtained for each patient upon admission to the health care setting. (Height should be obtained with the patient standing if possible, but if the patient is bed-bound use a tape measure to measure length with the patient as straight as possible.). - The patient should be weighed on the same scale (if possible), at the same time each day, and with the same clothing or linen (in order to have an accurate comparison).

e. Pain- Acute, Chronic, Pain scale, PQRST

Acute pain: *Short-term pain. *Typically less than 3-6 months. Examples: kidney stones, trauma, and incident pain. Chronic pain: *Long-term pain. *Last more than 6 months. *May be subdivided into cancerous and noncancerous pain. Examples: fibromyalgia, arthritis, cancer-related pain, and low back pain.

h. HypoAdrenals- Addisons; Know the signs and symptoms

Addisons: • Muscle weakness, anorexia, fatigue, dark pigmentation of skin, hypotension, low glucose, low sodium, high potassium, depression, confusion. • Addisonian crisis- hypotension, cyanosis, fever, nausea, vomiting, signs of shock.

a. Neuro- Mini Mental Status Exam

Appearance: •Posture. •Body movement. •Dress. •Grooming & Hygiene. Behavior: •Level of Consciousness. •Mood and Affect. •Speech. •Facial expression. Cognition • Orientation. • Attention /Concentration. • Memory -recent/ remote. • New learning. Thought: • Perception. • Thought Process. • Thought Content.

c. Respiration- Assessment, pulse oximetry

Assessment of Respirations: - Easy to assess, often haphazardly measured. - Do not estimate RR. - Accurate assessment requires observation and palpation of chest wall movements. Pulse oximetry - measurement of arterial oxygen saturation (SaO2), the percent of hemoglobin that is bound with oxygen in the arteries. - Usually 95% to 100%.

d. Cranial Nerves- 12, Names, number, how to assess

CN I: Olfactory - smell. Use an alcohol wipe to test for the smell. CN II: Optic - vision. Test visual acuity and visual fields. CN III: Oculomotor - moves eye, pupil. CN IV: Trochlear - moves eye. CN V: Trigeminal - face sensation. Motor: jaw is clenched. Sensory: blinking. CN VI: Abducens - move eye. EOM test is conducted. CN VII: Facial - moves face, salivates. Motor: smile, frown, close eyes tightly, lift eyebrows, or show teeth. Sensation: lightly touching someone with a cotton ball to their face. CN VIII: Vestibulocochlear - hearing, balance. Testing hearing acuity. CN IX: Glossopharyngeal - taste, swallow. Gag reflex. The patient will say "ahh". CN X: Vagus - heart rate, digestion. Have patient swallow. CN XI: Accessory - moves head. The patient will shrug their shoulders. CN XII: Hypoglossal - moves tongue. A patient will stick their tongue out upon request. - Cranial nerves 3, 4, and 6 test for eye movement. - Cranial nerves 9 and 10 are tested together.

f. Nail Assessment

Characteristics: § Shape and Contour. § Consistency. § Color. § Capillary Refill.

BMI

Classifications of BMI: •Underweight - below 18.5. •Normal weight - 18.5-24.9. •Overweight - 25-29.9. •Obesity - BMI of 30 or greater.

h. Clubbing, cyanosis

Clubbing - of the fingernails occurs when a patient has a chronic condition of oxygen deficiency. Clubbing is not reversible. Cyanosis - blue discoloration of the skin and mucous membranes.

i. Hyper Adrenal- Cushings- S/S

Cushing's: Cushing syndrome- central obesity, buffalo hump, heavy trunk, thin extremities, thin skin, ecchymosis, striae, moon face, hyperglycemia, weight gain.

d. Metabolism- Diabetes; Hypo and hyper glycemia

Diabetes: - Type 1: Insulin-Dependent - is a genetic condition that often shows up early in life. The pancreas doesn't make enough insulin. - Type 2: Non-insulin Dependent - is mainly lifestyle-related and develops over time. The pancreas makes less insulin than used to, and your body becomes resistant to insulin - Gestational Diabetes - occurs when your body can't make enough insulin during your pregnancy. • polyuria - excessive urinating. • polydipsia - excessive hunger. • polyphagia - excessive eating.

g. Documentation- Purpose, HIPPA

Documentation purpose: - Policies and procedures. - Communications that require a written/electronic copy. - Any actions, activities, or designations that require written/electronic records. HIPAA - confidentiality.

Factors of Blood Pressure, Hypertension & Hypotension

Factors Affecting Blood Pressure: - Age. - Stress. - Ethnicity. - Gender. - Daily Variation. - Medications. - Activity & Weight. - Smoking. - Hypertension - would be blood pressure that is consistently elevated above normal. - Hypotension - blood pressure below normal.

a. Immunity- Factors, lab, Health Promotion

Factors Affecting Immunity: - Gender- autoimmune diseases higher in female. - Age- aging causes changes in immune response. - Nutrition. - Presence of conditions or disorders. - Allergies- type of allergens. - Infection. - Immunization- vaccinations. - Lifestyle. - Medications and transfusions. - Immunologic factors.

Cellular Regulation: Tertiary Prevention

Focus is on monitoring for & preventing recurrence of the primary cancer as well as screening for development of second malignancies in cancer survivors. Health counseling. Focus on healthy lifestyles. Chemo-prevention.

Inspection

Inspection is the visual examination that is done deliberatively, in a systematic and focused approach. 1. Visual Examination. 2. Deliberate. 3. Systematic. 4. Focused.

c. Calculating I/O, what should be counted as intake/output

Intake: • IV fluids, blood, and tube feedings. • PO fluids all obvious fluids. • All foods that liquefy at room temp. • Ice counts as 1/2 its volume. • Applesauce, hot cereals, and custards usually are not counted as liquids. Output: • Urine. • Vomitus. • Diarrhea. • Gastric suction. • Drainage from tubes.

d. Interview- Technique, sources,

Interview techniques: § Observation. § Open-ended Questions. § Closed-ended Questions. § Non-verbal skills - body language. I.e., posture, gesture, facial expression, eye contact, foot tapping, touch etc.

g. Labs- CBCD, Electrolyte, Protein, Albumin

Look at Normal Lab Value flashcards on Quizlet.

f. Hyper thyroidism- S/S

Nervousness, irritable, hyperexcitable, palpitations, rapid pulse, flushed skin, fine tremors, exophthalmos, increased appetite, weight loss, amenorrhea.

b. Cognition- Learning new

Recalling new things. The Four Unrelated Words Test - tests a person's ability to lay down new memories. It is a highly sensitive and valid memory test.

g. Oxygen- Equipment, delivery methods, safety

Oxygen Equipment: •Nasal cannula. •Simple mask. •Partial rebreather mask. • Non-Rebreather mask. •Venturi mask. Oxygen Delivery Methods: A tracheostomy collar is placed over the tracheostomy tube or stoma to provide additional oxygen to the patient. Oxygen can also be connected to the tracheostomy via a T- piece. The settings are dialed on the flow meter just as with nasal cannula. It is especially important to use humidification with this system.

e. Throat/ Neck- Subjective, objective, lymph node assessment, thyroid gland assessment

Throat/Neck: Objective Data: • Symmetry (midline). • Trachea midline. • Range of motion. • Palpate lymph nodes circular motion with finger pads). • Note location, size shape, delimitation, mobility consistency, or tenderness if palpable. • Thyroid gland: • Visible Swelling. • Assess when patient swallows. • Palpate thyroid gland. • Stand behind pt, use both hands. • Enlarged lobes and nodules. • Tell the pt to swallow with a glass of water. Subjective Data: • Neck pain. • Lumps or swelling. • Limitation of range of motion. Lymph node assessment - palpate with tips of fingers bilaterally with circular motion. Note location, size shape, delimitation, mobility consistency, or tenderness if palpable

c. Health History-sources

Primary or Secondary Source: •Patient. •Family member. •Observer. •Caretaker. •Health care team •Electronic Medical Record (EMR). •Other records- Immunization, educational, military, employment. •Nurses Experience

b. Pulse- Landmarks, Factors, Assessment

Pulse Landmarks: A.Temporal - forehead. B.Carotid - neck. C.*Apical - under the chest. D.**Brachial - forearm. E.*Radial - wrist. F.Femoral - groin. G.Popliteal - knee cap. H.Posterior Tibial - ankle. I.*Dorsalis Pedis - between first and second toe.

c. Environmental survey-what to look for?

Safety.

a. SWIPE

Safety/Survey, Wash your hands, Identify yourself & client, Provide for privacy, and Explain.

Cellular Regulation: Secondary Prevention

Secondary prevention involves screening and early detection activities. WOMEN: Breast self-exam (BSE). Clinical breast exam (CBE). Mammograms. Pap smears. MEN: Prostate exam. Testicular exam.

a. Subjective and Objective data

Subjective Data: - Cough. - Shortness of breath. - Chest pain with breathing. - History of respiratory infections. - Smoking history. - Environmental exposure. - Patient-centered care. Objective Data: • Stethoscope. • Alcohol wipe. • Pulse Oximetry. • Respiratory Rate.

a. Head- Subjective and Objective data

Subjective Data: •Headache. •Head injuries. •Dizziness. •Limitation of movement. •Lumps or swelling. Objective Data: •Inspect and palpate skull. •Inspect face.

a. Skin assessment- ABCDE

Teach skin self-examination using ABCDE rule to detect suspicious lesions: A: asymmetry. B: border. C: color. D: diameter. E: elevation and enlargement.

Cellular Regulation: Primary Prevention

The goal is to reduce the risk of cancer through health promotion and risk reduction strategies. Vaccines. Health counseling. Diet. Smoking cessation. Decrease alcohol intake. Increase physical activity.

i. PIE or APIE

a process-oriented documentation system.

Pain scale

a tool used to help patients describe and identify their pain.

h. SOAP or SOAPIER

are notes that allow clinicians to document continuing patient encounters in a structured way.

Interview

§ Obtained on first patient encounter. § Completed by RN, cannot be delegated. § Consider age-specific prevention guidelines. § Gives a picture of the patient's current health history and health risk status.

a. Mini Nutritional Assessment (MNA)

designed and validated for use in older adults in long-term care and community settings.

j. SBAR

is a verbal or written communication tool that helps provide essential, concise information, usually during crucial situations.

g. Fall Risk Assessment

is used to find out if you have a low, moderate, or high risk of falling.

Physical Assessment

objective data: Observations or measurements of the patient's health status. Example- Checking Vital signs, nurse observing patient's behavior.

PQRST

palliative factors/provocative factors, quality, radiation/region, severity, and temporal factors.

Precautions (blood pressure)

surgeries (breast surgeries, AV fistula), IVs, bone fractures, etc.

d. Percussion- Resonance

• Begin percussing apices in supraclavicular areas. • Resonance (normal). - Resonance = low pitch normal sounds are from the lungs.

i. DTR- 2+

• Biceps. • Triceps. • Brachioradialis. • Quadriceps/Knee jerk. • Achilles. • Plantar. • Babinskis- Abnormal. Found in infants.

e. Auscultation- Normal sounds- Bronchial, Broncho-vesicular, Vesicular

• Bronchial: heard over the larynx and trachea, high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration. • Bronchovesicular: normal breath sounds heard over the main stem bronchus; moderate blowing sounds, with inspiration equal to expiration. • Vesicular: normal sound of respirations heard on auscultation over peripheral lung areas.

e. Hypothyrodidism- S/S

• Hair loss, brittle nails, dry skin, hoarseness, low body temperature, bradycardia, weight gain, feeling cold, amenorrhea in women, slowed speech, dementia. • Myxedema coma- depression, lethargy.

d. Nose- Examination

• Inspect external nose for symmetry, any deformity, or lesions. • Palpation: test patency of each nostril. • Inspect with nasal speculum nasal mucosa, septum, and turbinates. • Palpate the sinus area. • Sniff test can they breathe through both sides of their nose and is it equal? • Inspect for discharge and nosebleeds.

d. Communication technique

• Sending - verbal and non-verbal communication. • Receiving - the receiver uses his or her own interpretations of your own words. • Internal Factors- Respect, Empathy, Listening, Self-awareness • External Factors- Privacy, No Interruptions, Environment • Dress - the client must remain in street clothes when conducting the interview. The interviewer's appearance should be appropriate to the setting. • Note-taking - keep note-taking to a minimum.

f. Motor

• Size- Atrophy, Hypertrophy. • Strength- Paresis, Paralysis. • Tone- limited ROM, Flaccid, Spastic. • Involuntary Movements.

e. Data collection- Subjective and Objective data, Open ended, closed ended

• Subjective data - what the person says about himself or herself. • Objective data - what the interviewer obtains through physical examination. • Open-ended - allow clients to discuss their concerns freely. • Closed-ended - can be answered with "Yes" or "No," or they have a limited set of possible answers.

i. Health Promotion - Immunity

• Vaccinations: • Influenza, pneumococcal (Prevnar - PCV13 protects against 23 strains of pneumonia - 2 injections). • Healthy lifestyle: • Eliminating risk factors, eating right, and regular exercise. • Environmental pollutants: • Secondhand smoke, work chemicals, and pollutants.

f. Abnormal/Adventitious sounds- Wheeze, crackles, Rhonchi

• Wheeze (Sibilant)-musical or squeaking, high-pitched, continuous sounds, auscultated during inspiration and expiration, air passing through narrowed airways (whistling sound). • Rhonchi (Sonorous Wheeze)-sonorous or coarse; snoring quality, low-pitched, continuous sounds, auscultated during inspiration and expiration, coughing may clear the sound somewhat, air passing through or around secretions. • Crackles- bubbling, crackling, popping, low- to high-pitched, discontinuous sounds, auscultated during inspiration and expiration, opening of deflated small airways and alveoli. • Stridor-harsh, loud, high-pitched, auscultated on inspiration, narrowing of upper airway (larynx or trachea); presence of foreign body in airway (noisy breathing = see in babies). • Friction Rub- rubbing or grating, loudest over lower lateral anterior surface, auscultated during inspiration and expiration, inflamed pleura rubbing against chest wall (inflammation in the pleura).

b. Inspection of Lungs

•Thoracic Cage. •Position. •Skin color. •Lesions. •Symmetric chest expansion. •Quality of respirations.