• Collection of data
• Compare data with norms
• Analyze findings
• State the nursing diagnosis (es)
• Prioritize nursing diagnosis

You will ask about the history of present illness, past medical or surgical history, and family history

Collect information on Biographical Data, History of Present Illness, Past Medical /Surgical History- including hospitalizations, allergies and current meds and Family history

1.  
   1. Don't give false reassurance about the patient's findings or health status.
   2. Focus on the patient. don't say: "Oh I had...
2. Don't overuse professional jargon or language.
3. Don't use biased, judgemtal questions .
4. Use positive non-verbal communication techniques.
5. Be aware of how the patient is responding.

Inspection is defined as viewing the patient visually.

Palpation is the technique of pressing the patient's tissues to evaluate texture, temperature, dampness, organ location and size.

Percussion is tapping on a body part and listening for the sound that is emitted.

Auscultation is listening with a stethoscope to various body parts.

1) following commands,

2) limb strength (equal)

3) attention span

4) memory (long term/ short term)

5) Sensation- can you feel this on your arm?  Stereognosis: What are you holding in your hand?

the ability to think, learn, reason, perceive and remember.

The nurse assesses the patient's ability to remember things, use logic, make appropriate judgments, and ability to learn by asking a serious of questions.

the individual's perception of positive physical and emotional well-being. 

It

includes hygiene, pain management, and sleep and rest.

Some hospitals use a scale known as the FLACC scale for infants and young children who may be unable to use other scales.

F: face

L: leg movement

A: activity

C: cry

C: consolability

• Where is the pain located?
• Tell me about the quality of the pain such as burning, movement, etc.
• What things make the pain worse?
• What things improve the pain?
• Are there other symptoms with this pain (such as nausea)?

the processes by which the nervous system activates, coordinates and controls the functions of the body.

• 1)Facial symmetry, 2) Eyes open spontaneously and look in the direction of the nurse, 3) PERRLA,
• 4) Follows commands, 5) Gross motor and sensation intact, 6) Memory and attention, 7) Gag reflex

What is the CCBC concept definition of COMMUNICATION?

(note: it says in online module that communication is a concept and a thread)

Concept Definition: the exchange of blood, gases, and fluids between the vessels and tissues and organ systems.  This concept consists of cardiac sounds, palpating pulses, determining fluid volume, and blood pressure.

Tell me about your energy level. Fatigue is a symptom which can be associated with poor perfusion.

Have you felt like you want to faint or feel dizzy? These may be symptoms of poor perfusion to the brain.

Have you noticed any swelling in your legs? If the heart is pumping ineffectively, there may be edema in the lowest areas of the body.

In perfusion problems the skin may have blood shunted away from the skin to more vital organs. When this occurs the skin becomes cool, and moist. In severe infections (sepsis) this may occur.

Skin which is hot to the touch may also indicate a perfusion problem. Elevated metabolism increases perfusion.

1) How you you ID the heart sounds- First sound and Second sound?

2) What do they indicate (in terms of which valves doing what action)

The first sound (S₁-lub) is the closure of the mitral and tricuspid valves at the same time.

The second sound (S₂-dub) is the closure of the pulmonic and aortic valves at the same time.

a blowing, swooshing sound that occurs with turbulent blood flow in the heart or great vessels.

Murmurs may be caused by changes in the heart valves or leaflets.

• Jugular Venous Distension 
• 
  
• it's a marker of fluid volume
• Inspect the neck while patient is at a 30-45 degree angle, Turn head slightly and assess the neck for visible pulsations in this position.

How would you check perfusion of the legs?

Dorsalis Pedis: Palpate this pulse lightly. You will find it lateral to and parallel with the extensor tendon of the large toe. Don't forget to compare the left to the right.

Posterior Tibial: found around the medial malleolus. If you have difficulty palpating this pulse try to passively dorsiflex the foot to make the pulse more accessible. Remember to compare the extremities.

Edema is an accumulation of fluid in the intercellular space. Edema may be in extremities but can also be found in interstitial spaces of the lungs.

Dependent edema is edema that is collected in the patient's lowest body part. For a patient who sits or stands the lowest point would be the feet, ankles and legs. For a bedridden patient the area would be the buttocks and sacral area.

• Pitting: leaves an indentation in the tissue with pressure
• Brawny: chronic edema, with discoloration of the extremity, occurs with long standing swelling. This rarely abates and does not pit with pressure.
• Non-pitting: swelling is evident, but no pit is formed with pressure; swelling will abate with treatment.

1) Deep vien thrombosis

2) What is a Homans sign?

A marker found in a test that is used to determine a pathological finding.  The disorder is known as a deep vein thrombosis (DVT). If there is a known or questionable DTV the nurse does not do this test. Additionally, the nurse omits this test for patients with sensory impairment.

What is

Petechiae

What is

Purpura

Confluent and extensive patch of petechiae and ecchymosis, flat macular hemorrhage.

If petechiae larger than 0.5 cm in diameter they are known as purpura. Disorders: thrombocytopenia, scurvy, prednisone side effect and trauma.