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Inspection
used for the initial and focused assessment
Palpation
4 finger pads
uses to elicit crepitus on a patient who sustained an injury
Auscultation
use of stethoscope
used to listen to heart and lungs
Percussion
uses middle finger tips
techniques used for diaphragmatic excursion
Direct percussion
used to assess sinuses for sinusitis and sinus headaches
Indirect percussion
used to assess lungs and distended bladder
blunt percussion
used assess for tenderness or hematoma in the CVA area
Goniometer
used to measure the degree of joint flexion and extension
doppler
used to assess non-palpable pulses
Woods lamp
used to assess for fungal infections of the skin
skin fold caliper
measures subcutaneous thickness
transilluminator
used to detect blood, fluid, or massess in the body cavity
diaphragm of stethoscope
used for high pitched sounds
ex. heart and lungs
Bell of stethoscope
used for low pitched sounds
ex. cardiac murmurs or bruits
0 pulse grading
no pulse
1+ pulse grading
weak and thready
2+ pulse grading
normal pulse
3+ pulse grading
brisk
4+ pulse grading
bounding
radial pulse
palpated on the wrist laterally next to the thumb
ulner
palpated on the wrist medially inline with the pinky
brachial
palpated medially in the antecubital
popliteal
palpated behind the knee medially
femoral
palpated in the inguinal area
dorsalis pedis
palpated on the top of the foot in line with the big toe
carotid
palpated laterally on the neck, under the jaw
dorsal part of the hand
is used to assess skin temperature
annular lesion
singular circle
ex. ringworm
target lesion
concentric circles with dot in the center
ex. erythema
discrete lesion
separate lesions
confluent lesions
lesions that run together
linear lesions
lesions that form a line
grouped lesions
clusters or groups of lesions
wheal lesions
reddened with irregular border
ex. insect bites or hives
lichenification
rough, thick, hardened patch of skin due to itching and scrubbing
vesicle
palpable fluid filled mass with translucent walls
round or oval
grading edema
0: no edema
1+: 2mm
2+: 4mm
3+: 6mm
4+: 8mm
pneumonic for cranial nerves
Oh (olfactory) Some (sensory)
Oh (optic) Say (sensory)
Oh (oculomotor) Marry (motor)
To (trochlear) Money (motor)
Touch (trigeminal) But (both)
And (abducens) My (motor)
Feel (facial) Brother (both)
Very (vestibulocochlear) Says (sensory)
Good (glossopharyngeal) Big (both)
Vegas (Vagus) Business (both)
A-H (Accessory) Makes (motor)- (hypoglossal) Money (motor)
angle of louis
2nd ics
venous lake
soft lesion on lips or neck that are elevated, dark blue and compressible
common on elderly over 50
due to over exposure to sunlight
Port wine stain
flat irregular shape that pale red to deep purple
color deepens with extreme temp or emotions
present at birth and typically does not fade
hemangioma
bright red raised lesion
nonblanchable
present at birth
disappears around age 10
spider angioma
flat bright red dot with tiny radiating blood vessels
ranges from pinpoint to 2cm
blanches with pressure
light palpation
uses finger pads of one hand with depth 0.5-1cm
moderate palpation
uses finger pads of one hand with depth of 2-3 cm.
used to determine depth, shape, and consistency of organs
deep palpation
used by physicians or NPs by manual of 4-5cm
must be done with caution
used to asses organs that are deep within the body
ex. liver, spleen, kidneys
when client refuses
document what was done and what was refused
When suspecting Lyme disease ask
Have you been hiking or camping recently?
indication of an open sore on the head that has not healed for several months
skin malignancy/cancer