ANSWERS GRADED A+
✔✔Assessment of eyes objective - ✔✔-inspect external eye structures
✔✔Vision testing - ✔✔snellen test- measures distance vision
near vision test
confrontation test-measures peripheral vision
✔✔Assessment of sclera and cornea - ✔✔Normal- white color
-in dark skinned patients sclera may appear yellow
cornea should be transparent
-cloudy areas or dots can be result of injury
✔✔PEERLA - ✔✔pupils equal, round, reactive to light and accommodation
✔✔Assessing extraocular muscle function of eyes - ✔✔-Assess 6 cardinal positions
-note any involuntary rhythmic, rapid, twitching of eye balls
✔✔assessment of ears (subjective data) - ✔✔-difficulty hearing
-earaches
-drainage
-dizziness
-ringing in the ears
-hearing aid
-medications
✔✔Assessment of ears (objective data) - ✔✔-inspect and palpate external ear
-size, shape, symmetry
-inspect external auditory
✔✔Assessment of nose subjective - ✔✔-discharge, facial or sinus pain
-history of frequent colds
-altered sense of smell
-allergies
-medications
✔✔Assessment of mouth and throat subjective - ✔✔-sores or lesions
-bleeding from gums
-altered taste
-toothaches
-history of smoking
-history of infections
✔✔Assessment of nose objective data - ✔✔-external nose should be medial
,-patency of nostrils
-Use nasal speculum
✔✔Assessment of mouth objective - ✔✔-inspect external of mouth, lips
-assess teeth
-tongue inspection
-color, texture, drainage
✔✔Assessment of respiratory subjective - ✔✔-cough
-shortness of breath
-chest pain
-smoking history
-last tb test
✔✔Assessment of respiratory objective - ✔✔-inspection
-palpation
-percussion
-auscultation
✔✔Abnormal breathe sounds; wheezes - ✔✔-High pitched
-heard more with exhalation
-occurs in small airways
-heard in narrowed airway diseases
-ASTHMA
✔✔Abnormal breathe sounds; Rhonchi - ✔✔-Low pitched
-sounds like snoring
-Heard primary during exhalation
-sometimes cleared with coughing
-heard in disorders causing obstruction
-CHRONIC BRONCHITIS
✔✔Abnormal breathe sounds; Pleural friction Rub - ✔✔-Superficial, low pitched
-Sounds like two surfaces rubbing together
-Heard throughout inspiration and expiration
-not cleared by cough
-Heard in individual with Pleurisy ( inflammation of pleural surfaces)
✔✔Adventitious breath sounds; Crackles (pneumonia) - ✔✔- Fine: High-pitched
crackling and popping at the end of inspiration
- Medium: Medium-pitched, moist sounds heard around midpoint of inspiration
- Coarse: Low-pitched, bubbling and gurgling sounds heard throughout inspiration and
at beginning of expiration
- Caused by fluid in the lungs (Ex: pneumonia, heart failure, asthma)
, ✔✔Assessing the heart and peripheral vascular system; subjective - ✔✔-chest pain
-dyspnea
-cough
-fatigue
-edema
-nocturia
-leg pain
-changes in color of skin
-obesity
-medications
✔✔Assessing the heart and Peripheral vascular system; objective - ✔✔-inspection
-palpation
-percussion
-auscultation
✔✔Assessing Peripheral Vascular System - ✔✔-measure blood pressure
-palpate each artery
-compare bilaterally
-assess condition of skin and nails
-check for pretrial edema
-carotid artery
✔✔Radial - ✔✔located at thumb side of wrist
✔✔Ulnar - ✔✔located at pinky side of wrist
✔✔Brachial - ✔✔located above elbow
✔✔femoral - ✔✔located inner thigh
✔✔Popliteal - ✔✔located back of knee
✔✔Dorsalis pedis - ✔✔located top of foot
✔✔posterior tibial - ✔✔located inner ankle
✔✔Grading pulse force - ✔✔4+ strong and bounding
3+ full pulse, increased
2+ normal, easily palpable
1+ weak, barely palpable
✔✔Assessing the abdomen subjective - ✔✔-changes in appetite
-weight gain
-dietary intake