NURS 190 Physical Assessment Midterm Study Guide.

NURS 190 Physical Assessment Midterm Study Guide Apex: point of maximal impulse ; apical pulse • LMCL 5th ICS (heart sits here at 5th ICS) • Hold stethoscope for 1 full min (60 sec) on apical pulse • You should hear a soft vibration, tapping sensation Dark Skin Pallor: skin is ash-gray, yellow-tinged, looks dull Jaundice: Yellow undertone in oral mucosa, palm of hand and feet Erythema: purple or darker than surrounding skin, accompanied by higher temp, hardness & swelling Light Skin Pallor: loss of rosy tones, pt appears with yellow tones Jaundice: Yellow undertone Erythema: redness accompanied by higher temperature at site Shamroth Technique — assessing for clubbing — Ask pt to bring dorsal aspect o corresponding fingers together creating a mirror image AFIB: • No P-wave, irregular (Dysrhythmic atrial contraction with no regularity or pattern) • Atria is fluttering and pumping ineffectively, stasis (pooling) in the atria & ventricles • Pt can develop clot, pt’s with AFIB will be on blood thinners Atrial Flutter: No P-wave, sawtooth looking Dehydration: capillary refill, skin turgor HEART LANDMARKS: Aortic: RSB 2nd ICS Pulmonic: LSB 2nd ICS Erb’s: LSB 3rd ICS Tricuspid: LSB 4th ICS *Mitral: LMCL 5th ICS* 1Otoscope: pull ear up and back Arterial Insufficiency: Objective data: • Diminished pulses, cool shiny skin • absence of hair on toes, pallor lower extremities on elevation • Red color lower extremities Subjective data: • Pain, aching burning, discomfort in feet, calve, thighs • Numbness when at rest in legs/feet • Appearance of symptoms when walking uphill (claudication)