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P&P 1- Unit V
Fever
Flushed skin, warm to touch
Chills
Sweating
Change in LOC
Provide adequate fluids
Monitor Electrolytes and Fluid
Monitor vital signs, esp temperature
Remove excess clothing and blankets
Sponge bath with tepid water
2 mins
Vital Signs - Adult
Temperature (96.8-100.4 Degrees F) (36-38 Degrees C)
Rectal
Tympanic
Oral
Axillary
Temporal
Respiration (12-20)
Oxygen Saturation (94%-100%)
Pulse (60-100)
Blood Pressure (<120/80)
Pain
2 mins
Assessment
Health History
Objective Data
Subjective Data
TEST-TAKING STRATEGY: KEY WORDS
Identify
Determine
Obtain Information
CONSIDERATIONS
Assessment Always Done Before Treatments
3 mins
Child and Elder Physical Abuse Assessment
Physical Abuse
Inconsistent Injuries
Delay in Treatment
Various Stages of Healing
Child Abuse
Symmetrical Burns
Sexually Transmitted Infection
Bloody/Torn Undergarments
Shaken Baby Syndrome
Elder Abuse
Poor Hygiene
Overmedication
2 mins
Eye
Characteristics
Sclera
Cornea
Iris
Lens
Ciliary Muscles
Optic Nerve
Rods
Cones
Retina
1 min
Oral Cavity
Characteristics
Mouth
Mechanical Digestion
Salivary Amylase Begins Carbohydrate Breakdown
Lingual Lipase Begins Lipid Breakdown
Esophagus
Bolus
Peristalsis
1 min
Neck and Shoulder Muscles
Superficial
Splenius Capitis
Trapezius
Rhomboid Minor
Rhomboid Major
Deltoid
Latissimus Dorsi
Deep
Levator Scapulae
Supraspinatus
Infraspinatus
Teres Minor
Teres Major
2 mins
Thyroid Gland
Characteristics
TSH Stimulates T3 and T4 Release
Metabolism Regulation
Blood Calcium Sensor
Calcitonin Release
Blood Calcium Decreases
Bone Building
2 mins
Neurovascular Assessment 6 P's
Pain
Paresthesia
Pulse
Pallor
Pressure
Paralysis
1 min
Glasgow Coma Scale
LOC Assessment
Score of 3 to 15
8 or Less = Coma
Eye Opening
Verbal Response
Motor Response
1 min
Respiratory Anatomy
Characteristics
Nasal Cavity
Hair Filters
Mucus Filters and Moistens
Capillaries Warm
Pharynx (Throat)
Larynx (Voice Box)
Cilia Expel Mucus and Dust
Trachea
Bronchi
Alveoli
2 mins
Lung Sounds - Wheezes
Location
Throughout Lung
Description
High Pitched
Sounds Like
Musical
Cause
Air Moving through Narrowed Airways
38 secs
Lung Sounds - Crackles
Location
Lower Lobes
Description
Fine/Coarse
Sounds Like
Fine: Twisting Hair through Fingers
Coarse: Velcro
Cause
Collapsed Small Airways and Alveoli "Popping Open"
1 min
Lung Sounds - Rhonchi
Location
Trachea and Bronchi
Description
Low Pitched Rumbling
Sounds Like
Gurgling
Cause
Narrowed Airway
Secretions or Bronchospasm
49 secs
Lung Sounds - Pleural Friction Rub
Location
Anterior Lateral Lung
Description
Dry, Rubbing, or Squeaking
Sounds Like
Rubbing a Balloon with Finger
Cause
Inflamed Pleura
50 secs
Cranial Nerve Function
Sensory
CN I
CN II
CN VIII
Motor
CN III
CN IV
CN VI
CN XI
CN XII
Both
CN V
CN VII
CN IX
CN X
1 min
CN I
Olfactory Nerve
Sensory
Smell
36 secs
CN II
Optic Nerve
Sensory
Vision
35 secs
CN III
Oculomotor Nerve
Motor
Eye Movement
Accommodation
Eyelid Opening
Pupillary Constriction
1 min
CN IV
Trochlear Nerve
Motor
Abducts, Depresses, Internally Rotates
48 secs
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