1. Know the assessment techniques
A. Inspection= The visual examination
-The critical observation of the client for any physical signs that indicate alteration from normal
-Can be done during hygiene care
-Used to as
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1. Know the assessment techniques
A. Inspection= The visual examination
-The critical observation of the client for any physical signs that indicate alteration from normal
-Can be done during hygiene care
-Used to assess body surface, shape, size, color, position, and symmetry
B. Palpation= Using the sense of touch (DEEP PALPATION IS NOT WITHIN THE SCOPE OF LPN)
-Texture of hair
-Temperature of skin
-Vibration of joints
-Size/ Position/ shape/ Consistency/ Texture/ Mobility of masses
-Collection of fluid/ Presence of distention
-Pulses
-Tenderness and Pain
C. Percussion= The deliberate striking or tapping of a body part to elicit sounds/vibrations
-Direct percussion: striking an area directly with 1 to 3 finger pads or with the pad of the middle finger rapidly
-Indirect percussion: striking an object against the area (another finger)
-Assesses the size and shape of internal organs (boundaries)
-Assesses if the tissue is filled with fluid/ air/ solid
D. Auscultation= Listening for sounds produced by the body
-Direct: using the unaided ear
-Indirect: using a stethoscope
-Listen for intensity (loudness of softness of the sound)
-Listen for pitch (frequency of vibrations)
-Listen for duration (length of the sound; short to long)
-Listen for quality (the subjective description of the sound; whistling, gurgling etc.)
2. Difference between normal and adventitious breath sounds Normal Breath Sounds:
A. Vesicular= soft, breezy, sighing sound; best heard over periphery/ bases
B. Bronchovesicular= blowing sound & large amt. of air through lung tube; best heard over first and second intercostal spaces substernal
C. Bronchial= high pitched, harsh, loud sound caused by air moving through the trachea; best heard over anterior trachea, not normally heard over lung tissue.
Adventitious Breath Sounds:
A. Crackles (rales)= cause by air passing through fluid/ mucous in air passages
i. heard on inspiration and is most commonly heard in the bases of the lungs
ii. usually do not clear with coughing
B. Gurgles (rhonchi)= air passing through narrow air passages as a result of secretions, swelling or tumors.
i. clear with cough
CONTINUED....................
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