Romberg test

Check for balance by having the client stanf with feet together arms at both sides and eye closed and not move for at least 5 seconds

Glasgow coma scale

Used as a based line for level on consciousness

Assessment technique for the abdomen. Select all that apply

• Inspect ( look)
• Auscultation ( hear)
• purcussion
• palpation
• Ask client to urinate before performing the test
• client will lie supine
• knees sligthly bent
• inspect in quadrants starting with the right lower quadrant to right upper left upper left lower.

Heart Sound Abnormalities

• Murmurs: blowing or stwiching sound charateristic of heart desease ( altered flow)
• Thrills : palpate vibration that can come with murmurs or cardiac malfunctions.
• Bruits: blowing switching sounds indicative of obstructed perpheral blood flow

Ausculatory sites of the heart

1. Aortic: Right second intercoastal space
2. Pulmonic: Left second intercoastal space
3. Erb's point: Left intercoast speace
4. Tricuspid: Lower left strernal border 4th intercoastal
5. Mitral : left 5th intercoastal medial to misclavicular line

Lordosis

spine curves towards the abdomen

Kyphosis

( hunchback) spine curves towars the upper back and it affects the lungs because you're putting pressure towards the abdomen

Scoliosis

A lot of teen suffers from it and it is the curvature of the spine sideways

Lung sounds that are Abnormal

• Crackles(rales) : crackling sounds that can go away ( Discontinuous)
• Whezzing : a high pitch sound caused by airway construction ( continuous)
• Rhonchi : Sound like snoring ( continious)

Physical Assessment techniques (In

order)

1. Inspect (look)
2. Palpation ( feeling with hands and fingers)
3. Percussion ( tapping)
4. Ausculation ( Listening

Nursing process

APPIE

1. Assess
2. analyze
3. plan
4. implement
5. evaluate

ABC FRAME WORK (PRIORITY). (SELLECT ALL THAT APPLY)

• AIRWAY
• BREATHING
• CIRCULATION

Inspection

looking with the naked eye

Palpation

feeling with hands and fingers

Auscultation

listening to sound of the body

percussion

tapping of the body parts