MedSurg HESI Practice Exam 2 2024

nursing process - assess diagnose outcome/planning implement evaluate techniques of physical assessment - inspection palpation percussion auscultation start physical assessment with - general survey assess for -appearance -behavior -height/weight/BMI -nutritional status -waist circumference which can indicate obesity when assessing the integumentary system you are looking for - erythema - indicating fever/inflammation cyanosis - indicating O2 loss jaundice - ^ billiruben pallor - low on blood ecchymosis petechiae lesions integumentary assessment - palpate for temperature, moisture, turgor, edema and inspect adventitious breath sounds - wheeze - high pitch indicating airway obstruction crackles - bubbling on in/ex stridor - harsh high pitch sound on inhale ronchi - sonourus , coarse low pitch friction rub extra heart sounds - s3-normal in children s4- normal in older adults order to listen to heart sounds - APETM aortic, pulmonic, erbs point, tricuspid, mitral assessing the abdomen what order - inspect auscultate percussion palpate bowel sounds should occur - every 5-35 seconds gurgling if no sounds for 5 minutes = silent ileus bruits - abnormal bowel sound auscultated during abdominal assessment sounds like a swishing noise and indicates obstruction neurovascular assessment - 6 P's 1. pain 2. pallor 3. peripheral pulses 4. paresthesia 5. paralysis 6. pressure cranial nerve 5 - trigeminal -motor/sensation CHEWING cranial nerve 7 - facial SMILE cranial nerve 9 - glossopharyngeal SWALLOWING cranial nerve 12 - tongue STICK YOUR TONGUE OUT AT ME when to assess VS - on admission based on policy with CHANGE in condition loss of consciousness before/after invasive procedure before/after med admin heat production measures the body takes - shivering piloerection vasoconstriction