Prepare the client Explain the procedure to the client Client should empty the bladder Assess from LEAST INVASIVE to MORE INVASIVE Prepare the client Explain the procedure to the client Client should empty the bladder Assess from LEAST INVASIVE to MORE INVASIVE
Biological weapon na pwede gamitin sa world war 3…lol Kung ang pwet bumubuga ng di kanais-nais…ano nalang kaya ang bunganga? My geed….
Muscle size – check atrophy or hypertrophy Contractures – shortening of tendons
Confusion – loss of ability to think clearly Disorientation – loss of ability to recognize time, place and person Stupor – deepsleep Coma – no motor response na even deep pain Obtundation – reduced ability to be aroused Aphonia – Inability to understand written and spoken words Agnosia – inability to recognize objects by use of of the 5 senses
Ask the patient to walk back and forth across the room. Observe for equality of arm swing , balance and rapidity and ease of turning. Next, ask the patient to walk on his tiptoes, then on heels . Ask the patient to tandem walk. Test patient's ability to stand with feet together with eyes open and then closed. (Romberg's test). Reassure patient that you will support him, in case he becomes unsteady. Normal: Patient can walk in balance with the arms swinging at sides and can turn smoothly. They should be able to stand with feet together without falling with eyes open or closed.
PERRLA (pupils equal, round, reactive to light and accommodation)
Pupil should constrict quickly in direct response to light and the opposite pupil should also constrict. Pupils should be equal in size. Pupillary accommodation causes constriction in response to objects that are near, and dilation occurs to accommodate distant.
A normal mucosa with clear, watery nasal discharge that tests positive for glucose following head injury or nasal, sinus, or dental surgery usually indicates the leakage of cerebrospinal fluid. If present, stop the exam and notify the nursing supervisor immediately.
Palpate breast: Using the palmar surfaces of the fingers, palpate the breast by gently compressing the mammary tissues against the chest wall. Palpation may be performed from the periphery to the nipple, in either concentric circles or in wedge sections
Contour is flat or rounded and bilaterally symmetrical. Umbilicus is depressed and beneath the abdominal surface. Abdomen rises with inspirations and falls with expirations, free from respiratory retractions. Tympanic heard over the stomach. Dullness noted at RUQ.
Tympany is heard because of air in the stomach and intestines.