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HA- Final Exam

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Health

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- nonblanchable erythema of intact skin
- partial thickness skin loss with exposed dermis - viable, pink or red, moist, intact or ruptures serum filled blister
- full thickness skin loss - eschar may be visible
- full thickness skin and tissue loss - can see bone
Edema Assessment:
- Client sits facing examiner 2ft away, eyes should be at the same level, both cover eyes directly opposite of each other and stare at each other's uncovered eye; bring small object into peripheral visual field and test the superior, temporal, inferior and nasal field; have client state when they see object
- Use finger through 6 positions of gaze to assess for eye movement related to cranial nerves III, IV, and VI
- increased intraocular pressure leading to loss of peripheral vision
- loss of central vision
- damage to blood vessels in retina - causes blindness and black spots in vision
- pearly gray, shiny, translucent
- lesions, edema, erythema, tenderness, blue/pink-red
- smell - speech - concentration - planning - problem solving - motor control
- vision
- touch and pressure - taste - body awareness
- hearing - facial recognition
- balance and coordination
- inability to produce speech - Broken words, Motor, Frontal lobe (Bad Mother F*****)
- inability to comprehend speech - Wacky words, Sensory, Temporal lobe (Want Some Tea?)
- a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints
- 15 possible points - GCS of 3-8 = severe - GCS of 9-12 = moderate - GCS of 13-15 = mild
- bones of the shoulder, pelvis, and upper and lower extremities - think appendix = extra
- the skull, rib cage, and vertebral column - think axis = central
- inward curve of the spine
- lateral curvature of the spine
- thinning of the muscle - occurs in bedridden patients, stoke or brain disease, desk jobs, etc.
- thins and weakens bones causing them to become fragile and break easily
- toes point in
- toes point out
- high arch
- knock knees