NSE 13A/B Study Guide - Quiz Guide: General Order, Health Promotion, Spasm
16 Mar 2019
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Introduction of first and last name: hand hygiene, permission to touch, ensure confidentiality, pull curtains for privacy. General survey: alert, awake and conscious, ask them to state first and last name, speech is clear, posture is erect, no distress, looks stated age, dressed appropriately for the weather outside, normal walking gait. Size & contour: redness, are sizes equal bilaterally, lesions, skin is smooth. Stabilize joint proximal to area being moved *: proximal in the perspective of the pt, testing knee- stabilize the hip, testing wrist, stabilize the elbow, know the expected ranges (4) testing muscle strength. Inspect: equal and bilateral size and symmetry, skin is consistent with genetic background, round contour, no redness, swelling, deformities, masses, atrophy present, lesions. Palpation: normal temperature, no swelling or edema, no spasm or atrophy, no pain. Rom: flexion- 180 degrees, hyperextension - up to 50 degrees, external rotation ( hands at the back of head) -90 degrees.
