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PATIENTASSESSMENT (ADULT)

PART 2: PHYSICAL EXAMINATION

PENNY GILL

LECTURER WCCN/CPUT

ECP MARCH 2008

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PATIENTASSESSMENT (ADULT)

SUMMARY OF PART 1ASSESSING A PATIENT

Assess need for an interpreter.

taking a patients history- approach to the patient

- the interview

- special circumstances

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Revision of the interview

demographic information

reason for visit

history of the presenting problem

other health information/review of systems

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Revision of the interview

previous health history

family health history

information related to lifestyle

activities of daily living

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PHYSICAL EXAMINATION

preceded by history taking (subjective)

nurse examines patient in order to collect(objective) data about him/her

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APPROACH TO PATIENT

ensure privacy

exposure to a minimum onlywhen absolutely necessary

explain procedure to

patient

make sure patient iscomfortable

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APPROACH TO PATIENT

continue to build on trustestablished during history

taking talk to patient, reassure

explain steps ofexamination

continue to ask questions

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THE PHYSICAL EXAMINATION

Difference between signs and symptoms

Symptoms: the history tells the nursewhat the symptoms are.

Signs: the physical examination willreveal the signs related to the patientshealth problems.

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TECHNIQUES USED DURING THE

PHYSICAL EXAMINATION Inspection

Palpation

http://www.memorialhermann.org/library/healthguide/en-us/images/media/medical/hw/hwkb17_071.jpg

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TECHNIQUES USED DURING

THE PHYSICAL EXAMINATION Percussion

Ascultation

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TECHNIQUES USED DURING

THE PHYSICAL EXAMINATIONINSPECTION IS:

looking at or observing thepatient

focused & purposeful top-to-

toe survey of patient usingthe senses of vision, hearingand smell

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TECHNIQUES USED DURING

THE PHYSICAL EXAMINATIONINSPECTION CONT:

begins with general survey

and ends with a specificinspection of each area orpart of body: shape,colour, texture &movement

assessment of symmetry

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TECHNIQUES USED DURING THE

PHYSICAL EXAMINATION Palpation: means examine by touch

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TECHNIQUES USED DURING THEPHYSICAL EXAMINATION:

PALPATION: Aspects that can be determined are:

- swelling - present of masses

- spasm - temperature- tenderness - movement

- stiffness - enlargement

- shape - outline- texture - presence of

fluid/crepitations

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TECHNIQUES USED DURING

THE PHYSICAL EXAMINATION Percussion: means to strike or

tap (Used by doctors)

this technique involves lighttapping on the surface of thebody & analysing the soundsthat are produced

used to determine the amountof air &/or solid matter in thelungs & to determine the size,position & borders of the

other thoracic organs

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TECHNIQUES USED DURING

THE PHYSICAL EXAMINATION Ascultation: means listening by

means of a stethoscope

This technique is used to listendirectly to the sounds made by themovement of air or fluid in thebody

Used to assess movement of air inthe lungs, movement of blood in theblood vessels & movement of

digestive fluids in the GIT

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MEASUREMENTS

temperature

pulse

respiration

http://www.memorialhermann.org/library/healthguide/en-us/images/media/medical/hw/hwkb17_071.jpg

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MEASUREMENTS

blood pressure pain

http://images.google.co.za/imgres?imgurl=http://www.mediccast.com/blog/wp-content/uploads/2006/07/Patient%2520in%2520pain.jpg&imgrefurl=http://www.mediccast.com/blog/2006/10/&h=564&w=851&sz=544&hl=en&start=1&um=1&tbnid=5dhPO78e8tjmJM:&tbnh=96&tbnw=145&prev=/images%3Fq%3DPATIENT%2BIN%2BPAIN%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://en.wikipedia.org/wiki/Image:Wong_pain_scale.jpg

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PRINCIPLE FEATURES OF THEGENERAL PHYSICAL

ASSESSMENT patients name, age &

gender

carry out generalinspection of thepatient

take vital signs carry out systematic

physical assessment

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GENERAL EXAMINATION OF

THE PATIENT: INSPECTION general appearance of

the patient grooming/

hygiene: yes/no

posture & gait: uprightbent

http://images.google.co.za/imgres?imgurl=http://www.nursingassistanteducation.com/site/images/qol2_03.gif&imgrefurl=http://www.nursingassistanteducation.com/site/courses/eng/nae-qol-eng.php&h=286&w=236&sz=6&hl=en&start=17&um=1&tbnid=EP_jmRW1buiJOM:&tbnh=115&tbnw=95&prev=/images%3Fq%3DPOOR%2BGROOMING%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://www.davidgault.co.uk/fig-ear-deformity/buckled_rim_pre.jpg&imgrefurl=http://www.davidgault.co.uk/ear-deformity.php&h=280&w=200&sz=11&hl=en&start=217&um=1&tbnid=5CMDU-HoRQ5ClM:&tbnh=114&tbnw=81&prev=/images%3Fq%3DDEFORMITIES%26start%3D200%26ndsp%3D20%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://www.rucosm.com/IMAGES/foot1.jpg&imgrefurl=http://www.rucosm.com/operations/hallux.php&h=320&w=400&sz=35&hl=en&start=47&um=1&tbnid=PkeFAzgVGLCa4M:&tbnh=99&tbnw=124&prev=/images%3Fq%3DDEFORMITIES%26start%3D40%26ndsp%3D20%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://www.sciencenewsden.com/images/rheumatoid_arthritis.jpg&imgrefurl=http://www.sciencenewsden.com/2006/howcanidenticaltwinsbegeneticallydifferent.shtml&h=244&w=300&sz=11&hl=en&start=28&um=1&tbnid=jE1Z_tx7HNwUFM:&tbnh=94&tbnw=116&prev=/images%3Fq%3DDEFORMITIES%26start%3D20%26ndsp%3D20%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://www.nursingassistanteducation.com/site/images/qol2_03.gif&imgrefurl=http://www.nursingassistanteducation.com/site/courses/eng/nae-qol-eng.php&h=286&w=236&sz=6&hl=en&start=17&um=1&tbnid=EP_jmRW1buiJOM:&tbnh=115&tbnw=95&prev=/images%3Fq%3DPOOR%2BGROOMING%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DN

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COMMUNICATION

need for an interpreter:yes/no

language perception:good/poor

speech: clear/ unclear

http://images.google.co.za/imgres?imgurl=http://www.10kmarshmallows.com/wp-content/uploads/2007/04/community.jpg&imgrefurl=http://krnhaines.wordpress.com/&h=303&w=396&sz=71&hl=en&start=1&tbnid=utt-A5l84jC-lM:&tbnh=95&tbnw=124&prev=/images%3Fq%3Dpeople%2Bcommunicating%26gbv%3D2%26hl%3Den

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STATUS OF SPECIAL SENSES

Hearing

Discharges/pain Ear abnormalities

http://images.google.co.za/imgres?imgurl=http://www.davidgault.co.uk/fig-ear-deformity/buckled_rim_pre.jpg&imgrefurl=http://www.davidgault.co.uk/ear-deformity.php&h=280&w=200&sz=11&hl=en&start=217&um=1&tbnid=5CMDU-HoRQ5ClM:&tbnh=114&tbnw=81&prev=/images%3Fq%3DDEFORMITIES%26start%3D200%26ndsp%3D20%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://www.mtzionhearingaidcenter.com/images/saywhat.png&imgrefurl=http://www.mtzionhearingaidcenter.com/&h=450&w=362&sz=604&hl=en&start=6&tbnid=Pnyx6MIO5_GraM:&tbnh=127&tbnw=102&prev=/images%3Fq%3Dhearing%2Baid%26gbv%3D2%26hl%3Den%26sa%3DGhttp://images.google.co.za/imgres?imgurl=http://d.yimg.com/origin1.lifestyles.yahoo.com/ls/he/healthwise/nr55552038.jpg&imgrefurl=http://health.yahoo.com/hearing-resources/hearing-aid/healthwise--zm6101.html&h=300&w=460&sz=25&hl=en&start=1&tbnid=G6siRAgju4uLRM:&tbnh=83&tbnw=128&prev=/images%3Fq%3Dhearing%2Baid%26gbv%3D2%26hl%3Den%26sa%3DG

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STATUS OF SPECIAL SENSES

Sight

http://images.google.co.za/imgres?imgurl=http://www.beauty-advices.com/wp-content/uploads/2007/09/makeup-for-glasses-wearers.jpg&imgrefurl=http://www.beauty-advices.com/what-makeup-to-wear-with-glasses/&h=300&w=300&sz=52&hl=en&start=10&tbnid=19G2VoWSgzRmIM:&tbnh=116&tbnw=116&prev=/images%3Fq%3Dglasses%26gbv%3D2%26hl%3Den%26sa%3DG

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STATUS OF SPECIAL SENSES

Sight

http://images.google.co.za/imgres?imgurl=http://webmedia.unmc.edu/eye/cornealUlcer.jpg&imgrefurl=http://www.unmc.edu/dept/eye/index.cfm%3FL1_ID%3D5%26CONREF%3D25&h=180&w=275&sz=21&hl=en&start=7&um=1&tbnid=BmmuyA8y2vN8YM:&tbnh=75&tbnw=114&prev=/images%3Fq%3Deye%2Bdiseases%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://www.nanosweb.org/patient_info/brochures/images/ThyroidEyeDisease_2.jpg&imgrefurl=http://www.nanosweb.org/patient_info/brochures/ThyroidEyeDisease.asp&h=405&w=600&sz=68&hl=en&start=8&um=1&tbnid=mkmLRJk7-TJwBM:&tbnh=91&tbnw=135&prev=/images%3Fq%3Deye%2Bdiseases%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DN

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STATUS OF SPECIAL SENSES

Smell

Taste

touch

http://images.google.co.za/imgres?imgurl=http://www.abc.net.au/science/news/img/people/finger090606.jpg&imgrefurl=http://thedancingnewt.blogspot.com/2007/05/dear-newt.html&h=238&w=200&sz=5&hl=en&start=13&tbnid=hDVuj46RrdbI_M:&tbnh=109&tbnw=92&prev=/images%3Fq%3Dsense%2Bof%2Btouch%26gbv%3D2%26hl%3Denhttp://rosacea-support.org/wp-content/uploads/2007/10/rosacea-red-nose-1.jpghttp://images.google.co.za/imgres?imgurl=http://www.abc.net.au/science/news/img/people/finger090606.jpg&imgrefurl=http://thedancingnewt.blogspot.com/2007/05/dear-newt.html&h=238&w=200&sz=5&hl=en&start=13&tbnid=hDVuj46RrdbI_M:&tbnh=109&tbnw=92&prev=/images%3Fq%3Dsense%2Bof%2Btouch%26gbv%3D2%26hl%3Denhttp://images.google.co.za/imgres?imgurl=http://www.kidcyber.com.au/IMAGES/tongue.jpeg&imgrefurl=http://www.kidcyber.com.au/topics/body_senses.htm&h=278&w=278&sz=27&hl=en&start=2&tbnid=yf-l07kp2VcNUM:&tbnh=114&tbnw=114&prev=/images%3Fq%3Dtongue%2Btasting%26gbv%3D2%26hl%3Denhttp://images.google.co.za/imgres?imgurl=http://www.ehd.org/images/prenatal_article/sniff6-7wkspage.jpg&imgrefurl=http://www.ehd.org/dev_article_unit16.php&h=221&w=168&sz=17&hl=en&start=6&tbnid=SyupiAbtzi8rYM:&tbnh=107&tbnw=81&prev=/images%3Fq%3Dnose%2Bsmelling%26gbv%3D2%26hl%3Den

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EMOTIONAL STATUS

cheerful/withdrawn

calm/fearful

http://www1.istockphoto.com/file_thumbview_approve/1407368/2/istockphoto_1407368_icons_emotions.jpg

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EMOTIONAL STATUS

mental state of patient anxiety

agitation confusion withdrawal & aggression

signs of abuse

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NEUROLOGICAL STATUS

Eyes (perrla)

Pupils equal, round,reacting to light andaccomodation

left & right

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Glasgow Coma Scale

The Glasgow Coma Scale or GCS, is aneurologicalscale

aims to give a reliable,

objective way of recording the consciousstate of a person,

for initial as well as continuing assessment.

http://en.wikipedia.org/wiki/Neurologyhttp://en.wikipedia.org/wiki/Scale_%28ratio%29http://en.wikipedia.org/wiki/Scale_%28ratio%29http://en.wikipedia.org/wiki/Neurology

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NEUROLOGICAL STATUS

LEVEL OF CONSCIOUSNESS (LOC)

A frequent tool in evaluating LOC is theGlasgow coma scale (GCS) . This scores apatients response to voice and deeppressure using eye opening and verbal and

motor responses .

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Glasgow Coma Scale

A patient is assessed against thecriteria of the scale,

and the resulting points give a patientscore between 3 (indicating deepunconsciousness)

and either 14 (original scale) or 15 (themore widely used modified or revisedscale).

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GLASGOW COMA SCALE

Glasgow coma scale = /15

Obeys commands (6)

Localizes pain (5)Withdraws to pain (4)

Flexion (abnormal) to pain (3)

Extension to pain (2)

none(1)

Orientated (5)Confused (4)

Inappropriate words (3)

Incomprehensible sounds (2)

None (1)

Spontaneously (4)To speech (3)

To pain (2)

None (1)

Best motor response*Best verbal responseEyes open

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NUTRITIONAL & ORAL

STATUS build & general nutritional state

state/well nourished

http://bp1.blogger.com/_iOvDqB8bJAo/RnMEgkTGogI/AAAAAAAAB3w/LCoazmAFgYA/s400/1.jpghttp://images.google.co.za/imgres?imgurl=http://img.thesun.co.uk/multimedia/archive/00335/F_200705_May28ed_im_335189a.jpg&imgrefurl=http://www.thesun.co.uk/sol/homepage/woman/health/fit_squad/article230984.ece&h=360&w=265&sz=10&hl=en&start=1&tbnid=IBzDKg95leF4rM:&tbnh=121&tbnw=89&prev=/images%3Fq%3Dbikini%2Bbody%26gbv%3D2%26hl%3Denhttp://bp1.blogger.com/_iOvDqB8bJAo/RnMEgkTGogI/AAAAAAAAB3w/LCoazmAFgYA/s400/1.jpg

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NUTRITIONAL & ORAL STATUS

mass: normal for age,overweight/underweight

appetite: good/poor food restriction: no/yes

http://images.google.co.za/imgres?imgurl=http://www.freeearth.com.au/images/photos/obesity_picture_small.jpg&imgrefurl=http://www.freeearth.com.au/content/210/obesity-and-syndrome-x--.html&h=480&w=432&sz=104&hl=en&start=1&um=1&tbnid=RAjmAtuLphnemM:&tbnh=129&tbnw=116&prev=/images%3Fq%3DOBESITY%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DN

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NUTRITIONAL & ORAL STATUS

fluid intake normal/restricted

ability to chew/swallow

http://images.google.co.za/imgres?imgurl=http://biology.clc.uc.edu/fankhauser/Labs/Microbiology/Strep_Detection/oropharynx_P2253089_lbd.JPG&imgrefurl=http://flutterby01.blogspot.com/2007/05/lets-take-quick-peek-at-my.html&h=600&w=800&sz=107&hl=en&start=1&tbnid=A2lAuQ9P-CS1uM:&tbnh=107&tbnw=143&prev=/images%3Fq%3DTHROAT%2BNORMAL%26gbv%3D2%26hl%3Den%26sa%3DGhttp://www.dochazenfield.com/images/Normal%20Tonsils%20Labeled.jpghttp://images.google.co.za/imgres?imgurl=http://www.veyonline.com/images/images%2520ag/06.jpg&imgrefurl=http://www.veyonline.com/waterfacts.htm&h=423&w=640&sz=34&hl=en&start=18&tbnid=Rcm6uaPaSgYXrM:&tbnh=91&tbnw=137&prev=/images%3Fq%3Dfluid%2Bbalance%26gbv%3D2%26hl%3Den

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NUTRITIONAL & ORAL

STATUS

ability to chew/swallow

LYMPH GLANDS

1. SUBMENTAL 2. SUBMANDIBULAR 3. PAROTID 4. PREAURICULAR 5. POSTAURICULAR 6. OCCIPITAL 7. ANTERIOR CERVICAL

8. SUPRACLAVICULAR 9. POSTERIOR CERVICAL

http://images.google.co.za/imgres?imgurl=http://www.healthofchildren.com/images/gech_0001_0003_0_img0171.jpg&imgrefurl=http://www.healthofchildren.com/L/Lymphadenitis.html&h=240&w=240&sz=40&hl=en&start=82&um=1&tbnid=FMe1CmNqr0ds4M:&tbnh=110&tbnw=110&prev=/images%3Fq%3Dthroat%2Bneck%2Bdiseases%26start%3D80%26ndsp%3D20%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://www.qub.ac.uk/cskills/Images/webnecknodes.jpg

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NUTRITIONAL & ORAL STATUS

condition of oral cavity

mucosa

mouth/lips

http://images.google.co.za/imgres?imgurl=http://www.healthofchildren.com/images/gech_0001_0001_0_img0048.jpg&imgrefurl=http://www.healthofchildren.com/C/Canker-Sores.html&h=157&w=238&sz=29&hl=en&start=4&tbnid=G1LSR8Plv0e0tM:&tbnh=72&tbnw=109&prev=/images%3Fq%3Dsore%2Blips%26gbv%3D2%26hl%3Denhttp://images.google.co.za/imgres?imgurl=http://depts.washington.edu/hivaids/images/oral/tnoral_c1_d02.jpg&imgrefurl=http://depts.washington.edu/hivaids/oral/case1/discussion.html&h=89&w=125&sz=7&hl=en&start=18&tbnid=Bgmdg41FPjAp_M:&tbnh=64&tbnw=90&prev=/images%3Fq%3Dthrush%2Bin%2Bbuccal%2Bmucosa%26gbv%3D2%26hl%3Denhttp://images.google.co.za/imgres?imgurl=http://img.tfd.com/mosby/thumbs/500051-fx4.jpg&imgrefurl=http://medical-dictionary.thefreedictionary.com/candidiasis&h=204&w=250&sz=11&hl=en&start=7&tbnid=pVJfqP9QQhFGuM:&tbnh=91&tbnw=111&prev=/images%3Fq%3Dthrush%2Bin%2Bbuccal%2Bmucosa%26gbv%3D2%26hl%3Denhttp://images.google.co.za/imgres?imgurl=http://images.jupiterimages.com/common/detail/60/19/22561960.jpg&imgrefurl=http://www.jupiterimages.com/itemDetail.aspx%3FitemID%3D22561960&h=166&w=250&sz=4&hl=en&start=1&tbnid=uPCKMjSNCH8PIM:&tbnh=74&tbnw=111&prev=/images%3Fq%3Dmouth%2Blips%26gbv%3D2%26hl%3Den%26sa%3DG

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NUTRITIONAL & ORAL STATUS

record dentures/crowns/bridges

teeth

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MOTOR ABILITY STATUS

current mobility: ambulant/nonambulant easy/difficult

movements: coordinated/uncoordinated

prosthesis no/yes

http://images.google.co.za/imgres?imgurl=http://www.wcbl.com/images2/C-LegProsthesis.jpg&imgrefurl=http://www.wcbl.com/services/prosthetics-lowerextremity.asp&h=1644&w=1059&sz=453&hl=en&start=8&um=1&tbnid=Ke_abZuqxHetXM:&tbnh=150&tbnw=97&prev=/images%3Fq%3Dprosthesis%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DG

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STATUS OF PHYSICAL REST &

COMFORT sleep & rest pattern: good/poor

substances: unnecessary/required

painabsent/present

http://images.google.co.za/imgres?imgurl=http://www.zimfamilycockers.com/LilLadyInBed.jpg&imgrefurl=http://www.zimfamilycockers.com/FAQ.html&h=300&w=306&sz=17&hl=en&start=55&tbnid=c1-65YZytmn4oM:&tbnh=115&tbnw=117&prev=/images%3Fq%3Dperson%2Bsleeping%2Bin%2Bbed%26start%3D40%26gbv%3D2%26ndsp%3D20%26hl%3Den%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://i2.photobucket.com/albums/y20/FatBeGoneStacy/Basha%2520Journal/sleeping3.jpg&imgrefurl=http://journals.aol.com/bashamomma/oHnOshEdidnTwooFwooF/entries/2007/06/22/do-your-dogs-sleep-in-bed-with-you/372&h=392&w=450&sz=34&hl=en&start=52&tbnid=DTG3V2tK-6wrgM:&tbnh=111&tbnw=127&prev=/images%3Fq%3Dperson%2Bsleeping%2Bin%2Bbed%26start%3D40%26gbv%3D2%26ndsp%3D20%26hl%3Den%26sa%3DNhttp://en.wikipedia.org/wiki/Image:Wong_pain_scale.jpg

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ELIMINATION STATUS

bowel habits: regular/ changed incontinent: faeces no/yes

medication needed: no/yes

http://images.google.co.za/imgres?imgurl=http://www.natural-herbal-remedies.net/images/constipation1.jpg&imgrefurl=http://www.natural-herbal-remedies.net/home-remedy-for-constipation.html&h=120&w=101&sz=5&hl=en&start=5&tbnid=b_95bz2rIRULLM:&tbnh=88&tbnw=74&prev=/images%3Fq%3Dconstipation%2Bremedies%26gbv%3D2%26hl%3Denhttp://images.google.co.za/imgres?imgurl=http://www.constipationadvice.co.uk/images/constipation_treatment_bulk.jpg&imgrefurl=http://www.constipationadvice.co.uk/treating_constipation/constipation_remedies.php&h=199&w=250&sz=11&hl=en&start=3&tbnid=Od5uLd7bgZkJsM:&tbnh=88&tbnw=111&prev=/images%3Fq%3Dconstipation%2Bremedies%26gbv%3D2%26hl%3Den

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ELIMINATION STATUS

stoma: no/yes

haemorrhoids

http://www.lisp.com.au/~merinda/images/stoma2.jpghttp://www.riversideonline.com/source/images/image_popup/r7_hemorrhoids.jpghttp://images.google.co.za/imgres?imgurl=http://www.hemroids-treatment.com/prolapsed_hemorrhoids.jpg&imgrefurl=http://www.hemroids-treatment.com/hemroid_pictures.htm&h=400&w=600&sz=19&hl=en&start=41&tbnid=z6ojr1OHcIjOCM:&tbnh=90&tbnw=135&prev=/images%3Fq%3Dhemorrhoids%26start%3D40%26gbv%3D2%26ndsp%3D20%26hl%3Den%26sa%3DN

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ELIMINATION STATUS

micturition: normal/abnormal urinary output: normal/abnormal incontinent: urine no/yes urinary stoma

http://images.google.co.za/imgres?imgurl=http://www.ostomy-medical-supplies.com/Normal%2520Skin%2520Around%2520Ostomy%2520Stoma.jpg&imgrefurl=http://www.ostomy-medical-supplies.com/Glossary.html&h=221&w=299&sz=15&hl=en&start=8&tbnid=3hT1PPoP1zUHEM:&tbnh=86&tbnw=116&prev=/images%3Fq%3Durinary%2Bstoma%26gbv%3D2%26hl%3Denhttp://images.google.co.za/imgres?imgurl=http://www.clevelandclinic.org/health/health-info/Pictures/ileal%2520conduit%2520urinry%2520diversion.GIF&imgrefurl=http://www.clevelandclinic.org/health/health-info/docs/3900/3927.asp%3Findex%3D12546%26src%3Dnews&h=235&w=200&sz=12&hl=en&start=13&tbnid=fMdggoFKAUSdSM:&tbnh=109&tbnw=93&prev=/images%3Fq%3Durinary%2Bstoma%26gbv%3D2%26hl%3Denhttp://www.ncnm.ie/isccna/images/Urostomy.jpghttp://images.google.co.za/imgres?imgurl=http://www.menshealth.com.my/images/Cartoon_Page_1.jpg&imgrefurl=http://www.menshealth.com.my/prostate_0.htm&h=229&w=150&sz=135&hl=en&start=2&tbnid=sRcxuxh5PuGnNM:&tbnh=108&tbnw=71&prev=/images%3Fq%3Durine%2Bstream%2Bcartoon%26gbv%3D2%26hl%3Den%26sa%3DG

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REPRODUCTIVE SYSTEM: Male

urinary streamcontinuous/broken

past STI: no/yes

current symptoms: no/yes

http://images.google.co.za/imgres?imgurl=http://www.menshealth.com.my/images/Cartoon_Page_1.jpg&imgrefurl=http://www.menshealth.com.my/prostate_0.htm&h=229&w=150&sz=135&hl=en&start=2&tbnid=sRcxuxh5PuGnNM:&tbnh=108&tbnw=71&prev=/images%3Fq%3Durine%2Bstream%2Bcartoon%26gbv%3D2%26hl%3Den%26sa%3DGhttp://images.google.co.za/imgres?imgurl=http://bp2.blogger.com/_H-vDYxJNOxk/Rv9fsOv5KtI/AAAAAAAAAOI/Stn64IUY8vQ/s400/AIDS_ribbon4.jpg&imgrefurl=http://sukhsandhu.blogspot.com/2007/09/what-is-std-or-sti.html&h=400&w=284&sz=13&hl=en&start=34&tbnid=E-Rjt3tUluac4M:&tbnh=124&tbnw=88&prev=/images%3Fq%3DSTD%2BSTI%26start%3D20%26gbv%3D2%26ndsp%3D20%26hl%3Den%26sa%3DNhttp://www.phac-aspc.gc.ca/publicat/std-mts/gfx/sti_e.jpghttp://islandsexualhealth.org/images/31.jpghttp://images.google.co.za/imgres?imgurl=http://www.menshealth.com.my/images/Cartoon_Page_1.jpg&imgrefurl=http://www.menshealth.com.my/prostate_0.htm&h=229&w=150&sz=135&hl=en&start=2&tbnid=sRcxuxh5PuGnNM:&tbnh=108&tbnw=71&prev=/images%3Fq%3Durine%2Bstream%2Bcartoon%26gbv%3D2%26hl%3Den%26sa%3DG

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REPRODUCTIVE SYSTEM: FEMALE

breasts: present/absent

menstrual cycle: regularabsent/irregular

contraceptive use: no/yes/method

http://images.google.co.za/imgres?imgurl=http://perso.orange.fr/pharma.rocheville/Images/contraception.jpg&imgrefurl=http://piginthekitchen.blogspot.com/2007_10_01_archive.html&h=372&w=353&sz=56&hl=en&start=5&tbnid=uF3-FcH-N5mxLM:&tbnh=122&tbnw=116&prev=/images%3Fq%3Dcontraception%26gbv%3D2%26hl%3Den%26sa%3DGhttp://images.google.co.za/imgres?imgurl=http://www.dancewithshadows.com/society/images/contraception.jpg&imgrefurl=http://www.dancewithshadows.com/society/understanding-contraception.asp&h=301&w=375&sz=29&hl=en&start=2&tbnid=6LW8s_k_PfuRwM:&tbnh=98&tbnw=122&prev=/images%3Fq%3Dcontraception%26gbv%3D2%26hl%3Den%26sa%3DG

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REPRODUCTIVE SYSTEM: Female

pregnant: no/yes/gestation

past STI: no/yes

current symptoms STI

STI sexually transmitted infections

http://www.phac-aspc.gc.ca/publicat/std-mts/gfx/sti_e.jpghttp://images.google.co.za/imgres?imgurl=http://bp2.blogger.com/_H-vDYxJNOxk/Rv9fsOv5KtI/AAAAAAAAAOI/Stn64IUY8vQ/s400/AIDS_ribbon4.jpg&imgrefurl=http://sukhsandhu.blogspot.com/2007/09/what-is-std-or-sti.html&h=400&w=284&sz=13&hl=en&start=34&tbnid=E-Rjt3tUluac4M:&tbnh=124&tbnw=88&prev=/images%3Fq%3DSTD%2BSTI%26start%3D20%26gbv%3D2%26ndsp%3D20%26hl%3Den%26sa%3DNhttp://www.ci.austin.tx.us/health/smartmoms/images/carmen-left.jpg

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SELF EXAMINATION OF THE

BREAST

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BREAST EXAMINATION:CHANGES

http://www.breastselfexam.ca/section5slide3.htmlhttp://www.breastselfexam.ca/section5slide1.html

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PHYSIOLOGICAL STATUS

respiratory statuschest shape: normal/abnormal

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PHYSIOLOGICAL STATUS

character of respiration

regular/irregular easy some difficulty

cough: absent/present

Tracheostomy: no/yes

http://images.google.co.za/imgres?imgurl=http://newsimg.bbc.co.uk/media/images/44018000/jpg/_44018386_oxygengrab203.jpg&imgrefurl=http://news.bbc.co.uk/1/hi/england/cornwall/6914253.stm&h=152&w=203&sz=14&hl=en&start=1&tbnid=HGgbpdabQbOR5M:&tbnh=79&tbnw=105&prev=/images%3Fq%3Dpatient%2Bon%2Boxygen%26gbv%3D2%26hl%3Den%26sa%3DGhttp://www.persiflage.ca/archives/coughing.jpghttp://images.google.co.za/imgres?imgurl=http://www.jansenmedical.net/files/images/small/t_5270.jpg&imgrefurl=http://www.jansenmedical.net/Dale-240-Blue-Tracheostomy-Tube-Holder-pr-5270.html&h=229&w=250&sz=34&hl=en&start=12&tbnid=75J3FXrcz58sxM:&tbnh=102&tbnw=111&prev=/images%3Fq%3Dtracheostomy%26gbv%3D2%26hl%3Den%26sa%3DG

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PHYSIOLOGICAL STATUS

circulatory status

perfusion adequate/poor

pulses: all extremities: present/ absent

rhythm regular/irregular volume: strong/weak

extremities: warm/cold L R

Pacemaker no/yes

http://uk.gizmodo.com/pacemaker.jpghttp://images.google.co.za/imgres?imgurl=http://www.rcsed.ac.uk/eselect/images/cc9_11_1.jpg&imgrefurl=http://www.rcsed.ac.uk/eselect/cc9.htm&h=286&w=440&sz=10&hl=en&start=20&tbnid=g1RaS2wfqD0cPM:&tbnh=83&tbnw=127&prev=/images%3Fq%3Dpoor%2Btissue%2Bperfusion%26gbv%3D2%26hl%3Den

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PHYSIOLOGICAL STATUS

oedema: no/yes

fluid balance status

skin turgidity normal/ loss of turgidity hydration: adequate/ inadequate

http://www.uihealthcare.com/topics/medicaldepartments/pediatrics/bonemarrowtransplant/images/31.gifhttp://images.google.co.za/imgres?imgurl=http://www.veyonline.com/images/images%2520ag/06.jpg&imgrefurl=http://www.veyonline.com/waterfacts.htm&h=423&w=640&sz=34&hl=en&start=18&tbnid=Rcm6uaPaSgYXrM:&tbnh=91&tbnw=137&prev=/images%3Fq%3Dfluid%2Bbalance%26gbv%3D2%26hl%3Denhttp://images.google.co.za/imgres?imgurl=http://www.activahealthcare.co.uk/images/conditions/dependency.jpg&imgrefurl=http://www.activahealthcare.co.uk/conditions.php%3Fq%3DChronic_Oedema&h=217&w=250&sz=17&hl=en&start=1&tbnid=DKFDo4mghmZBxM:&tbnh=96&tbnw=111&prev=/images%3Fq%3Dleg%2Boedema%26gbv%3D2%26hl%3Den

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PHYSIOLOGICAL STATUS

skin turgidity normal/ loss of turgidity

hydration: adequate/ inadequate

http://medinfo.ufl.edu/year2/mmid/bms5300/images/a2.jpghttp://staff.vbi.vt.edu/pathport/pathinfo_images/Vibrio_cholerae/vc_dehydration.JPG

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STATUS OF SKIN & APPENDAGES

skin integrity: intact/ brokenareas/lesions/wounds

http://www.itim.nsw.gov.au/images/2_Stab_wounds.jpghttp://images.google.co.za/imgres?imgurl=http://www.unchealthcare.org/site/woundmanagement/images/DM990730.JPG&imgrefurl=http://www.unchealthcare.org/site/woundmanagement/nonhealingwounds&h=340&w=340&sz=23&hl=en&start=18&um=1&tbnid=fVUx7fqru9QMxM:&tbnh=119&tbnw=119&prev=/images%3Fq%3Dwounds%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DN

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STATUS OF SKIN & APPENDAGES

pressure sores: no/yes

http://www.manukahoneyusa.com/images/pressure-sore-on-buttock.jpghttp://images.google.co.za/imgres?imgurl=http://www.theberries.ns.ca/Archives/2006Winter/images/neuropathic_ulcer.jpg&imgrefurl=http://answers.yahoo.com/question/index%3Fqid%3D20080102172939AAQuFiR%26show%3D7&h=440&w=338&sz=47&hl=en&start=7&tbnid=F87l__Zlh4OC1M:&tbnh=127&tbnw=98&prev=/images%3Fq%3Dpressure%2Bsores%26gbv%3D2%26hl%3Denhttp://images.google.co.za/imgres?imgurl=http://library.med.utah.edu/kw/derm/mml/22320032.jpg&imgrefurl=http://answers.yahoo.com/question/index%3Fqid%3D20080102172939AAQuFiR%26show%3D7&h=344&w=500&sz=40&hl=en&start=3&tbnid=UwEbhJjSvHFtJM:&tbnh=89&tbnw=130&prev=/images%3Fq%3Dpressure%2Bsores%26gbv%3D2%26hl%3Den

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STATUS OF SKIN & APPENDAGES

scars: no/yes

bruises:no/yes

http://farm2.static.flickr.com/1407/1464680893_9fe363ef83.jpghttp://images.google.co.za/imgres?imgurl=http://rpolk.com/BobMediaPages/GoldwingPage/GoldwingPics/Bruises.jpg&imgrefurl=http://rpolk.com/BobMediaPages/GoldwingPage/Goldwing.htm&h=600&w=800&sz=46&hl=en&start=1&tbnid=yEcqCLJ1aRk4IM:&tbnh=107&tbnw=143&prev=/images%3Fq%3Dbruises%26gbv%3D2%26hl%3Den%26sa%3DGhttp://www.safe-nz.org.nz/Image/joanhicks1.jpghttp://images.google.co.za/imgres?imgurl=http://www.medwatchtoday.com/Images/MT.Nieto-Shows-Scars.jpg&imgrefurl=http://www.medwatchtoday.com/826.htm&h=432&w=287&sz=23&hl=en&start=32&tbnid=7lPOmj2lsnuuFM:&tbnh=126&tbnw=84&prev=/images%3Fq%3Dscars%26start%3D20%26gbv%3D2%26ndsp%3D20%26hl%3Den%26sa%3DNhttp://tobacco.health.usyd.edu.au/site/supersite/resources/images/scars.jpg

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STATUS OF SKIN & APPENDAGES

rash:no/yes

http://images.google.co.za/imgres?imgurl=http://www.davita.com/UploadedImages/SkinProblems.gif&imgrefurl=http://www.davita.com/dialysis/complications/a/522&h=200&w=200&sz=8&hl=en&start=17&tbnid=KsAAXYUVuX8X9M:&tbnh=104&tbnw=104&prev=/images%3Fq%3Dskin%2Bconditions%26gbv%3D2%26hl%3Den%26sa%3DGhttp://images.google.co.za/imgres?imgurl=http://www.davita.com/UploadedImages/SkinProblems.gif&imgrefurl=http://www.davita.com/dialysis/complications/a/522&h=200&w=200&sz=8&hl=en&start=17&tbnid=KsAAXYUVuX8X9M:&tbnh=104&tbnw=104&prev=/images%3Fq%3Dskin%2Bconditions%26gbv%3D2%26hl%3Den%26sa%3DGhttp://images.google.co.za/imgres?imgurl=http://www.childhoodhealth.com/images/varicella_large.jpg&imgrefurl=http://www.childhoodhealth.com/health-information/diseases-and-symptoms/chicken-pox-varicella&h=434&w=590&sz=20&hl=en&start=12&um=1&tbnid=Rd-BnXJ5xpxxpM:&tbnh=99&tbnw=135&prev=/images%3Fq%3Dskin%2Brashes%2Bchickenpox%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DGhttp://images.google.co.za/imgres?imgurl=http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19687.jpg&imgrefurl=http://www.nlm.nih.gov/medlineplus/ency/imagepages/19687.htm&h=320&w=400&sz=14&hl=en&start=6&tbnid=vMPH_z70Obd9fM:&tbnh=99&tbnw=124&prev=/images%3Fq%3Dskin%2Bconditions%2B%2Bshingles%26gbv%3D2%26hl%3Denhttp://images.google.co.za/imgres?imgurl=http://srs.dl.ac.uk/Annual_Reports/AnRep99_00/Meningitis_Figure_1.jpg&imgrefurl=http://srs.dl.ac.uk/Annual_Reports/AnRep99_00/meningitis.htm&h=759&w=1152&sz=78&hl=en&start=1&um=1&tbnid=gb8WOnUcPFbfzM:&tbnh=99&tbnw=150&prev=/images%3Fq%3Dskin%2Brashes%2Bmeningococcal%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DG

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STATUS OF SKIN & APPENDAGES

skin feels: warm/cold

skin colour: normal/abnormal

http://www.coalitionforpf.org/images/clubbing.jpghttp://images.google.co.za/imgres?imgurl=http://www.cprflorida.net/images/sfrostbite2.jpg&imgrefurl=http://www.cprflorida.net/cprreview.html&h=268&w=300&sz=9&hl=en&start=6&tbnid=ZynTBntmnlJQGM:&tbnh=104&tbnw=116&prev=/images%3Fq%3Dcold%2Bskin%26gbv%3D2%26hl%3Den%26sa%3DG

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STATUS OF SKIN & APPENDAGES

hair texture,

parasites

http://www.weaddhair.com/images/chemotherapy-prothesis-utah.gifhttp://images.google.co.za/imgres?imgurl=http://www.trevorsorbie.com/template_images/fe4ce1ae47725fd0f25509c5946ca6b7_1%2520-%2520Before..jpg&imgrefurl=http://www.trevorsorbie.com/templates/tmpl_wighead.php%3Ftemplateid%3D9%26pageid%3D167&h=188&w=334&sz=13&hl=en&start=9&um=1&tbnid=6dKrA3ofnL6lcM:&tbnh=67&tbnw=119&prev=/images%3Fq%3Dchemotherapy%2Bhair%2Bloss%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231http://www.co.lucas.oh.us/health/images/lice1b.jpghttp://images.google.co.za/imgres?imgurl=http://www.sacimdokuluyor.com/images/other/baldness.jpg&imgrefurl=http://www.sacimdokuluyor.com/html_page.php%3Fpage%3Dhair_removal_cause%26lang%3Den&h=355&w=323&sz=17&hl=en&start=19&um=1&tbnid=Uus8l56IlqRnUM:&tbnh=121&tbnw=110&prev=/images%3Fq%3Dbaldness%2Balopecia%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DGhttp://images.google.co.za/imgres?imgurl=http://futurederm.files.wordpress.com/2007/11/110907-beautiful-hair.gif&imgrefurl=http://laura.moncur.org/&h=332&w=447&sz=80&hl=en&start=26&um=1&tbnid=DpsUhdWg31sR5M:&tbnh=94&tbnw=127&prev=/images%3Fq%3Dbeautiful%2Bclean%2Bshiny%2Bhair%26start%3D20%26ndsp%3D20%26um%3D1%26hl%3Den%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://www.pg.com/science/haircare/hair_twh_127/hair_127_03.jpg&imgrefurl=http://www.pg.com/science/haircare/hair_twh_114.htm&h=220&w=303&sz=8&hl=en&start=3&um=1&tbnid=bty6Co2Iu0bjGM:&tbnh=84&tbnw=116&prev=/images%3Fq%3Dbaldness%2Bdandruff%2Bringworm%2Bof%2Bscalp%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DG

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STATUS OF SKIN & APPENDAGES

Arms/hands

http://images.google.co.za/imgres?imgurl=http://www.sclero.org/medical/symptoms/photos/ulcers/digital/jeanne-n/01-photo-finger-ulcer-100px.jpg&imgrefurl=http://www.sclero.org/medical/symptoms/photos/a-to-z.html&h=115&w=100&sz=3&hl=en&start=1&um=1&tbnid=02f1JwUFYVhDHM:&tbnh=87&tbnw=76&prev=/images%3Fq%3Dfinger%2Bdiseases%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://www.lib.uiowa.edu/hardin/md/pictures22/dermnet/64_finger_clubbing_01.jpg&imgrefurl=http://www.lib.uiowa.edu/hardin/md/dermnet/nails10.html&h=341&w=512&sz=26&hl=en&start=3&um=1&tbnid=kLBAt25JKN2XkM:&tbnh=87&tbnw=131&prev=/images%3Fq%3Dfinger%2Bdiseases%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://medicineworld.org/images/blogs/10-2006/osteoarthritis-late-6180.jpg&imgrefurl=http://medicineworld.org/news/news-archives/rheumatology-news/June-20-2007.html&h=306&w=340&sz=13&hl=en&start=7&um=1&tbnid=QSBpXm0eQoYG5M:&tbnh=107&tbnw=119&prev=/images%3Fq%3Dfinger%2Bdiseases%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://www.vascularweb.org/graphics/northpoint_graphics_jpg/ArmArtDisease_02_Base_275.jpg&imgrefurl=http://www.vascularweb.org/patients/NorthPoint/Arm_Artery_Disease.html&h=345&w=275&sz=70&hl=en&start=2&um=1&tbnid=pnvroT_mcJsDpM:&tbnh=120&tbnw=96&prev=/images%3Fq%3Darm%2Bhand%2Bdiseases%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DN

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STATUS OF SKIN & APPENDAGES

Legs/feet

http://images.google.co.za/imgres?imgurl=http://www.ghi.com/WebMD/topics/fracture.jpg&imgrefurl=http://www.ghi.com/topic.aspx%3Fpage%3D276&h=328&w=280&sz=19&hl=en&start=1&um=1&tbnid=hn3CLO3VQcrpTM:&tbnh=118&tbnw=101&prev=/images%3Fq%3Dfractures%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://www8.georgetown.edu/dml/facs/graphics/images/Basic%2520Hip%2520Fractures.jpg&imgrefurl=http://www8.georgetown.edu/dml/facs/graphics/gallery.htm&h=405&w=450&sz=26&hl=en&start=20&um=1&tbnid=55mmSXbyucCP4M:&tbnh=114&tbnw=127&prev=/images%3Fq%3Dfractures%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://www.scholl.co.il/art_images/catalog/87/athletes-foot_03.jpg&imgrefurl=http://ez002.k12.sd.us/Chapter%2520Seven%2520Science.htm&h=183&w=250&sz=9&hl=en&start=5&um=1&tbnid=dFopbbH9KufHLM:&tbnh=81&tbnw=111&prev=/images%3Fq%3Dathletes%2Bfoot%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DGhttp://images.google.co.za/imgres?imgurl=http://www.activahealthcare.co.uk/images/conditions/dependency.jpg&imgrefurl=http://www.activahealthcare.co.uk/content/conditions/oedema.html&h=217&w=250&sz=17&hl=en&start=3&um=1&tbnid=DKFDo4mghmZBxM:&tbnh=96&tbnw=111&prev=/images%3Fq%3Doedema%2Bof%2Blegs%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DGhttp://images.google.co.za/imgres?imgurl=http://www.myfootshop.com/images/medical/pvd/PAD_mod.jpg&imgrefurl=http://www.myfootshop.com/xq/ASP/Method.Condition/Value.Peripheral%2520Vascular%2520Disease/qx/searchresults.htm&h=321&w=422&sz=44&hl=en&start=19&um=1&tbnid=CZnNq2Z2v94cmM:&tbnh=96&tbnw=126&prev=/images%3Fq%3Dleg%2Bdiseases%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://www.smh.com.au/ffximage/2006/01/11/meningococcal_narrowweb__300x452,0.jpg&imgrefurl=http://www.smh.com.au/news/health/early-signs-hold-key-to-fatal-disease/2006/01/11/1136956243002.html&h=452&w=300&sz=15&hl=en&start=17&um=1&tbnid=eMA4aZZjZImzQM:&tbnh=127&tbnw=84&prev=/images%3Fq%3Dleg%2Bdiseases%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DNhttp://images.google.co.za/imgres?imgurl=http://www.myfootshop.com/images/medical/pvd/gangrene5_mod.jpg&imgrefurl=http://www.myfootshop.com/xq/ASP/Method.Condition/Value.Peripheral%2520Vascular%2520Disease/qx/searchresults.htm&h=267&w=333&sz=21&hl=en&start=8&um=1&tbnid=jhu71sA1qxtf4M:&tbnh=95&tbnw=119&prev=/images%3Fq%3Dleg%2Bdiseases%26um%3D1%26hl%3Den%26rlz%3D1T4ADBR_enZA223ZA231%26sa%3DN

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GENERAL EXAMINATION

2nd YEAR NURSE cardiovascular

system

respiratory system

lower limbs

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BIBLIOGRAPHY

Uys.L.R.Ed.1999.Fundamental Nursing. Pinelands:

Maskew Miller Longman

Young,A.Ed.2003.Jutas Manual of Nursing.

Lansdowne:Juta & Co.

http://images.google.co.za/images

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