NURS3320 Assessment Final Review
What are some signs and symptoms of vitamin C deficiency?
Petechiae or ecchymoses Sore that will not heal Soft, spongy, bleeding gums
What causes small testes?
SMALL TESTES Small (less than 3.5 cm long), soft testes indicate atrophy. Atrophy may result from cirrhosis, hypopituitarism, estrogen administration, extended illness, or the disorder may occur after orchitis. Small (less than 2 cm long), firm testes may indicate Klinefelter's syndrome.
Describe assessment of male reproductive system.
-Inspect the base of the penis and pubic hair. Sit on a stool with the client facing you and standing. Ask the client to raise his gown or drape. Note pubic hair growth pattern and any excoriation, erythema, or infestation at the base of the penis and within the pubic hair. -Inspect the skin of the shaft. Observe for rashes, lesions, or lumps. -Palpate the shaft. Palpate any abnormalities noted during inspection. Also note any hardened or tender areas. -Note the location of the urinary meatus on the glans. -Palpate for urethral discharge. Gently squeeze the glans between your index finger and thumb -Inspect the size, shape, and position of the scrotum. Ask the client to hold his penis out of the way. Observe for swelling, lumps, or bulges. -Inspect the scrotal skin. Observe color, integrity, and lesions or rashes. To perform an accurate inspection, you must spread out the scrotal folds (rugae) of skin. Lift the scrotal sac to inspect the posterior skin. -Palpate the scrotal contents. Palpate each testis and epididymis between your thumb and first two fingers. Note size, shape, consistency, nodules, masses and tenderness. -Palpate each spermatic cord and vas deferens from the epididymis to the inguinal ring. The spermatic cord will lie between your thumb and finger. Note any nodules, swelling, or tenderness. -Inspect for inguinal and femoral hernia. Inspect the inguinal and femoral areas for bulges. Ask the client to turn head and cough or to bear down as if having a bowel movement, and continue to inspect the areas. -Palpate for inguinal hernia and inguinal nodes. Ask the client to shift his weight to the left for palpation of the right inguinal canal and vice versa. Place your right index finger into the client's right scrotum and press upward, invaginating the loose folds of skin. Palpate up the spermatic cord until you reach the triangular-shaped, slit-like opening of the external inguinal ring. Try to push your finger through the opening and, if possible, continue palpating up the inguinal canal. When your finger is in the canal or at the external inguinal ring, ask the client to bear down or cough. Feel for any bulges against your finger. Then, repeat the procedure on the opposite side. -Palpate for femoral hernia. Palpate on the front of the thigh in the femoral canal area. Ask the client to bear down or cough. Feel for bulges. Repeat on the opposite thigh. -Inspect the perianal area. Spread the client's buttocks and inspect the anal opening and surrounding area (Fig. 26-15) for the following: Lumps, Ulcers, Lesions, Rashes, Redness, Fissures, Thickening of the epithelium -Ask the client to perform Valsalva's maneuver by straining or bearing down. Inspect the anal opening for any bulges or lesions. -Palpate the anus. Inform the client that you are going to perform the internal examination at this point. Explain that it may feel like his bowels are going to move but that this will not happen. Lubricate your gloved index finger; ask the client to bear down. As the client bears down, place the pad of your index finger on the anal opening and apply slight pressure; this will cause relaxation of the sphincter. -When you feel the sphincter relax, insert your finger gently with the pad facing down -Palpate the rectum. Insert your finger further into the rectum as far as possible (Fig. 26-18). Next, turn your hand clockwise then counterclockwise. This allows palpation of as much rectal surface as possible. Note tenderness, irregularities, nodules, and hardness -The prostate can be palpated on the anterior surface of the rectum by turning the hand fully counterclockwise so that the pad of your index finger faces toward the client's umbilicus -Tell the client that he may feel an urge to urinate but that he will not. Move the pad of your index finger over the prostate gland, trying to feel the sulcus between the lateral lobes. Note the size, shape, and consistency of the prostate, and identify any nodules or tenderness. -Inspect the stool. Withdraw your gloved finger. Inspect any fecal matter on your glove. Assess the color, and test the feces for occult blood. Provide the client with a towel to wipe the anorectal area.
What's an easy method of identifying a client's intake?
24-hour food recall
What would be a normal capillary refill finding? Why is that important?
<2 seconds per finger or toe When blood is not returning as quickly as expected, it may indicate vasoconstriction, decreased cardiac output, shock, arterial occlusion, or hypothermia.
What is a black, hairy tongue indicative of?
A black tongue indicative of bismuth (Pepto-Bismol) toxicity: black, hairy tongue. Could point to tobacco use as well.
What is a torus palatius?
A bony protuberance in the midline of the hard palate, called a torus palatinus, is a normal variation seen more often in females, Eskimos, Native Americans, and Asians
What is a focused assessment?
A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.
Why would someone have a small tongue?
A very small tongue suggests malnutrition.
CN VI
Abducens; Motor -Have patient look side to side.
What is neuropathic pain?
Abnormal processing of pain messages as a result of past damage to peripheral or central nerves due to sustained neurochemical levels, but exact mechanisms for the perception of neuropathic pain are unclear
What are some signs and symptoms of menopause?
About 60% of menopausal women experience hot flashes and night sweats. Mood swings, decreased appetite, vaginal dryness, spotting, and irregular vaginal bleeding may also occur. In older women, the cervix appears pale after menopause
What is accommodation and how do you test for it?
Accommodation is a functional reflex allowing the eyes to focus on near objects. Accommodation occurs when the client moves his or her focus of vision from a distant point to a near object, causing the pupils to constrict. Hold your finger or a pencil about 12 to 15 inches from the client. Ask the client to focus on your finger or pencil and to remain focused on it as you move it closer in toward the eyes. The normal pupillary response is constriction of the pupils and convergence of the eyes when focusing on a near object (accommodation and convergence).
CN VIII
Acoustic, Vestibulocochlear; Motor -Test hearing with Whisper, Weber, and Rinne tests.
Breath odor associated with kidney disease
Ammonia breath
Why would someone have longitudinal fissures on their tongue?
Among possible abnormalities are deep longitudinal fissures seen in dehydration.
Why would someone's tongue be atrophied?
An atrophied tongue or fasciculations point to cranial nerve (hypoglossal, CN 12) damage.
What is an emergency assessment?
An emergency assessment is a very rapid assessment performed in life-threatening situations. In such situations (choking, cardiac arrest, drowning), an immediate assessment is needed to provide prompt treatment. An example of an emergency assessment is the evaluation of the client's airway, breathing, and circulation (known as the ABCs) when cardiac arrest is suspected.
Why would someone have an enlarged tongue?
An enlarged tongue suggests hypothyroidism, acromegaly, or Down's syndrome, and angioneurotic edema of anaphylaxis.
What is a comprehensive assessment?
An initial comprehensive assessment involves collection of subjective data about the client's perception of his or her health, past health history, family history, and lifestyle and health practices (which includes information related to the client's overall function) as well as objective data gathered during a step-by-step physical examination. It serves as a baseline of data on a patient.
How do you assess for egophony?
Ask the client to repeat the letter "E" while you listen over the chest wall. Normal: Voice transmission will be soft and muffled but the letter "E" should be distinguishable.
What is pulse pressure?
Assess the pulse pressure, which is the difference between the systolic and diastolic blood pressure levels. Record findings in mmHg. For example, if the blood pressure was 120/80, then the pulse pressure would be 120 minus 80 or 40 mmHg. A pulse pressure lower than 30 mmHg or higher than 50 mmHg may indicate cardiovascular disease.
What is the first step in the nursing process? Why is it critical to the rest of the process?
Assessment is the first and most critical step of the nursing process, and accuracy of assessment data affects all other phases of the nursing process.
What are the ABC's of Melanoma?
Asymmetry, Borders, Color, Diameter, Elevated Malignant melanoma can be deadly if not discovered and treated early, which is one reason why professional health assessment and skin self-assessment can be life-saving procedures. Malignant melanoma is usually evaluated according to the mnemonic ABCDE: A for asymmetrical; B for borders that are irregular (uneven or notched); C for color variations; D for diameter exceeding 1/8 to 1/4 of an inch; and E for elevated, not flat. Danger signs of malignant melanoma include any of these factors. However, smaller areas may indicate early-stage melanomas. Other warning signs include itching, tenderness, or pain, and a change in size or bleeding of a mole. New pigmentations are also warning signs.
What are some signs and symptoms of vitamin B12 deficiency?
Beefy, red tongue Altered mental status Paresthesia
Christianity
Beliefs focus around the Old and New Testaments of the Bible and view Jesus Christ as the Savior. Prayers may be directed to one or all of the Holy Trinity (God, Holy Spirit, and Jesus Christ). Most view illness as a natural process for the body and even as a testing of faith. There is belief in miracles, especially through prayer. Western medicine is usually held in high regard. Memorial services rather than funerals and cremation rather than burial are more common in Christian religions than in other sects. No special or universal food beliefs are common to Christian religions.
Describe assessment of kidney tenderness.
Blunt percussion is used to detect tenderness over organs (e.g., kidneys) by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface. (blunt percussion over posterior back. The kidneys are located high and deep under the diaphragm. Additionally, kidney tenderness can be assessed at the costovertebral angle. The right kidney is positioned slightly lower because of the position of the liver. Therefore, in some thin clients, the bottom portion of the right kidney may be palpated anteriorly.
What are the signs and symptoms of glans penis cancer?
CANCER OF THE GLANS PENIS Appears as hardened nodule or ulcer on the glans. Painless. Occurs primarily in uncircumcised men.
What is cryptorchidism in males?
CRYPTORCHIDISM Failure of one or both testicles to descend into scrotum. Scrotum appears undeveloped and testis cannot be palpated. Causes increased risk of testicular cancer. It is typical to surgically correct as an infant.
How can you identify a cyst?
CYST Encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis. Examples include sebaceous cyst and epidermoid cyst.
What is the function of the peripheral nervous system?
Carrying information to and from the CNS, the peripheral nervous system consists of 12 pairs of cranial nerves and 31 pairs of spinal nerves. The somatic nervous system mediates conscious, or voluntary, activities; the autonomic nervous system mediates unconscious, or involuntary, activities.
Which patients are at risk for over hydration or fluid volume excess?
Clients at risk for overhydration or fluid retention are those with kidney, liver, and cardiac diseases in which the fluid dynamic mechanisms are impaired. Seriously ill clients who are on humidified ventilation or who are receiving large volumes of parenteral fluids without close monitoring of their hydration status are also at risk.
What are the signs of arterial insufficiency?
Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, especially over the lower legs, are associated with arterial insufficiency.
What is consensual response and how do you test for it?
Consensual response happens when exposure to light in one eye results in constriction of the pupil in the opposite eye To test consensual response, shine a light obliquely into one eye and observe the pupillary reaction in the opposite eye.
Equipment needed for Neurologic Examination
Cotton tipped applicators, newspaper, Ophthalmoscope, flexible tape, common small object like key or coin, reflex hammer, cotton ball, paper clip, substances to smell and taste, Snellen E chart, pen light, tongue depressor, and tuning fork.
How do you assess for crepitus?
Crepitus, also called subcutaneous emphysema, is a crackling sensation (like bones or hairs rubbing against each other) that occurs when air passes through fluid or exudate. Use your fingers and follow the sequence in when palpating. Use your fingers to palpate for tenderness, warmth, pain, or other sensations. Start toward the midline at the level of the left scapula (over the apex of the left lung) and move your hand left to right, comparing findings bilaterally. Move systematically downward and out to cover the lateral portions of the lungs at the bases. Crepitus can be palpated if air escapes from the lung or other airways into the subcutaneous tissue, as occurs after an open thoracic injury, around a chest tube, or tracheostomy. It also may be palpated in areas of extreme congestion or consolidation.
What is critical thinking?
Critical thinking is the way in which the nurse processes information using knowledge, past experiences, intuition, and cognitive abilities to formulate conclusions or diagnoses.
What is culture?
Culture includes contexts beyond the basic beliefs and behaviors that vary. Culture also includes family structure and function, spirituality and religion, and community, which serve as context for growth and development, health and illness, and health care delivery. Culture is learned, shared, associated with adaptation to the environment, and is universal. All people have a socially transmitted culture. Our own culture forms our worldview based on the values, beliefs, and behaviors sanctioned by it. That worldview becomes, for us, reality.
What is the best way to measure fluid volume?
Daily weights are the most accurate measurement.
What are some signs and symptoms of vitamin A deficiency?
Dry, flaky skin Rough, scaly skin with bumps Night blindness
What happens in the perimenopausal period?
During the perimenopausal period, hormone levels may fluctuate, resulting in menstrual irregularities. Periods may be heavier or may become scant.
What is dysphagia and complications associated with it?
Dysphagia (difficulty swallowing) or odynophagia (painful swallowing) may be seen with tumors of the pharynx, esophagus, or surrounding structures, narrowing of the esophagus such as in post radiation, gastroesophageal reflux disease (GERD), anxiety, poorly fitting dentures, or neuromuscular disorders. Dysphagia increases the risk for aspiration, and clients with dysphagia may require consultation with a speech therapist.
What is epispadias in males?
EPISPADIAS The urethral meatus is located on the top of the glans (dorsal side); occurs rarely. This condition is a congenital defect.
Equipment needed for skin, nail, and hair exam
Exam light, pen light, hand mirror for patient, metric ruler to measure size of lesions, magnifying glass, Wood's light to test fungus, Braden's scale, Pressure Ulcer Scale for Healing (PUSH)
What is the leading cause of lip cancer?
Exposure to the sun is the primary risk factor associated with lip cancer.
How do you assess for meningitis?
First, make sure that there is no injury to the cervical vertebrae or cervical cord. Then, with the client supine, place your hands behind the patient's head and flex the neck forward until the chin touches the chest if possible. Pain in the neck and resistance to flexion can arise from meningeal inflammation, arthritis, or neck injury. Then check by testing the Brudzinski and Kernig signs.
Equipment needed for Musculoskeletal Examination
Flexible measuring tape, goniometer,
Breath odor associated with diabetic ketoacidosis.
Fruity or acetone breath
CN IX
Glossopharyngeal; Sensory & Motor -Test swallowing and gag reflex. -Look for soft palate symmetry and midline uvula when saying "ahhhh". -Can patient identify sour on anterior 1/3 of tongue?
Equipment needed for Male Genitalia and Rectum Examination
Gloves and water soluble lubricant, pen light, occult blood specimen card
Equipment needed for all exams
Gown and gloves
What is bruxism?
Grinding the teeth (bruxism) may be a sign of stress or of slight malocclusion. The practice may also precipitate temporomandibular joint (TMJ) problems and pain.
What are the signs and symptoms of herpes progentialis in males?
HERPES PROGENITALIS Clusters of pimple-like, clear vesicles that erupt and become ulcers. Painful. Initial lesions of this STI—typically caused by HSV-1 or HSV-2—disappear, and the infection remains dormant for varying periods of time. Recurrences can be frequent or minimally episodic.
What is hypospadias in males?
HYPOSPADIAS Urethral meatus is located underneath the glans (ventral side). This condition is a congenital defect. A groove extends from the meatus to the normal location of the urethral meatus.
What are signs of venous disease?
Heaviness and an aching sensation aggravated by standing or sitting for long periods of time and relieved by rest are associated with venous disease.
What is intractable pain?
High resistance to pain relief
CN XII
Hypoglossal; Motor -To assess strength and mobility of the tongue, ask the client to protrude tongue, move it to each side against the resistance of a tongue depressor, and then put it back in the mouth.
What is the grading scale for tonsillitis?
In a client who has both tonsils and a sore throat, tonsillitis can be identified and ranked with a grading scale from 1 to 4 as follows: 1+ Tonsils are visible. 2+ Tonsils are midway between tonsillar pillars and uvula. 3+ Tonsils touch the uvula. 4+ Tonsils touch each other.
What assessment findings would you expect in a patient with CHF?
Increased cardiac output, increased fluid balance, crackles in lungs possibly
What is the Occipital lobe of the cerebrum responsible for?
Influences the ability to read with understanding and is the primary visual receptor center.
How do you perform the positions test and why is it important?
Instruct the client to focus on an object you are holding (approximately 12 inches from the client's face). Move the object through the six cardinal positions of gaze in a clockwise direction, and observe the client's eye movements. Eye movement should be smooth and symmetric throughout all six directions. This test assesses eye muscle strength and cranial nerve function.
What is the spiritual assessment?
It is an active and ongoing conversation that assesses the spiritual needs of the client. Characteristics: Formal or informal Respectful Non-biased
Why must you validate the assessment data?
It serves to ensure that the assessment process is not ended before all relevant data have been collected, and helps to prevent documentation of inaccurate data. Validation of data is the process of confirming or verifying that the subjective and objective data you have collected are reliable and accurate.
What is the function of the cerebellum?
Its primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone
Judaism
Judaism includes religious beliefs and a philosophy for a code of ethics with four major groupings of Jewish beliefs: Reform, Reconstructionist, Conservative, and Orthodox. Prayer shawls are common and are often passed between generations of family. The clergy are known as Rabbi. Restrictions related to work on holy days are removed to save a life. However, tests, signatures, and assessments for medical needs that can be scheduled to avoid holy days are appreciated. Psalms and the last prayer of confession (vidui) are held at bedside. At death, arms are not crossed; any clothing or bandages with client's blood should be prepared for burial with the person. It is important that the whole person be buried together. Orthodox or kosher rules involve no mixing of meat with dairy; separate cooking and eating utensils are used for food preparation and consumption. Kosher laws include special slaughter and food handling. "Keeping kosher" is predominantly an Orthodox practice. When food has passed kosher laws of preparation, a symbol (K) appears on the label. Many holy days include a fasting period.
How can you identify a macule or patch?
MACULE AND PATCH Small, flat, nonpalpable skin color change (skin color may be brown, white, tan, purple, red). Macules are less than 1 cm with a circumscribed border, whereas patches are greater than 1 cm, and may have an irregular border. Examples include freckles, flat moles, petechiae, rubella, vitiligo, port wine stains, and ecchymosis.
Where are breast tumors typically found?
Malignant tumors are most often found in the upper outer quadrant of the breast. They are usually unilateral, with irregular, poorly delineated borders. They are hard and nontender and fixed to underlying tissues.
What is stereotyping?
Many people are aware of other cultures and their different beliefs, values, and accepted behaviors but do not recognize the considerable variation that can exist within any cultural group. Not recognizing this variation tends to lead to stereotyping all members of a particular culture, expecting group members to hold the same beliefs and behave in the same way.
What are the primary considerations for a diabetic?
Medications like steroids can cause hyperglycemia. Having a diabetic patient NPO can cause hypoglycemia. Wound healing is complex.
What are the three most common skin cancers?
Melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC). BCC and SCC are nonmelanomas. Precursor lesions occur for some melanomas (benign or dysplastic nevi) and for invasive SCC (actinic keratoses or SCC in situ), but there are no precursor lesions for BCC.
When does menopause begin?
Menopause is a normal physiologic process that occurs in women between the ages of 40 to 58 years, with a mean age of 50. Menopause occurring before age 30 is termed premature menopause; menopause between ages 31 and 40 is considered early; menopause occurring in women older than age 58 years is termed delayed menopause. Premature and delayed menopause may be due to genetic predisposition, an endocrine disorder, or gynecologic dysfunction. Artificial or surgical menopause occurs in women who have dysfunctional ovaries or who have had their ovaries removed surgically.
Is it normal for an older adult to have a higher systolic BP? Why?
More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults. Systolic pressure over 140 but diastolic pressure under 90 is called isolated systolic hypertension.
Signs of cancer of the mouth or tongue.
Mouth or tongue sores that do not heal; red or white patches that persist; a lump or thickening; or rough, crusty, or eroded areas are warning signs of cancer and need to be referred for further evaluation.
How can you identify a nodule or tumor?
NODULE AND TUMOR Elevated, solid, palpable mass that extends deeper into dermis than a papule. Nodules are 0.5-2 cm and circumscribed; tumors are greater than 1-2 cm and do not always have sharp borders. Examples of nodules include keloid, lipoma, squamous cell carcinoma, poorly absorbed injection, and dermatofibroma. Examples of tumors include larger lipoma and carcinoma.
Hinduism
Nirvana (oneness with God) is the primary purpose of the religion. Illness is the result of past and current life actions (Karma). The right hand is seen as holy, and eating and intervention (IV) needs to be with the right hand to promote clean healing. At death the soul may be reborn as another person and one's Karma is carried forward. Many, but not all, are vegetarians. Many holy days include fasting.
Gathering subjective data for a nutritional assessment.
Nutritional assessment begins with questions regarding the client's dietary habits. Questions should solicit information about average daily intake of food and fluids, types and quantities consumed, where and when food is eaten, and any conditions or diseases that affect intake or absorption. -Usual height and weight -Recent loss or gain -Any special diets -Fluid intake daily -24 hour food recall -Recent N, V, or constipation -Food allergies -Chronic illnesses -Recent surgeries/trauma -Current meds/supplements -Family obesity -Family chronic illnesses (heart, DM) -Religious dietary restrictions -Who cooks at home -Who does the shopping -Eating out ___x week -Exercise
What is orchitis in males?
ORCHITIS Inflammation of the testes, associated frequently with mumps. Client complains of pain, heaviness, and fever. Scrotum appears enlarged and reddened. Swollen, tender testis is palpated. The examiner may have difficulty differentiating between testis and epididymis.
When is someone considered obese?
Obesity is defined as a weight more than 20% above normal body weight, and is also determined by a BMI over 30.
CN III
Oculomotor; Motor -Inspect margins of the eyelids of each eye; look for drooping. -Have client follow your hand in all six cardinal directions, especially up and in.
What is cancer pain?
Often due to the compression of peripheral nerves or meninges or from the damage to these structures following surgery, chemotherapy, radiation, or tumor growth and infiltration
Equipment needed for ear exam
Otoscope and tuning fork
What is overflow incontinence?
Overflow incontinence is the involuntary loss of urine associated with overdistention of the bladder. Prostatic hypertrophy is a common cause in men; diabetic neuropathy is a common cause in both sexes.
How can you identify papule or plaque?
PAPULE AND PLAQUE Elevated, palpable, solid mass. Papules have a circumscribed border and are less than 0.5 cm; plaques are greater than 0.5 cm and may be coalesced papules with a flat top. Examples of papules include elevated nevi, warts, and lichen planus. Examples of plaques include psoriasis (psoriasis vulgaris) and actinic keratosis.
What is paraphimosis in males?
PARAPHIMOSIS Foreskin is so tight that, once retracted, it cannot be returned back over the glans.
What is phimosis in males?
PHIMOSIS Foreskin is so tight that it cannot be retracted over the glans.
How can you identify a pustule?
PUSTULE Pus-filled vesicle or bulla. Examples include acne, impetigo, furuncles, and carbuncles.
Equipment needed for Mouth, Throat, Nose, and Sinus Examination
Pen light, 4x4 gauze, tongue depressor, and otoscope
Equipment needed for eye exam
Pen light, Snellen E chart, newspaper, opaque card, and Ophthalmoscope
What is radiating pain?
Perceived both at the source and extending to other tissues
What is referred pain?
Perceived in body areas away from the pain source
What is phantom pain?
Perceived in nerves left by a missing, amputated, or paralyzed body part
How do you perform the hypersensitivity test for appendicitis?
Perform hypersensitivity test. Stroke the abdomen with a sharp object (e.g., broken cotton tipped applicator or tongue blade) or grasp a fold of skin with your thumb and index finger and quickly let go. Do this several times along the abdominal wall. Pain or an exaggerated sensation felt in the RLQ is a positive skin hypersensitivity test and may indicate appendicitis.
How do you assess for diaphragmatic excursion?
Place your hands on the posterior chest wall with your thumbs at the level of T9 or T10 and pressing together a small skin fold. As the client takes a deep breath, observe the movement of your thumbs. When the client takes a deep breath, the examiner's thumbs should move 5 to 10 cm apart symmetrically. Unequal chest expansion can occur with severe atelectasis (collapse or incomplete expansion), pneumonia, chest trauma, or pneumothorax (air in the pleural space). Decreased chest excursion at the base of the lungs is characteristic of COPD.
Common allergy irritants.
Pollens cause seasonal rhinitis, whereas dust may cause rhinitis year round.
What is the Temporal lobe of the cerebrum responsible for?
Receives and interprets impulses from the ear. Contains Wernicke's area, which is responsible for interpreting auditory stimuli.
What is the correlation between religion, spirituality, and health?
Religion and spirituality have been related to a person's greater well-being in the face of chronic disease management and need to adhere to medical regimens. Religion and spirituality can be powerful coping mechanisms when a person faces end-of-life issues.
What is religion?
Religion is defined as the rituals, practices, and experiences shared within a group that involve a search for the sacred. (i.e., God, Allah, etc.) Characteristics: Formal Organized Group oriented Ritualistic Objective, as in easily measurable (e.g., church attendance)
What does the right lymphatic duct drain?
Right lymphatic duct, which drains the upper right side of the body
What are some risk factors for DVT?
Risk factors for DVT include reduced mobility, dehydration, increased viscosity of the blood, and venous stasis
When will you have rust-colored sputum?
Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.
What communication tool is used in handoffs?
SBAR (SITUATION, BACKGROUND, ASSESSMENT, AND RECOMMENDATION)
What is a scrotal hernia?
SCROTAL HERNIA A loop of bowel protrudes into the scrotum to create what is known as an indirect inguinal hernia. Hernia appears as swelling in the scrotum. Palpable as a soft mass and fingers cannot get above the mass.
What is spermatocele?
SPERMATOCELE Sperm-filled cystic mass located on epididymis. Palpable as small and nontender, and movable above the testis. This mass will appear on transillumination.
What acronym can help as a quick reference guide for a spiritual assessment of a client?
SPIRIT S—Spiritual belief system Do you have a formal religious affiliation? P—Personal spirituality In what ways is your spirituality/religion meaningful for you? I—Integration with a spiritual community Do you belong to any religious or spiritual groups or communities? R—Ritualized practices and restrictions What lifestyle activities or practices does your religion encourage, discourage, or forbid? I—Implications for medical care What aspects of your religion/spirituality would you like me to keep in mind as I care for you? T—Terminal events planning Are there particular aspects of medical care that you wish to forgo or have withheld because of your religion/spirituality?
Stage I Pressure Ulcer characteristics
STAGE I Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones.
Equipment needed for nutritional exam
Skinfold calipers, platform scale with height attachment, flexible tape, skin marker
When inspecting the tongue, what would indicate a vitamin B12 deficiency?
Smooth, reddish, shiny tongue without papillae due to vitamin B12 deficiency.
What is spirituality?
Spirituality is defined as a search for meaning and purpose in life; it seeks to understand life's ultimate questions in relation to the sacred. Characteristics: Informal Non-organized Self-reflection Experience Subjective, as in difficult to consistently measure (e.g., daily spiritual experiences, spiritual well-being, etc.)
Equipment needed for Heart and Neck Vessel Examination
Stethoscope and two metric rulers to measure jugular venous pressure
Equipment needed for head and neck exam
Stethoscope to auscultate thyroid and small cup of water to help client swallow when examining thyroid
Equipment needed for Abdominal Exam
Stethoscope, flexible measuring tape, skin marking pen, and two small pillows
Equipment needed for Thoracic and Lung Examination
Stethoscope, metric ruler, skin marking pen,
What is stress incontinence?
Stress incontinence is the involuntary loss of urine during coughing, sneezing, laughing, or other physical activities that increase abdominal pressure. In women, stress incontinence may result from weakened and relaxed muscles from the combined effects of aging superimposed on the effects of childbirth.
Buddhism
Suffering is a part of human existence Prayer and meditation are used for cleansing and healing. Terminal illness may be seen as a unique opportunity to reflect on life's ultimate meaning and the meaning of one's relation with the world. Death is associated with rebirth. Serene surroundings are important to the dignity of dying. Many are strict vegetarians. Some holy days include fasting from dawn to dusk.
How do you assess for obturator sign for appendicitis?
Support the client's right knee and ankle. Flex the hip and knee, and rotate the leg internally and externally Pain in the RLQ indicates irritation of the obturator muscle due to appendicitis or a perforated appendix.
What is a testicular tumor and its symptoms?
TESTICULAR TUMOR Initially a small, firm, nontender nodule on the testis. As the tumor grows, the scrotum appears enlarged and the client complains of a heavy feeling. When palpated, the testis feels enlarged and smooth—tumor replaces testis. Will not transilluminate.
What is torsion of spermatic cord?
TORSION OF SPERMATIC CORD Very painful condition caused by twisting of spermatic cord. Scrotum appears enlarged and reddened. Palpation reveals thickened cord and swollen, tender testis that may be higher in scrotum than normal. This condition requires immediate referral for surgery because circulation is obstructed.
How do you determine BMI?
Take your weight in pounds divided by your height in inches then divide by your height in inches once more and multiply by 708. 150 lbs/65 in/65in x 708 = 25 BMI
How do you test the Brudzinski's sign for meningitis?
Test for Brudzinski's sign. As you flex the neck, watch the hips and knees in reaction to your maneuver. Pain and flexion of the hips and knees are positive Brudzinski's signs, suggesting meningeal inflammation.
How do you test the Kernig's sign for meningitis?
Test for Kernig's sign. Flex the client's leg at both the hip and the knee, then straighten the knee. Pain and increased resistance to extending the knee are a positive Kernig's sign. When Kernig's sign is bilateral, the examiner suspects meningeal irritation.
How do you test for referred rebound tenderness for appendicitis?
Test for referred rebound tenderness. Palpate deeply in the LLQ and quickly release pressure. Pain in the RLQ during pressure in the LLQ is a positive Rovsing's sign. It suggests acute appendicitis.
What is the Allen test and how is it performed?
The Allen test evaluates patency of radial and ulnar arteries. • Patient rests arm palm side up on exam table and makes a fist • Use your thumbs to occlude radial and ulnar arteries while patient releases fist (don't over extend hand or false positive) *palm gets pale • Release pressure on ulnar artery and watch color return • Repeat, but then release pressure on radial artery and watch • **pink color returns to hand in 3-5 seconds = normal, if pallor persists, suggests insufficiency in corresponding artery
What makes up the autonomic nervous system?
The autonomic nervous system is made up of the sympathetic nervous system and the parasympathetic nervous system.
What does the Braden Scale assess?
The lower the score=the higher the risk 1. Prolonged pressure to body, especially bony prominences 2. Decreased/absent perception or sensation 3. Decreased/absent mobility 4. Increased moisture 5. Increased/decreased nutrition 6. Friction or shearing forces 7. Fragile tissues and skin due to age, vascular incompetence, diabetes mellitus, or body weight (excessive or underweight)
What does the parasympathetic nervous system do?
The parasympathetic nervous system functions to restore and maintain normal body functions, for example, by decreasing heart rate. The parasympathetic fibers arise from the craniosacral regions (S1 to S4 and cranial nerves III, VI, IX, and X).
What is the function of the pons?
The pons links the cerebellum to the cerebrum and the midbrain to the medulla. It is responsible for various reflex actions.
How do you perform the visual fields test and why is it important?
To perform the confrontation test, position yourself approximately 2 feet away from the client at eye level. Have the client cover the left eye while you cover your right eye. Look directly at each other with your uncovered eyes. Next, fully extend your left arm at midline and slowly move one finger (or a pencil) upward from below until the client sees your finger (or pencil). Test the remaining three visual fields of the client's right eye (i.e., superior, temporal, and nasal). Repeat the test for the opposite eye. With normal peripheral vision, the client should see the examiner's finger at the same time the examiner sees it. Normal visual field degrees are approximately as follows: -Inferior: 70 degrees -Superior: 50 degrees -Temporal: 90 degrees -Nasal: 60 degrees This tests peripheral vision.
CN V
Trigeminal; Sensory motor -Ask the client to clench the teeth while you palpate the temporal and masseter muscles for contraction -Touch client's face with sharp and dull objects and have them communicate which was used. -Test corneal reflex. Ask the client to look away and up while you lightly touch the cornea with a fine wisp of cotton. Repeat on the other side.
CN IV
Trochlear; Motor -Have client look down and in.
Arterial ulcers
Ulcers associated with arterial disease are usually painful and are often located on the toes, foot, or lateral ankle.
What happens when pain is undertreated in children?
Undertreated pain in children can lead to chronic pain conditions when they become adults.
What is urge incontinence?
Urge incontinence is the involuntary loss of urine associated with an abrupt and strong desire to void. It is frequently caused by a neurologic disorder such as a cerebrovascular accident (CVA) or multiple sclerosis (MS), which impairs the ability of the bladder or urinary sphincter to contract and relax.
When should you use Mouth, Nose, and Eye Protection?
Use PPE to protect the mucous membranes of the eyes, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed.
What is a closed-ended question? When is it used?
Use closed-ended questions to obtain facts and to focus on specific information. The client can respond with one or two words. The questions typically begin with the words "when" or "did." An example of this type of question is: "When did your headache start?" Closed-ended questions are useful in keeping the interview on course and to clarify statements.
How do you determine ideal body weight (IBW)?
Use this formula to calculate the client's IBW: Female: 100 lb for 5 ft + 5 lb for each inch over 5 ft ± 10% for small or large frame Male: 106 lb for 5 ft + 6 lb for each inch over 5 ft ± 10% for small or large frame.
How to perform the Tenel test.
Use your finger to percuss lightly over the median nerve (located on the inner aspect of the wrist). Tingling or shocking sensation experienced with test for Tinel's sign. Median nerve entrapped in the carpal tunnel results in pain, numbness, and impaired function of the hand and fingers
How is acute pain defined?
Usually associated with a recent injury
How is chronic pain defined?
Usually associated with a specific cause or injury and described as a constant pain that persists for more than 6 months
What is varicocele in males?
VARICOCELE Abnormal dilation of veins in the spermatic cord. Client may complain of discomfort and testicular heaviness. Tortuous veins are palpable and feel like a soft, irregular mass or "a bag of worms," which collapses when the client is supine. Infertility may be associated with this condition.
How can you identify a Vesicle or a Bulla?
VESICLE AND BULLA Circumscribed elevated, palpable mass containing serous fluid. Vesicles are less than 0.5 cm; bullas are greater than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn. Examples of bulla include pemphigus, contact dermatitis, large burn blisters, poison ivy, and bullous impetigo.
What is a wheal?
WHEAL Elevated mass with transient borders that is often irregular. Size and color vary. Caused by movement of serous fluid into the dermis; it does not contain free fluid in a cavity (e.g., vesicle). Examples include urticaria (hives) and insect bites.
What are the signs of venous insufficiency?
Warm skin and brown pigmentation around the ankles are associated with venous insufficiency.
Contact with C. Diff... Alcohol or Soap?
Wash hands with nonantimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., Clostridium difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores.
When should you wear a gown?
Wear a gown that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient care activities when contact with blood, body fluids, secretions, or excretions is anticipated.
Describe typical changes of hearing with aging.
When interviewing an older client, you must first assess hearing acuity. Hearing loss occurs normally with age, and undetected hearing loss is often misinterpreted as mental slowness or confusion. Presbycusis, a gradual hearing loss, is common after the age of 50 years. Presbycusis often begins with a loss of high-frequency sounds (woman's voice) followed later by the loss of low-frequency sounds.
When will you have white or mucoid sputum?
White or mucoid sputum is often seen with common colds, viral infections, or bronchitis.
What is Candida albicans infection?
Whitish, curd-like patches that scrape off over reddened mucosa and bleed easily indicate "thrush" (Candida albicans) infection.
When would you find yellow nail syndrome?
Yellow Nail Syndrome Yellow nails grow slow and are curved. May be seen in AIDS and respiratory syndromes.
When will you have yellow or green sputum?
Yellow or green sputum is often associated with bacterial infections.
What is hydrocele in males?
HYDROCELE Collection of serous fluid in the scrotum, outside the testes within the tunica vaginalis. Appears as swelling in the scrotum and is usually painless. Usually the examiner can get fingers above this mass during palpation. Will transilluminate (if there is blood in the scrotum, it will not transilluminate and is called a "hematocele").
When would you see half-and-half nails?
Half-and-Half Nails Nails that are half white on the upper proximal half and pink on the distal half. May be seen in chronic renal disease.
How do you assess for Peripheral Vascular Disease in Arms?
- Observe arm size and venous pattern, look for edema: Lymphedema indication breast surgery (if not pitted) or venous obstruction - Observe coloration of the hands: Raynaud's disorder + vasoconstriction or vasospasm of fingers/toes characterized by rapid color changes (pallor, cyanosis, redness) Common bilaterally in 5% of population - Temp in fingers, hands, arms: cool extremity sign of arterial insufficiency - Cap refill time: refill >2 sec = vasoconstriction, decreased cardiac output, shock, arterial occlusion, or hypothermia - Radial pulse: increased pulse (3+ or higher) indicates hyperkalemia. Diminished (0, 0r 1+) suggests partial or complete arterial occlusion, Buerger's syndrome, or scleroderma ** use doppler or ultrasound for hard to locate pulses*** - Palpate ulnar pulse: obliteration of pulse may be external force (compartment syndrome). Lack of elasticity = arteriosclerosis - If suspect arterial insufficiency (radial/ulnar) palpate brachial pulse - Palpate epitrochlear lymph nodes: enlarged because of lesion/infection
How do you assess for Peripheral Vascular Disease in Legs?
- Observe skin color: pallor when elevated, when dependent, suggests arterial insufficiency. Cyanosis, or a rusty brownish pigmentation when dependent suggests venous insufficiency - Distribution of hair: loss of hair on legs suggests renal insufficiency (or thin and shiny) - hair loss also natural for older adult - Lesions or Ulcers: Ulcers with smooth, even margins that occur on toes or lateral ankles are from arterial insufficiency. Ulcers with irregular edges and bleeding & possible bacterial infection on medial ankle from venous insufficiency. - Edema (uni or bi lateral): bilateral usually a systemic problem. Unilateral = 1cm in ankle or 2cm difference in calf circumference. Usually caused by venous insufficiency - Palpate edema: pitting = venous insufficiency (+1 - +4 grade) - Temperature (bilaterally): coolness = arterial insufficiency, warmth = superficial thrombophlebitis from secondary inflammation in tissue around vein - Inguinal lymph nodes: larger than 2cm = local infection or lymphadenopathy - Femoral pulses: (bilaterally) weak or absent suggest arterial occlusion - Popliteal pulses( under knee): (bilaterally) weak or absent = occluded artery - Dorsalis pedis pulses: weak or absent = impaired arterial circulation - Posterior tibial pulses: weak or absent = partial or complete arterial occlusion o Auscultate - Femoral pulses: listen for bruits bilaterally. + bruits = partial obstruction
Suspicious findings during a breast assessment.
-A recent increase in the size of one breast may indicate inflammation or an abnormal growth. -A pigskin-like or orange-peel (peau d'orange) appearance results from edema, which is seen in metastatic breast disease. -A prominent asymmetric venous pattern may occur as a result of increased circulation due to a malignancy. -Red, scaly, crusty areas are may appear in Paget's disease - A recently retracted nipple that was previously everted suggests malignancy -Any type of spontaneous discharge should be referred for cytologic study and further evaluation. -Dimpling or retraction is usually caused by a malignant tumor that has fibrous strands attached to the breast tissue and the fascia of the muscles. As the muscle contracts, it draws the breast tissue and skin with it, causing dimpling or retraction. -Enlarged (greater than 1 cm) lymph nodes may indicate infection of the hand or arm. Large nodes that are hard and fixed to the skin may indicate an underlying malignancy.
How can a person prevent bone loss?
-Adequate calcium and vitamin D intake (recommendations range from country to country, varying between 800 to 1300 mg per day, depending on age) -Regular, weight-bearing exercise -Not to smoke or quit if smoking -Avoid heavy drinking -Middle-aged and older adults should follow these fundamental principles: Assess their risk of developing osteoporosis and, with medical advice, consider medications to help maintain an optimal bone mass and to decrease the risk of fracture.
What are the risk factors for prostate cancer?
-African-American -Older than 60 -Having a father or brother with prostate cancer -Exposure to agent orange -Excessive alcohol consumption -Working on a farm, in a tire plant, with paint, with cadmium -Diet high in fat, especially animal fat. Note that prostate cancer is less common in people who do not eat meat (vegetarians).
Unmodifiable risks for osteoporosis
-Age -Female gender -Family history -Previous fracture -Race/ethnicity -Menopause/hysterectomy -Long-term glucocorticoid therapy -Rheumatoid arthritis -Primary/secondary hypogonadism in men
Modifiable risks for osteoporosis
-Alcohol (greater than 2 drinks a day) -Smoking (past or current history) -Low body mass index (<20 kg/m2) -Poor nutrition (low calcium intake and low protein intake) -Vitamin D deficiency -Eating disorders (lead to nutrition deficiencies) -Insufficient exercise (especially sedentary lifestyle)
What changes in the lungs would be expected with heart failure?
-Difficulty with breathing or dyspnea can be a sign of chronic heart failure - Orthopnea (difficulty breathing when lying supine) may be associated with heart failure. -Paroxysmal nocturnal dyspnea (severe dyspnea that awakens the person from sleep) also may be associated with heart failure. -Nonproductive coughs are often associated with upper respiratory irritations and early congestive heart failure (CHF). -Fine crackles heard upon auscultation -Cheyne-Stokes respiration-Regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea - results from severe heart failure. -Fluid accumulation in the lungs from heart failure can cause one to cough up white- or pink-tinged sputum.
What assessment changes might be found in a patient with heart failure?
-Gallop and S3 sounds can be heard with people suffering from heart failure. -They also suffer from fluid overload which means peripheral edema, jugular distention and crackles in the lungs.
What are the non-modifiable risk factors for breast cancer?
-Gender: Females are 100 times more likely to develop breast cancer than males (estrogen and progesterone are implicated). -Age: Risk increases with age -Genetics: About 5%-10% of breast cancer cases are thought to be hereditary. -Race/ethnicity: Caucasian women are at greater risk for diagnosis of breast cancer and Black women are at greater risk for dying of breast cancer in the United States. -Family history (genetics and ethnicity): even if father or brother has had breast cancer, risk is increased. -Personal history of breast cancer (three- to fourfold risk of cancer in the same or other breast) -Breast consistency: denser breasts increase risk. -Early menstruation (before 12 years of age) or later menopause (older than 55 years) -Previous chest radiation (for therapy) before age 40 -Diethylstilbestrol exposure (1940s and 1950s) to avoid miscarriage, or daughters of mothers who took this medication
What physiological changes should you expect with emphysema?
-Gradual onset of dyspnea is usually indicative of lung changes. -Ribs appearing horizontal at an angle greater than 45 degrees with the spinal column are frequently the result of an increased ratio between the anteroposterior-transverse diameter (barrel chest). -Pursed lip breathing may be seen in asthma, emphysema, or CHF as a physiologic response to help slow down expiration and keep alveoli open longer. -Client leans forward and uses arms to support weight and lift chest to increase breathing capacity, referred to as the tripod position. -Hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax. -high pitched, musical sounds or wheezes heard upon ausculation
How does the normal ear under otoscopic examination appear?
-The tympanic membrane, or eardrum, has a translucent, pearly gray appearance and serves as a partition stretched across the inner end of the auditory canal, separating it from the middle ear. -Handle and short process of the malleus—the nearest auditory ossicle that can be seen through the translucent membrane. -Cone of light—the reflection of the otoscope light seen as a cone due to the concave nature of the membrane.
What are the modifiable risk factors for breast cancer?
-Having no children or giving birth to first child after 30 years of age -Recent oral contraceptive use (risk declines to normal after 10 years of no use) -Use of menopausal combined hormone replacement therapy (both estrogen and progesterone, risk is highest in first 2-3 years but long use increases risk; risk reduces to normal risk after 2-3 years without therapy). Estrogen-only therapy increases risk if used for 10 years or longer. -No history of breast-feeding. Breast feeding may have a protective effect due to reduced lifetime number of menstrual cycles. -Alcohol consumption (increased risk with increased intake) -Excess weight or obesity (due to increased fat tissue after menopause increasing estrogen levels) -Weight gain as adult female -Limited physical activity: increasing activity (45-60 minutes per day for 5 or more days per week of intentional exercise) seems to reduce breast cancer risk (ACS, 2011).
Gathering objective data of the mouth.
-Inspect lips -Inspect teeth and gums -Inspect bucca mucosa -Inspect and palpate the tongue -Ask the client to touch the tongue to the roof of mouth, and use a penlight to inspect the ventral surface of the tongue, frenulum, and area under the tongue -Palpate the area if you see lesions, if the client is over age 50, or if the client uses tobacco or alcohol. Note any induration. Check also for a short frenulum that limits tongue motion (the origin of "tongue-tied"). -Inspect for Wharton's ducts -Observe and palpate the sides of the tongue for any lesions, ulcers, or nodules for induration. -Check tongue for strength and taste -Inspect hard and soft palate and uvula -Inspect the nostrils -Inspect the posterior pharyngeal wall
How do you conduct the breast assessment?
-Inspect size, symmetry, color, and texture -Inspect areolas and nipples for color and retraction -Palpate for texture, elasticity, tenderness, and tempature - Palpate for masses -Palpate nipples for discharge -Palpate any surgery scars -Inspect and palpate axillary lymph nodes Ask the client to lie down and to place overhead the arm on the same side as the breast being palpated. Place a small pillow or rolled towel under the breast being palpated. Use the flat pads of three fingers to palpate the client's breasts Palpate the breasts using one of three different patterns. Be sure to palpate every square inch of the breast, from the nipple and areola to the periphery of the breast tissue and up into the tail of Spence. Use the bimanual technique if the client has large breasts. Support the breast with your nondominant hand and use your dominant hand to palpate.
What are the essential elements of critical thinking?
-Keep an open mind. -Use rationale to support opinions or decisions. -Reflect on thoughts before reaching a conclusion. -Use past clinical experiences to build knowledge. -Acquire an adequate knowledge base that continues to build. -Be aware of the interactions of others. -Be aware of the environment.
What is the best way to document assessment data?
-Keep confidential all documented information in the client record - HIPAA. -Document legibly or print neatly in nonerasable ink. Errors in documentation are usually corrected by drawing one line through the entry, writing "error," and initialing the entry. Never obliterate the error with white paint or tape, an eraser, or a marking pen. Keep in mind that the health record is a legal document. -Use correct grammar and spelling. Use only abbreviations that are acceptable and approved by the institution. -Avoid wordiness; be concise. For example, "Bowel sounds present in all quadrants at 36/minute." -Use phrases instead of sentences to record data. -Record data findings, not how they were obtained. -Write entries objectively without making premature judgments or diagnoses. Use quotation marks to identify clearly the client's responses. -Record the client's understanding and perception of problems. For example, record: "Client expresses concern regarding being discharged soon after gallbladder surgery because of inability to rest at home with six children." -Avoid recording the word "normal" for normal findings. Write only observations. -Record complete information and details for all client symptoms or experiences. -Include additional assessment content when applicable. For example, include information about the caregiver or last physician contact. -Support objective data with specific observations obtained during the physical examination. For example, when describing the emotional status of the client as depressed, follow it with a description of the ways depression is demonstrated such as "dressed in dirty clothing, avoids eye contact, unkempt appearance, and slumped shoulders."
What changes in the lungs would be expected with bronchitis?
-Labored and noisy breathing is often seen with severe asthma or chronic bronchitis. -Fine crackles and sonorous wheezing can be heard upon auscultation
How do you assess localized edema?
-Palpate to detect edema. Use your thumbs to press down on the skin of the feet or ankles to check for edema (swelling related to accumulation of fluid in the tissue). -If edema is noted during inspection, palpate the area to determine if it is pitting or nonpitting -A 1+ to 4+ scale is used to grade the severity of pitting edema, with 4+ being most severe -If there is an observable difference, measure bilaterally the circumference at the same locations with each re-measurement and record findings in centimeters.
What are some normal findings of the male reproductive system?
-Pubic hair is coarser than scalp hair. The normal pubic hair pattern in adults is hair covering the entire groin area, extending to the medial thighs and up the abdomen toward the umbilicus. -The base of the penis and the pubic hair are free of excoriation, erythema, and infestation. -Pubic hair may be gray and sparse in older adult clients. In addition, the penis becomes smaller and the testes hang lower in the scrotum in older adult clients. -The penis in a nonerect state is usually soft, flaccid, and nontender. -The glans size and shape vary, appearing rounded, broad, or even pointed. The surface of the glans is normally smooth, free of lesions and redness. -The foreskin retracts easily. A small amount of whitish material, called smegma, normally accumulates under the foreskin. -The urinary meatus is normally free of discharge. -The scrotal sac hangs below or at the level of the penis. The left side of the scrotal sac usually hangs lower than the right side. -Lesions and rashes are not normally present. However, sebaceous cysts (small, yellowish, firm, nontender, benign nodules) are a normal finding. -Normally scrotal contents do not transilluminate. -The anus and rectal mucosa are normally soft, smooth, nontender, and free of nodules. -The prostate is normally nontender and rubbery. It has two lateral lobes that are divided by a median sulcus. The lobes are normally smooth, 2.5 cm long, and heart-shaped.
What are some signs of Parkinsonism?
-Relatively slow, fine, pill-rolling tremor of parkinsonism, about 5 per second. -Shuffling gait, turns accomplished in very stiff manner. -Stooped-over posture with flexed hips and knees.
What are symptoms of prostate enlargement?
-Trouble urinating -Decreased force in the stream of urine -Blood in the urine -Blood in the semen -Swelling in the legs -Discomfort in the pelvic area -Bone pain -Many of the above symptoms are also symptoms for prostate cancer. -Prostate enlargement is increasingly common in men over age 40.
What changes in the lungs would be expected with pneumonia?
-Unequal chest expansion can occur with severe atelectasis (collapse or incomplete expansion), pneumonia, chest trauma, or pneumothorax (air in the pleural space). -Dullness is present when fluid or solid tissue replaces air in the lung or occupies the pleural space, such as in lobar pneumonia, pleural effusion, or tumor. -When auscultating voice sounds, the words are easily understood and louder over areas of increased density. This may indicate consolidation from pneumonia, atelectasis, or tumor. -Fine or coarse crackles can be heard with auscultation of the lungs -Pneumonia is the most common cause of infection-related deaths in older adults.
Which cultural beliefs and values should be assessed? Why?
-Value orientation -Beliefs about human nature -Beliefs about relationship with nature -Beliefs about purpose of life -Beliefs about health, illness, and healing -Beliefs about what causes disease -Beliefs about health -Beliefs about who serves in the role of healer or what practices bring about healing Assessing these beliefs will help the nurse to understand the client's approach to health care providers and to illness and healing.
What factors contribute to blood pressure?
1. Cardiac output 2. Peripheral vascular disease (increased resistance = increased BP) 3. Circulating blood volume (increased volume = increased BP; decreased volume through internal bleeding = decreased BP) 4. Viscosity (thicker blood = increased BP) 5. Elasticity of vessel walls (increased stiffness = increased BP)
What are some signs and symptoms of fluid volume deficiency?
1. Dehydration 2. Orthostatic Hypotension 3. Skin tenting 4. Flat veins 5. Slow capillary refill >5 6. Loud, harsh breath sounds
What are some signs and symptoms of fluid volume excess?
1. Edema 2. Crackles heard in lungs upon auscultation 3. Urinary retention 4. Bounding pulses 5. Tight, shiny skin 6. Elevated pulse rate and blood pressure
What are the seven steps in analyzing assessment data using critical thinking skills?
1. Identify abnormal data and strengths. 2. Cluster data. 3. Draw inferences. 4. Propose possible nursing diagnoses. 5. Check for presence of defining characteristics. 6. Confirm or rule out nursing diagnoses. 7. Document conclusions.
What are the four steps of the health assessment?
1. collecting subjective data, 2. collecting objective data, 3. validation of data, and 4. documentation of data.
What are the five constructs in the cultural competence process?
1. cultural awareness, 2. cultural skill, 3. cultural knowledge, 4. cultural encounters, and 5. cultural desire
What are the four basic assessment techniques?
1. inspection, 2. palpation, 3. percussion, and 4. auscultation
What are the four main divisions of the brain?
1. the cerebrum, 2. the diencephalon (holds the thalamus and hypothalamus), 3. the brain stem (holds the midbrain, pons and medulla oblongata), and 4. the cerebellum
What is a partial assessment?
An ongoing or partial assessment of the client consists of data collection that occurs after the comprehensive database is established. This consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data.
How do you assess for appendicitis?
Appendicitis is typically associated with right lower quadrant pain and nausea, vomiting, and the inability to stand up straight. 5 different tests can be used: -Test for rebound tenderness -Test for referred rebound tenderness -Assess for psoas sign -Assess for obturator sign -Use hypersensitivity test
How do you perform the cover test and why is it important?
Ask the client to stare straight ahead and focus on a distant object. Cover one of the client's eyes with an opaque card. As you cover the eye, observe the uncovered eye for movement. Now remove the opaque card and observe the previously covered eye for any movement. The uncovered eye should remain fixed straight ahead. The covered eye should remain fixed straight ahead after being uncovered. Repeat test on the opposite eye. The cover test detects deviation in alignment or strength and slight deviations in eye movement by interrupting the fusion reflex that normally keeps the eyes parallel.
How do you assess the whispered pectoriloquy?
Ask the client to whisper the phrase "one-two-three" while you auscultate the chest wall. Normal: Transmission of sound is very faint and muffled. It may be inaudible.
How do you assess for psoas sign for appendicitis?
Ask the client to lie on the left side. Hyperextend the right leg of the client. Pain in the RLQ (psoas sign) is associated with irritation of the iliopsoas muscle due to appendicitis (an inflamed appendix).
How do you assess for bronchophony?
Ask the client to repeat the phrase "ninety-nine" while you auscultate the chest wall. Normal: Voice transmission is soft, muffled, and indistinct. The sound of the voice may be heard but the actual phrase cannot be distinguished.
How to perform the Phalen test.
Ask the client to rest elbows on a table and place the backs of both hands against each other while flexing the wrists 90 degrees with fingers pointed downward and wrists dangling. Have the client hold this position for 60 seconds. If symptoms develop within a minute with Phalen's test, carpel tunnel syndrome is suspected. Client may report tingling, numbness, and pain with carpal tunnel syndrome.
How do you perform the Romberg test?
Ask the client to stand erect with arms at side and feet together. Note any unsteadiness or swaying. Then with the client in the same body position, ask the client to close the eyes for 20 seconds. Again note any imbalance or swaying. Positive Romberg test: Swaying and moving feet apart to prevent fall is seen with disease of the posterior columns, vestibular dysfunction, or cerebellar disorders.
How do you assess for cholecystitis?
Assess RUQ pain or tenderness, which may signal cholecystitis (inflammation of the gallbladder). Press your fingertips under the liver border at the right costal margin and ask the client to inhale deeply. Accentuated sharp pain that causes the client to hold his or her breath (inspiratory arrest) is a positive Murphy's sign and is associated with acute cholecystitis.
How does a nurse address spiritual care?
By addressing the spiritual needs of the client as they unfold through spiritual assessment. Characteristics: Individualistic Client oriented Collaborative
What is direct reflex and how do you test for it?
Direct reflex happens when constriction occurs in the eye exposed to the light. To test direct reflex, shine a light directly into one eye and observe the pupillary reaction.
What is the frontal lobe of the cerebrum responsible for?
Directs voluntary, skeletal actions (left side of lobe controls right side of body and right side of lobe controls left side of body). Also influences communication (talking and writing), emotions, intellect, reasoning ability, judgment, and behavior. Contains Broca's area, which is responsible for speech.
What is epididymitis in males?
EPIDIDYMITIS Infection of the epididymis. Client usually complains of sudden pain. Scrotum appears enlarged, reddened, and swollen; tender epididymis is palpated. Usually associated with prostatitis or bacterial infection.
What is a fissure in the skin?
FISSURE Linear crack in the skin that may extend to the dermis and may be painful. Examples include chapped lips or hands and athlete's foot. Interdigital tinea pedis with fissures and maceration.
CN VII
Facial; Sensory & Motor -Check for symmetry when patient puffs out cheeks, raises eyebrows, smiles, puckers lips, and frowns. -Can patient distinguish between sweet or salty on anterior 2/3 of tongue?
Increased waist circumference is related to which disorders?
Females: Greater than 35 inches (88 cm) Males: Greater than 40 inches (102 cm) These findings are associated with such disorders as diabetes, hypertension, hyperlipidemia, and cardiovascular disease.
What is functional incontinence?
Functional incontinence is the inability to get to the bathroom in time or to understand the cues to void due to problems with mobility or cognition.
What are the signs and symptoms of genital warts in males?
GENITAL WARTS Single or multiple, moist, fleshy papules. Painless. STI caused by the human papillomavirus.
How do you perform the corneal light reflex test and why is it important?
Hold a penlight approximately 12 inches from the client's face. Shine the light toward the bridge of the nose while the client stares straight ahead. Note the light reflected on the corneas. The reflection of light on the corneas should be in the exact same spot on each eye, which indicates parallel alignment. This test assesses parallel alignment of the eyes.
How do you test for rebound tenderness for appendicitis?
If the client has abdominal pain or tenderness, test for rebound tenderness by palpating deeply at 90 degrees into the abdomen one halfway between the umbilicus and the anterior iliac crest (McBurney's Point). Then suddenly release pressure. Listen and watch for the client's expression of pain. Ask the client to describe which hurt more—the pressing in or the releasing—and where on the abdomen the pain occurred. The client has rebound tenderness when the client perceives sharp, stabbing pain as the examiner releases pressure from the abdomen (Blumberg's sign). It suggests peritoneal irritation (as from appendicitis).
How to perform the bulge test on the knee.
If you notice swelling, perform the bulge test to determine if the swelling is due to accumulation of fluid or soft-tissue swelling. The bulge test helps to detect small amounts of fluid in the knee. With the client in a supine position, use the ball of your hand firmly to stroke the medial side of the knee upward, three to four times, to displace any accumulated fluid. Then press on the lateral side of the knee and look for a bulge on the medial side of the knee. Bulge of fluid appears on medial side of knee, with a small amount of joint effusion.
What steps are taken when identifying various skin lesions?
If you observe a lesion: -Note color, shape, and size of lesion. -For very small lesions, use a magnifying glass to note these characteristics. -Note its location, distribution, and configuration. -Measure the lesion with a centimeter ruler. If you suspect a fungus, shine a Wood's light (an ultraviolet light filtered through a special glass) on the lesion. Palpate skin to assess texture. Palpate the lesion between the thumb and index finger for size, mobility, consistency, and tenderness. Observe for drainage or other characteristics.
What is objective data?
Information directly observed by the nurse. -Physical characteristics (e.g., skin color, posture) -Body functions (e.g., heart rate, respiratory rate) -Appearance (e.g., dress and hygiene) -Behavior (e.g., mood, affect) -Measurements (e.g., blood pressure, temperature, height, weight) -Results of laboratory testing (e.g., platelet count, x-ray findings)
What is subjective data?
Information elicited or verified only by the patient. -Biographical information (name, age, religion, occupation) -History of present health concern: Physical symptoms related to each body part or system (e.g., eyes and ears, abdomen) -Personal health history -Family history -Health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity, relationships, cultural beliefs or practices, family structure and function, community environment)
What are signs of peripheral arterial disease (PAD)?
Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity. These symptoms are quickly relieved by rest but reproducible with same degree of exercise and may indicate peripheral arterial disease
What is the Parietal lobe of the cerebrum responsible for?
Interprets tactile sensations, including touch, pain, temperature, shapes, and two-point discrimination.
When would you find spoon-shaped (koilonychias) nails?
Koilonychia Spoon-shaped nails that may be seen with trauma to cuticles or nail folds or in iron deficiency anemia, endocrine or cardiac disease).
What points to early signs of measles?
Koplik's spots (tiny whitish spots that lie over reddened mucosa) are an early sign of the measles.
Islam
Mohammed is believed to be the greatest of all prophets. Worship occurs in a mosque. Prayer occurs five times a day: dawn through, sunrise, noon, afternoon, sunset, and evening. Prayers are done facing east toward the sacred place in Mecca and often occur on a prayer rug with ritual washing of hands, face, and feet prior to prayer. Women are to be "modest" and are not to view men, other than their husbands, naked. Allah is in control of the beginning and end of life, and expressions of powerlessness are rare. To question or ask questions of health care providers is considered a sign of mistrust, thus clients and family are less likely to ask questions. All outcomes, whether death or healing, are seen as predetermined by Allah. It is important for dying clients to face east and to die facing east. Consumption of pork or alcohol is prohibited. Other meats must meet ritual requirements and many use kosher (Jewish ritual) foods because these meet the requirements of Islamic believers as well. During the holy days of Ramadan (29 days determined by the moon), neither food nor drink is taken between sunrise and sunset, though frail, ill, and young children are exempt.
CN I
Olfactory; Sensory -Ask the client to clear the nose to remove any mucus, then to close eyes, occlude one nostril, and identify a scented object that you are holding such as soap, coffee, or vanilla. Repeat procedure for the other nostril.
One liter of fluid is equivalent to...
One kilogram or 2.2 pounds
What is an open-ended question? Why is it important?
Open-ended questions are used to elicit the client's feelings and perceptions. They typically begin with the words "how" or "what." An example of this type of question is: "How have you been feeling lately?" Asking open-ended questions may help to reveal significant data about the client's health status.
CN II
Optic; Sensory -Use a Snellen chart to assess far vision in each eye. Have client stand about 20 feet from chart. -Ask the client to read a newspaper or magazine paragraph about 14 inches away to assess near vision. -Ask client to cover one eye and test for peripheral field view. Repeat procedure for other eye. -Use an ophthalmoscope to view the retina and optic disc of each eye. Normal: Round red reflex is present, optic disc is 1.5 mm, round or slightly oval, well-defined margins, creamy pink with paler physiologic cup.
What is visceral pain?
Pain of the abdominal cavity, thorax, cranium
What is deep somatic pain?
Pain of the ligaments, tendons, bones, blood vessels, nerves
What is cutaneous pain?
Pain of the skin or subcutaneous tissue
What's the difference between acute and chronic sinusitis?
Pain, tenderness, swelling and pressure around the eyes, cheeks, nose or forehead is seen in acute sinusitis, which is a temporary infection of the sinuses. In chronic sinusitis, the sinuses become inflamed and swollen, but symptoms last 12 weeks or longer even with treatment.
What is paronychia of the nails?
Paronychia Local infection.
When do you perform hand hygiene?
Perform hand hygiene: -Before having direct contact with patients -After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings -After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient) -If hands will be moving from a contaminated body site to a clean body site during patient care -After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient -After removing gloves
Gathering objective data for a nutritional assessment.
Physical examination includes observing body build, measuring weight and height, taking anthropometric measurements, and assessing hydration. -Observe client's general status and appearance -Observe body build as well as muscle mass and fat distribution -Measure height -Measure weight -Determine ideal body weight (IBW) -Measure body mass index (BMI) -Determine waist circumference -Measure mid-arm circumference (MAC). -Measure triceps skin fold thickness -Check skin turgor -Check for pitting edema -Observe skin for moisture -Assess venous filling -Observe neck veins with client in the supine position then -with the head elevated above 45 degrees -Inspect the tongue's condition and furrows -Gently palpate eyeball -Observe eye position and surrounding coloration. -Auscultate lung sounds
When will you have pink, frothy sputum?
Pink, frothy sputum may be indicative of pulmonary edema.
When would you find pitting in the nails?
Pitting Seen with psoriasis.
Stage II Pressure Ulcer characteristics
STAGE II Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.
Stage III Pressure Ulcer characteristics
STAGE III Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
Stage IV Pressure Ulcer characteristics
STAGE IV Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The depth of a stage IV pressure ulcer varies by anatomic location (see stage III). Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
Equipment needed for Peripheral Vascular Examination
Sphygmomanometer and stethoscope, flexible metric measuring tape, tuning fork, and Doppler ultrasound
Equipment needed for vital signs
Sphygmomanometer and stethoscope, thermometer, watch, pain scale
CN XI
Spinal accessory; Motor -Ask the client to shrug the shoulders against resistance to assess the trapezius muscle. -Ask the client to turn the head against resistance, first to the right then to the left, to assess the sternocleidomastoid muscle
Identify possible significance of pain in head, face, and neck.
Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. Stress, tension, poor posture while performing work and lack of proper exercise may lead to head and neck discomfort. The most common types of headaches are related to vascular (e.g., migraine), muscle contraction (tension), traction, or inflammatory causes. Older clients who have arthritis or osteoporosis may experience neck pain and a decreased range of motion. Previous head and neck trauma may cause chronic pain and limitation of movement. Sudden weakness or numbness in the face, arms, or legs—especially on one side of the body—may indicate an impending stroke
What are the signs and symptoms of a syphilitic chancre in males?
Syphilitic Chancre Initially a small, silvery-white papule that develops a red, oval ulceration. Painless. A sign of primary syphilis (a sexually transmitted infection [STI]) that spontaneously regresses. May be misdiagnosed as herpes.
Describe the Rinne test and possible findings.
The Rinne test compares air and bone conduction sounds. Strike a tuning fork and place the base of the fork on the client's mastoid process. Ask the client to tell you when the sound is no longer heard. Move the prongs of the tuning fork to the front of the external auditory canal. Ask the client to tell you if the sound is audible after the fork is moved. Air conduction sound is normally heard longer than bone conduction sound (AC > BC). With conductive hearing loss, bone conduction (BC) sound is heard longer than or equally as long as air conduction (AC) sound (BC ≥ AC).
Describe the Weber test and possible findings.
The Weber test assesses sound conducted via bone. Perform Weber's test if the client reports diminished or lost hearing in one ear. The test helps to evaluate the conduction of sound waves through bone to help distinguish between conductive hearing (sound waves transmitted by the external and middle ear) and sensorineural hearing (sound waves transmitted by the inner ear). Strike a tuning fork softly with the back of your hand and place it at the center of the client's head or forehead. Centering is the important part. Ask whether the client hears the sound better in one ear or the same in both ears. With conductive hearing loss, the client reports lateralization of sound to the poor ear—that is, the client "hears" the sounds in the poor ear. The good ear is distracted by background noise and conducted air, which the poor ear has trouble hearing. Thus the poor ear receives most of the sound conducted by bone vibration. With sensorineural hearing loss, the client reports lateralization of sound to the good ear. This is because of limited perception of the sound due to nerve damage in the bad ear, making sound seem louder in the unaffected ear.
How do you assess for fremitus?
The ball of the hand is best for assessing tactile fremitus because the area is especially sensitive to vibratory sensation. Start toward the midline at the level of the left scapula (over the apex of the left lung) and move your hand left to right, comparing findings bilaterally. Move systematically downward and out to cover the lateral portions of the lungs at the bases. Use the ball or ulnar edge of one hand to assess for fremitus (vibrations of air in the bronchial tubes transmitted to the chest wall). As you move your hand to each area, ask the client to say "ninety-nine." Assess all areas for symmetry and intensity of vibration. Unequal fremitus is usually the result of consolidation (which increases fremitus) or bronchial obstruction, air trapping in emphysema, pleural effusion, or pneumothorax (which all decrease fremitus). Diminished fremitus even with a loud spoken voice may indicate an obstruction of the tracheobronchial tree.
What is characteristic of SLE? Who is most at risk?
The butterfly rash (also called Malar rash) across the bridge of the nose and cheeks is characteristic of systemic lupus erythematosus (SLE). SLE is seen in a 9:1 female-to-male ratio and is more common in black and Hispanic people.
What happens to the older person's teeth and gums as they age?
The gums recede, become ischemic, and undergo fibrotic changes as a person ages. Tooth surfaces may be worn from prolonged use. These changes make the older client more susceptible to periodontal disease and tooth loss.
What is the function of the hypothalamus?
The hypothalamus (part of the autonomic nervous system) is responsible for regulating many body functions including water balance, appetite, vital signs (temperature, blood pressure, pulse, and respiratory rate), sleep cycles, pain perception, and emotional status.
What are the four main purposes of assessing culture in a health care setting?
The main purposes of assessing culture in a health care setting are: -To learn about the client's beliefs and usual behaviors associated with health and illness, including beliefs about disease causes, caregiving, expected treatments (both Western medicine and folk practices), daily hygiene, food preferences and rituals, religious beliefs relative to health care. -To compare and contrast the client's beliefs and practices to standard Western health care. -To compare the client's beliefs and practices with those of other persons from a similar cultural background (to avoid stereotyping). -To assess the client's health relative to diseases prevalent in the specific cultural group.
What is the function of the medulla oblongata?
The medulla oblongata contains the nuclei for cranial nerves, and has centers that control and regulate respiratory function, heart rate and force, and blood pressure.
What is the function of the midbrain?
The midbrain serves as a relay center for ear and eye reflexes, and relays impulses between the higher cerebral centers and the lower pons, medulla, cerebellum, and spinal cord.
Assessing urinary incontinence.
The nursing assessment varies somewhat depending on the client's general health status and whether the problem is an acute or chronic one. In general, however, a comprehensive nursing assessment can be described as a five-step process that includes screening for an infection with urinalysis, obtaining a voiding diary, evaluating functional status, compiling a health history, and performing a physical examination. Key features within the five steps follow: -Record all incontinent and continent episodes for 3 days in a voiding diary. -Review medication for any newly prescribed drugs that may be triggering incontinence. Follow up with physician regarding need to discontinue therapy or change medication. -Rule out constipation or fecal impaction as a source of urinary incontinence. If client has had no bowel movement within last 3 days or is oozing stool continuously, check for impaction by digital examination or abdominal palpation. Problem should be treated if identified. -Assess functional status along with signs and symptoms as they relate to incontinence. Contributors to incontinence may include immobility, insufficient fluid intake, and confusion. Accompanying signs and symptoms include polyuria, nocturia, dysuria, hesitancy, poor or interrupted urine stream, straining, suprapubic or perineal pain, urgency and characteristics of incontinent episodes (precipitated by walking, coughing, getting in and out of bed, and so forth). -Consult physician regarding physical examination and need to measure postvoid residual volume by straight catheterization (particularly if client dribbles, reports urgency, has difficulty starting stream). Components of the physical examination include direct observation of urine loss using a cough stress test; abdominal, rectal, genital, and pelvic examination; and identification of neurologic abnormalities. Abdominal and vaginal examinations are performed to detect prolapse or a palpable bladder after micturition.
What is the purpose of a nursing health assessment?
The purpose of a nursing health assessment is to collect holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment. The nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client. Thus the nurse performs holistic data collection.
What do the superficial inguinal nodes drain?
The superficial inguinal nodes consist of two groups: a horizontal and a vertical chain of nodes. The horizontal chain is located on the anterior thigh just under the inguinal ligament, and the vertical chain is located close to the great saphenous vein. These nodes drain the legs, external genitalia, and lower abdomen and buttocks
What does the sympathetic nervous system do?
The sympathetic nervous system ("fight-or-flight" system) is activated during stress and elicits responses such as decreased gastric secretions, bronchiole dilatation, increased pulse rate, and pupil dilatation. These sympathetic fibers arise from the thoracolumbar level (T1 to L2) of the spinal cord.
What is the function of the thalamus?
The thalamus is responsible for screening and directing impulses to specific areas in the cerebral cortex.
What does the thoracic duct drain?
The thoracic duct drains the rest of the body that the right lymphatic duct does not drain
Identify ways of validating assessment data.
There are several ways to validate your data: -Recheck your own data through a repeat assessment. For example, take the client's temperature again with a different thermometer. -Clarify data with the client by asking additional questions. For example, if a client is holding his abdomen the nurse may assume he is having abdominal pain, when actually the client is very upset about his diagnosis and is feeling nauseated. -Verify the data with another health care professional. For example, ask a more experienced nurse to listen to the abnormal heart sounds you think you have just heard. -Compare your objective findings with your subjective findings to uncover discrepancies. For example, if the client states that she "never gets any time in the sun," yet has dark, wrinkled, suntanned skin, you need to validate the client's perception of never getting any time in the sun by asking exactly how much time is spent working, sitting, or doing other activities outdoors. Also, ask what the client wears when engaging in outdoor activities.
Common signs and symptoms of chronic allergies.
Thin, watery, clear nasal drainage (rhinorrhea) can indicate a chronic allergy A line across the tip of the nose just above the fleshy tip is common in clients with chronic allergies. Small, pale, round, firm overgrowths or masses on mucosa (polyps) are seen in clients with chronic allergies Nasal mucosa is swollen and pale pink or bluish gray in clients with allergies.
How to perform the ballotment test on the knee.
This test helps to detect large amounts of fluid in the knee. With the client in a supine position, firmly press your nondominant thumb and index finger on each side of the patella. This displaces fluid in the suprapatellar bursa, located between the femur and patella. Then with your dominant fingers, push the patella down on the femur. Feel for a fluid wave or a click. Fluid wave or click palpated, with large amounts of joint effusion. A positive ballottement test may be present with meniscal tears.
Equipment needed for Female Genitalia and Rectum Examination
Vaginal speculum and water-soluble lubricant, Bifid spatula, endocervical broom to obtain endocervical swab and cervical scrape and vaginal pool sample, large swabs, liquid pap medium, pH paper, feminine napkins
CN X
Vagus; Sensory Motor -Test swallowing and gag reflex. -Look for soft palate symmetry and midline uvula when saying "ahhhh". -Listen for hoarseness when patient speaks. -Check HR, O2 saturation and bowel sounds as they are all related to CN X.
Venous ulcers
Venous ulcers are usually painless and occur on the lower leg or medial ankle.
When should you use gloves?
Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur. Change gloves during patient care if the hands will move from a contaminated body site (e.g., perineal area) to a clean body site (e.g., face).
