Physical Examination Notes Exam One, Two, and Three
SOAP note
Different from nursing process but part of the assessment in the nursing process - subjective - objective - assessment - planning
Flat percussion
Heard over the sternum, muscle or areas of atelectasis.
Physical Exam Techniques
Inspection Palpation Percussion Auscultation
inspection
Inspection is concentrated watching. It is close, careful scrutiny, first of the individual as a whole and then of each body system. Inspection begins the moment you first meet the person and develop a general survey.
medical diagnosis vs nursing diagnosis
Medical Diagnosis: is used to evaluate the cause or etiology of disease Nursing Diagnosis: clinical judgements about a persons response to an actual or potential health state
Arm band
Patient identifiers
How to do percussion
Use the middle finger as the striking finger and other hand to lay out of body.
pitch
a tone's experienced highness or lowness; depends on frequency
Environment
every nongenetic influence, from prenatal nutrition to the people and things around us
Percussion
tapping the persons skin with short, sharp strokes to assess underlying structures.
palpation: base of the fingers or ulnar surface of the hand
vibration
Outcome Identification
· Identify expected outcomes · Individualize to the person · Culturally appropriate · Realistic and measurable · Include a timeline
Implementation
· Implement in a safe and timely manner · Use evidence based interventions · Collaborate with colleagues · Use community resources · Coordinate care delivery · Provide health teaching and health promotion · Document implementation and any modification
Mobility equipment in room
· Walker · Wheelchair · Gait belt · Transfer equipment
Disease based precautions - airborne
- N95 respirator - gloves - gown
Toddler age
1-3 years
Adolescent age
12-18
Preschooler age
3-5 years
tympany
A bell-like noise when tapping the abdomen
Primary care
A doctor who provides general medical care and coordinates other health care.
Allergies
Allergies and need to know their reactions(itchiness vs shortness of breath)
Ask Tell Ask
A simple reminder to clinicians to increase their chances of their advice sticking to the patients - ask permission to give advice - ask what they know or want to know - tell simply and things personal and specific to that individual - ask what they think of the info or ask teach back question to check understanding
Sinus Arrhythmia
A sinus rhythm in which the rate varies with respiration, causing an irregular rhythm. Increase with inhale and decrease with exhale
acute illness
A sudden illness from which a person is expected to recover
Culture and Genetics: PAD - ABI
ABI is a noninvasive screening tool for PAD
Rinne test normal finding
AC greater than BC
diastole - Rapid filling
AV open, blood going to atria and ventricles
What is the most common location for an aortic aneurysm
Abdominal aorta - lose a lot of blood quickly
CN VI
Abducens controls lateral rectus muscle that abducts eye
---- is very common in our society and impacts client care in every nursing context.
Abuse(drug/alcohol)
CN XI
Accessory Nerve swallowing, head, neck, and shoulder movements
AIDET procedure
Acknowledge Introduce Duration Explain Thank
Adventitious sounds
Added sounds that are not normally heard in the lungs - crackles - rhonchi - wheezing - stridor - pleural friction rub
Sutures
Adjacent cranial bones mesh at sutures - coronal, sagittal, lambdoid
Simpler term for respiratory dead space
Air that goes into nasal cavity and goes down into trachea and does not actually get down into the lungs for gas exchange - ventilation without perfusion
Bronchioles
Airways in the lungs that lead from the bronchi to the alveoli.
What causes a high risk of breast cancer?
Alcohol use - screening mammograms are important at the age of 40 and should continue
Precordium Auscultation Points
All People Enjoy Time Magazine - Z pattern
What happens when measuring infant blood pressure when crying?
Allow crying infant to become quiet for 5 to 10 minutes before measuring the BP, crying may elevate the SP by 30-50 mmHg
Trachea
Allows air to pass to and from lungs. Midline and has cartilage which gives ridgitidy and protection
Abnormal findings: Lumps and Lesions on External Ear - chondrodermatitis nodularis helicis
Along helix of ear, due to mechanical pressure(MMA fighters), red, painful, hardened area
Leukonychia
Also known as white spots, whitish discoloration of the nails caused by injury
Important things for assessing for vascular and peripheral circulation
Always look at bilateral extremities and compare them when assessing. Assess both radial pulses. Use both hands and compare each side.
Inspection of the Face: Facial structures
Always should be symmetric - when smile are lips the same
Dementia
An abnormal condition marked by multiple cognitive defects that include memory impairment.
obsessive-compulsive disorder
An anxiety disorder characterized by unwanted repetitive thoughts (obsession) and/ or actions (compulsions).
Physical examination: Infants and children - Neck appearance
An infant's neck looks short; it lengthens during the first 3 to 4 years
Medications that cause gynecomastia
Anabolic steroids and estrogens and methadone
Nurse palpates sternum and finds a horizonal ridge, what is this?
Angle of Louis
precordium
Anterior portion of the chest that lays over the - great vessels(connected to the heart) - location of base and apex
Posterior assessment - inspection: AP diameter
Anterior posterior in comparison to transverse diameter - transverse should be longer than anterior and posterior - AP:T = 1 to 2
When asked a personal question
Anwser then direct it back to them
Subjective Questions: Earache - any?
Any accompanying cold symptoms or sore throat? Any problems with sinuses or teeth?
Vision Difficulty Questions
Any difficulty seeing or any blurring? Blind spots? Come on suddenly or slowly? One eye or both? Constant, or does it come and go? Do objects appear out of focus or clouding of objects? Do spots move in front of your eyes? One or many? In one or both eyes? Any halos, rainbows, rings around objects? Any blind spot? Does it move as you shift your gaze? Any loss of peripheral vision? Any night blindness?
Subjective data questions: mouth and throat - dysphagia
Any difficulty swallowing? how long have you had it? do you feel as if food gets stopped at a certain point? any pain with this?
Subjective Questions: Infections and Discharge - Discharge
Any discharge from your ears? Does it look like pus, or is it bloody? Any odor to the discharge? Any relationship between discharge and ear pain?
Additional History for Infants and Children questions
Any dryness in the mouth? are you taking any medications? have you had any loss of teeth? can you chew all types of food? are you able to care for your own teeth or dentures? have you noticed a change in your sense of taste or smell?
Subjective Questions: Infections and Discharge - Infections
Any ear infections? As an adult or in childhood? How frequent were they? How were they treated?
Eye pain questions
Any eye pain? please describe. Come on suddenly? Burning or itching? or sharp, stabbing pain; pain with bright light? A foreign body sensation? or deep aching? or headache in brow area?
Past history of ocular problems questions
Any history of injury or surgery to eye? any history of allergies?
Subjective data questions: nose - frequent colds
Any unusually frequent or severe colds(upper respiratory infections)? How often do these occur?
Watering and discharge questions
Any watering or excessive tearing? Any discharge? Any matter in the eyes? Is it hard to open your eyes in the morning? what color is the discharge? how do you remove matter from eyes?
Abnormal Findings: Pediatrics - Allergic salute and crease
Appearance of transverse line on the nose in response to chronically repeated use of hand to push the nose up and back
Iris
Appears flat, with round regular shape and even coloration
Weight in adults adults
Appears sharper in contour with more prominent bony landmarks than younger adult - weight decreases during 80s and 90s; this factor more evident in males - distribution of fat also changes during 80s and 90s
culturally appropriate
Applying underlying background knowledge necessary to provide the best possible health care
Abnormal percussion - pleural effusion
Area of dullness
What is the difference with arterial and venous issues?
Arterial is there is too much blood returning to the heart while with venous there is trouble getting it back to the heart and there is extra blood flow in a specific area
Arterial and Venous insufficiency - Nails
Arterial: Thick and brittle Venous: normal
Arterial and Venous insufficiency - Pain
Arterial: Worse with elevation and exercise; sudden and severe; rest pain; claudication; no compression socks Venous: Better with elevation; dullness or heaviness
Arterial and Venous insufficiency - Temperature of extremity
Arterial: cool Venous: warm
Arterial and Venous insufficiency - Pulses
Arterial: decreased, weak or absent Venous: normal or bounding
Arterial and Venous insufficiency - Ulcers
Arterial: dry and necrotic Venous: moist
Arterial and Venous insufficiency - color
Arterial: pale Venous: Ruddy
Auscultation - Breath Sounds
Ask patient to take deep breath each time move stethoscope. Move it each side 9 times - voice sounds - adventitous sounds
Health Promotion and Patient Teaching - Appropriate aspirin therapy
Aspirin prevent cardiac or stroke event - when the potential benefit of preventing a heart attack outweighs potential bleeding
Inspection and Palpation: Skin - Edema
Assess for fluid accumulation in the interstitial space - push and see if there is an indentention in skin
Inspection and Palpation: Skin - vascularity or bruising
Assess for presence of tattoos and/or variations
Infants and children visual fields
Assess peripheral vision with confrontation test in children older than 3 years
Inspection and Palpation: Skin - Mobility and turgor
Assess skin elasticity on sternum or wrist - pinch and skin will stay raised w222222
Corneal Light Reflex (Hirschberg Test)
Assess the parallel alignment of the eye axes by shining a light toward the person's eyes. Direct the person to stare straight ahead as you hold the light about 30 cm away. Note reflection of light on corneas; should be in exactly same spot on each eye
Pain scores
Assigned using pain assessment tools
Physical examination: Infants and children - two common variations in newborn cause shape of skull to look markedly?
Asymmetric due to birth trauma
Additional History for Infants and Children questions: Ear Infections
At what age was child's first episode? How many ear infections in past 6 months? How many total? How were these treated? Has child had any surgery, such as insertion of ear tubes or removal of tonsils? Are infections increasing in frequency, in severity, or staying same? Does anyone in the home smoke cigarettes? Does child receive care outside your home? In daycare center or someone else's home? How many children in group care?
High-Pitched, Polyphonic Wheeze
Auscultated mainly in expiration - high pitched musical instrument with more than one type of sound quality - asthma/lung disease
Low-Pitched, Monophonic Wheeze
Auscultated mainly in expiration - low pitched whistling tune or whine with one type of sound quality - asthma/lung disease
Does it matter what time of the month a women performs the self breast exam? If so, how would you educate them?
BSE should be performed after the menstrual period. I would tell the patient to perform the exam in the day or two after their period ends for the most accurate results.
Health promotion - average-risk women should not perform?
BSE. Several studies have shown lack of benefit and a higher rate of breast biopsy that shows benign disease with routine BSE. Up-to-date
Health
Balance of a person is complex, interrelated phenomenon - within one's being: physical, mental, spiritual - in outside world: natural, communal, metaphysical
abnormal inspection - increase AP diameter
Barrel chest commonly seen in COPD because have enlarged lungs from overinflating - ribs horizontal rather than slope - 1:1
Developmental Competence: Children
Be on the lookout for poor weight gain, developmental delay, persistent tachycardia, tachypnea, dyspnea on exertion, cyanosis, and clubbing - palpate apical pulse
What is not a way to show empathy?
Be stone faced while listening
Objective data - Preparing for the assessment: Infection control
Be sure to clean the stethoscope
Inspection of the mouth
Begin with anterior structures and move posteriorlu; use tongue blade to retract structures and bright light for optimal visualization
Annular or Circular
Begins in center and spreads to periphery(round shape)
The spirit of MI is based on what four elements?
Being collaborative, evocative, respectful of autonomy, compassionate
Which side of the stethoscope should you use to listen to a patient's blood pressure?
Bell or diaphragm
Physical examination: Infants and children - Face - Parotid gland enlargement
Best seen when child looks up; swelling appears below angle of jaw
Common skin lesions - Tinea pedis(ringworm of the foot - athletes foot)
Between the toes, contagious
Seizure activity
Bicycling motion or sucking movements are manifestation of seizure.
Double Billing
Billing more than one client for the same billable time period. Safeguards to prevent this
Health history includes
Biographic data, reason for seeking care, present health or history of present illness, past history, medication reconciliation, family history, review of systems, functional assessment or activities of daily living
Liniagura
Black line that forms on the belly, usually goes away
Abnormal findings: ear canal abnormalities - excessive cerumen
Blocking the entire eardrum
venoustasis
Blood that sits still in the vessels - if there is a dysfunction in the three things
Facial nerve palsy
Borrelia burgdorferi (Lyme disease)
equal-status seating
Both you and the patient should be comfortably seated at eye level, about 4-5 feet apart. Avoid standing which communicates haste and superiority
What is the best method to assess heart rate in an infant?
Brachial pulse when larger but for an infant auscultate the heart rate.
What is one of the most important ways to interrupt the spread of infection?
Breaking the chain at the 'mode of transmission'
Developmental Competence - Puberty
Breast begin to enlarge and alveoli
Aging women breasts - on palpation
Breasts feel more glandular; terminal ducts around nipple feel more prominent and stringy
What does it mean when breasts feel more glandular?
Breasts will feel more lumpy, this isnt concerning for aging women because they couldve been always present so since the skin is changing they may become more prominent
Do you breathe in or out in a spirometer?
Breath in
Abnormal respiratory patterns - hyperventilation
Breathing fast and breathing deep - fully expand and bring air in - putting off more CO2 so use paper bag to breath it back in
Abnormal respiratory patterns - Hypoventilation
Breathing slow and shallow - not blowing off waste products so patient can become acidotic state(sleepy, LOC)
Reason for seeking care
Brief statement in the persons own words that describes the reason for the visit.
Infants and Children: Special procedures - auscultation
Bruits are common in skull of children under 4 or 5 years or children with anemia - systolic or continuous; heard over temporal area
spinal nerves
C3, C4, C5 keep your diaphragm alive - if damaged will not be able to breath on their own
Farenheit to Celsius
C= 5/9 (F-32)
Alcohol, benzodiasepines(xanax, valium, ativan, ambien), opioids(oxycodone, morphine, methadone) behaviors
CNS depressants: somnolent, sleep apnea - calming effect so counters withdrawal symptoms
Cocaine, amphetamine behaviors
CNS stimulants: intense high, agitation, paranoid
Abnormal inspection - neck muscles
COPD - neck muscles and shoulder muscles are bulked up and skin is pulled in which is a sign of respiratory distress - acute respiratory distress can also have these retractions
Those with DVT may also have a Homans' sign which is?
Calf pain brought on by dorsiflexion of the foot - not advised and not a reliable predictor - most reliable is ultrasound of the leg
Health Promotion and Patient Teaching - Smoking cessation
Can damage lining of arteries which can cause plaque buildup
Abnormal findings: Lumps and Lesions on External Ear - sebaceous cyst
Can get anywhere on body, sebaceous material can cause a pimple or cyst on back of ear
What does CRAFFT stand for?
Car Relax Alone Forget Friends Trouble
CRAFFT
Car Relax Alone Forget Friends Trouble - teens
veins - intraluminal valves in veins
Cause blood to flow in one direction, shaped like SL valves
Abnormal findings: ear canal abnormalities - polyp
Causes irritation and block the hearing
Abnormal findings: red eye - vascular disorders - Iritis(circumcorneal redness)
Causes pain, more redness, irregular shape from swelling, light sensitivity, constricted pupil, throbbing, referral, blurring
Stetching of the skin
Causes stretch marks and scarring, very vascularized and cant resist sunlight
pustule
Cavity filled with fluid but filled with exudate, purdulent drainage
Developmental Competence: The aging adult - Skin breakdown due to multiple factors
Cell replacement is slower and wound healing is delayed due to thinner skin, less fat,
Occasionally ear canal partially filled with?
Cerumen, which obstructs view of TM
Heart structures - Chambers - left atrium
Chamber that receives oxygenated blood from the pulmonary veins and pumps it into systemic circulation.
generalized anxiety disorder
Characterized by excessive anxiety or worry about numerous things, lasting for 6 months or longer.
Physical examination: Infants and children - Face
Check facial features for symmetry, appearance, and swelling - note symmetry of wrinkling when infant cries or smiles(normally no swelling is evident)
Ask the person to bite as if?
Chewing something, and note alignment of upper and lower jaw
Past health
Childhood Illnesses, accidents or injuries, serious or chronic illnesses, hospitalizations, operations, obstetric history, immunizations, last examination date, allergies, current medications.
When should a doppler be used?
Children younger than 3 have small arm vessels which is hard to hear Korotkoff sounds, use a doppler ultrasound device to amplify the sounds
confrontation
Clarifying inconsistent information Focusing client's attention on an observed behavior, action, or feeling
Names of opioids
Class 2 oxycodone, morphine, methadone, OxyContin, fentanyl
A 67 year old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved when sitting.
Claudication
rhinorrhea
Clear nasal discharge, "runny nose"
mental disorder
Clinically significant behavior that is cognitive or emotional that is associated with significant distress or disability involving social, occupational, or key activities(affecting every day life)
Who is the first and most frequent person to come in contract with a someone using substances that can complete the screening?
Clinician
Grouped
Cluster of lesions(shingles or scabies)
Lymphatics
Collects excess fluid and plasma proteins from the interstitial spaces and returns it to the blood stream
Common skin lesions - erythema migrans of lyme disease
Common with tic bite, center red mark or target appearance ask if they have been biten, been outdoors, and is it in the time frame that tics are out
Communicating with toddler
Communicate with limited vocab, telegrpahic speech is a combination of noun and verb. Older toddlers want to know why so provide simple explanation and keep it simple
Ankle Brachial Index
Comparison of the blood pressure in the leg vs. the arm; normal ratio is greater than 1 - can determine the extent of peripheral artery disease
Which of the following actions is appropriate for a nurse who has witnessed a breach of a patient's privacy in a primary care providers office?
Complete a health information privacy complaint form and submit it to the appropriate agency
Attention Span
Complete a thought without wandering
Complete database
Complete health history and full physical examination. It describes the current and past health state and forms a baseline against which all future changes can be measured. Yields the first diagnoses. Collected in primary care setting. For well and ill people, it must screen for pathology and determine the ways people respond to that pathology or to any health problem. In acute hospital care it is gathered on admission to the hospital.
carotid sinus hypersensitivity
Condition in which pressure over the carotid sinus leads to a decreased heart rate, decreased BP, and cerebral ischemia with syncope. May occur in older adults with hypertension or occlusion of the carotid artery
Cooper ligaments are?
Connective tissue and support the breast
Objective data preparation
Consciously attend to skin characteristics; the danger is one of omission
Communicating with adolescent
Consider attitude, respectful, communication needs to be honest, stay in chracter, focus on person not the problem, be positive, confidentiality
holistic health
Consideration of the whole person is the essence of holistic health. It views the mind, body, spirit as interdependent and functioning as a whole within the environment. In a holistic model, assessment factors are expanded to include such things as lifestyle behaviors, culture and values, family and social roles, self care behaviors, job-related stress, developmental tasks, and failures and frustrations of life. All are significant to health.
When performing a respiratory assessment on a client, the nurse notes breath sounds that are of medium pitch and loudness with a ratio of inspiration and expiration being equal near the anterior sternal area:
Considers these normal bronchovesicular breath sounds for this location
After completing a respiratory assessment, the nurse documents: AP:T diameter 1:2, symmetrical chest expansion, respiratory rate 16 and regular:
Considers these normal findings
What causes increased fremitus?
Consolidation in the lung tissue because sound is conducted better in dense structure - pneumonia
Reporting a violation
Contact the privacy officer for first point of contact and he will investigate and document privacy breach
Heart Structures - Layers Pericardial cavity
Contains fluid that lubricates the heart and its layers
What does the diaphragm do?
Contracts and relaxes to allow a person to breath
Rate
Counting that rate over a minute, count the number of beats in 30 seconds and multiply by 2. Lower you go the more likely you will have errors. If abnormal do the whole minute. When begin to count the rate start with 0 then count.
Scale
Debris on the surface but usually dead keratinized skin cells building up causing scaley surface(scorisis)
veins - Inspiration pump
Decreases thoracic pressure and increase abdominal pressure which helps flow
Abnormal respiratory patterns - kussmaul
Deep and shallow breaths but rapid breathing - diabetic ketoacidosis
Abnormal respiratory patterns - cheyne-stokes respiration
Deep respirations, shallow respirations, and periods of apnea - close to death - regular(pattern)
Ulcer
Deeper depression that extends into the dermis that causes bleeding and is irregular shape
Heritage consistency
Degree to which a person's lifestyle reflects his or her traditional heritage
conjunctiva
Delicate membrane lining the eyelids and covering the eyeball
Example of Nursing Plan Outcome
Demonstrate relief of pain as evidenced by stable vital signs, absence of muscle tension and restlessness 30 minutes after administration of medications
Atherosclerosis
Deposits of fatty plaques in the layers of the arterial wall - related to diet exercise and obesity
Inspection and Palpation: Nails - capillary refill
Depress nail edge to blanch and then release, noting return of color; indicates status of peripheral circulation
Abnormal Conditions of the Nails - habit-tic dystrophy
Depression down middle of nail or multiple horizontal ridges, caused by continuous picking of cuticle by another finger of same hand, which causes injury to nail base and nail matrix.
Ethnicity
Describes a group united by the following: - common geographic origin - migratory status - religion - race - language - shared values, traditions, or symbols - food preferences
Nursing Process Planning
Determine an outcome(goal) for the patient related to their nursing diagnosis
School age child major task
Develop industry. Basic competency in school and social and desires the approval of caregivers and teachers and has feeling of accomplishment.
Toddler major task
Developing autonomy, so may cling to caregiver
Preschool child major tasks
Developing initiative, tasks independently, plans the tasks and sees them through. Cooperative, helpful, and easy to involve. Fears body injury and mutilation.
Abnormal Findings: Primary Headaches
Diagnosed by patient history with no abnormal findings on exam or lab results
Common skin lesions in children - diaper dermatitis
Diaper rash, inflammation of diaper area, red, moist, burning - leave diaper off, baking soda bath, zinc oxide
The bases of the lungs rest on the?
Diaphragm bilaterally
Hearing loss Questions: Every had any trouble hearing? Onset
Did loss come on slowly or all at once?
Abnormal findings: tympanic membrane - insertion of tympanostomy tubes
Did not heal right and can see the bones
If hearing loss was noted, what questions do you use?
Did you obtain a hearing aid? How long have you had it? Do you wear it?How does it work? Any trouble with upkeep, cleaning, changing batteries?
Clinical Portrait of Heart Failure
Dilated pupils, skin pale, gray or cyanotic, dyspnea, orthopnea, crackles, cough, decreased BP, N&V, ascites, pitting edema, anxiety, falling O2 sat, confusion, JVD, MI, fatigue, S3 gallop, enlarged spleen, decreased urine output, weak pulse.
Signs of Retraction and Inflammation
Dimpling Fixation Edema (peau d'orange) Deviation in nipple pointing Nipple Retraction
Common skin lesions in children - Chickenpox(varicella)
Discrete vesicles, herpes zoster is latent version of this - measles, german measles(rubella)
Discrete
Distinct and separate
Common skin lesions in children - Intertrigo(candidiasis)
Distinct borders, a brighter red, due to yeast infection, aggrevated by heat, moisture, burning, hurts when go to bathroom
Concussion symptoms
Dizziness Confusion Trouble concentrating Headache Memory loss Balance/coordination problems light sensitivity nausea behavior changes - how many concussions have you had
Hearing loss Questions: Every had any trouble hearing? Efforts to treat:
Do you have any hearing aid or other device? Anything that helps hearing?
Environmental noise questions - coping strategies
Do you take any steps to protect your ears, such as headphones or earplugs?
A patient is brought to the emergency department after a motor-vehicle crash. She is unresponsive due to a head injury. Permission for emergency surgical stabilization of a cervical injury was obtained over the phone from her husband, who is currently overseas. Which of following should the assigned nurse document to verify HIPAA guidelines were maintained?
Document the patient's condition and that consent was obtained after the primary care provider discussed the proposed surgery with the husband.
Additional history for infants and children - mouth infections or sores
Does child have any mouth infections or sores, such as thrush or canker sores? how frequently? Does child have frequent sore throat or tonsillitis? how often? how are these treated? have they ever been documented as streptococcal infections?
Subjective Questions: Earache - Location
Does it feel close to surface or deep in head? Does it hurt when you push on ear?
Abnormal findings: cornea and iris - pterygium
Does not need treatment, happens with those in hot, dry, sandy areas - thin tissue growing into the cornea from the conjunctiva, usually caused from sun exposure
Region and radiation
Does your pain radiate? Where does it spread? Point to where it hurts the most. Where does you pain go from there?
Abnormal findings: eyelid abnormalities - upward palpebral slant
Down syndrome
Veins
Drain deoxygenated blood and waste products from tissues and return it to heart
Common skin lesions in children - Atopic dermatitis(eczema)
Dry scaley skin and itches bad, papules or vesicles
Lower extremities - peripheral heart
Due to calf muscle contraction and relaxation which moves blood closer to the heart - mobility
spider veins
Due to the weight gain and skin color changes
stridor
During inspiration - high pitched whistling or gasping sound with harsh sound quality - croup or epiglottitis, airway obstruction - requires medical treatment
Physical Examination: Pregnant Female
During second trimester - chlosma may shoe on face(blotchy, hyperpigmented area over cheeks and forehead that fades away after delivery) Thyroid gland may be palpable normally during pregnancy
Infants and children - lumen surrounded by lymphoid tissue, which increase?
Duroing childhood and is easily occluded - these factors place infants at greater risk for middle ear infections than adults
Example of nursing assessment
EKG abnormal, chest pain, abnormal vital signs, troponins elevated
Abnormal findings: ear canal abnormalities - Otitis externa
Ear canal is swollen with drainage
Communicating with preschooler
Egocentric, and view world from their point of view. Scared.
HIPPA mandated that health care entities implement which of the following strategies to help reduce Medicare fee-for-service error rate and prevent payment for potential fraudulent activity?
Electronic health records
Goal of healthy people?
Eliminate health disparities. A health disparity is a type of health difference that is closely linked with social, economic, and environmental disadvantage - health disparities affect groups of people who have experienced obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, age, mental health, sexual orientation, geographic location
Abnormal Facial Appearances - Acromegaly
Elongated head, massive face, overgrowth of nose, lower jaw, heavy eyebrow ridge, and coarse facial features
What does mental status mean?
Emotional and cognitive functioning of a patient - cannot be explored as directly like characteristics of a physical assessment
Abnormal Findings: Swellings of Head and Neck - simple diffuse goiter
Endemic goiter due to iodine deficiency that results in chronic enlargement of the thyroid gland
what are the four tasks of MI?
Engage, Focus, Evoke, Negotiate
A 35 year old man is seen in the clinic for an infection in his left foot. Which of these findings may be an expected finding during an assessment?
Enlarged and tender inguinal nodes
Epitrochlear lymph nodes
Epitrochlear lymph nodes- drains from the hand and forearm proximally via epitrochlear lymph node. Near brachial pulse. Not palpable. - HIV, lymphoma
Which of the following is an example of a best practice strategy to prevent fraud, waste, and abuse?
Establish procedures for maintaining and distributing medication samples
Subjective Questions: Earache - past injuries
Ever been hit on ear or on side of head or had any sport injury? Ever had any trauma from a foreign body?
Tinnitus questions
Ever felt ringing, crackling, or buzzing in your ears? When did this occur? Does it seem louder at night? Are you taking any medications?
Vertigo questions
Ever felt vertigo, that the room is spinning around or feel that you are spinning? Ever felt dizzy, like you are not quite steady, or falling or losing your balance? Giddy, light-headed?
lymph nodes
Everything that goes through lymphatics goes through lymph nodes. Inflamed with infection because filtering it and doesn't want to return it back to the heart. - don't feel unless there is an inflammatory response going on
Keloid
Excessive scaring when scar tissue grows a lot. Raised scarring. More often in dark skinned patients
Developmental competence - The pregnant women: skin color
Expected skin color changes due to increased hormone levels
What are the four basic principles of MI?
Express empathy, develop discrepancy, roll with resistance, support self-efficacy
broca aphasia
Expressive aphasia. The person can understand language but cannot express himself or herself using language. This is characterized by nonfluent, dysarthric, and effortful speech. The speech is mostly nouns and verbs (high-content words) with few grammatic fillers, termed agrammatic or telegraphic speech. Repetition and reading aloud are severely impaired. Auditory and reading comprehensions are surprisingly intact. Lesion is in anterior language area called the motor speech cortex or Broca area.
Eyeballs
Eyeballs aligned normally in their sockets with no protrusion or sunken appearance African Americans normally may have slight protrusion of eyeball beyond supraorbital ridge
Celsius to Fahrenheit
F=(9/5*C) + 32
External carotid supplies?
Face, salivary glands, and superficial temporal area
CN VII
Facial Facial expression and produces both saliva and tears.
Aging adult
Facial bones and orbits appear more prominent, facial skin sags resulting from decreased elasticity, decreased subcutaneous fat, and decreased moisture in skin Lower face may look smaller if teeth have been lost
Inspection of Face: Note?
Facial expression and appropriateness to behavior or reported mood
Abnormal Respiration Patterns - tachypnea
Fast breathing, normal depth just fast. Greater than 18-20 range
Developmental competence - The pregnant women: Fat deposits
Fat deposits are laid down as maternal reserves for nursing baby - teeth, bones weaken if not get proper nutrition and too much can cause diabetes and high blood pressure
Adolescent preparation
Feedback that their body is healthy, Communicate with some care, Promote wellness
Why is the femoral artery not good for placement?
Femoral artery is a location of infection and bad hygiene so need to replace after 24 hours or take it out.
Apical pulse is found where?
Fifth intercostal mid clavicular line
First level priority
First level: life threatening/emergent/ABC's(establishing an airway or supporting breathing)
Mouth
First part of the digestive system, airway for respiratory system - oral cavity has hard and soft tissue(palate, cheek, tongue, salivary gland)
APGAR score
First respiratory assessment that is performed on a newborn and scored on what they look like - appearance, pulse, grimace, activity, respiration 1-5 min after birth
Macule vs Patch
Flat discoloration in skin - macule is small one cm or less freckle - patch is larger one that is greater than one cm
Cyst
Fluid filled sac under the skin can tap and feel the fluid, drain the cyst and it will usually refill compared to cutting it out
Spirituality
Focused on a connection of something larger than oneself and belief in transcendence
Baby's temperature in the rectum
For best results in babies and toddlers up to 3 years of age, take temp in rectum. Place in anus. This method is accurate and gives a quick reading of the baby's internal temperature. For infants and toddlers, be sure to use a rectal thermometer correctly. A rectal thermometer may accidentally poke a hole in the rectum.
Why is educating a patient on quadrants important?
For patient education, upper outer quadrant and axillary tail of Spence are the spots where most breast cancers arise - convenient map to describe clinical findings
What are you assessing for with the Six P's
For some type of arterial issue
Test Near Vision
For those who report increasing difficulty reading - test near vision with handheld vision screener with various sizes of print(Jaeger card)
Blood pressure
Force of blood pushing against the side of its container
Developmental Competence: The aging adult - Hair matrix
Functioning melanocytes decrease, leading to gray fine hair(usually on head then coarser and gray in other spots)
Abnormal findings: tympanic membrane - fungal infection(otomycosis)
Fungi in ear and needs antibiotics
The RNs first assessment is the?
General Survey. This is a high frequency assessment as the RN performs a general survey with each client encounter.
Epidermis
Gives color and ridgidness
Waist to Hip Ratio gives what information?
Gives general health information and risk assessment for diseases like diabetes
CN IX
Glossopharyngeal Nerve taste and touch from tongue; control of a pharynx muscle
Which piece of legislation mandated the establishment of a joint Health Care Fraud and Abuse Control program?
HIPPA
Clergy visits
HIPPA allows as long as patients approve of it, the person has to have closure of this information unless a patient has restricted this - if patient cant agree or object the disclosure may be made if they have indicated before
Vistors
HIPPA does not reject visitors unless patient has rejected - clergy can ask for religious affiliation without names if patient has given it
Abnormal Hair Conditions - Traction alopecia
Hair loss that is the result of prolonged, tightly pulled hairstyles
What is a pneumothorax?
Happens when there is air or gas in the parietal space between the lungs and the chest wall which causes the lungs to collapse
Nails
Hard plates of keratin on dorsal edges of fingers and toes
Hearing loss Questions: Every had any trouble hearing? Character
Has all your hearing decreased or just on hearing certain sounds?
high oncotic pressure from plasma proteins
Has to do with pressure and pulling power that plasma proteins have - to big to be pushed out of arterioles but can be pushed into venules, pulling power to where fluid can be pulled back into vessels
Kussmaul
Have rapid breathing and will be irregular shallow. - diabetic ketoacidosis
What do you have to do for orthostatic hypotension?
Have the client in supine, sitting, and standing position for 3-5 minutes before taking heart rate and blood pressure again.
Additional history for aging adults questions
Have you noticed any visual difficulty with climbing stairs or driving? any problem with night vision? when was last time tested for glaucoma? any aching pain around eyes? any loss of peripheral vision? if you have glaucoma, how do you manage your eyedrops? if there history of cataracts? any loss or progressive blurring of vision? do your eyes every feel dry or burning? what do you do for this? any decrease in usual activities, such as reading or sewing?
Sternomastoid enables
Head rotation and flexion and divides each side of neck into two triangles: anterior and posterior triangles
During fetal period, head growth predominates:
Head size is greater than chest circumference at birth and reaches 90% of final size at 6 years old
Healthly vs abnormal costal angle
Healhy people have a less than 90 degree costal angle. Someone with enphazema or overinflation of lungs the costal angle is increased
Cardiac output is an indicator of?
Heart function - dependent on metabolic demand - normal adult 4-6L/min(average 5L/min)
Abnormal Conditions of the Nails - Splinter hemorrhages
Hemorrhages caused by trauma or injury to the nail bed that damage the capillaries and allow small amounts of blood flow.
Signs of health care fraud
Higher than average numbers of patient encounters, diagnostic tests and procedures, fees for service, patients from distant locations, prescriptions for certain drugs
Nystagmus test
Horizontal gaze eye test used for testing sobriety levels.
Patient-Centered Care Questions
How do you clean your ears? Last time you had your hearing checked?
Hearing loss Questions: Every had any trouble hearing? Coping strategies:
How does loss affect your daily life? Any job problems? Feelings of embarrassment or frustration? How do your family and friends react?
ABG is the most accurate way to know?
How much oxygen is in the blood - more accurate than pulse oximeter
Subjective data questions: mouth and throat - Patient-centered care
How often do you use a toothbrush and floss? last dental exam? do dental problems affect which foods you eat? do you have a dental appliance: braces, bridge, headgear? do you wear dentures? all of the time? how long have you had this set? how do they fit? any sores or irritation on the palate or gums?
Why are fluids in interstitial spaces?
Hydrostatic pressure in arterioles(extra force). To much force for veins to take - w/o = edema
Health Promotion and Patient Teaching - Blood pressure control
Hypertension is often silent killer - educate patient on checking BP and what numbers are warning signs
CN XII
Hypoglossal Nerve tongue movement
Teach Back Examples
I want to make sure I gave you the correct referral information. Could you let me know what you will do when you get home?
DVT Prevention
If a patient has vessel damage, hypercoaguability, stasis - early mobilization - hydration - medications - compression stockings, SCDs
Why would it be important to assess last menstrual cycle as part of the "breast history questions?"
If there are concerns with the breasts, those symptoms or concerns could be associated with the menstrual cycle, therefore, you need to know when the last period was to factor out some possibly abnormal findings.
Culture and genetics: PAD and CAD
If you have PAD(peripheral), you're at risk for CAD(coronary) = essential to screen and treat
Lymphatics forms a major part of the?
Immune system that defends body against disease - detects and gets rid(infection or foreign body)
Abnormal inspection - position
In a tripod position commonly seen in acute and chronic lung problems
You can only place an IV catheter in?
In a vein because it is returning to the heart - never in artery or in valve - find vein, occlude the vein, push blood out, where it backflows that is the vein
thyroid gland has two lobes connected?
In middle by a thin isthmus and above that by the cricoid cartilage or upper tracheal ring
Infants and children eyelids and lashes - setting-sun
In newborns, setting-sun sign common; eyes appear to deviate down with white rim of sclera visible over iris
With infant how to take vital signs?
In opposite order
Hearing loss Questions: Every had any trouble hearing? Other questions
In what situations do you notice loss: conversations, using telephone, listening to TV, at a party? Do people seem to shout at you? Do ordinary sounds seem hollow, as if you are hearing in a barrel or under water? Have you recently traveled by airplane? Do you have a family history of hearing loss?
Blood viscosity
Increase viscosity(increased hematocrit in polycythemia)
Moro reflex
Infant reflex where a baby will startle in response to a loud sound or sudden movement.
Pain differences
Infants have the same capacity for pain as adults, but we measure different for the ages, and the cognitive processes are different for those who can rate it and those who cannot understand it. Gender differences also affects it and cultural and genetic differences.
Physical examination: Infants and children - Neck - children have a higher incidence of?
Infection, so you will expect a greater incidence of inflammatory adenopathy; no other mass should occur in the neck
Dental caries
Infectious process leading to tooth decay due to interaction of bacteria is on the rise
Abnormal Findings: Lesions on the eyelids - blepharitis
Inflammation of the eyelids, staph infection, burning, itching, pain, tearing, foreign body sensation, dermatitis, no antibiotic
Abnormal Findings: Lesions on the eyelids - Dacryocystitis
Inflammation of the lacrimal sac
What information does palpation of pulse provide?
Info about the heart and the quality of the artery
What prevention steps can you take or educate your patient's parents about burns, skin lesions/illnesses, and safety?
Informing patient's parents about effects of too much skin exposure is crucial for the child's safety. Steps I can take to inform these individuals of risks include doing a universal skin cancer screening, regarldess of age. Explaining to the parents why we do skin screenings. Teaching ways to avoid sun exposure which would minimize risk of lesions and illnesses. Like wearing SPF 30+, seeking shade, wearing hats, limiting time outside.
Skin has two layers - dermis
Inner supportive layer - connective tissue or collagen - elastic tissue
Heart Structures - Layers - Endocardium
Innermost layer
fine crackles
Inspiration - high pitched, crackling sound(fire crackling)
Drug diversion can be defined as the:
Intentional misuse of a drug intended for medical purposes and recreational use of a prescription or a scheduled drug
Nurse is reviewing venous blood patterns. Which of these statements best describes that mechanisms by which venous blood returns to the heart?
Intraluminal valves ensure unidirectional flow towards the heart.
Rhythm
Is it regular(boom boom boom boom), is it irregular, what fingers are you using, do not use thumb because of your own pulse.
What is the lymphatic system a major part of the immune system?
It detects and eliminates foreign substances from the body
Anterior landmarks - suprasternal notch
It is a common landmark on the anterior chest which is a hollow U-shaped depression that is between the clavicles - where the first part of the sternum starts(manubrium)
Broken nose?
It may swell and have hematoma. can they breath out of both sides? are they breathing normally and in a normal pattern?
Jittery Movements
Jitteriness most commonly occurs in well appearing infant on the first day of life. Most common cause is hypoglycemia so any baby with this kind of activity on exam should have glucose level checked.
Abnormal Hair Conditions - AIDS-related Kaposi Sarcoma: Patch Stage
Kaposi sarcoma (KS) is a vascular tumor and is the most common tumor in HIV-infected persons. Considered an AIDS-defining illness, KS can occur at any stage of HIV infection. Here multiple patch-stage early lesions are faint pink on the temple and beard area. They easily could be mistaken for bruises or nevi and be ignored.
Triple negative breast cancer
Kind of breast cancer that does not have any of the receptors that are commonly found in breast cancer. - estrogen, progesterone, HER2
Anterior landmarks - sternum
Known as the breastbone and it is the center of the anterior chest
ADDITIONAL THINGS TO DO
LOOK OVER TEXTBOOK AND REVIEW GUIDES
Abnormal findings: ear canal abnormalities - furuncle
Large painful red infected hair follicle
Patient Centered Care questions
Last vision test? ever tested for color? any environmental conditions at home or at work that may affect your eyes? If so, do you wear goggles to protect your eyes? What medications are you taking? systemic or topical? any specifically for eyes? do you smoke? if you have experienced vision loss, how do you cope? do you have books with large print, books on audio tape, braille? do you maintain living environment the same? do you sometimes fear complete loss of vision?
Health Promotion and Patient Teaching - Cholesterol control
Late 30s or 40s is when screening begins and how it may cause coronary artery disease. - how often and what they mean and what to d(diet changes, exercise)
Where is the location for dorsalis pedis pulse?
Lateral to the extensor tendon of the great toe
Diagnostic Positions test
Leading patient through six cardinal positions of gaze: - follow movement of penlight or object proceeding clockwise - assess for potential EOM muscle weakness, nystagmus, or lid lag
5 areas for listening to the heart - Pulmonic
Left 2nd intercostal space - pulmonary valve closure
5 areas for listening to the heart - mitral
Left 5th intercostal, medial to midclavicular line
What is on either side of the mediastinum and contain the lungs?
Left and right pleural cavities
Where does a cardiac catheter go into?
Left side artery to go to left side of the heart - puts at risk for bleeding
Temperature in aging adults
Less reliable due to hypothermia and decreased sweat gland activity
Postnasal drip
Less swelling, see the postnasal drip
Zosteriform
Linear arrangement following a unilateral nerve route(goes with dermatome)
Nasal cavity
Lined by mucous cells that have lyzozymes which kill bacteria and trap debris forming boogers.
increased incidence of oral cancers
Linked to HPV and changes in sexual norms
Complications r/t periodontal disease
Linked to type 2 diabetes
Common skin lesions - labial herpes simplex
Lips, HSV 1, cold sores - can pass HSV 1 to genitals
Assessment
List of diagnoses/differential diagnoses
Abnormal findings: Lumps and Lesions on External Ear - tophi
Little pieces of uric acid that you can see on boarders on ear, may be from gout
Abnormal percussion - adolectasis
Lobe has collapsed so in that area you will hear a dull note because dont have airflow like you typically would
Aortic artery disease(aneurysms)
Localized dilation of an artery. Forms when the middle layer of the artery is weakened and produces a stretching effect on the inner and outer layers - diameter of artery can be enlarged to at least 2x's the normal circumference
Related organs - thymus
Located behind sternum above mediastinum - inflammatory response and filters things - after puberty it shrinks and replaced by fat. During growth it is important because involved in development in disease fighting cells
Carotid artery pulse
Located in the groove between the trachea and the sternomastoid muscle - never check both at the same time
achondroplastic dwarfism
Long bones stop growing in childhood Normal torso, short limbs Failure of cartilage growth in metaphysis Spontaneous mutation produces mutant dominant allele
Order of preparing eardrum
Look first with otoscope, irrigate, then relook to make sure eardrum is intact and there is no irritation or bleeding to that skin
Precordium Inspection and Palpation - Pulsations
Look over chest to look for pulsations especially the apical pulse
When looking for accommodation what are you looking for?
Looking for lens changing shape from distance to up close.
Illness
Loss of a person's balance - within one's being: physical, mental, spiritual - in outside world: natural, communal, metaphysical
5 areas for listening to the heart - Tricuspid
Lower left sternal border 4th intercostal
Fourth function of the respiratory system
Maintains heat exchange(not very important in humans, think about dogs panting)
Third function of the respiratory system
Maintains homeostasis in the body by balancing acid and base in arterial blood
Posterior assessment - inspection: Skin color
Make sure it matches the patients genetic background, look for scars, lesions, uneven pigmentation
What is the recommended guideline that men and women should follow in regard to limiting the amount of drinks consumed per day?
Males: 2 a day Females: 1 a day
What amount of alcohol consumed by men and women in a single setting is considered binge drinking?
Males: 5+ drinks Females: 4+ drinks
What is the best test to find breast cancer early?
Mammograms
The sternum is made up of what three sections?
Manubrium, body, and xiphoid process - doing CPR do not press process because will break and puncture liver or spleen
Aging women breasts - nipples
May be retracted but can be pulled outward
Preschool position
May hold by caregiver or sit on table
Physical examination: temporal arteries
May look twisted and prominent
Aging adult ocular structures - eyebrows
May show loss of outer one third to one half of hair because of decrease in hair follicles; remaining brow hair is coarse
Tuning Fork Tests
Measure hearing air conduction or by bone conduction, in which sound vibrates through cranial bones to the inner ear
head circumference
Measure infant's head circumference at birth and at each well visit up to age 2 years and then yearly up to 6 years Circle tape around head at prominent frontal and occipital bones; widest span is correct. Compare infant's head size with that expected for age.
Health-Related Behaviors affected by Religion
Meditating Exercising/physical fitness Sleep habits Vaccinations Willingness to undergo physical examination Pilgrimage Truthfulness about how patient feels Maintenance of family viability Hoping for recovery Coping with stress Genetic screening and counseling Living with a disability Caring for children Fasting
Patterns of alcohol use - moderate drinking
Men - less than 2 a day Women - less than 1 a day
Capillaries
Microscopic vessel through which exchanges take place between carbon dioxide and oxygen - waste product is carbon dioxide or carbonic acid from body processes
The RN is caring for client who had an ABI. the brachial finding for left arm was 160 and the ankle finding for the left leg was 130. These findings suggest?
Mild(some) peripheral artery disease
Aging adults developmental competence - Dysrhythmias are?
More common in aging adults - CAD and cardiac related deaths incidence increases with age
Scar
More permanent due to break in the skin and the fabric tissues are coming together to heal it.
Abnormal Findings: Pediatrics - Down syndrome
Most common chromosomal abnormality with characteristic facial abnormalities - upslanting eyes - flat nasal bridge and small, broad nose - protruding thick tongue and ear dysplasia - broad beck with webbing and small hands with single palmar crease
in 2012, over 21% of Americans over 5 years of age speak a language other than English in their homes
Most common non-english language is spanish
Contact
Most frequent mode of transmission of health care associated infections and can be divided into direct and indirect
Muddy brown sclera
Mostly only elderly African Americans
How if RN practice guided by law?
NC Nurse Practice Act
Two client identifiers
Name and DOB
Opiods antidote
Narcan/Naloxone
Gastrointestinal pain
Nausea, vomiting
FLACC
Neonatal and less than or equal to 3 y/o · Face, legs, activity, cry, consolability · Each category is scored 0-2, scores are added · Total score range: 0-10
Cries
Neonatal post op. Crying, increase in oxygen requirement from baseline, increase in vital sings from baseline, expression on face, sleeping
Infants and children conjunctiva
Newborn may have transient chemical conjunctivitis from instillation of silver nitrate; appears within 1 hours and lasts nor more than 24 hours after birth
Direction of drainage patterns of lymph nodes
Nodes abnormal - check area they drain for source of problem Explore area proximal (upstream) to location of abnormal node - flows down from the face and up from the neck
Abnormal Findings: Lesions on the eyelids - Chalazion
Nodule that is on the inside of the eyelid, not painful, lasts longer, compress, can turn into stie
Physical examination: In some aging adults, a mild rhythmic tremor of head may be?
Normal - senile tremors are benign and include head nodding and tongue protrusion
If women have different tanner staging for hair and breasts?
Normal - breasts develop sooner
Tanner 2 breasts, tanner 1 genitalia, growing and developing normally
Normal deviation which is benign, breast development is early, reassurance is needed
With preschooler how to take vital signs?
Normal fear of body mutilation increased with any invasive procedure(no rectal) and want reverse order. Have to show them on your finger.
When performing respiratory assessment on adult, note costal angle of 80 degrees.
Normal finding
When performing an assessment on a 3 y/o, note childs chest is cylindrical in shape and is using abdominal muscles.
Normal findings
Child height and weight recorded at every health care visit to determine
Normal growth patterns.
External nose appearance
Normally nose is symmetric, in midline, and in proportion to other facial features - inspect for any deformity, asymmetry, inflammation, or skin lesions
Decrease risk of CVD
Not smoking, active, healthy weight, healthy diet
NPO
Nothing by oral route. Which means we will not bring them a breakfast trey because they have disease process or procedure coming up.
Abnormal findings: Visual Field Loss
Notice any loss, refer, help with ADLs, set up their lunch and tell them where it is all at(milk is at 2:00), stand where they can see you
Common skin lesions - Herpes zoster(shingles)
Numbness or tingling neurological pain before getting the rash, get vesicles or target which move into a crusty - cant pass shingles but if that person has never had chicken pox they can get chicken pox , can be detrimental to pregnant woman's baby, stress
Why does it take 17 years for research to be implemented into practice?
Nurses lack research skills, are isolated from those knowledgeable, do not have time, lack confidence
Physical examination: Infants and children - head and neck control
Observe for appearance of tonic neck reflex which disappears between 3 and 4 months of age - tummy time
Abnormal Findings: Pediatrics - hydrocephalus
Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head
Otitis Media
Obstruction of eutachian tube or passage of nasopharyngeal secretions into middle ear - one of the most common illnesses in children
Abnormal palpation - Subcutaneous emphysema(krepadis/tissue emphysema)
Occurs when air gets trapped underneath skin and as moved into the tissue - chest or neck area most common - result of surgery, trauma, injury to thoracic cavity or facial bones. Feels like it is made of air.
Cranial Nerve III
Oculomotor eyelid elevation, pupil constriction and accommodation
A patient feels his privacy has been violated and wants to file a formal complaint. Through which of the following agencies should the nurse instruct the patient to file the complaint?
Office of Civil Rights
Which of the following agencies of the US government has the authority to exclude individuals and entities from participating in federal health care programs?
Office of inspector general
Usual dosages for means by mouth - opiods
Often combined with Tylenol. This combination can lead to liver damage related to Tylenol overdose.
Cranial Nerve I
Olfactory - ask about any changes to sense of smell
Results of height and weight are plotted?
On growth charts based on data from National Center for Health Statistics
Cardiac cycle is?
One heartbeat(lub and dub)
Pupil Abnormalities - Monocular blindness
One sided blindness
Cranial Nerve II
Optic Nerve - see if eyes dilate
Religion and Spirituality
Organized system of beliefs versus individual's unique experience
Abnormal findings: ear canal abnormalities - osteoma
Ossification looking like single stone hard nodules that affect the eardrum
Abnormalities of external ear: Cellulitis
Otitis externa or media has spread to surrounding tissue and given that skin an infection
Skin has two layers - epidermis
Outer highly differentiated layer - basal cell layer forms new skin cells - outer horny cell layer of dead keratinized cells
Nails are a good indication of what?
Overall health, can indicate if something is going on like lupus, cardiac disease, anemia
Abnormal findings: tympanic membrane - cholesteatoma
Overgrowth of epidermal tissue that grows over middle ear or temporal bone, can erode the bone so need to refer
Parts of an EKG?
P wave, PR segment, QRS complex, ST segment, T wave, U wave, PR interval, QT interval
Use an observational tool such as
PAINAD to measure the presence of pain
Six P's of Arterial Insufficiency
Pain Pallor Pulselessness(faint or gone) Paresthesia(arm falling asleep) Paralysis Poikilothermia (coolness)
Define pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of damage. Pain is subjective thus a careful assessment and evaluation is needed.
Nursing Diagnosis - Alteration in comfort,
Pain r/t surgical procedure as evidenced by... Pain r/t chronic back pain as evidenced by...
breakthrough pain
Pain that occurs between doses of pain medication
Somatic pain
Pain that originates from skeletal muscles, ligaments, or joints.
Herpes Zoster Oticus (Ramsay Hunt Syndrome)
Painful chicken pox or shingles-like rash involving the pinna and ear canal Viral infection typically occurs in adults Can cause SNHL, vertigo and facial palsy
Physical examination: Infants and children - Neck - During infancy, cervical lymph nodes are not?
Palpable normally, but child's lymph nodes are palpable - palpable nodes less than 3 mm are normal
Posterior Assessment - Palpation: Tactile fremitus
Palpable vibration when speaking - either use palm of fingers or ulnar side of hands - side to side or bilateral at the same time - get patient to say ninety nine - avoid scapula area
Inspection and Palpation of the Neck: Lymph nodes
Palpate nodes noting location, size, shape, delimitation, mobility, consistency, and tenderness - slow, circular motion
Inspection and Palpation of the Skull: temporal area
Palpate temporal artery above zygomatic(cheek) bone between each eye and top of ear
Course of veins?
Parallel to arteries, bur direction of blood flow is opposite
Abnormal findings: extraocular muscle dysfunction - Diagnostic positions test
Paralysis indicates cranial nerve dysfunction
A client reports having difficulty breathing in supine position and requires two or three pillows to breathe comfortably. What is this consistent with?
Paroxysmal noctural dyspnea
Subjective Data Health History Questions
Past history of skin disease, allergies, hives, psoriasis, or eczema? Change in pigmentation or color, size, shape, tenderness? Change in mole(size or color?) Excessive dryness or moisture? Pruritus or skin itching? Excessive bruising? Rash or lesions? Medications: prescription and over-the-counter? Hair loss? Change in nails' shape, color, or brittleness? Environmental or occupational hazards? Patient Centered care?
Abnormal Hair Conditions - Toxic Alopecia
Patchy, asymmetric balding that accompanies severe illness or use of chemotherapy where growing hairs are lost and resting hairs are spared. Regrowth occurs after illness or discontinuation of toxin.
Acute Behavior
Patient isnt used to, short term and self limiting, stops once healed - Guarding - Grimacing - Vocalization - Agitation - Restlessness - Stillness - Diaphoresis - Vital Sign Change
Teach Back
Patients have to state to you in their own words what you were saying - doctors teach in too much detail - ensures patient education - validates patient clear understanding and show us how well we gave the info
Self-report
Patients unable to understand instructions and point or verbalize(most reliable)
Do not irrigate if history or exam suggests?
Perforation or infection
Posterior Assessment - Palpation: Symmetric expansion
Place thumbs along spinal column where the bottom of the ribs are so you can feel if both sides are expanding symmetrically
Health Assessment
Plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
Objective Data Preparation
Position sitting up straight with head and eye level
Abnormal Findings: Pediatrics - Plagiocephaly
Positional or deformational due to sleeping position
Culturally sensitive
Possessing basic knowledge of and constructive attitudes toward diverse cultural populations
Abnormal Findings: Pediatrics - Craniosynostosis
Premature closing of one or more cranial sutures that leads to head malformation
A nurse is examining lymphatic system of a healthy 3 year old. Which finding is within normal limits for this child.
Presence of palpable lymph nodes
Why would someone have jugular vein distention?
Pressure in right atrium is increased from more fluid. Increased central venous pressure = fluid volume overload - fluid starts to back up.
What is communication?
Process of sending and receiving messages through verbal and nonverbal means
Related Organs - Tonsils(palatine, adenoid, and lingual)
Produce local inflammation when something is going on in that region
Anti-kickback Statute
Prohibits offering, paying, soliciting or receiving anything of value to induce or reward referrals or generate federal healthcare program business.
Stark Law
Prohibits physicians or their family members who own health care facilities from referring patients to those entities if the federal government, under Medicare or Medicaid, will pay for treatment.
Lichenification
Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen)
ABCDEF Skin Assessment
Promoting health and self-care - teach skin self exam using this rule to detect suspicious lesions - asymmetry - border irregularity - color variations - diameter greater than 6mm - elevation or evolution - funny looking - different from others
SBAR - Background
Provide pertinent history as it directly relates to patient's current health status
Developmental Competence - Birth
Puberty inverted nipple, flat, no alveoli
Arteries
Pump oxygenated blood to all body tissues - strong walls to withstand HIGH pressure system - smaller than veins - walls of arteries are thicker than veins
Heart structures - Chambers - left ventricle
Pumps oxygenated blood to the rest of the body
Review of systems
Purpose of this section are to evaluate the past and present health state of each body system, to double-check in case of any significant data were omitted in the Present Illness section, roughly head to toe.
Abuse Assessment Screen (AAS)
Questions that measure the amount of violence in pt's life - introduce the topic before giving the screening instrument to make them trust you - "because domestic violence is so common in our society, we are asking all patients the following questions"
Physical examination: Infants and children - Assess muscle development with gentle passive?
ROM - cradle infant's head with your hands and turn it side to side and test forward flexion, extension, and rotation - note resistance to movement, especially flexion
Physical examination: aging adult - maintain patient safety by indicating patient peform
ROM and position changes slowly - minimize potential for dizziness
Papule vs Plaque
Raised and elevated - papule is raised but very small and in superficial thickening of epidermis - plaque is multiple papules together so much larger
Nodule vs Tumor
Raised large lesions, hard or soft - soft nodule or hard nodule and does it move around(that would be cyst). Nodule is 1cm or less - tumor is much larger and goes down to dermis
Vesicle vs Bulla
Raised lesion and clear fluid filled - vesicle is 1mm or less or single blister - bulla is 1cm or less single blister that is large. Deeper than vesicle
Common skin lesions - Psoriasis
Raised red scaley to it, can be white and plaque like, knees, elbow, lower back
What is the difference between rectal and oral thermometers?
Red is rectal, blue is oral. - probe of rectal is smaller - oral thermometer to take axillary, but rectal is only for rectal
sucking reflex
Reflex that causes a newborn to make sucking motions when a finger or nipple if placed in the mouth
Second function of the respiratory system
Removes carbon dioxide from the body, which is a waste product of energy reactions at the cellular level
Target or Iris
Resembles iris of eyes, concentric rings(bullseye rash - tic bite)
shallow respirations
Respirations characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion.
The Aging Adult Ocular Fundus
Retinal structures generally have less shine; blood vessels look paler, narrower, and attenuated; arterioles appear paler and straighter, with a narrower light reflex Drusen, or benign degenerative hyaline deposits, are normal development on retinal surface Often symmetrically placed in eyes with no effect on vision
Routine audits
Reviewing and analyzing data of security procedures and activities as in integral part of continual security awareness.
5 areas for listening to the heart - aortic
Right 2nd intercostal space - aortic valve closure
What is the difference with the right and left bronchi?
Right main bronchus is where most people get pneumonia because it is more vertical than the left and easier for food and fluid to pass there
Skull
Rigid box that protects the brain - includes bones of cranium and face - supported by cervical vertebra
Abnormal Hair Conditions - Tinea Capitis (Scalp Ringworm)
Rounded, patchy hair loss on scalp, leaving broken-off hairs, pustules, and scales on skin. Caused by fungal infection; lesions may fluoresce blue-green under Wood's light. Usually seen in children and farmers; highly contagious; may be transmitted by another person, by domestic animals, or from soil.
5 areas for listening to the heart - Erb's point
S1, S2 - left 3rd intercostal space
Lactrimal apparatus check by pressing finger against?
Sac, just inside lower orbital rim, not against side of the nose - pressure will slightly evert lower lid, but there should be no other response to pressure
Laying for an infant is the --- position.
Safest.
Infants pain
Same capacity as pain as adults. Inhibitory neurotransmitters are insufficient until birth at full term. Therefore the preterm infant is rendered more sensitive to painful stimuli. Preverbal infants are at risk for undertreatment of pain.
CIWA
Scale measuring objective data related to withdrawal of patient - vital signs(Similar to pain) - ox sat - sweating - agitation
Common skin lesions - Tinea corporis(ringworm of the body)
Scale, inside that is white and very red border, contagious
Color Analog Scale
Score recorded in centimeters(0-10)
Visual Analog Scale
Score recorded in centimeters(0-10) - no pain, worst possible pain no numbers
Linear
Scratch, streak, line or stripe(poison ivy)
Abnormal findings: tympanic membrane - retracted drum
See more bones than supposed to
Posterior thoracic landmarks - the inferior border of the scapula
See the inferior border protruding. Do not listen over scapula because wont hear anything. Listen in intercostal spaces on both sides of spine until you get below scapula you can go laterally. Anterior, posterior, laterally.
race and ethnicity
Self-identification and social group
Developmental Competence - Tanner Staging
Sexual maturity rating 1 - preadolescence: small elevated nipple 2 - breast bud stage: small amount of nipple and breast and alveoli widen 3 - breast enlarge and nipple is flush with breast surface 4 - nipple forms secondary mound 5 - mature: nipple protrudes(tanner stage)
Malignant skin lesions - Squamous cell carcinoma
Sharp margins, one cm or more, central ulceration and redness - stay out of sun - skin protection
Whispered voice test step two
Shield your lips so the person cannot compensate for a hearing loss(consciously or unconsiously) by lip reading or using the "good" ear
SMAST-G
Short Michigan Alcohol Screening Test - Geriatric Version - yes/no questions to address aging adults' specific emotional and physical reactions to drinking any amount of alcohol
Why do people get shorter with age?
Shortening in spinal column, thinning of vertebral disks, shortening of individual vertebrae, and kyphosis, and slight flexion in knees and hips.
Biots
Similar to Cheyne stokes but more irregular and seen with head injuries and traumas, heat stroke, etc.
Additional Health History Questions - adolescents
Skin problems such as pimples, blackheads?
What side should a pregnant women sleep on?
Sleep on the left side because the heart is on the left side making the hearts pumping action easier and keeps uterus off the liver
Abnormal respiratory patterns - bradypnea
Slower respirations than 10-12 range
Culture and Genetics: PAD - environmental factors
Smoking, diabetes, hypertension, total levels of cholesterol and obesity, and genetics
Abnormal findings: ear canal abnormalities - exostosis
Soft bony hard nodules that can cover the epithelium, impairs hearing
New Learning
Specific test that validates memory - pick 4 words and ask them to remember them, ask them to recall the 4 words later
Common skin lesions in children - Impetigo
Staff or strep infection on skin that gives honey colored crust. Vesicles to a crusty top to it. Contagious
Abnormal findings: Opacities in the lens - star-shaped opacity - cortical cataract
Star shaped, rapid and progressing
SBAR - Assessment
State pertinent assessment findings obtained with interpretation of data. Your clinical evaluation
SBAR - Recommendation or Request
State what you need or want for the patient in terms of medical treatment and/or assistance. Your interpretation and solution
Abnormal findings: extraocular muscle dysfunction - asymmetric corneal light reflex
Strabismus - esotropia: inward turning of eye - exotropia: outward turning of eye
thyroid - Endocrine gland
Straddles trachea in middle of the neck
Grasp Reflex Foot
Stroking middle of foot will make the babys toes curl under
Pain Assessment "OPQRSTU"
Subjective Assessment(SOAP)
Nurses on a clinical unit wish to research the incidence of falls among patients following joint replacement surgery. Which of the following should they do to ensure the study complies with the HIPAA Privacy Rules?
Submit their proposal to the institutional review board for review and describe how they will de-identify patient information
Precordium Inspection and Palpation - Apical Impulse
Supine or on left side 4th or 5th intercostal space mid clavicular line
Eyes - External Anatomy: bony orbital cavity
Surrounded by cushion of fat that protects the eye
Heart Structures - Layers - Parietal pericardium
Surrounds the pericardial cavity and is a tough fibrous layer
Extra Heart Sounds - Murmurs
Swooshing sound heart on the chest wall. Conditions cause blood flow to be more turbulent - may be benign - blood flow increases, viscosity decreases, structural defect
Abnormal Hair Conditions - Folliculitis barbae
Synonym tinea barbae. Also known as barbers itch, inflammation of the hair follicles caused by a bacterial infection from ingrown hairs. The cause is typically from ingrown hairs due to shaving or other epilation methods.
Blood pressure in aging adults
Systolic may be lower
Neck vessels - auscultate carotid artery
Take a breath and exhale and hold - 3 spots
When should serial blood pressure be taken?
Take serial measurements when you suspect volume depletion, when the person is known to have hypertension or is taking antihypertensive medications, or when the person reports fainting or syncope.
Places where you can take pulse?
Temporal artery, facial artery, carotid artery, brachial artery, radial artery, femoral artery, popliteal artery, posterior tibial artery, dorsalis pedis artery
whispered voice test step one
Test one ear at a time while masking hearing in other ear by placing one finger on tragus and rapidly pushing it in and our of auditory meatus
The adolescent health history
The HEEADSSS method of interviewing focuses on assessment of the Home environment, Education and employment, Eating, peer related Activities, Drugs, Sexuality, Suicide and depression, and Safety from injury and violence.
If a client scores 0 on the CRAFFT, what additional services need to be rendered?
The administrator of the CRAFFT should still provide brief advice or provide praise and encouragement
Mobility wise in the hospital, how would an adult stand on the weight?
The bed can weigh the patient. But pillows and clothing can affect it so have to 0 it out.
The angle of louis is where?
The bronchi bifurcate into the left and right stem main bronchi
atherosclerotic plaque
The cholesterol-rich material that is deposited in the arteries of individuals with atherosclerosis. It consists of cholesterol, smooth muscle cells, fibrous tissue, and eventually calcium. - platelets prevent total blockage of artery
If you have atherosclerosis which is causing PAD,
The fat buildup wont be specific and will happen throughout body so need to screen for cardiovascular disease if have PAD
Which two types of questions should be asked for pre-screening and screening all young adults?
The friend and C or CAR questions
How do we assess pain?
The kid-friendly basics: - Speak calmly and gently - Get down on their level - Use the child's name - Ask the parents to remain calm - Physical exam and pain scores
Neuropathic Pain
The nerve fibers themselves may be damaged, dysfunctional, or injured. These damaged nerve fibers send incorrect signals to other pain centers. Falling asleep on arm, hitting funny bone. Hot and cold, numbing. A small neuropathic pain or stimulus can cause significant pain
Transmission
The pain impulse moves from the spinal cord to the brain
What is the difference between the right and left lung?
The right lung has 3 lobes and the left lung only has 2. - left only has superior and inferior lobe
Follow-Up Database
The status of any identified problems should be evaluated at regular and appropriate intervals. This type of database is used in all settings to follow up both short term and chronic health problems.
Client that has strained trapezius muscle, and now complaining of shortness of breath. Why would this be?
The strained muscle is an assessory muscle of respirations
Why is it important for health care providers to be familiar with the CRAFFT model?
The structured screening device would most likely improve identification of adolescents with substance related pathology
If there is a tracheal shift?
The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax. The trachea is pulled toward the affected side with large atelectasis, pleural adhesions, or fibrosis
Respiratory dead space
The volume of a breath that does not participate in gas exchange. This is about 150 cc of air in an adult
cardiac output
The volume of blood ejected from the left side of the heart in one minute.
Neuropathy Pain scale
There are several different aspects of pain which we are interested in measuring: pain sharpness, heat/cold, intensity, overall unpleasantness, and surface vs deep pain
Folk Healers
There are traditional treatments in folk healers that we may not see in our region
Why do nurses not perform fremitus test a lot?
There as to be gross change, a lot of change, a lot of consolidation
Abnormal findings: tympanic membrane - blue drum(hemotympanum)
There has been skull damage, need to go to ER
Crust
Thickened and dryed out exudate, scab crusty part of pustule drained
Heart Structures - Layers - Myocardium
Thickest layer
Emergency database
This is an urgent, rapid collection of crucial information and often is compiled concurrently with lifesaving measures. Diagnosis will be swift and sure.
Focused or Problem-Centered Database
This is for a limited or short term problem. Here you collect a "mini" database, smaller in scope and more targeted than the complete database. It concerns mainly one problem, one cue complex, or one body system. It is used in all settings.
Nociceptive Pain
This is the normal functioning nerve pattern, when the nerve is intact(transduction, transmission, perception, modulation). Typical type of pain.
Anterior landmarks - The Angle of Louis(the sternal angle)
This is where the manubrium meets the sternum. It is continuous with the second rib and is where you can start counting ribs
Pharynx
Throat - nasopharynx(soft palate and valve close when swallow) - oropharynx - laryngopharynx(larynx - voicebox)
thyroid gland synthesizes and secretes what?
Thyroxine(T4) and triiodothyronine(T3), which are hormones that stimulates rate of cellular metabolism
Structure and Function: Middle ear
Tiny filled cavity inside temporal bone - contains tiny ear bones: malleus, incus, and stapes
Structure and Function: Middle ear - several openings are present
To the outer and inner ear eustachian tube: opening that connects middle ear with nasopharynx and allows passage of air - normally closed, but opens with swallowing or yawning
Communicating with school age child
Tolerate and understands others viewpoints. Wnat to know how things work and why things are done.
New enginered body parts
Took cells out of lung and put it into chamber and let it grow and was made in the lab - take a long time(10-12) years on pigs then humans because dont know if it will do gas exchange - there is a synthetic trachea already
Eyes - External Anatomy: Conjunctiva
Transparent protective covering of the eye
What suture closes first on baby?
Triangle than diamond - use fontanel to help you determine developmental stages and hydration
CN V
Trigeminal general sensation chewing
Arm abnormalities - Raynaud phenomenon
Triggered by cold vibration or stress. - the arteries constrict and causes abnormal shape paleness(white, blue and red)
CN IV
Trochlear eye movement, superior oblique muscle
Gyrate
Twisted, coiled, or snakelike(not common)
Abnormal Facial Appearances - Stroke or brain attack
UMN lesion leading to paralysis of lower facial muscles
culturally competent
Understanding and attending to total context of patient's situation including the following: Immigration status Stress and social factors Cultural similarities and differences
Prebycusis is accentuated when?
Unfavorable background noise is present - gender and ethnic differences
Teeth may look slightly yellowed, but color is?
Uniform - yellowing results from dentin visible through worn enamel
S-creening
Universal screening for quickly assessing use and severity of alcohol; illicit drugs; and prescription drug use, misuse, and abuse
How to measure infant?
Until age 2, measure infant's body length supine by using a horizontal measuring board. Above age 2 can stand and take height. If adult cant stand you can measure height by laying on flat surface.
Eversion of the upper lid
Used when one suspects foreign body or eye pain
Clarification
Useful when person's word choice is ambiguous or confusing Summarize person's words, simplify the statement, and ensure that you are on the right track
Examining lymph nodes
Using a gentle circular motion of finger pads, palpate lymph nodes Beginning with preauricular lymph nodes in front of ear, palpate the 10 groups of lymph nodes in routine order Many nodes are closely packed, so you must be systematic and thorough in your examination Do not vary sequence or you may miss some small nodes
palpation of sinus areas
Using thumbs, press frontal sinuses by pressing up and under the eyebrows and over maxillary sinuses below cheekbones
Prebycusis onset
Usually occurs in 50s and slowly progresses - first notice a high frequency tone loss - ability to localize sound is impaired
Numeric/descriptive scales
VAS: Adults
CN X
Vagus -assess mouth for movement of soft palate and the gag reflex -assess swallowing and speech
Veins carry? Arteries carry?
Veins carry deoxygenated blood and arteries carry oxygenated blood - pulmonary is the exception
Cardiac Cycle: Systole
Ventricles contract Blood pushes against AV valves and they shut Blood pushes through open semilunar valves into aorta and pulmonary trunk
Cardiac Cycle: Diastole
Ventricles relaxed Blood entering atria Blood flows through AV valves into ventricles Semilunar valves are closed
Abnormal findings: tympanic membrane - bullous myringitis
Vesicle(blisters) on the eardrum from bacterial or viral infection, refer out and may cause permanent damage, pain
Developmental Competence Aging Adult: Arteriosclerosis
Vessels become more rigid with age - DP and PT pulses may become more difficult to find - changes associated with arterial insufficiencies
arteriosclerosis
Vessels become more rigid with age - related to age
CN VIII
Vestibulocochlear Sensory: equilibrium (vestibular portion) Hearing (cochlear portion)
Which of the following methods of information exchange is in compliance with HIPPA?
Walking rounds that involve two nurses discussing an assigned patient at his bedside in a private room
Communicating with older adult
Want to have a purpose, address by last name, be slow, like touch
Infants and children respirations
Watch infant's abdomen for movement
Posterior assessment - inspection: Position
Watch patient as take breath and make sure theyre relaxed and dont use extremities to support breathing
Abnormalities of external ear: Otitis externa(swimmers ear)
Water becomes trapped by a cyst, bone growths, earwax plugs or swelling caused by allergies.
Clinical
We learn from other nurses and other faculty health assessment practices in a hospital.
How to weigh infant?
Weigh infant on a platform-type balance scale
BMI calculation
Weight(lbs)/Height(inches) * 703
Lymphoid tissue
Well developed at birth and grows to adult size when the child is 6 y/o
Situation
What brought you here, what is your main health problem, who have you all seen today in the hospital?
Quality
What does it feel like? Can you describe it?(throbbing, stabbing, dull)
Recent Memory
What have you had to eat in 24 hours, when did you get to the hospital?
Subjective Questions: Earache - At home
What have you tried to relieve pain?
Ask Me 3
What is my main problem? What do I need to do? Why is it important for me to do this? - People who know the anwsers get better quicker, better manage conditions
Severity
What is the intensity(pain scale of 1-10, visual scales of the symptoms? Right now? At worst? Are there any other symptoms that accompany the pain? Pain scales
Cumulative violence
When a patient has experienced more than one violence - severe mental and physical health problems are associated with cumulative trauma from abuse
Asymmetric crying facies
When baby cries, the mouth is pulled downward on one side while not moving on the other side.
Protective reflex
When eyes and nose are covered with cloth the baby makes effort to push it away. Enables baby to breath while breastfeeding.
Cheyne Stokes
When people are nearing the end of life. Times when they will stop breathing rapid and shallow then no breathing.
Apex of the heart
When the heart contracts you can feel the contraction on the chest wall called the apical pulse - bottom of the heart
Place
Where are we, what hospital are we at
Posterior thoracic landmarks - the vertebra prominens
Where you can feel on your posterior neck the bony prominences(C7 and thoracic vertebra 1)
Infants and Children: Special Procedures - Percussion
With an infant you may directly percuss with your plexor finger against head surface - this yields resonant or "cracked pot" sound, which is normal before closure of fontanels
All individuals have varying amounts(red, yellow, brown)
With relative proportion affecting prevailing color. Also modified by thickness of skin and presence of edema(elderly have thinner skin so more pale) - genetically determined, environmental(where you live and what you eat)
Whispered voice test step three
With your head 1 to 2 feet from the persons ear, exhale and whisper slowly some two syllable words. Normally, the person repeats each word correctly after you say it
When do you measure infant blood pressure?
You dont, less than 2 years do not measure it. Unless right after birth or if there are problems
Observational or behavioral
Young or cognitively impaired patients(pre-verbal; unable to understand self-report scale)
hyoid bone
a U-shaped bone in the neck that supports the tongue.
rooting reflex
a baby's tendency, when touched on the cheek, to turn toward the touch, open the mouth, and search for the nipple
third degree burn
a burn involving all layers of the skin; characterized by the destruction of the epidermis and dermis, with damage or destruction of subcutaneous tissue. white to brown with dry leathery texture, no pain due to so deep - ER and elevation
Thrill is compared to what
a cat purr
It is important to catch any problem early because?
a child with hearing loss is at risk for delayed speech and social development and learning deficit
What is motivational interviewing?
a client-centered, method to encourage change within client
bifid uvula
a condition in which uvula is spit either completely or partially; occurs in 10% of some American Indian groups
incentive spirometer
a device used to force the client to concentrate on inspiration and promote full inflation of the lungs, while providing immediate feedback; used particularly after surgery and in lung disorders. - does not measure oxygenation just pulmonary function
Assess respirations for how long?
a full minute to look for irregularities - normally pulse and respiratory rates rise as a response to exercise or anxiety
flat affect
a lack of emotional responsiveness
Trachea
a large membranous tube reinforced by rings of cartilage, extending from the larynx to the bronchial tubes and conveying air to and from the lungs; the windpipe.
Resonance (percussion sound)
a low-pitched, hollow sound, usually heard over normal lung tissue
isthmus of thyroid
a narrow band of tissue that connects the two lobes of the thyroid gland
Baby's temperature on the forehead
a newer method to take temperature is called temporal artery thermometry. This is also very accurate. It measures the temperature of the blood flowing through the temporal artery, on the forehead. Less stressful to a newborn.
Erb's Palsy
a paralysis of the arm that most often occurs as an infant's head and neck are pulled toward the side at the same time as the shoulders pass through the birth canal
What is collaboration?
a partnership
visceral pain
a poorly localized, dull, or diffuse pain that arises from the abdominal organs, or viscera. originates from larger internal organs. Dull, deep, squeezing, or cramping. Pain can stem from direct injury to the organ or stretching of the organ from tumor, distention, or severe contraction. Ulcer pain, appendicitis. The pain impulse is transmitted by ascending nerve fibers along with nerve fibers of ANS.
Montgomery glands in breasts secrete?
a protective liquid material during lactation
Depression
a sadness and hopelessness that keeps a person from carrying out everyday activities
Glasgow Coma Scale (GCS)
a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints - eye opening response, verbal response, motor response
Darwin's tubercle
a small painless nodule at the helix; this is a congenital variation and not significant
podiatrist
a specialist in care for the feet
Delerium
a state of temporary but acute mental confusion,signs; anxiety, tremors, allucinations, delusions, attention problems, decline in level of conciousness, memory problems
arterial blood gases (ABGs)
a test performed on arterial blood to determine levels of oxygen, carbon dioxide, and other gases present - respiratory therapist normally does it - acidic or alkalotic(CO2 = acidic)
whispered pectoriloquy
a whispered phrase heard through the stethoscope that sounds faint and inaudible over normal lung tissue - abnormal would be clear - consolidation
Steps with physical exam are all the same except for?
abdominal exam
varicose veins
abnormally swollen, twisted veins with defective valves; most often seen in the legs - risk factor for venoustasis
Risk factors of otitis media
absence of breastfeeding in first 3 months of life, preterm birth, secondhand tobacco smoke exposure, daycare attendance, male sex, pacifier use, seasonality(fall and winter), and bottle-feeding
With cilia becoming coarse and stiff cerumen does what?
accumulate and oxidize which reduces hearing - cerumen is drier because of atrophy of apocrine glands - reversible cause of hearing loss
Oral temperature is?
accurate and convenient
Making a loud noise to 3-4 months
acoustic blink reflex, infant stops movement and appears to listen, halts sucking, quiets if crying, cries if quiet
Summary Checklist: Head, Face, and Neck, including regional lymphatics examination - Inspect and palpate the neck
active ROM, potential enlargement and position of trachea
Example of nursing diagnosis
acute pain related to decreased myocardial blood flow(chest pain/heart attack) as evidence by "stabbing" substernal pain radiating down left arm an dup to left side of the jaw, patient states pain is 9 out of 10, patient is diaphoretic, and patient is restless
Different classes based on
addiction and seriousness
Nose develops during?
adolescence, along with other secondary sex characteristics - this growth starts at 12-13, reaching full growth at age 16 in females and age 18 in males
Adults health promotion
advise to stay at moderate consumption
inappropriate affect
affect clearly discordant with content of person's speech
Vital signs are done differently depending on?
age
Glaucoma incidence increases with?
age - african americans 3 to 6 times more likely to develop than Caucasian Americans - primary angle glaucoma is leading cause of blindness in African Americans and Hispanics - family history increases risk
Pulse normally varies with?
age and gender
Why? HEENT - understanding changes in these body areas based on?
age or abnormalities is important to your nursing practice
What affects blood pressure?
age, weight, stress, motion, exercise, sex and race
Aging adult respirations
aging causes decrease in vital capacity and decreased inspiratory reserve volume - shallower inspiratory phase and an increased respiratory rate
Sinuses
air-filled spaces in the skull that open into the nasal cavity - frontal, maxillary, ethmoid, sphenoid
Tools to assess alcohol and drug use - AUDIT
alcohol consumption, drinking behavior, adverse consequences
Opiods interactions with food/drink
alcohol exaggerates side effects
Abnormal percussion - emphysema
alveoli are ballooned out, overextended lung - should hear resonance but this causes hyper resonance
Diminished sense of taste and smell decreases
an aging persons interest in food and may contribute to malnutrition
PTSD
an anxiety disorder characterized by haunting memories, nightmares, social withdrawal, jumpy anxiety, and/or insomnia that lingers for four weeks or more after a traumatic experience
anorexia nervosa
an eating disorder in which an irrational fear of weight gain leads people to starve themselves
Ischemia
an inadequate oxygenated blood supply to an organ or part of the body, Caused by obstruction of that artery. - complete blockage tissue will die - partial will notice when exercising
Abnormal Hair Conditions - seborrheic dermatitis
an inflammation that causes scaling and itching of the upper layers of the skin or scalp
Critical thinking must be applied to achieve?
an interpretation
A sign
an objective abnormality that you as the examiner could detect on physical examination or through diagnostic testing.
Psychiatric mental illness
an organic(brain) etiology has not yet been established (anxiety disorder or schizophrenia) - Do not know the cause like an organic disorder
How to calculate ABI
ankle pressure signal/brachial pressure signal
Subjective data questions: nose - allergies
any allergies or hay fever? to what are you allergic, for example, pollen, dust, or pets? how was this determined? what type of environment makes it worse? can you avoid exposure? do you use inhalers, nasal spray or nose drops? how often? which type? how long have you used this?
Subjective data questions: mouth and throat - bleeding gums
any bleeding gums? how long have you had this?
Subjective data questions: mouth and throat - altered taste or?
any change in sense of taste?
Olfactory nerve
any changes in sense of smell
Subjective Questions: Earache
any earache or other pain in ears?
Strabismus, diplopia
any history of crossed eyes? now or in the past? does this occur with eye fatigue? - ever see double? constant, or does it come and go? In one eye or both?
Subjective data questions: mouth and throat - hoarseness
any hoarseness, voice change? for how long? feel like having to clear your throat? or, like a "lump in your throat?" use your voice a lot at work, recreation? Does hoarseness seem associated with a cold or sore throat?
pressure ulcer
any lesion caused by unrelieved pressure that results in damage to underlying tissue
Subjective data questions: nose - discharge
any nasal discharge or runny nose? continuous? is discharge watery, purulent, mucoid, bloody?
Subjective data questions: nose - nosebleeds
any nosebleeds? how often? how much bleeding, a teaspoonful or does it pour out? color of the blood, red or brown? clots? from one nostril or both? aggrevated by nose-picked or scratching? how do you treat nosebleeds? are they difficult to stop?
Redness, swelling questions
any redness or swelling in eyes? any infections? now or in the past? when do these occur? in a particular time of the year?
Subjective data questions: nose - sinus pain
any sinus pain or sinusitis? how is this treated? do you have chronic postnasal drip?
Subjective data questions: mouth and throat - toothache
any toothache? do your teeth seem sensitive to hot, cold? Have you lost any teeth? last dental exam?
Additional history for infants and children questions
any vaginal infections in mother at delivery? considering age of child, which developmental milestones of vision have you(parent) noted? does child have routine vision testing at school? are you(parent) aware of safety measures to protect child's eyes from trauma? do you inspect toys? have you taught child safe care of sharp objects and how to carry and how to use them?
Blood pressure in aging adult
aorta and major arteries tend to harden with age increasing blood pressure - as heart pumps against stiffer aorta, SP increases, leading to widened pulse pressure
Where do you palpate or auscultate a pulse for infants and children?
apical rate - count pulse for full minute
Anxiety
appear unhurried, take time to listen, avoid interview traps
Eversion of upper lid procedure may cause?
apprehension; therefore use directed, deliberate approach - multi-step procedure using applicator stick - color change, swelling, lesion, evidence of foreign body
Why? HEENT - the nose mouth and throat
are important areas of the respiratory and gastro-intestinal system and many health care devices are inserted in the body openings. Your assessment of these areas is an important step before insertion
General survey - body structure - position
arms relaxed at sides - leaning forward, curled in fetal position
Arterial and Venous insufficiency - edema
arterial: none or minimal venous: usually present
posterior tibial artery
artery supplying the foot, behind the medial ankle
General survey - behavior - speech
articulation - speech defect, monotone, few words, constant talking
Abnormal palpation - decreased or increased fremitus
as assess for it make note of things not equal on both sides
Asymmetric Tonic Neck Reflex
as the infant's head is turned to one side, the arms will briefly come into a fencers position, with the arm on the same side as the face stright out to the side and the arm behind the head flexed at the elbow
Developmental Adaptation - Children
ask child questions and gather more information from family
Time
ask day of the week, season, year - many have troubles knowing what day of the week and date
Open ended questions
ask for narrative information. It states the topic but only in general terms. - unbiased
Closed or direct questions
ask for specific information - one or two word answer, elicit specific information.
Lacrimal Apparatus test
ask the person to look down; with thumb, slide outer part of upper lid up along bony orbit to exposure under lid; inspect for any redness or swelling
Conjuctiva and Sclera test
ask the person to look up; using thumbs, slide lower lids down along orbital rim, being careful not to push against eyeball
To test cranial nerve XII, hypoglossal nerve?
asking a person to stick out tongue; should protrude in midline; note any tremor, loss of movement, or deviation to side
Initial pain assessment
asks the patient to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors.
The short-form McGill Pain Questionnaire
asks the patient to rank a list of descriptors in terms of their intensity and to give an overall intensity rating to their pain
The brief pain inventory
asks the patient to rate the pain within the past 24 hours using graduated scales with respect to its impact on areas such as mood and ability to sleep
optic nerve
assess pupil size and alignment, visual acuity(snellen chart), pupil reflexes(direct and consensual), accommodation reflex(constriction and convergence), assess color vision, visual fields
Glossopharyngeal and vagus nerve
assess soft palate and uvula rise, assess swallow for vagus
Is visual acuity even lower,
assess whether the person can count your fingers when they are spread in front of eyes or distinguish light perception from your penlight
Acculturation
assimilation is one dimensional, and biculturalism/integration is bidimensional
What is the most common thing that weakens the middle layer?
athersclerosis
diastole - Presystole
atria give a little squeeze to give rest of blood to ventricles - atrial kick
P wave
atrial depolarization - atria contracting
Extra Heart Sounds - S4
atrial gallop during ventricular diastole - heard at cardiac apex with bell - diastolic heart failure, ventricular hypertrophy, active cardiac ischema(heart fails to relax) - tennesee(S4, S1, S2)
Ventricular diastole is happening when there is?
atrial systole
Inspection and Palpation - nasal cavity
attach a short wide-tipped speculum to otoscope head and insert apparatus into nasal vestibule - view each nasal cavity with the person's head erect and then with head tilted back
Conduction - heart has unique ability:
automaticity - can contract by itself independent of any signals or stimulation from body - contracts in response to an electrical current conveyed by a conduction system
Laterally, the lungs extend from the ---- down to the -----
axilla area; 7th or 8th rib
Baby's temperature in the armpit
axillary measurement. May be used as a first way of checking to see if a child may have a fever. If this shows a fever, the temperature should then be checked by rectum or forehead.
Salivation starts at 3 months:
baby will drool periodically for a few months before learning to swallow saliva
Weight
balance scales, electronic scales, bed scales
Should you measure someones blood pressure on a bare arm or over clothing?
bare arm
The neck is delimited by?
base of skill and inferior border of mandible above, and by manubrium sterni, clavicle, first rib, and first thoracic vertebra below
Lymph nodes: occipital
base of skull
popliteal artery
behind the knee
Abnormal Findings: Swellings of Head and Neck - pilar cyst
benign growth that presents as smooth, fluctuant swelling on scalp
Trained interpreter is the?
best option - Family members who speak the same language may invade confidentiality and other problems
Heart Structures - Valves - left semilunar valve
between left ventricle and aorta(aortic valve)
Heart Structures - Valves - right semilunar valve
between right ventricle and pulmonary trunk(pulmonary valve)
Developmental competence pregnant women: expect diffuse?
bilateral pitting edema in the lower extremities especially at the end of the day
Upcoding
billing for a service at a higher level than was actually provided
Cataracts are leading cause of?
blindness worldwide - estimated that 80% are preventable or curable with surgery
peripheral arterial disease (PAD)
blockage of arteries carrying blood to the legs, arms, kidneys and other organs - obstruction of artery(aging, poor diet, exercise)
Subcutaneous
blood vessels, adipose tissue, nerves,
Abnormal inspection - cyanosis
blue/purple common with lack of oxygen
Personal hygiene
body odor, scent of alcohol, unkempt appearance
Abnormal Hair Conditions - furuncle and abscess
boil; suppurative inflammatory skin lesion due to infected hair follicle
Inner Ear contains
bony labyrinth, which holds sensory organs for equilibrium and hearing
Full pulse force
bounding pulse denotes increased stroke volume
In pit of elbow pulse
brachial artery
Atrophic scar
break in the skin and fabric tissues coming together. Due to loss of skin or thinning kind of look like stretch marks
School age preparation
break the ice with small talk, child should undress, leave underpants on and use gown, demonstrate equipment because curious, comment on the body and how it works
American cancer society no longer recommends?
breast self-exam as a screening tool for women with an average risk of breast cancer
American College of Obstetricians and Gynecologists guidelines dont recommend?
breast self-exam for average-risk women - screening mammogram annual starting at age 40 for average risk
Aging women breasts - on inspection
breasts look pendulous, flat, and sagging
B-rief I-ntervention
brief motivational and awareness-raising intervention given to risky or problematic substance users
Abnormal findings: ear canal abnormalities - foreign body
bugs, toys get trapped in wax, dont irrigate if it is alive
second degree burn (partial thickness)
burn affecting the epidermis and part of the dermis and characterized by redness, blistering or larger bullae, and pain with little or no scarring - cool water several minutes, ointment, bandage
fourth degree burn
burn in which full thickness of the skin and underlying muscle and bone is damaged - ER and elevation
Although the inner hear is not accessible to direct examination, its functions?
can be assessed
Infants and children eyelids and lashes - many infants have an epicanthal fold,
can excess skinfold extending over inner corner of eye, partly or totally overlapping inner canthus
Otoscopic examm is not performed at birth because
canal is filled wtih amniotic fluid and vernix caseosa; after a few days the TM is examined
Things to do when documenting EHR
cannot document before you do something(legal purposes) document in real time. Do not avoid early warning signs - never leave workstation open, violation of privacy - do not leave papers out in the open
Vital signs are accessible measures of?
cardiac and pulmonary function. There are physiologic limits to them and they provide a quick assessment of an individual's health status when combined with the general survey.
Infant position
caregiver present, place baby on flat padded examination table
clouding of the lens
cataract
Inspection of tongue
check tongue color, surface characteristics, and moisture
A chest tube does what?
chest tube with suction which reestablishes lung pressure by draining fluid. Lets them expand back to normal size
Physical growth charts is perhaps the best index of a?
child's general health. Measure on growth chart than by itself so you can see the trend of a growth spurt or growth hormone issue.
Complex Regional Pain Syndrome or Reflexive Sympathetic Dystrophy
chronic progressive nerve condition characterized by burning sensation, swelling, stiffness, discoloration. Men and women around 40-60 y/o and occurs weeks to months after a nerve injury(carpal tunnel syndrome, broken leg).
mucociliary escalator
cilia that transport mucus and foreign material out of the respiratory tract
Abnormal Facial Appearances - parkinson syndrome
classic "maskline" appearance, elevated eyebrows, staring gaze, oily skin and drooling due to dopamine deficiency
Abnormal Facial Appearances - Cushing syndrome
classic "moonlike" face, red cheeks, and hirsutism
What does autonomy mean?
clients right to make their own choices
Vestibular nerve
close eyes and march standing up
General survey - behavior - dress
clothing too large, too tight, Velcro present
Abnormal findings: Opacities in the lens - central gray opacity - nuclear cataract
cloudiness and thickness, look for after the age of 40, slow development and causes vision changes
In aging persons, cilia lining ear become
coarse and stiff
Inspection of face: Abnormal facial features
coarse facial features, exophthalmos, changes in skin color or pigmentation, or abnormal swellings
atelectasis
collapsed lung; incomplete expansion of alveoli
Toddler sequence
collect objective data during the history, begin with games, start with nonthreatening areas.
If any discharge is present note?
color and odor
Inspection of throat - observe oval, rough-surfaced tonsils
color is same pink as oral mucosa, and their surface peppered with identations, or crypts; there should be no exudate on tonsils
Deep somatic pain
comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Pain may result from pressure, trauma. Aching or throbbing
Internal carotid branches off?
common carotid and runs inward and upward to supply brain
Adults - Otosclerosis:
common cause of conductive hearing loss in 20-40 adults - gradual hardening that causes footplate of stapes to become fixed in oval window(progressive deafness)
In aging adults pingueculae
commonly show on sclera
silence
communcates that client has time to think, provides you with a chance to obseve the client and note nonverbal cues
Plain language
communication your client can understand the first time they read it or hear it
Fraud detection methods - complex reviews
complete medical history analysis
Physical examination: aging adult - neck may show an increased
concave curve - to compensate for kyphosis
Summary
condenses facts and validates what was discussed, both client and examiner should be active participants, signals termination of interview is imminent
Wernicke's aphasia
condition resulting from damage to Wernicke's area, causing the affected person to be unable to understand or produce meaningful language
motivating often means resolving --- and --- feelings and thoughts
conflicting, ambivalent
Tetralogy of Fallot
congenital malformation involving four (tetra-) distinct heart defects. missing part of the septum in the heart so blood flows
Cultural and Lingustic Competence
congruent behaviors, attitudes, and policies that come together in a system among professionals that enables work in cross cultural situations
If pain is suspected,
consider a time limited trial of an appropriate type and dose of an analgesic agent. Use self-report and observational pain measures to evaluate the pain before and after administering the analgesic
Age greater than 12
consider using self-report scale such as NRS, numeric, visual or color analog scales
Respectful care
considers values, preferences, and expressed needs of patient
direct light reflex
constriction of the same-sided pupil
Abnormal Hair Conditions - Scabies
contagious skin disease transmitted by the itch mite, commonly through sexual contact
Eyes - External Anatomy: Tarsal plates
contain meibomian glands, which are modified sebaceous glands that secrete an oily lubricating material onto lids
Common vehicle applies to microorganisms that are transmitted by?
contaminated items such as food, water, medications, medical devices and equipment.
RNs interpret vital signs in?
context.
Heart Structures - Valves - right atrioventricular valve (tricuspid valve)
controls the opening between the right atrium and the right ventricle
Primary care is one of the most?
convenient points of contact for substance issues. Many patients are more likely to discuss this subject with their family physician than a relative, therapist or rehab specialist
Eyes - External Anatomy: Lower lid margin, at limbus, borders between
cornea and sclera - canthus: corner of eye, angle where lids meet - inner canthus: caruncle is a small fleshy mass containing sebaceous glands
Trigeminal nerve
cotton ball on face
With a glove, hold tongue with a?
cotton gauze pad for traction and swing tongue out to each side; inspect for any white patches or lesions; normally none are present - if any occur, palpate these lesions for induration
hemoptysis
coughing up blood
hemaptysis
coughing up blood(lung cancer)
Eyes - External Anatomy: Cornea
covers and protects the iris and pupil
visceral pericardium (epicardium)
covers the heart's outer surface (ON the surface)
tension headache
crosses midline, any part of the head, grip tightness not throbbing, gradual onset(2 days), stress, depression
Being bilingual does not mean that the interpreter is?
culturally aware
Abnormal inspection - scoliosis
curvature in spine from posterior view to the left or the right
As cited by Miller and Rollrick, MI is compared to a
dance
Developmental Competence: The aging adult - sweat and sebaceous glands
decrease in number and function, leaving skin dry
Blood volume
decrease volume(hemorrhage), increase volume(increased sodium and water retention, intravenous fluid overload)
Side effects of opiods
decreased respirations, decreased blood pressure, decreased response to stimuli
Lymph nodes: deep cervical
deep under the sternomastoid muscle
hypopituitary dwarfism
deficiency in growth hormone in childhood results in retardation of growth below the 3rd percentile, delayed puberty, adrenal insufficiency.
Abnormalities of external ear: Brachial remnant and ear deformity
deformity in ear and facial remnant, embroytic stages
P-R segment
delay in impulse through AV node(before ventricular contraction)
cultural sensibility
deliberate proactive behavior by heath care providers who examine cultural situations through thoughtful reasoning, responsiveness, and discreet interactions
superior oblique muscle
depresses eye and turns it laterally
inferior rectus muscle
depresses eye and turns it medially
Enlarge your view of posterior pharyngeal wall by?
depressing tongue with tongue blade - scan posterior wall for color, exudate, or lesions - touching posterior wall with tongue blade elicits gag reflex; this test cranial nerves IX and X, the glossopharyngeal and vagus
Poorly controlled chronic pain
depression, isolation, limited mobility and function, confusion, family distress, diminished quality of life
Cutaneous pain
derived from skin surface and subcutaneous tissues. Superficial, sharp, or burning.
Tattoos are injected into the?
dermis layer of the skin
A complete family history is to send home a?
detailed questionnaire before the health care/hospital encounter because the information takes time to compile and often comes from multiple family members.
gynecomastia
development of breast tissue in males during adolescence. It is normal for it to appear but should disappear but can reappear with aging due to testosterone deficiency and medications
Inspection and Palpation: Skin - moisture
diaphoresis, dehydration
The inferior part of the thoracic cage is the?
diaphragm which is made up of muscles and tendons
Trouble with mastication can lead to?
dietary pattern changes which may place the older adult at risk for nutritional deficits(protein, vitamins, and minerals)
Certain skin presentations are associated with?
different ethnic groups
Dyspnea
difficulty breathing or shortness of breath
dysphonia
difficulty producing speech sounds, usually due to hoarseness
Arteries are capable of?
dilating and constricting to control rate of blood flow
Common finding for acutely ill patients
diminished or decreased breath sounds - secretions, mucus, foreign body which obstructs air flow - pneumothorax - pleural effusion
If any discharge is present clean any?
discharge from speculum before examining other ear to avoid contamination with possible infectious material
Developmental Competence: The aging adult - senile purpura
discoloration due to increasing capillary fragility
peripheral vascular disease (PVD)
disease of blood vessels away from central region of body, most typically in legs; symptoms include pain, numbness, and impaired circulation
In the age of genomics an accurate family history highlights what?
diseases and conditions for which a particular patient may be at increased risk.
test for accommodation by asking the person to focus on a?
distant object - this dilates pupils; then have the person shift gaze to near object, such as your finger held about 7-8 cm from nose
For aging adults - patient-centered care health history questions
dizziness and/or neck pain(how does it affect your daily activities?)
Anger
do not ask about the anger and hear the person out
Additional History for Infants and Children - did child's teeth erupt on time?
do teeth seem straight to you? is child using a bottle? does child sleep with a bottle? noticed any thumb sucking after child's secondary teeth came in? have you noticed child grinding his or her teeth?
Subjective data questions: mouth and throat - smoking, alcohol consumption
do you smoke? pipe or cigarettes? smokeless tobacco? how many pack per day? for how many years? what was your last alcohol drink? how much alochol did you drink that time? how much alcohol do you usually drink?
Use of glasses or contact lenses questions
do you wear glasses or contact lenses? how do they work for you? last time your prescription was checked? was it changed? if you wear contact lenses, are there any problems such as pain, photophobia, watering, or swelling? how do you care for contacts? how long do you wear them? how do you clean them? do you remove them for certain activities?
Developmental competence pregnant women: growing uterus obstructs?
drainage of iliac veins and inferior vena cava - leads to dependent edema, varicosities in legs and vulvs, and hemorrhoids - do not sleep on back because uterus will occlude vena cava
Abnormal findings: eyelid abnormalities - ptosis
drooping upper lid, lazy eye
You may elicit these maneuvers to assess?
drum mobility - avoid them with an aging person because they may disrupt equilibrium
Biculturalism
dual pattern of identification and often of divided loyalty
Increased risk for dental disease
due to socioeconomic status, lack of access and comorbidities
Which of the following health care resources or services is most vulnerable to fraud, waste, and abuse?
durable medical equipment
At lower oxygen saturations what probe is more accurate?
earlobe probe is more accurate and less affected by peripheral vasoconstriction
Thyroid Palpation: Anterior Approach
easier from posterior but use the right thumb to displace and the left thumb to palpate - posterior the right hand palpates and the left hand displaces
reflection
echoes client words by repeating part of what person has said, express feelings behind words, helps elaborate on problem
Physical examination: Infants and children - two common variations - caput succedaneum
edematous swelling that is self-limiting and extends across suture lines
Why? HEENT - sensory problems(eyes and ears)
effect a person's ability to function well in our society without assistance
diastolic pressure
elastic is resting or recoiling and getting ready to repump
EASI
elder abuse suspicion index
respirations
electronic, visual, and palpated
inferior oblique muscle
elevates eye and turns it laterally
superior rectus
elevates eye and turns it medially
Eyes - External Anatomy: palpebral fissure
elliptical open space between eyelids
Abnormal findings: red eye - vascular disorders - Primary angle-closure glaucoma
emergency treatment, abnormal pupil and coloring
What is the thoracic cage?
encloses and protects the lungs. It is in the shape of a cone
Facilitation
encourages client to say more, shows person you are interested
lymphadenopathy
enlarged lymph nodes
Summary Checklist: Head, Face, and Neck, including regional lymphatics examination - auscultate thyroid if?
enlarged, for bruit
Pregnant female - thyroid glande
enlarges slightly during pregnancy as a result of hyperplasia of tissue and increased vascularity
chronic pain
episode of pain that lasts for 6 months or longer; may be intermittent or continuous
General survey - body structure - symmetry
equal parts - unilateral atrophy
The infant major task
establishing trust because it is dependent on the caregiver for his and her basic needs
Abnormal findings: red eye - vascular disorders - herpes simplex virus
evaluation because if virus affects optic nerve then can have permanent visual changes - viral illness
General survey - physical appearance - skin color
even pigmentation varying with background, skin intact with no lesions, make note of tattoos and piercings and stage of healing - pallor, jaundice
What is the normal rhythm of pulse?
even tempo
regular pulse
evenly spaced beats, 60-100bpm
Subjective data questions: nose - trauma
ever had any trauma or a blow to the nose? do you breathe through your nose?
According to Miller and Rollnick, MI is about ---- what is already present, not installing what is missing.
evoking
Preschool sequence
exam thorax, abdomen, extremities, and genitalia first. Head, eye, ear, nose last
Aging adult preparation
examination pace to meet the slowed pace of aging person, use physical touch, do not mistake diminished vision or hearing for confusion, more stress - Head to toe approach
If crying episodes occur earlier,
examine open mouth and oropharynx
hypercapnia
excessive carbon dioxide in the blood
Abnormal Hair Conditions - hirsutism
excessive hair growth over the body
abnormal inspection - kyphosis
excessive outward curvature of the spine, causing hunching of the back. Common in elderly
Gigantism
excessive secretion of growth hormone by the pituitary results in overgrowth of the entire body
Acromegaly
excessive secretion of growth hormones in adult after normal completion of body growth causes overgrowth of bone in face, head, hands, and no change in height.
Developmental competence infants and children - with infection, what happens?
excessive swelling and hyperplasia
euphoria
excessive well being, unusually cheerful which is inappropriate considering physical and mental condition
cardiac stress testing
exercise tolerance test to raise your heart rate and monitor the effect on cardiac function - exercise or medications
Child's age in months minue 6 should equal?
expected number of deciduous teeth
Subjective data questions: nose - altered smell
experienced any change in sense of smell? COVID 19
Naturalistic - hot/cold theory
explantory model with origins in greece. The four humors of the body - blood, phlegm, black and yellow bile - regulate body functions and are described in terms of temperature, dryness, and mositure. The treatment of diseases consists of adding or subtracting these elements restores health.
Most important environmental risk factor for skin cancer is?
exposure to UV radiation both from sun and indoor tanning sources
sternomastoid muscle
extends from the sternum upward along the side of the neck to the mastoid process
Abducens nerve
eye movement left and right
Abnormal findings: eyelid abnormalities - periorbital edema
eyelids are swollen and puffy, excessive fluid, local infections, crying really hard, trauma from getting hit in the eye, allergies
Facial expressions are formed by?
facial muscles, which are mediated by cranial nerve VII, the facial nerve
Communication techniques
facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, summary
neglect
failure to provide for a childs basic needs. prenatal drug exposure, child abandoment.
Descriptor Differential Scale
faint(+/-), moderate(+/-), barely strong(+/-), intense(+/-), weak(+/-), strong(+/-), very mild(+/-), extremely intense(+/-), very weak(+/-), slightly intense(+/-), very intense(+/-), mild(+/-)
The goal of the self breast exam is for women to become?
familiar with their breast
specific phobia
fear of objects or specific situations or events
agoraphobia
fear of open spaces
CNS pain
fear, anxiety, fatigue
Depersonalization
feelings of detachment from one's mental processes or body
General survey - mobility - gait
feet are shoulder width apart - wide base, stumbling, dragging
If bronchial breath sounds were heard in the peripheral of the lungs, this could be a?
finding which is abnormal and suspicious for pneumonia, pleural effusions or atelectasis
How to assess a patient in clinical
first measure height, weight, blood pressure, temperature, pulse, and respirations. Use an icebreaker. Ask the person to change into an examining gown leaving underwear on, reenter the room and clean your hands in the persons presence, touch hands, write out examination sequence, offer teaching about body, if linger in one location to concentrate on finding reassure them, summarize your findings, and share the information with the person.
General survey - behavior - facial expression
flat, depressed, angry, sad, anxious
Tympanic membrane: position: TM is
flat, slightly pulled in at center, and flutters when a person performs Valsalve maneuver or holds nose and swallows
Physical examination: Infants and children - skull - positional molding
flattening of the head due to infant sleeping position
catheter
flexible tube that is going into a narrow body cavity
pleural effusion
fluid or pus in thoracic cavity where lung cant expand all the way
Communicating with acutelly ill
focus on making them comfortable first, then ask priority questions.
Fetal circulation
foramen ovale open so can move right and left side of heart. Can go out pulmonary artery but connects to aorta(ductus aneseus) - heart problems can be from these places not closing. Close within 24 hours.
Inspection and Palpation of the Skill: Size and shape - bones
forehead, lateral edge of parietal bones, occipital bone, and mastoid process behind each ear
Cranial Bones
frontal, parietal, occipital, temporal
Abnormal Conditions of the Nails - onychomycosis
fungal infection of the nail
Abnormal Inspection - pectus excavatum
funnel chest - chest hollowed out. May be congenital
rage
furious, loss of control
Extra Heart Sounds - S3
gallops - best heard at cardiac apex, heard with bell - low pitched(kentucky - S1, S2, S3) - most common
Marfan Syndrome
genetic connective tissue disorder that can cause a ruptured aorta
Disease based precautions - enteric
gloves and gown
Disease based precautions - protective
gloves, gown, masks/respirators, goggles, face shield
Office of the Inspector General (OIG)
government agency that investigates and prosecutes fraud
Disease based precautions - contact
gown and gloves
Tonsils grading
grade 0: cant see them at all grade 1: barely visible 2: not touching uvula but swollen 3. touching the uvula
Dry cerumen
gray, flaky, and frequently forms thin mass in ear canal
arcus senilis
gray-white arc or circle around the limbus due to deposition of lipid material - as more lipids accumulate, cornea may look thickened and raised, but arcus has no effect on vision - aging adults
femoral artery pulse
groin
Signs of respiratory distress in infant
grunting and nasal flares, retraction
Teeth may look longer as ----- recede
gum margins - old dental work deteriorates, teeth loosen with bone resorption - tongue looks smoother as a result of papillary atrophy - aging buccal mucosa is tinned and may look shiner
Gum inspection
gum margins are tight and well defined - check for swelling, retraction of gingival margins; and spongy, bleeding, or discolored gums
Lymph nodes: submandibular
halfway between angle and tip of mandible
Glaucoma questions
have you ever been tested for glaucoma? what were the results? do you have any family history of glaucoma?
Subjective data questions: mouth and throat - sores or lesions
have you noticed any sores or lesions in the mouth, tongue, or gums? how long have you had it? every had this lesion before? is it single or multiple? does it seem associated with stress, season change, or food? how have you treated sore? how you applied any local medication?
During infancy, trunk growth predominates so that?
head size changes in proportion to body height
Adolescent sequence
head to toe, genitalia last and do it quickly.
A persons culture defines
health and illness, identifies when treatment is needed and which treatments are acceptable, and informs a person of how symptoms are expressed and which symptoms are important
Technology play a critical role in
health care fraud, use, and abuse
First and landmark standard
health care organizations should ensure that all patients receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language
Sharing protected information
health care staff can share info with family friends and primary care provider as long as the patient does not object - if cannot respond, then can share if in the best interest of patient
Naturalistic - yin yang theory
health exists when all aspects of the person are in perfect balance
Summary Checklist - Teach self examination
health promotion
Acoustic
hearing
JVD is common with?
heart failure - hear S3 most commonly
Electrical conduction does not mean that the?
heart muscle is functioning properly
Hypothalamus/body balances what?
heat production(from metabolism, exerecise, food digestion, external factors) with heat loss(through radiation, evaporation of sweat, convection, conduction)
anthropometric measurements
height and weight
General survey - body structure - stature
height is within normal range - too tall or too short
the use of electronic medical records
helps maintain a clear process between the services providers render and the use of accurrate diagnostic and billing codes
Lymphatic drainage does what?
helps prevent potentially harmful substances from entering the circulation
Abnormal Findings: Swellings of Head and Neck - Congenital torticollis
hemotoma in one sternomastoid muscle, probably injured by intrauterine malposition, results in head tilt to one side and limited neck ROM to opposite side
Deflating cuff too slowly
high
Failure to wait 1-2 minutes before repeating reading
high
Under the heart
high
leg position
high
too loose
high
too narrow
high
Person supports own arm
high diastolic
drive to breathe in healthy individuals
high levels of CO2 in pts with COPD: low levels of oxygen
If i am looking to assess the apex of the lung where would you assess?
high up in clavicle area
Measuring thigh pressure will be --- due to ---
higher; larger artery
Lumps or swelling health history questions
history of recent infection, radiation, smoking, alcohol, difficulty swallowing, thyroid issues
Screening for hearing deficit begins during?
history; how well does a person hear conversational speech?
Jaeger card instructions
hold card in good light about 35 cm (14 in away) from the eye this distance equls the print size on the 20 ft chart. test each eye separately, with glases on. A normal result is 14/14 in each eye, read without hesitancy and without moving the card closer of farther away - when no card is available ask the person to read from a magazine or newspaper
Abnormal findings: tympanic membrane - perforation
holes that should ear on their own
Wet cerumen
honey brown to dark brown and moist
Position of eardrum is more
horizontal in neonate, making it more difficult to see completely and harder to differentiate from canal wall
General survey - behavior - mood and affect
hostile, distrustful, crying
Additional History for Infants and Children - patient-centered care
how are child's dental habits? use a toothbrush regularly? how often does child see a dentist? do you use fluoridated water or fluoride supplement? are vaccinations up to date?
Subjective data questions: mouth and throat - sore throat
how frequently do you get them? do you have a sore throat now? when did it start? is it associated with cough, fever, fatigue, decreased appetite, headache, postnasal drip? or hoarseness? is it worse when arising? what is humidity level in room where you sleep? any dust or smoke inhaled at work? do you usually get a throat culture for the sore throats? were any documented as streptococcal? how have you treated this sore throat: medication, gargling? how effective are these? have your tonsils or adenoids been taken out?
Oral temperature - external and internal environment may cause?
hypothermia or fever due to infections, neurological problems, stroke, cancer
Pulmonary pain
hypoventilation, hypoxia, decreased cough
Risk factors will decrease if?
identification, early treatment, health promotion
Goal of SBIRT
identify and effectively intervene with those who are at moderate or high risk for psychosocial or health care problems related to their substance use
Communicating with infant
ifants use coos, gurgles, and cries to identify their needs. Nonverbal communication is the primary method of communicating with infants.
Essential to determine patency of nares in?
immediate newborn period
Immune pain
impaired cellular immunity, impaired wound healing
What is RN practice implemented and supported by?
implemented by the nursing process and supported by policy and procedure.
Lymph nodes: preauricular
in front of the ear
On infants how do you measure vital signs?
in reverse(respiration, pulse, temperature, blood pressure)
lymph nodes: posterior cervical
in the posterior triangle along the edge of the trapezius muscle
Natural tooth loss is exacerbated by?
inadequate dental care, poor oral hygiene, and tobacco use - can lead to malocclusion leading to further tooth loss and pain
Hallucinogens
inappropriate sometimes violent behavior, super human strength and insensitivity to pain
Children health history is adapted to
include information specific for the age and developmental stage of the child. Developmental history and nutritional data are listed as separate sections because of their important for current health.
What is the most common error with blood pressure measurements
incorrect cuff size
Peripheral vascular resistance
increase resistance(vasoconstriction), decrease resistance(vasodilation)
Elasticity of vessel walls
increase rigidity, hardening as in arteriosclerosis(heart pumping against greater resistance)
Cardiac output
increase with heavy exercise to meet body demand for increased metabolism, decrease with pump failure
Tacile fremitus will increase or decrease with pneumonia?
increase(more solid) - voice sounds will also be more clear as well due to consolidation and dull percussion - decreases when less solid(less air flow - obstruction or pneumothorax)
In many older people, both systolic and diastolic pressure?
increase, making it difficult to distinguish normal aging values from abnormal hypertension.
Endocrine pain
increased adrenergic activity
Succession of genetic mutations leading to?
increased chromosome sensitivity to sun damage - dark skinned
Increased risk for melanoma <=
increased number of sunburns during ones lifetime
Older adult health promotion
increased risk - less muscle mass - prescription drug interactions - decreased kidney and liver function - increased risk for; falls, depression, GI problems(bleeding)
Nasal stuffiness and epistaxis may occur during pregnancy as a result of?
increased vascularity in the upper respiratory tract
If you start with a different vital sign on children you may get a strong reading because they may cry which = ?
increasing the rates of respiratory and heart rate.
condition of teeth is an?
index of the person's general health - note any diseased, absent, loose, or abnormally positioned teeth
Regional physical examination
individuals may seek health care for skin problems and assessment focused on skin alone
As you introduce an object to infant's line of vision, not these attending behaviors: by 1 month
infant can fixate and follow light or bright toy
As you introduce an object to infant's line of vision, not these attending behaviors: 6-10 months
infant can fixate and follow toy in all directions
As you introduce an object to infant's line of vision, not these attending behaviors: 2-4 weeks
infant can fixate on an object
As you introduce an object to infant's line of vision, not these attending behaviors: 3-4 months
infant can fixate, follow, and reach for toy
Making a loud noise to 6-8 months
infant turns head to localize sound; responds to own name
Heart rate normally fluctuates more with who?
infants and children than adults from exercise, emotion, and illness
Abnormal Hair Conditions - pediculosis capitis
infestation of the hair and scalp with head lice
conjuctivitis
inflammation of the conjunctiva (pink eye)
Abnormal Conditions of the Nails - paronychia
inflammation of the nail fold
Explanation
informing patient, sharing information
Thickening of the what, for aging women?
inframammary ridge at lower breast is normal, feels more prominent with age - women over 50 y/o have increased risk of breast cancer
inhalation and exhalation
inhalation lungs contract and exhale lungs relax which pushes air out
Color blindness
inherited recessive X-linked trait affecting about 8% of White males and 4% of African American males; rare in females
Transduction
injured tissue releases chemicals that propagate pain message. Action potential moves along an afferent fiber to the spinal cord.
defensive wounds
injury typically on the victim's hands and ulnar side of the arms
How to test sucking reflex
insert gloved finger into baby's mouth and palpate hard and soft palate as baby sucks - sucking reflex can be elicited in infants up to 12 months
Conjuntiva and sclera inspect
inspect exposed area; eyeball should look moist and glossy - numerous small blood vessels normally show through transparent conjunctiva
Hypoglossal nerve
inspect tongue at rest, stick tongue out, press tongue into fingers
opthalmoscope
instrument used to examine the interior of the eye
social anxiety disorder
intense fear of social situations, leading to avoidance of such
The five social determinants of health are?
interconnected and affect a persons health from preconception to death - poverty has the greatest influence on health status
Red reflex
interruption indicates opacity in the cornea or lens. Absent red reflex occurs with congential cataracts or retinal disorders
Developmental Competence Aging Adult: Enlargement and loss of?
intramuscular calf veins and loss of lymphatic tissue which decreases lymph nodes and size of lymph nodes
Inspection of face: note any --- movements
involuntary(tics) in facial muscles; normally none occur
nystagmus
involuntary, jerking movements of the eyes
Indirect
involves contact between a person and a contaminated object. This is often a result of unclean hands contaminating an object or environment. The microorganism remains on this surface to be picked up by the next person who touches it.
Direct
involves direct body surface to body surface contact and physical transfer of microorganism between an infected or colonized person to another person by touch.
Culturally based variability present in color of?
iris and retinal pigmentation
Infants and children iris and pupils
iris normally blue or slate grey in light-skinned newborns and brown in dark-skinned infants; by 6 to 9 months, permanent color differentiated
Pedigree or genogram
is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations such as parents, grandparents, and siblings.
Subjective Questions: Earache - Character
is it dull, aching, or sharp, stabbing? Is it constant or does it come and go? Is it affected by changing position of head?
Adolescent major task
is self identity. They are self conscious
General survey - physical appearance - age
is stated age - appears older than stated age with chronic illness or chronic alcoholism
The head being larger than body causes what?
issues with walking and coordination
pruritus
itching
Inspect nasal mucosa, noting?
its normal red color and smooth moist surface - note any swelling, discharge, bleeding, or foreign body
elation
joy and optimism, overconfidence, increased motor activity, not necessarily pathologic
Lymph nodes: supraclavicular
just above and behind the clavicle, at the sternomastoid muscle
Gradual loss of subcutaneous fat starts during?
later middle adult years, making the nose appear more prominent in some people
Most common causes of decreased visual functioning in older adults - diabetic retinopathy
leading cause of blindness in adults ages 25-75 years of age
Four basic concepts of culture(characteristics of culture)
learned, shared, adapted, dynamic
confluent
lesions run together (hives)
Right side of the heart has --- pressure?
less pressure than the left because pulmonary system has lower pressures. Systemic pressure is much higher.
Tools to assess alcohol and drug use - CAGE
less than a minute: - has anyone ever asked you to cut down, has anyone been annoyed, eye opener
Aging adults developmental competence - must consider what?
lifestyle, habits, and disease
General survey - mobility - range of motion
limited joint range of motion, paralysis
Common skin lesions - primary contact dermatitis
linear shape, vesicles or papular, scales, hives, itchy what caused this? what came into contact? - red
interpretation
links events implies cause, not based on direct observations, but on conclusion, incorrect but helps further discussion
Lobes are composed of?
lobules, and lobule clusters of alveoli produce milk
Developmental competence infants and children - vaccines can produce
local lymphadenopathy(enlargement)
Posterior thoracic landmarks - twelfth rib
located midway between the spine and the patient's side
Bundle of His (AV bundle)
located next to the AV node; provides the transfer of the electrical impulse from the atria to the ventricles - then to right and left bundle branches to perkinjie fibers
Microorganisms carried airborne remain suspended in the air for?
long periods of time and can be dispersed widely by air currents. Because of this, there is risk that all the air in a room may be contaminated.
Third level priority
long term problems, require a collaboration between patient and health care provider, ie. Sedentary lifestyle, readiness for enhanced self-concept, chronic low self-esteem
Chronic Behavior
longer than 6 months, cancer related or not, doesn't stop once pain heals. Shingles causes long lasting pain. - Bracing - Rubbing - Decreased activity - Sighing - Change in appetite - Sleeping - Self-distracting - Prayer
Posterior assessment - inspection: Muscle Development
looking at muscles in neck and shoulders because if someone has trouble breathing then they would be using those muscles more
Trochlear nerve
looking down
Oculomotor nerve
looking up
Developmental Competence: The aging adult - elasticity
loses elasticity; skinfolds and sags
hypotonia
loss of muscular tone or a diminished resistance to passive stretching
acculturative stress
losses and changes associated with integration of new beliefs
Rhonchi
loud rumbling sounds heard on auscultation of bronchi obstructed by sputum
Above the heart
low
Deflating cuff too quickly
low
Pushing stethoscope on artery
low
not inflating high enough
low
hypotensive
low blood pressure - 90/60. Shock, hemorrhage, vasodilation, Addison disease, acute myocardial infarction, decreased cardiac output, low BP, increased pulse, dizziness, confusion, blurred vision, cool and clammy, shoulder pain
Veins are a ----- system?
low pressure system that lies closer to skin surface - thin walled with large diameter(hold more blood)
Physical examination: aging adult - if some teeth have been lost
lower face looks unusually small, with mouth sunken in
Abnormal findings: eyelid abnormalities - entropion
lower lid rolling in, irritation which is the eyelashes in the eye
Abnormal findings: eyelid abnormalities - ectropion
lower lid rolling out, irritation, dryness
Blink and pupillary reflex indicate that the?
lower portion of the visual apparatus is intact. But cannot infer that infant can see; that requires later observation to show that brain has received images and can interpret them
The lymphatic system as a rich supply of what?
lymph nodes - greatest supply is in the head and neck
The breast has an extensive?
lymphatic drainage - around nipples - outward direction around that - towards the neck/armpit by armpit
What is the purpose of assessment?
make a judgement or diagnosis
Sexually aggressive people
make it clear that you are a health professional but that you also accept the person
tonsils
masses of lymphatic tissue in the back of the oropharynx. Borderline of mouth and throat
Gums may be hyperemic and softened in pregnant women and may?
may bleed with normal tooth brushing
Aging adult lacrimal apparatus
may decrease tear production, causing eyes to look dry and lusterness and the person to report a burning sensation
Aging adult cornea
may look cloudy with age
Physical examination: Infants and children - Skull
measure infants head at each visit up to age 2 years and yearly to age 6 - note infant's head posture and head control; infant can turn head side to side by 2 weeks
Functional assessment
measures a persons self care ability in the areas of general physical health such as bathing, toileting, eating, walking, independent living, nutrition/elimination, social relationships, self concept, and home environment, activity/exercise, sleep/rest, interpersonal relationships/resources, spiritual resources, coping and stress management, personal habits, alcohol, illicit or street drugs, environment/hazards, intimate partner violence, occupational health.
It is imperative that the nurse's care tailored to?
meet the person's perceived needs
Basal layer(dermis)
melanocytes(cancer), sweat glands, hair, hair follicle
Tympanic membrane(eardrum)
membrane stretched across a surface. Can concave or convex depending on sound and fluid in middle ear - maleus and cone of light: cant see means swelling. If prominate then there is pressure and fluid
Why are there droplet and contact precautions required at the same time?
microorganisms are relatively large and travel only short distances (up to 6 feet/2 metres). However these infected droplets may linger on surfaces for long periods of time, so these surfaces (within the range of the coughing/sneezing person) will need additional cleaning.
Posterior Assessment - How to do percussion sounds
middle finger of nondominant hand on patient and elevate other fingers and use other hand middle finger to tap
The mediastinum makes up the?
middle section of the thoracic cavity and it houses the esophagus, trachea, heart, and great blood vessels
Lymph nodes: submental
midline, behind tip of mandible
Overall pain assessment tools
more useful for chronic pain conditions or problematic acute pain problems.
cleft lip and cleft palate
most common in Asians, intermediate in whites, and least common blacks
CVD (cardiovascular disease)
most common underlying cause of death globally
Two trapezius muscles do what?
move shoulders and extend and turn head
medial rectus muscle
moves eye medially
Abnormal Findings: Swellings of Head and Neck - Thyroid - Multinodular goiter
multiple nodules usually indicate inflammation or multiodular goiter rather than a neoplasm; however, suspect any rapidly enlarging or firm nodule
If salivary glands are enlarged what could it mean?
mumps
Making loud noise to preschool and school age child
must be screened with audiometry
Biographic data include:
name, address, and phone number; age, birth date, birthplace, gender, relationship status, race, ethnic origin, and occupation.
empathy
names a feeling and allows its expression, allows person to feel accepted, useful when client hasnt identified the feeling
Abnormal Findings: Pediatrics - Fetal alcohol spectrum disorders
narrow palpebral fissures, epicanthal folds, thin upper lip, and midfacial hypoplasia, short nose, low nasal bridge, minor ear abnormalities
Avoid ----- ------ when examining infant and young child
nasal speculum - instead, gently push up the tip of the nose with your thumb while using your other hand to shine light into naris - with a toddler, be alert for possible foreign body lodged in nasal cavity
Steps for ABI for arm
need doppler and blood pressure cuff - remind patient not to speak and have lie down for 10 minutes to stabilize blood pressure - apply blood pressure cuff and use doppler to listen for brachial pulse - inflate the cuff to eliminate the signal and deflate the cuff until hear the signal(return of signal is the denominator) - repeat process of other arm and choose the highest measure for denominator - numerator will be the leg number
Modulation
neurons from brainstem release neurotransmitters that clock the pain impulse
Strep throat symptoms
no coughing, sore throat, exudate, fever, fatigue, decreased appetite, swollen red tonsils, nausea, vomiting
Verbal pain intensity scale
no pain, mild pain, moderate pain, severe pain, very severe pain, worst possible pain - Where is your pain?: Mark on the drawings to areas where you feel pain. E if external and I if internal. EI if both.
Health Promotion - under 21 and pregnancy
no safe level - legal risk - accident risk
General survey - physical appearance - overall appearance
no signs of distress - cardiac or respiratory signs, clutching the chest, pain, wheezing
Why is the jugular vein assessment important?
no valve between superior vena cava and right atrium, so indicator of heart function
Tender vs Non-tender lymph nodes
non-tender classical for malignancy
Epstein pearls on palate are --- finding in newborns and infants
normal - small, whitish, glistening, pearly papules along median raphe of hard palate an on gums, where they look like teeth - small retention cysts that disappear in first few weeks
Inspection and Palpation of the Skill: Size and shape - Cranial bones that have?
normal protrusions
Inspection and Palpation: Skin - texture
normal skin feels smooth and firm with even surface
torus palatinus
normal variation, is a nodular bony ridge down middle of hard palate; benign growth arises after puberty and is more common finding in American Indians, Inuits and Asians
Abnormal findings: red eye - vascular disorders - subjunctival hemorrhage
normal when coughing hard, self resolving as long as not going into cornea area
Observe uvula
normally looks like fleshy pendant hanging in midline; ask a person to say "ahhh" and note soft palate and uvula rise in midline - tests on function of cranial nerve X, the vagus nerve
Most newborns are obligate?
nose breathers - nares blocked with amniotic fluid are suctioned gently with a bulb syringe - if obstruction suspected, a small-lumen catheter is passed down each naris to confirm patency
When you are born, cranial bones are?
not fused together - brain needs time to grow - birthing process
For a person with a hearing aid,
note any irritation on canal wall from poorly fitting ear molds
Lashes
note that eyelashes are evenly distributed along lid margins and curve outward
Compare number of teeth with?
number expected for the person's age
Heart rate
number of complete cardiac cycles/min
Percussion sounds may sound different on?
obese and body builders so a lot of nursing professionals do not use this - scapula, vertebrae, and below 10th vertebrae sound different
endogenous obesity
obesity caused by hormonal disorders
Vital signs
objective measure of the body's basic functions.
Age less than four
observational/behavioral scale such as FLACC
Physical examination: Infants and children - skull - fontanels
observe anterior and posterior fontanel to see if bulging or sunken, if theyre closed
Inspection and Palpation: Nails - Consistency
observe for smooth, regular, not brittle or splitting, uniform nail thickness
Inspection and Palpation: Skin - thickness
observe for thickened areas(callus formation)
Chemotherapy-induced pain
occurs during or after chemotherapy treatment for cancer. Risk increases with the number of agents used in the course of treatment, higher doses, preexisting neuropathy. Numbness, burning, shooting pain.
DVT complications - pulmonary embolism
occurs when a dislodged blood clot travels to the lungs, where it can partially or completely block a pulmonary artery or one of its branches - 1/3 of DVT patients - thrombosis is a fixed clot
decreased fremitus occurs with
occurs when anything obstructs transmission of vibrations. i.e. obstructed bronchus, plerural effusions or thickening, emphysema, pneumothorax
early clubbing
occurs with congenital heart disease, hypoxia, lung cancer, cystic fibrosis, graves disease, chronic lung disease, malabsorbtion, crohns the angle straightens out to the nail base feels spongy to palpation, then the nail becomes convex as the digit grows - make a heart with pointer fingers and if no gap with light = clubbing
Posterior thoracic landmarks - The spinous processes
on all vertebrae for ligament and muscle attachment project posteriorly.
AV node (atrioventricular node)
on base of right atrium(backup pacemaker - slower) Receives impulse from SA node and slowly passes the signal to the AV bundle. Pause for atrial kick before sending signal.
Common skin lesions - Tinea versicolor
on light complection it is scaley of pink, tan or white irregular color - where you are hot and sweaty, fungi gets overgrown
bronchus
one of the two tubes that connect the lungs with the trachea
Alcohol abuse
one or more of these - legal trouble, failure to fulfill a role, social problems, continued use
Cluster headache
one side, behind eye/temple/forehead/cheek, piercing, burning, continuous, alcohol, stress, wind/heat exposure, napping
Migraine
one side, stabbing/throbbing going through the eye, rapid onset with peak in 2 hours can last 72 hours, can have back to back, genetic related, hormonal flucuation
Cornea and lens test - there should be no
opacities(cloudiness) in cornea, anterior chamber, or lens behind the pupil - do not confuse an arcus senilis with an opacity; arcus senilis is normal finding in aging persons
open/closed comodone
open: black head closed: white head
The AUDIT does not screen for what?
opioids
Opioid
opium or any of the drugs derived from opium, including morphine, heroin, and codeine
Most common causes of decreased visual functioning in older adults - Age-related macular degeneration
or breakdown of cells in macula of retina; loss of central vision
Most common causes of decreased visual functioning in older adults - glaucoma
or incrased intraocular pressure; chronic open-angle glaucoma is most common type
Most common causes of decreased visual functioning in older adults - cataract formation
or lens opacity, resulting from a clumping of proteins in lens
Neural control - humoral regulation
or the change in carbon dioxide and oxygen levels in the blood and to a lesser extent, the hydrogen ion levels is what causes us to breathe
Inspect carefully entire U-shaped area under tongue behind teeth
oral malignancies are most likely here
Abnormalities of external ear: Mastoiditis(mastoid bone involvement)
otitis media can lead to this, severe, if going into bone and getting it infected the patient can go septic, if there are lots of pain in ear after antibiotics want to make sure the bone is or is not involved, ER if it is, IV antibiotics
For adults, BMI is a good indication for?
overall health for adults, based on height and weight
Abnormal findings: Lumps and Lesions on External Ear - keloid
overgrowth of scar tissue
Lymph Nodes: superficial cervical
overlying the sternomastoid muscle
Physical examination: Infants and children - skull - molding
overriding of the cranial bones during birth process that resolves over a few days or a week
The provider needs to be attune to and monitor his or her ---- as well as the client's.
own aspirations
inflating too high
pain
Effects of opiods
pain relief and euphoria
PAINAD
pain scale for older adults who have advanced dementia
referred pain
pain that is felt in a location other than where the pain originates
acute pain
pain that is felt suddenly from injury, disease, trauma, or surgery
claudication
pain, tension, and weakness in a leg after walking has begun, but absence of pain at rest
Lymph nodes and thyroid gland should not be
palpable - if have issues with lower one want to check upper one so can look for drainage
Developmental competence infants and children - superficial nodes may be?
palpable even when child is healthy because they are larger in general - note characteristics of any palpable lymph nodes and if they are local or generalized
If an injury is reported or suspected,
palpate gently for any pain or break in contour
Where do you palpate the carotid artery?
palpate middle of neck or lower because higher up there is a coronary sinus that will make the heart rate drop
Neck Vessels - Palpation and Auscultation - palpate carotid artery
palpate only one carotid artery at a time to avoid compromising arterial blood to brain - not doing pulse, just quality - smooth contour and amplitude(2+),
Abnormal Facial Appearances - Bell palsy
paralysis on one side of the face as a result of LMN lesion
The first four vital aspects of the spirit of MI is that it involves?
partnership
patent ductus arteriosus
passageway between the aorta and the pulmonary artery remains open after birth. hasnt closed correctly
The health history provides a complete picture of the persons?
past and present health. It describes the individual as a whole and how the person interacts with the environment. It records health strengths and coping skills. The history should recognize and affirm what the person is doing right.
Make sure to include cultural and genetic questions where?
patient-centered care to indicate risk factors or additional health promotional items - goggles for hob, sunglasses, eye wear for sports
database
patients record and lab studies. From the database you can make clinical judgements or diagnosis about the individual's health state, response to actual or potential health problems, and life processes.
Aging adult: May have ____ earlobes with linear wrinkling because of loss of elasticity of pinna
pendulous
Nociception
perception of pain
panic attack
period of extreme fear or discomfort that develops abruptly; symptoms of panic attacks are both physiological and psychological
General survey - physical appearance - level of consciousness
person is alert and oriented - confused, drowsy, lethargic
General survey - body structure - posture
person stands erect as appropriate for age - rigid spine, moves as one unit, stuff, tense
Every SPO2 result must be evaluated in context of?
person's hemoglobin level, acid-base balance, and ventilatory status(rate and pattern, ventilator)
Hypertensive
pertaining to or suffering from high blood pressure - 130 or higher, 80 or higher
As you proceed through the health history, the measurements and vital signs, consider to make notes on:
physical appearance, body structure, mobility, and behavior
Age 4-12
pictorial self-report scale such as Wong Baker Faces, FPS, and oucher scale
abnormal inspection - pectus carinatum
pigeon chest - a chest that protrudes like the keel of a ship
chloasma
pigmentary skin discoloration usually occurring in yellowish brown patches or spots
Inspection and Palpation of the Skill: Size and shape - Assess shape
place fingers in person's hair and palpate scalp
The agency privacy officer is the first?
point of contact for privacy issues, their job to inspect the privacy breach
Patients who have limited English proficiency are at risk for?
poor health care outcomes due to the barrier that language presents during health care delivery instructions - health care facilities may have established interpreters who can assist with therapeutic communication
Objective Data Preparation
position a person standing for vision screening; then sitting up with head at your eye level
Effective care
positive outcomes and satisfaction for patient
Fraud detection methods
post payment claim reviews, recovery audit contractors
Mean arterial pressure
pressure that propels blood to tissues. Greater than 60 mmHg to maintain adequate tissue and organ transfusion. - SP+2(DP)/3
Neural control - our breathing is?
pretty much automatic without our awareness in response to cellular needs
Health prevention
prevention can be achieved through counseling from primary care providers designed to change people's unhealthy behaviors related to smoking, alcohol and other drug use, lack of exercise, poor nutrition, injuries, and STIs. Health promotion is a set of positive acts that we can take.
acculturation
process of adapting to and acquiring another culture
Diagnostic reasoning
process of analyzing health data and drawing conclusions to identify diagnosis.
Socialization
process of being raised within a culture and acquiring characteristics of that group
Assimilation
process of developing a new cultural identity and becoming like members of dominant culture
Inspection and Palpation: Nails - Shape and contour
profile sign: view index finger at its profile and note angle of nail base; it should be about 160 degrees
School age sequence
progress from head to toe like an adult, examine alone
Vibrations are most prominent where?
prominent between scapula and around sternum(major bronchi - closest to chest wall) and will decrease as move down. Easier to feel on someone with thin chest wall - Obese or muscle harder to feel.
Genetic attributes of dark-skinned individuals afford?
protection against skin cancer due to melanin
perception of pain
protects the body from damage, and is stimulated by extremes of pressure and temperature, as well as chemicals released from damaged tissues
Arm abnormalities - Lymphedema
protein rich fluid accumulates in interstitial spaces of arm - when remove axillary lymph nodes(breast cancer) - need to wear a compression garment, strength draining, elevation
Abnormal findings: eyelid abnormalities - exophthalmos
protruding eyes, eyes are opened and widened, lid is lagging, hyperthyroidism
meningomyelocele
protrusion of the spinal cord and meninges through a defect in the vertebral arch of one or more vertebrae
SBAR - situation
provide a brief description of pertinent patient variables, demographics, clinical diagnosis, and location
Why? HEENT - the eyes
provide information about neurological function
Eyes - External Anatomy: Lacrimal apparatus
provides irrigation to the eye
What does the pulmonary artery and pulmonary veins do?
pulmonary artery carries deoxygenated blood to the lungs and the pulmonary veins carry oxygenated blood back to the heart from the lungs
When assessing for the presence of bronchophony, the nurse notes clear and more distinct words over left upper lobe:
pulmonary consolidation(pneumonia)
Measurement of oxygen saturation
pulse oximeter - arterial oxygen saturation
Pulse oximeter
pulse rate and oxygenation
veins - skeletal muscle pump
pumping effect of contracting skeletal muscles on blood flow through underlying vessels
Heart structures - Chambers - Right ventricle
pumps deoxygenated blood to the lungs
Normal response includes
pupillary constriction, convergence of axes of eyes - record normal response to all these maneuvers as PERRLA, or Pupils Equal, Round, React to Light, and Accommodation
turbinates (conchae) are
quite vascular and tender if touched - note any polyps, benign growths that accompany chronic allergy, and distinguish them from normal turbinates
Some groups carry an excess burden of CVD?
race, ethnicity, gender, socioeconomic status, education - less access to care, not educated on ways to decrease CVD, lack of money for healthy food
Side of the thumb pulse side
radial pulse
In children older than 2, where do you find pulse?
radial site - count pulse for full minute
Facial nerve
raise eyebrows, close eyes as tight as can, puff out cheeks, purse lips, bare teeth
Tachypnea vs bradypnea
rapid breathing vs slow breathing
Abnormal Findings: Swellings of Head and Neck - parotid gland enlargement
rapid painful enlargement seen in response to mumps, blockage of duct, abscess, or tumor
Lability
rapid shift of emotions
atrial fibrillation
rapid, random, ineffective contractions of the atrium - easier to have a clot and stroke
Health literacy is more than just the ability to?
read - includes understanding and following directions that lead to effective communication between the patient and the health care provider - a patient may be literate but not have health literacy
External Canal - note any
redness and swelling, lesions, foreign bodies, or discharge
Routine practices are designed to
reduce the risk of transmission
R-efferal to T-reatment
referrals to specialty care for patients with substance use disorders
As you introduce an object to infant's line of vision, not these attending behaviors: birth to 2 weeks
refusal to reopen eyes after exposure to bright light; increasing alertness to object; infant may fixate on an object
What is breathing normally like?
relaxed, regular, automatic, and silent - passive activity
Bronchophony
repeat 99 in auscultation locations or abnormal location - if clearly say it then abnormal - normal is indistinct - consolidation
Abnormal findings: tympanic membrane - scarred drum(TM)
repetitive damage and scar tissue overgrows
Stronger, more efficient heart muscle pushes out a larger stroke volume with each beat, thus?
requiring fewer beats per minute to maintain a stable cardiac output
Afterload
resistance the ventricles must overcome to eject blood into systemic circulation - high blood pressure ventricle will have to squeeze harder
systemic vascular resistance
resistance to blood flow out of the left ventricle created by the systemic circulatory system. Raises blood pressure
Viscosity
resistance to flow
Why is respiratory system important in babies?
respiratory arrest in peds is common cause of heart stopping. All respiratory issues taken seriously - Small airways and less control of breathing
Neural control - involuntary control of breathing is regulated by the?
respiratory center in the brainstem which is the pons and the medulla
Nose
responsible for warming, moistening, and filtering incoming air, begins respirations
Oral sublingual site has?
rich blood supply from cartid arteries that quickly responds to changes in inner core temperature.
Which veins are involved in returning fluid to venous system?
right and left subclavian which returns to venous system which then returns to heart
Listen laterally on the patients chest in order to hear the?
right middle lobe and some of the lower lobes on the patients sides
tinnitus
ringing or buzzing in the ears
Ask the person to touch tongue to?
roof of mouth - ventral surface looks smooth, glistening, and shows veins
Testing hearing acuity for infants and young children - environment
room should be silent and baby contented; make a loud sudden noise
lateral rectus
rotates eye laterally
Inspection and Palpation of the Skill: Size and shape - normocephalic
round and symmetric
deep veins
run alongside deep arteries and conduct most of the venous return from the legs - femoral, popiteal, anterior and posterior tibial
Egophony
say "E" and hear "A" due to distortion caused by consolidation of a lung - normal hear E - pleural effusion
Infants and children sclera
sclera should be white and clear, although it may have a blue tint as a result of thinness at birth; lacrimal glands are not functional at birth
Erosion
scooped out, shallow depression in skin, if something sits on the skin for too long. Diapers
Key points for screening include all the following except:
screen only indicated patients/clients
SBIRT defined
screening, brief intervention, and referral to treatment(SBIRT) is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services. It is used for - persons with substance use disorders - those whose use is at higher levels of risk
Breast cancer is the?
second most common cancer among women in the US
Developmental competence - the pregnant women: increase in metabolism leads to increase?
secretion of sweat and sebaceous glands to dissipate heat
Excoriation
self-inflicted abrasion on skin due to scratching
External ear
sensing organ, important to hear to sense our surroundings
Air conduction route through ear canal and middle ear usually the more
sensitive route
Title VI of Civil Rights Act of 1964
services cannot be denied to people of limited English proficiency
National standards for culturally and linguistically appropriate services in health care
set of 15 standards provides blueprint to improve quality of care and eliminate health disparities for culturally diverse populations.
General survey - physical appearance - sex
sexual development is appropriate for sex and age, if transgender, note the stage of transformation - delayed or precocious puberty
Cornea and lens test
shine light from side across cornea, and check for smoothness and clarity - oblique view highlights any abnormal irregularities in corneal surface
If the person is unable to see even the largest letters,
shorten distance to chart until the person sees it, and record that distance
Infant's and young child's external auditory canal is?
shorter and has a slope opposite to that of adult's
Accessory nerve
shrug shoulders and dont let push down, turn head to right and dont let hand stop you
Once you complete data collection, develop a list of?
significant signs and symptoms. cluster together the assessment data that appear to be associated or causal. Validate information and fill in the gaps.
Amphetamines
similar to cocaine, talkativeness, agitiation, impaired judgement - withdrawal: similar to cociane
Consensual light reflex
simultaneous constriction of the other pupil
Aging adult position
sitting on table, frail may need to lay supine, arrange the sequence as few position changes, rest period when needed
Adolescent position
sitting on table, try to keep street clothes on and work around them
School age position
sitting or lying on the table. Let 11-12 decide if want caregiver present
Toddler position
sitting up on the caregivers lap for all the examination, supine, enlist caregiver to help position toddler during invasive procedures
What do note for iris and pupil?
size, shape, equality of pupils; normally pupils appear round, regular, and of equal size in both eyes
Burns
skin injuries caused by heat, electricity, radiation, chemicals - treatment based on size and layers of skin affected - seek treatment if its 3 in in diameter, located on face, hands, feet, groin, major joint
Sinus Arrhythmia
skipping a beat
Infant sequence
sleeping baby to listen to heart, startle reflex at the end
Pleurae are?
slippery, serous membranes - visceral: surrounds lung themselves - parietal: surrounds cavity - fluid allows them to slide easily
Abnormal Findings: Lesions on the eyelids - Hordeolum(stye)
small purulent infection of sebaceous gland of eye treated with hot compresses and surgical incision; also called hordeolum
Objective Data Equipment needed
snellen eye chart, handheld visual screener, opaque card or occluder, penlight, applicator stick, opthalmoscope
New health care delivery frameworks must strive for?
social and physical environments that promote quality of life free from preventable illness, disabiility, and premature death.
An individuals health status is influenced by a constellation of factors known as?
social determinants of health. - economic stability - education - social and community context - neighborhood - built environment - health and health care
Aging adults - xanthelasma
soft, raised yellow plaques occurring on lids at inner canthus - they commonly occur around fifth decade of life and more frequently in women, occur with both high and normal levels of cholesterol, and have no pathologic significance
Consistency of lymph nodes
soft, rubbery, hard
If TM intact and no current infection present, a method of cleaning canal is to?
soften cerumen with a warmed solution of mineral oil and hydrogen peroxide - irrigate with warm water with a bulb syringe or a low-pulsatile dental irrigator - direct fluid to posterior wall; leave space around irrigator tip for water to escape
intercostal space
space between the ribs
Musculoskeletal pain
spasm, joint stiffness
communicating with deaf
speak slow and supplement with hand gestures, dont speak loud, written communication or interpreter
Developmental Adaptation last population
special needs population - drug and alcohol abuse - emotional distress
How does heart rate vary with the respiratory cycle?
speeding up at peak of inspiration and slowing to normal with expiration. - inspiration momentarily causes a decreased stroke volume from left side of the heart. To compensate, heart rate increases.
global aphasia
spontaneous speech is absent or reduced to few words or sounds. Comprehension is absent or reduced to only their name and select words
Making a loud sudden noise in newborn
startle(moro) reflex, acoustic blink reflex
Malignant skin lesions - basal cell carcinoma
starts as very small, pink/red papule, goes to translucient top, difficult to remove due to bleeding, red ulcerated center that can look like a large pore
To activate tuning fork, hold it by?
stem and strike tines softly on back of your hand - perform weber and rinne tests
Major neck muscles
sternomastoid and trapezius are innervated by cranial nerve XI
What is the thoracic cage made up of?
sternum, twelve pairs of ribs, and twelve thoracic vertebrae
exotropia strabismus
strabismus in which there is deviation of the visual axis of one eye away from that of the other eye, resulting in diplopia; also called wall-eye and divergent strabismus
Contractility
strength of contraction
What is force of pulse?
strength of heart stroke volume
Normal ranges of blood pressure are affected by?
stress, exercise, age, weight, emotions, gender, race, so will vary throughout the day.
Abnormal findings: red eye - vascular disorders - allergic conjunctivitis
stringy, red, injected look - bilateral, itching, thin, stringy clear discharge
systolic pressure
strongest, maximum pressure
Nose may appear more prominent on face from loss of?
subcutaneous fat - in edentulous person, mouth and lips fold in, giving a purse-string appearance
Beneath these layers is a ---- layer of ---- tissue
subcutaneous; adipose - stores fat for energy, provides insulation for temperature control and aids in protection
A symptom
subjective sensation that the person feels from the disorders
Physical examination: Infants and children - two common variations - cephalohematoma
subperiosteal hemorrhage, well defined over one cranial bone over periosteum reabsorbed during first few weeks of life
Mouth and throat normal finding in infants is
sucking tubercle, a small pad in middle of upper lip from friction of breastfeeding or bottle-feeding - note number of teeth and, if appropriate for childs age - note pattern of eruption, position, condition, and hygiene
paroxysmal nocturnal dyspnea
sudden awakening from sleeping with shortness of breath
Abnormal findings: eyelid abnormalities - enophthalmos
sunken eyes
Abnormal Facial Appearances - Cachectic appearance
sunken eyes, hollow cheeks, and defeated expression that accompanies chronic wasting diseases
Aging adult eyes may appear
sunken from atrophy of orbital fat; orbital fat may herniate, causing bulging at lower lids and inner third of upper lids
Lymph nodes: posterior auricular(mastoid)
superficial to mastoid process
first degree burn
superficial, red, dry, no blisters, mild pain, epidermis - cool water, antibitoic ointment, bandage
Disease Causation Theories - magicoreligious
supernatural powers predominate in area of health and illness - voodoo, witchcraft, faith healing
coronary arteries
supply oxygen-rich blood to the myocardium - decrease in blood flow = heart attack
First function of the respiratory system
supplying oxygen to the body for use in the body to maintain functions of life at the cellular level - capillaries
Risk factors or venoustasis
surgery, prolonged standing or sitting, bedrest, trauma to vessel, hypercoaguable state(blood clot easier)
Precordium Inspection and Palpation - Heaves and Lifts
sustained forceful thrusting - right is at the sternal border - left is at the apex - due to heart enlargement (hypertrophy)
Bones of neonatal skull are separated by?
sutures and fontanels, spaces where the sutures intersect - these membrane-covered "soft spots" allow growth of brain during first year; gradually ossify
Abnormal findings: tympanic membrane - otitis media with effusion
swollen ear drum, fluid
Peripheral Neuropathy
symmetric damage to peripheral nerves, resulting in pain without stimulation of the nerves. Numbness or tingling.
General survey - physical appearance - facial features
symmetric with movement - immobile, drooping
A full mental status exam is what?
systematic check of emotional and cognitive functioning, health history interview is when can be done, but not always needed to be done - find abnormality in behavior .
Cardiac pain
tachycardia, elevated blood pressure, increased myocardial oxygen demand, increased cardiac output
rapid respirations
tachypnea - over 20 breaths per minute
Crying enhances?
tactile fremitus and breath sounds - have parent hold baby - breath sounds when sleeping - warm stethoscope
Height measurements
tape measures, wall mounted, scale
Polycyclic
target shapes coming together
Compliance and Code of Ethics
teaches polices that prevent violation of federal and state laws that address fraud, abuse, and waste prevention
Thermometer
temporal artery, tympanic membrane, rectal, oral(mercury, electronic)
The temporal artery lies superior to?
temporalis muscle, and pulsation is palpable anterior to ear
Abnormalities of external ear: frostbite
tenderness, burning, swollen, redish blue, could cause permanent damage
Posterior Assessment - Palpation: Chest wall
tenderness, lumps, masses, skin temperature, moist or dry skin
hypothesis
tentative explanation for a cue or set of cues that can be used as a basis for further investigation.
Denver II screening test
test gives a chance to interact directly with child to assess mental status -For child from birth to 6 years of age, Denver II helps identify those who may be slow in development in behavioral, language, cognitive, and psychosocial areas -An additional language test is the Denver Articulation Screening Examination
Infants and children color vision test
test only boys for color vision, once between ages 4-8; use ishihara test
Sense of smell, mediated by cranial nerve I, is usually not?
tested in a routine exam
Preload
the degree of myocardial fiber stretch at the end of diastole and just before contraction - how much blood is returning to the heart and able to fill the heart before systole
health literacy
the degree to which someone can obtain, process, and understand basic health care and services needed to make appropriate decisions - what do you clients really understand?
ambivalence
the existence of opposing emotions toward an idea, object, person
The interview
the first point of contact with a client and the most important part of data collection
Health history for the ill person
the health history includes a detailed and chronologic record of the health problem.
Health history for everyone
the health history is a screening tool for abnormal symptoms, health problems, concerns.
Health history for the well person
the history is used to assess his or her lifestyle
dysarthria
the inability to use speech that is distinct and connected because of a loss of muscle control after damage to the peripheral or central nervous system
Neural control - Hypercapnia
the normal stimulus to breath is an increase in carbon dioxide in the blood which is called this - low oxygen levels too
Try to reduce any anxiety so that the data will more closely describe?
the persons natural state. Act like a patient so that you can deal with the real situation while still in a safe setting
The costal angle
the right and left costal margins form an angle where they meet at the xiphoid process. - wider in old age, pregnant women, children
Heart structures - Chambers - Right atrium
the right upper chamber of the heart that receives blood from the venae cavae and coronary sinus
What is the general survey?
the study of the whole person. begin at the moment you first encounter a person, kind of like a judgement call, but dont make assumptions.
During the first few days, TM often looks
thickened and opaque; may look "injected" and have mild redness from increased vascularity - looks injected after crying
Sublingual glands
third pair of salivary glands that lies in the floor of the mouth
Present health or history of present illness for the well person
this is a short statement about the general state of health
JVD (jugular vein distention)
this is bulging of the external jugular vein which indicates increased blood volume and usually congestive heart failure (CHF)
Present health or history for the ill person
this section is a chronological record of the reason for seeking care, from the time the symptom first started until now
Lungs are located in the?
thoracic cavity
Respiratory dead space is important for?
those on ventilators because when a patient is on one it increases their dead space so need to make sure setting is correct to not cause lung injury with too much dead space
Culture
thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups
Weak pulse force
thread pulse reflects a decreased stroke volume
Alcohol dependence
three or more of these - tolerance, diminished effect, withdrawal, investment in drinking/use behavior, unable to cut down
Dull
thudlike sounds are normally heard over dense areas such as the heart or liver
General survey - mobility - no involuntary movement
tics, tremors
Because oral exam is intrusive for infant or young child, ---- is?
timing is best toward end with ear exam
Infant preparation
timing should be 1 or 2 hours after feeding, maintain warm environment, diaper only, touched is okay keep warm, soft voice, eye contact, smile, smooth movements, pacifier for crying, bright toys.
Alveoli
tiny sacs of lung tissue specialized for the movement of gases between air and blood
Be discriminating in use of?
tongue blade; it may be necessary for a full view of oral structures, but it produces a strong gag reflex in infant - may avoid tongue blade completely with cooperative preschooler and school-age child
Mobility should allow ---- to extend at least as far as ----
tongue; alveolar ridge - note any bruising or laceration on buccal mucosa or gums of infant or young child
Tonsils in infants and children
tonsils are not visible in newborn; gradually enlarge during childhood, remaining proportionately larger until puberty - tonsils appear still larger if infant is crying or gagging
Taking blood pressure reading when person is angry or active
too high
Dorsal pedis (pulse site)
top of foot - if can't find pulse get a doppler and mark it so can find it, if can't find then there is a problem
Bednar aphthae are?
traumatic areas or ulcers on posterior hard palate on either side of midline; result from abrasions while sucking
Mitral valve closes just before?
tricuspid so may here two sounds during lub. Aortic closes before pulmonary.
Bruit
turbulent blood flow from narrowing or occluding of artery
Aging adult: presbycusis
type of hearing loss that occurs with aging, even in people living in quiet environment - gradual sensorineural loss caused by nerve degeneration in inner ear or auditory nerve
History of head or neck surgery health history questions
type of surgery, reason for surgery, response to surgery
Atrophic tissues ---- easily
ulcerate - increasing risk for older people for infections, such as oral moniliasis and malignant lesions
Abnormal Findings: Lesions on the eyelids - Basal cell carcinoma
ulceration
Abnormal findings: Lumps and Lesions on External Ear - carcinoma
ulceration or destroyed tissue which will bleed
side of pinky pulse
ulnar pulse
Wood's light
ultraviolet light used for diagnosing skin conditions - other(magnifying glass, potassium hydroxide and glass slide)
BMI underweight is considered
under 18.5
Lymph Nodes: Jugulodiagastric
under the angle of the mandible
Proficient nurse
understands a patient situation as a whole rather than a list of tasks.
Pain in older adults if very often?
undertreated, and it may be especially so in older adults with severe dementia. Changes in a patient's ability to communicate verbally present special challenges in treating pain, since self-report is considered the gold standard of pain assessment
palmar erythema
unusual redness of the palms of the hands
According to recent estimates, which of the following sources of health care waste has had the largest financial impact?
unwarranted use of medical resources or services
Avoid middle ear insufflation in a person with?
upper respiratory infection because it could propel infectious matter into middle ear
By age 2 or 3, use what type of scale?
upright scale, for age 2-3, measure child's height by standing child against pole on platform scale or back against a flat ruler taped to the wall
Second level priority
urgent/require prompt intervention to halt further deterioration(ie. Mental status, acute pain, urinary elimination problems, risk for safety, risk for infection)
Rental pain
urinary retention
Unbundling
use multiple codes that can be represented by a single code
Toddler preparation
use symbols, greet the child, do not like taking off clothes, like to make choices, demonstrate procedures on caregiver, praise the child
crying
use touch, gained insight to a serious concern
Snellen alphabet chart is most commonly?
used and accurate measure of visual acuity - it has lines of letters arranged in decreasing size
When documenting for hearing acuity
useful to document presence of hearing loss - refer to any abnormal findings for more accurate measures with pure tone audiometry
Notice any breath odor, halitosis
usually due to local cause; poor oral hygiene, consumption of odor food, alcohol, smoking, or dental infection
Teeth, both sets, begin development in?
utero
Facial bones grow at?
varying rates - in toddler, mandible and maxilla are small and nasal bridge is low
Developmental competence pregnant women: hormonal changes cause?
vasodilation and a resulting drop in blood pressure
expert nurse
vaults over the steps and arrive at a clinical judgement in one leap.
superficial veins
veins located near the body surface - cephalic, cubital, saphenous
QRS complex
ventricular contraction(depolarization)
T wave
ventricular repolarization(relaxing)
Preschool preparation
verbal communication, but understanding limited, underdress, explain steps of exam, enhance autonomy, allow child to play with equipment to reduce fears, use games, use slow approach, give feedback, compliment the child
Posterior thoracic landmarks - Reference Lines
vertebral line scapular line
Surface of incisors may show?
vertical cracks from a lifetime of exposure to extreme temperatures
What structures are in the neck?
vessels, muscles, nerves, lymphatics, and viscera of respiratory and digestive systems
What composes the vestibular apparatus?
vestibule and semicircular canals within bony labyrinth - cochlea contains central hearing apparatus
Childs age determines
visual acuity screening measures used
Stroke volume
volume of blood ejected from left ventricle with each cardiac cycle; influenced by 3 variables(preload, afterload, contractility)
Cardiac output
volume of blood in liters is ejected by heart each minute - CO = HR * SV
Prevention
wash off makeup, wash eyelids, wash and dry hands before touching eyes, keep contacts clean, replace eye makeup, dont rub the eyes
Function of skin
waterproofing, protecting, adaptive, sensation, temperature regulation, self identifying, communicate with body, wound repair, vitamin D
General survey - body structure - Nutrition
weight normal for height and body build - obesity, cachetic, emaciated
Provoking or palliating factors
what brings it on? What makes it better? What makes it worse? What makes it better or worse?
Understanding your impact
what do you believe is causing this? How is this affecting your ADLs you and/or your family? Do you have any other concerns?
person
what is your name?
When should thigh pressure be obtained?
when blood pressure at the arm is abnormally high, it should be compared to thigh pressure
Time and treatment
when did he symptoms first begin? What medications are you currently taking for this? How effective are these? Side effects? Intermittent, constant?
Onset
when did it begin? How long does it last in duration? How often does it occur? What were you doing when the pain started?
Transmission occurs when?
when droplets containing microorganisms generated during coughing, sneezing and talking are propelled through the air. These microorganisms land on another person, entering that new person's system through contact with his/her conjunctivae, nasal mucosa or mouth
Stepping reflex
when placed upright with weight bearing on the feet, a baby will make stepping motions
Abnormal findings: Lumps and Lesions on External Ear - battle sign
when there is trauma to side of head that leads to fracture behind the ear
The only places in your heart that do not contain valves are?
where the little holes of the heart are(where backing up and increase in pressure is)
Ask family or caregivers what?
whether the patient's behavior is different from their customary behavior.
Abnormal Conditions of the Nails - Beau lines
white lines across the fingernails; usually a sign of systemic disease or injury
Increased likelihood of skin cancer in?
whites than in black and hispanic populations - if blacks get than its later detected and more serious
Common skin lesions - allergic drug reaction
widespread red rash that is generalized
From an MI perspective, the assumption is there is a deep well of ---- and ----- within the person from which the counselor can draw - a key element in MI
wisdom and experience
size of lymph nodes
with less than 2 cm considered insignificant
Where does the motivation for change come from?
within the client
anxiety
worried, uneasy, apprehensive from the anticipation of a danger whose source is unknown
Aging adult - as a result of atrophy of elastic tissues, skin around eyes may show
wrinkles or crows feet; upper lid may be so elongated as to rest on lashes, resulting in pseudoptosis
icteric sclera
yellow sclera
What do safety assessments protect?
you and your clients
Gift from a patient
you must maintain professional integrity, if gift has cash value cannot accept, if edible can accept it.
Wong Baker FACES
· 0 = no hurt · 2 = hurts little bit · 3 = hurts little more · 6 = hurts even more · 8 = hurts whole lot · 10 = hurts worse Used in children 4-12 years. Score 0-10.
CHEOPS
· 6 categories, each with 3-4 levels · Total score 4-13
Assessing pain
· Assess pain as part of general patient care · Every patent experiencing pain should be considered a candidate for pain management, regardless of transport time
Alder Hey Triage Pain Score
· Developed specifically for emergency setting · Total score range 0-10
Normal temperature is influenced by?
· Diurnal cycle: of 1F to 1.5F, with trough occurring in early morning hours and peak occurring in late afternoon to early evening · Menstruation cycle in women; progesterone secretion change normal temperature variations · Exercise · Age - smoking, chewing gum, hot or iced liquids
Planning
· Establish priorities · Develop outcomes · Set timelines for outcomes · Identify interventions · Integrate evidence-based trends and research
Aging adult pain
· No evidence suggests that older individuals perceive pain to a lesser degree or that sensitivity is diminished. Not a normal process of aging. Many clinicians assume that pain should be expected in aging, which leads to underreporting of pain and less aggressive treatment. · Dementia does not impact the ability to feel pain but cant report as well
Numerical Rating Scale(NRS)
· Scored 0-10 - Also known as Verbal Numerical Scale(VNS) · Record score as number- 0 0 no pain, 5 moderate pain, 10 worst possible pain
Oucher
· Used in children 4-12 years · Patients point to face that represents pain · Score 0-10
Use a standarized tool to assess pain intensity such as?
· a numerical rating scale(NRS) or verbal descriptor scale(VDS)
Airborne transmission of infectious agents occurs either by?
• Airborne droplet nuclei (small particles of 5 mm or smaller in size) • Dust particles containing infectious agents.
Fraudulent billing
"...the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to himself/herself or some other person..." or "...to purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced."
A nurse is orienting to his new place of employment. Information is being provided regarding HIPPAs privacy rule. Which of the following comments by the nurse indicates an accurate understanding of these standards?
"I can give information about a patient over the phone if the patient gives his permission"
nurse is discussing the use of a computer to document in the clients health record with a newly licensed nurse. which one of the following comments by the new nurse indicates an understanding of the information
"I should remain aware of my surroundings when documenting on the computer."
A 70 year old patient is scheduled for open heart surgery. THe surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, "what happens to my circulation when this vein is removed?"
"This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition"
The pleural cavity is?
"potential space"
Culture has four basic characteristics
(1) learned from birth through the processes of language acquisition and socialization; (2) shared by all members of the same cultural group; (3) adapted to specific conditions related to environmental and technical factors and to the availability of natural resources; and (4) dynamic and ever changing.
Remote memory
(long term memory), verify past events - describe past health history, when is their birthday, what was your first job
Heart Structures - Valves - left atrioventricular valve
(mitral or bicuspid valve) Blood leaving the left atrium flows into the left ventricle through this valve; most commonly replaced due to more pressure on left side of the heart
Pitting edema grading scale
- 0+ no pitting edema - 1+ slight pitting and its hard to see(2mm indentation, disappears immediately) - 2+ mild pitting edema(4mm, disappears 10-25 sec) - 3+ moderate pitting edema(4-6mm, more than 1 minute) - 4+ severe pitting(6mm+, lasts several minutes)
Consolability
- 0: no need to console - 1: distracted or reassured by voice or touch - 2: unable to console, distract or reassure
Negative vocalization
- 0: none - 1: occasional moan or groan. Lowlevel speech with a negative or disapproving quality - 2: repeated troubled calling out. Loud moaning or groaning. Crying
Breathing independent of vocalization
- 0: normal - 1: occasional breathing. Short period of hyperventilation - 2: noisy labored breathing. Long period of hyperventilation. Cheyne Stokes respirations
Body language
- 0: relaxed - 1: tense, distressed pacing, fidgeting - 2: rigid, fists clenched, knees pulled up, pulling or pushing away, striking out
Facial expression
- 0: smiling or inexpressive - 1: sad. Frightened. Frown - 2: facial grimacing
Tonsils graded in size as follows:
- 1+ visible - 2+ halfway between tonsillar pillars and uvula - 3+ touching uvula - 4+ touching each other
Health promotion and patient teaching
- 1,3,6 program of universal newborn hearing screening - early intervention and amplification leads to better outcomes - ear protection - use good hygiene with ear devices - use unnecessary ear devices with caution and limited use - distractions from the use of headphones/electronic devices
Illicit drug statistics
- 12 years and older 10.1% current illicit drug use - marijuana most common 80% - 1-2 in 10 adolescents are illicit drug users - Impacts: legal status, healthy relationships, prospects, school
Age ranges for rectal thermometers
- 3 moths or less need rectal - Up to three years rectal is most accurate, but after use axillary
Lung fields for percussion
- 3 spots on each side of middle upper back - down intercostal spaces 4 times - curve out for the next two - 2 on each side vertical under scapula
Childhood mental disorders
- ADHD - ODD - eating disorder - autism spectrum disorder
Substance Use - standard drink
- Alcohol(one mixed drink with 1.5 fl oz of 80 proof liquor, wine is 5 fl oz, 12 fl oz of beer or wine cooler) - Drug
Environmental noise questions
- Any loud noises at home or on the job?(For example, do you live in a noise-polluted area, near an airport or busy traffic area? Now or in the past?) - Are you hearing other noises such as heavy machinery, loud persistent music, or gunshots while hunting?
Vestibular Apparatus - Romberg sign
- Assesses ability of vestibular apparatus in inner ear to help maintain standing balance - Also assesses intactness of cerebellum and proprioception as it is part of the neurologic system
Inspect with Otoscope: Insert speculum slowly and carefully along axis of canal
- Avoid touching inner "bony" section of canal wall covered by a thin epithelial layer because it is sensitive to pain. - Once in place, you may need to rotate otoscope slightly to visualize all the TM; do this gently. - Last, perform otoscopic examination before you test hearing.(Canals with impacted cerumen give the erroneous impression of pathologic hearing loss)
Pain Scales(quality) Inspection
- CRIES - FLACC - PAIN-AD
Inspect with otoscope: As you inspect external ear, note size of auditory meatus
- Choose largest speculum that will fit comfortably in ear canal. - Tilt the person's head slightly away from you to bring obliquely sloping eardrum into better view. - Pull pinna up and back on an adult or older child to straighten S-shape of canal.(Pull pinna down on an infant and a child under 3) - Hold pinna gently but firmly; do not release traction on ear until you have finished examination and removed otoscope.
To inhibit the transmission of microorganisms by vehicle
- Clean patient equipment between uses with different patients - Handle, store and prepare food properly - Careful store and draw up doses of medication from multidose medication vials.
Rinne test abnormal finding relates to:
- Conductive loss: AC = BC or even longer (AC less than BC) - Sensorineural loss: Normal ratio intact but reduced, the person hears poorly both ways
Microorganisms are transmitted in health care settings by four main routes:
- Contact - Droplet - Airborne - Common vehicle
Factors to review for headaches
- Definition, location, character, duration, quantity, and severity, and timing - aggravating symptoms or triggers, associated symptoms and relieving factors, effort to treat
Respirations(inspection)
- Do not announce this assessment - Count for at least 30 seconds, if abnormality then do full minute if possible - Often measured while still holding a person's pulse - Notice outside 10-20 respirations per minute or abnormal rising and falling of chest then do the full minute
Pain Scales(severity) interview
- FACES - VAS
What does the review of systems consist of?
- General overall health state - Skin, hair, and nails - Ears, eyes, head, nose and sinuses, mouth and throat, neck, breast, axilla, respiratory system, cardiovascular, peripheral vascular, gastrointestinal, urinary system, male genital system, female genital system, sexual health, musculoskeletal system, neurologic system, hematologic system, endocrine system
Additional History for Infants and Children Questions - Does child seem to be hearing well?
- Have you noticed that infant startles with loud noise? Did infant babble around 6 months? Does he or she talk? At what age did talking start? Was speech intelligible? Ever had child's hearing tested? If there was a hearing loss, did it follow any diseases in child or in mother during pregnancy? Does child tend to put objects in ears? Is older child or adolescent active in contact sports?
Hazardous and Harmful drinking
- Hazardous: at risk for adverse consequences - harmful: causing physical or psychological harm
Ask the person directly if there is a hearing difficulty.
- If answer is yes, perform audiometric testing or refer for audiometric testing. - If the answer is no, screen using the whispered voice test.
Pulse(palpation)
- Infant brachial(palpated) - Adult radial(palpated) - Start counting with 0
Integrity of the tympanic membrane
- Inspect TM and entire circumference of annulus for perforations. - Normal TM is intact - Some adults may show scarring, which is a dense white patch on TM, a sequela of repeated ear infections.
Assessing: Objective Data
- Inspection: patient sitting, disrobed to waist - note symmetry, size, shape - skin normally smooth and even in color - discharge, bleeding? - nipples: symmetrical?, flat?, inverted? - observe the axillary and supra clavicular areas for any bulging, discoloration or edema
How to detect skin cancer
- Learn asymmetry, border, color, diameter, evolving - new spots or moles that itch or bleed
During history, notice clues from normal conversation indicating possible hearing loss:
- Lip reading or watching your face and lips rather than your eyes - Frowning or straining forward to hear - Posturing of head to catch sounds with better ear - Misunderstands questions; frequently asks you to repeat - Irritable or shows startle reflex when you raise your voice - The person's speech sounds garbled, vowel sounds distorted - Inappropriately loud voice - Flat, monotonous tone of voice
Blood pressure(ascultation)
- Manual - Automated
Safety precautions
- NOP - fluid restriction - fall precautions - standard precautions
Weber test
- Normal finding: sound is equally heard in both ears - Abnormal finding: sound lateralizes to one ear - Conductive loss: sound lateralizes to poorer ear - Sensorineural loss: sound lateralizes to better ear
Temperature(palpation)
- Oral: glass(3-8 minutes)/digital(20-30 sec) - Rectal: Class(2.5 minutes)/digital(30 sec) - Surface: Tympanic membrane(2-3 sec)/Temporal Artery(6 sec) - Say how you got it(oral/rectal/surface) and if it is Celsius or Fahrenheit
Objective data equipment
- Otoscope with bright light, fresh batteries give off white, not yellow light. - Pneumatic bulb attachment, sometimes used with infant or young child - Tuning forks in 512 and 1024 Hz
What are the four main areas of a general survey?
- Physical appearance - Body structure - Mobility - Behavior
Two types of pain assessment tools
- Self-report - Observational or behavioral
Risk factors for heart disease
- Smoking - chemicals in vessels that are causing chronic inflammation and rapid building up of plaque - diet - excessive glucose - high blood pressure - sedentary lifestyle - genetic disposition
Vascular lesions - Telangiectases
- Spider or star angioma(small red dot and then star shape around it - pregnancy, chronic liver disease) - Venous lake(purple blue dilation of venules empty or disappear when pressure applied - lips, face, ears, chest)
great vessels
- Superior and inferior vena cava - pulmonary artery - pulmonary vein - aorta
Tympanic membrane - color and characteristics
- Systematically explore landmarks - Normal TM shiny and translucent, with a pearl-gray color - Cone-shaped light reflex prominent in anteroinferior quadrant, a reflection of the otoscope light - Sections of malleus are visible through translucent drum: the umbo, manubrium, and short process. - At periphery annulus looks whiter and dense
Teaching Methods
- Teach Back - Ask me 3 - Plain Language
Electronic Health Record problems
- Technology interface can affect communication in the healthcare provider-patient relationship - doesnt always capture psychological and emotional info - do not allow the computer to become a barrier in the communication exchange process
Evidence based practice
- The conviction that all patients deserve to be treated with the most current and best practice techniques led to the development of evidence based practice. Systemic reviews and clinical trials. - Evidence shows that other assessment skills are effective for patient care.
Steps to Cultural Competence
- Understand one's own heritage-based values, beliefs, attitudes, and practices - Identify meaning of "health" to patient Understand how health care system works - Acquire knowledge about social backgrounds of patients - Become familiar with languages, interpretive services, and community resources available to nurses and patients
Developmental Adaption - Older Adults
- Use last name - Hearing impaired - speak slowly, use gestures, nodding is "friendly"
Wheal vs Urticaria/Hives
- Wheal is superficial, raised, transient, eryothema due to inflammation(scratch kind of hives) - Urticaria are larger and more of a rash and itchy
Abnormal Findings: Pediatrics - Atopic(allergic) facies
- a variety of presentation seen in children who have chronic allergies - include exhausted face, allergic shiners, morgan lines, central facial pallor and allergic gaping
Talking to a victim
- a yes response to AAS questions requires further investigation - assess when the abuse occurred - assess the seriousness of the abuse - convey concern and even distress - emphasize that it is not the persons fault - communicate that help is available red flag: noting physical findings not consistent with history(different colored bruising - still act on it)
Physical exam of someone who has experienced violence
- abrasion - avulsion - bruise - contusion - cut - exxhymosis - hematoma - hemorrhage - incision - laceration -lesion - patterned injury - pattern of injuries - petechiae - stab wound - traumatic alopecia - wound DEFINE FROM BOOK
Health effects of violence
- abuse victims have more chronic health problems/mental health problems(substance abuse, depression)/impacts brain development - physical injury is just the beginning
What type of sensory should i use?
- adhesive sensors are good for children on the earlobe, nose bridge, toe - clip sensors are good for adults
Stages of level of consiousness
- alert - lethargic: not fully alert - obtunded: difficult to arose - stupor: spontaneously unconscious - coma: completely unconscious - delirium: clouding of consciousness
Nictoine
- alert, increased systolic, increased heart rate, vascoconstriction, nausea, vomiting, ingestion, loss of appetite - withdrawal: vasodilation, headaches, anger, irrability, frustration, anxiety, nervousness, depression
Infants and children visual acuity testing
- allen test, picture card, screens children from 2 1/2 to 2 years, 11 months, and is relaible with cooperative toddlers as young as 2 - use picture chart or snellen E chart for preschooler from 3-6; normally a child achieves 20/20 acuity by age 6-7
Communication between personnel and family members
- allows communication as long as the patient hasnt objected - ask patient directly if you may disclose info to this person
Female Breast
- also known as mammary gland - reproductive organs - produce milk
Infants and children developmental competence
- always consider developmental milestones - Denver II screening test
Characteristics of eating problems
- anorexia nervosa - binge eating - bulemia nervosa
Inspection of palate
- anterior hard palate white with irregular transverse rugae - posterior soft palate is pinker, smooth, and upwardly movable
Anterior and Posterior chest in relation to lung lobes
- anteriorly is mostly upper and middle lobe - posterior chest is almost all lower lobes
Aortic aneurysms may be located in the?
- aortic arch - descending/thoracic aorta-above diaphragm - abdominal aorta - below diaphragm(AAA)
The 4 main categories of the mental status assessment
- appearance - behavior - cognition - thought processes
Ask Me 3 guidelines
- ask 3 questions - ask early - write down answers
Under the influence: interview
- ask simple direct questions - avoid confrontation - avoid scolding or disgust - use the spirit of MI and maintain professional reaction to the circumstance
Disease Causation Theories - Biomedical
- assumes cause and effect - views the body as a machine - life can be divided into parts - endorses germ theory
Malignant skin lesions - malignant melanoma
- asymmetrical, irregular boarders, dark color, diameter is larger than 6mm, elevated, looks funny
DVT clinical manifestations
- asymptomatic - pain, swelling, tenderness, redness, warmth at affected area
Diagnostic reasoning four components
- attending to initially available cues, forming diagnostic hypotheses, gathering data relative to the tentative hypotheses, and evaluating each hypothesis with the new data collected arriving at a final diagnosis.
external ear
- auricle and pinna are cartilage that help funnel sound waves - auditory canal which leads to tympanic membrane. Should have wax to protect the eardrum
Abnormal findings: red eye - vascular disorders - conjunctivitis
- bacterial, viral, and allergy related - redness in eye with injected look, different discharge depending on the type - Bacterial and viral are one sided infection - bacterial thick yellow/green, wipes away and comes back, contagious - viral has clear thick discharge and is contagious
health-related beliefs and practices
- balance and beliefs about causes of illness - biomedical or scientific theory - naturalistic or holistic theory(hot and cold, tin and yang) - magicoreligious perspective - traditional beliefs and health healers
What to do when no interpreter is available
- be polite, pronounce name correctly, unhurried, use words you may know in their language, low, moderate voice, simple words, give instructions, discuss one topic at a time, validate they understand, write them if that works for them, ask if family can interpret
homocide risk factors
- being physically abused increases the risk of being killed by the abuser - intervene to decrease the danger
Religion
- belief in a divine or superhuman power, or powers to be obeyed and worshipped as creator/ruler of universe - system of beliefs, practices, and ethical values - shared experience of spirituality
In newborn, test visual reflexes and attending behavior: test light perception using -
- blink reflex: neonate blinks in response to bright light - pupillary light reflex: shows that pupils constrict in response to light
Though process abnormalities
- blocking: interruption in train of thought - confabulation: fabricates to fill in memory gaps - circumlocution: round about expression - circumstantiality: excessive or unnecessary detail - lossening assoications: shifting from one topic to unrelated topic - flight of ideas: abrupt change - word salad: incoherent mixture of words - perserveration: persistent repeating of verbal response - exholalia: imitation - clanging: word choice based on sound
Pregnant Women developmental competence
- blood volume increases by 30-40% during pregnancy for oxygen and nutrients to baby - increases SV(more blood), HR(help move blood), murmur, bigger heart, pseudoanemia
How to use an incentive spirometer - do not do
- blow into rather than inhaling - inhale and exhale quickly
Sending: nonverbal communication
- body language helps to provide cues which may be correlated with truer feelings - recognize importance of unconscious messages
Pregnancy Changes in breasts
- breast changes occur 2nd month of pregnancy - breast enlarge - feel more nodular - nipples grow larger, darker, and erect - areolae enlarge and darken - increase venous pattern - 4th month Colostrum may be expressed
The structures and mechanisms of breathing
- breath in through noose or mouth - trachea - bronchi - acinus: functional unit of lungs(alveoli surrounded by capillaries, pulmonary artery and vein, gas exchange)
Thyroid disorders: Graves Disease
- butterfly look - eyelid retraction - exophthalmos - goiter
When is S3 normal and abnormal?
- can be normal in young adults and children, pregnancy, athletes - may signify severe mitral or tricuspid regurgitation, cardiomyopathy, or heart failure
Level of blood pressure is determined by what five factors?
- cardiac output - peripheral vascular resistance - blood volume - blood viscosity - elasticity of vessel walls
Differential diagnosis of chest pain - cardiovascular
- cardiovascular - pulmonary - gastrointestinal(reflux) - dermatologic(shingles) - musculoskeletal/neurologic(strain, injury, anxiety, depression) - psychogenic
Drugs which induce nystagmus
- central nervous system depressants - most inhalants - dissociative anesthetics - alcohol
Pulse oximetry - inspection
- check skin condition and temperature - capillary refill - make sure skin is free of nail polish, not same limb as blood pressure cuff, dont use thumb - watch waveform(consistent and regular) - check pulse to make sure matches oximeter
Head and neck vessels subjective data
- chest pain - dyspnea - orthopnea - cough - fatigue - cyanosis or pallor - edema - nocturia - past cardiac history - family cardiac history - patient centered care(cardiac risk factors)
palpation of anterior chest
- chest wall - symmetric expansion - tactile fremitus(palm of hand 4 times side to side)
Infants and young children behavorial manifestations of hearing loss
- child is inattentive in conversations - reacts more to movement and facial expression than to sound - facial expression strained or puzzled - asks to have statements repeated - confuses words that sound alike - speech problem - shy and withdrawn - complains of earaches - ears better at times when environment is more conducive
Symptoms of aging ears
- coarse hairs - eardrum is whiter and more opaque, duller, thicker - high tone frequency loss apparent for those affected with presbycusis(revealed in difficulty hearing whispered words in voice test and in difficulty hearing consonants during conversation) - feels like others mumble and feels isolated in family and friends
What makes the oxygen saturation inaccurate?
- cold finger - thick fingernail polish - acyrilic nails
What other things can affect the reading?
- cold(hypovolemia, circualtory compromise, hypothermia)
Inspection and Palpation: Skin - Lesions, if any are present note the following
- color - elevation - pattern or shape - size - location and distribution on body - any exudate: color and odor - use a wood's light(UV light) to detect fluorescing lesions
Summary Checklist - Inspection of the skin, hair, and nails
- color and pigmentation - texture and distribution - shape, contour, and consistency
Inspect the legs
- color(red, pallor) - hair distribution(thin hair or missing - lack of oxygenated blood flow) - venous pattern(varicose veins) - size/symmetry(edema) - lesions or ulcers ANTERIOR AND POSTERIOR
Summary Ear Examination - inspect tympanic membrane
- color, characteristisc, position, integrity - last do the test hearing acuity
Three functions of the middle ear
- conducts sound vibrations from outer ear to central hearing apparatus in inner ear - protects inner ear by reducing amplitude of loud sounds - eustachian tube allows equalization of air pressure on each side of TM so that it doesnt rupture
Conjuntiva and sclera test notes
- conjunctiva clear and show normal color of structure below; pink over lower lids and white over sclera - note any color change, swelling, lesions - ethnic variations
Mental status assessment involves factors such as?
- consciousness, language, mood, affect - orientation and attention - memory and abstract reasoning - though process, through content, and perception
Interpreter - family members
- convenient - may not know/understand medical language - may violate confidentiality
Research demonstrates effectiveness
- cost effectivenss - effective way to reduce drinking and substance abuse problems
Anterior Inspection - shape and configuration
- costal angle of 90 degrees if greater than may have barrel chest
Subjective data collection
- cough - shortness of breath - chest pain with breathing - history of respiratory infections - smoking history - environmental exposure - patient centered care - interrogate more if get yes answer (know highlighted terms in book)
Skin the the largest body organ
- covers 20 square feet of surface area in adults - skin is the sentry that guards body
How can we help?
- create a supportive environment - plain language vs. medical terms - use visual models to explain procedures or tests - asses ability to read and understand by using Teach Back
How many teeth do adults have
- crown, neck, root - adults have 32(16 on top and bottom)
To test pupillary light reflex
- darken room and ask person to gaze into distance; this dilates pupils; advance a light in from side and note response - in acute care setting, pupil size is measured in millimeters before and after the light reflex
For older patients, culture is likely to do the following:
- define their family responsibilities - affect their view and knowledge of health care systems used by dominant culture
Documentation of normal breast exam
- denies breast pain, lump, discharge, rash, swelling, trauma. denies past history of breast disease or surgery - Inspection: breasts symmetric. Skin smooth with even color. No dimpling or retraction elicited. No nipple discharge. No lesions - Palpation: breast contour and consistency firm and homogeneous. No masses or tenderness. No lymphadenopathy - healthy breasts bilaterally with no S/S of abnormalities
A score of 18 on the AUDIT would place a person at which use level?
- dependent use(20+) - harmful use(16-19) - at risk use(8-15) - low risk(0-7)
Modified Allen's Test
- depress radial and ulnar arteries - person opens and closes fist(skin should blanch) Keep thumb on radial artery and release ulnar artery. - normal: blood returns via ulnar artery within 7 seconds(negative) - occluded ulnar artery: no blood return(positive)
Related Organs - Spleen
- destroys old red blood cells - stores red blood cells - produces antibodies and filters the blood
Steps of ABG interpretation
- determine on PH if dealing with acidosis or alkalosis - second step is who is to blame(respiratory or metabolic?). Which one matches? - do we have compensation? is the metabolic or respiratory system trying to compensate?
Alcohol related disorders
- diabetes - liver cirrhosis - oral cancer - esophageal cancer - pharyngeal cancer - liver cancer - cardiomyopathy - atrial fibrillation - hypertension - GI bleeding - birth defects
When would you use ABG?
- diabetic ketoacidosis - renal failure - drug overdose - toxic substance ingestion - sepsis
Developmental Competence - Pregnant Women
- diaphragm is elevated 4 cm from enlarged uterus - costal angle widens 50% - respirations are deeper because fetus is increasing oxygen demands
Words with Multiple Meanings
- diet - dressing - sometimes - frequently - rarely - stool - supper - dinner
Health Promotion and Patient Teaching - Lifestyle changes
- diet - staying active - maintain healthy weight
Emerging Minority Group trends
- differences noted in age, poverty level, and household composition - emerging majority groups tend to be as follows: younger with lower median ages and higher proportions under 18 years old - all ethnic and racial minority groups exceed the national poverty level - family size and multigenerational families are more evident in minority groups
Inspection and Palpation of the Neck: Thyroid gland
- difficult to palpate; check for enlargement, consistency, symmetry, and presence of nodules - position patient for best approach(posterior approach, anterior approach) - auscultate thyroid for bruit, if enlarged
A simple, common instruction "take one teaspoon 4 times each day"
- do i take all 4 teaspoons in the morning or all at night - how long do I wait in between doses? - what could we have said to be more clear to the patient
Infants and children ear examination
- do this as later thing because it is invasive - holding othalmoscope so need barrier with finger or hand since have shorter canal - pull down and back to straighen out ear canal where as an adult you pull up and back
Additional History questions for infants and children
- does child have any birthmarks? - any change in skin color as a newborn? - does child have any rash or sores? - does child have diaper rash? - does child have any burns or bruises? - has child been exposed to contagious or communicable disease? - does child have habits such as nail biting or twisting hair? - what steps are taken to protect child from sun exposure?
Peripheral vascular disease: venous
- dull, achy pain - lower leg edema - pulse present drainage - sores with irregular borders - yellow slough or ruddy skin - location of sores on ankles
Inspect and Palpation - inspect and palpate external ear: size and shape
- ears are of equal size bilaterally with no swelling or thickening - ears of unusual size and shape may be a normal familial trait with no clinical significance
Sweat glands
- eccrine produce sweat - apocrine produce milky secretion and open into hair follicles
Jugular Venous pulse and pressure
- empty unoxygenated blood directly into superior vena cava - two jugular veins present on each side of neck(internal and external)
External factors defining the environment so as to foster communication
- ensure privacy - avoid interruptions - physical environment - dress - note taking
Developmental competence: children
- epidermis thickens, darkens, and becomes lubricated - hair growth accelerates
Skinfold thickness
- estimates body fat - 10th percentile > or < = over/under nutrition - body fat is best indication for risk factors but least convenient
What are some ways that you can garner truthful responses from your clients?
- explain condifentiality agreement - normalize the issue by telling them you screen for alc and drugs with every client - if the client is younger, have time set aside that you speak with them without their parents
Summary Ear Examination - Otoscopic examination
- external canal:redness or swelling - cerumen discharge, foreign bodies or lesions
Infants and children eye developmental competence
- eye exam often deferred at birth because a transient edema of lids from birth trauma or form the instillation of silver nitrate at birth - eyes should be examined within a few days and at every well-child visit thereafter
In adolescence
- facial hair also appears on boys at this time; first on upper lip, then on cheeks and lower lip, and last on chin - enlargement of thyroid cartilage occurs, and with it, the voice deepens
Infants and Children developmental competence
- fetal heart begins to beat after 3 weeks gestation - inflation and aeration of lungs at birth produces circulatory changes - oxygen comes from placenta so no blood to the lungs
Safety Assessment in the Care environment
- first assess the room for safety for patient and yourself - Client identification - hourly rounding
Heart sounds - S1
- first heart sound - closure of AV valves - beginning of systole LUB
Pendulous breasts
- flat sloping upper breast - nipples sit low on the breast - weight loss, age, pregnancy
Mini-mental state exam
- focuses on cognitive functioning only - takes 5-10 minutes to complete - standard set of questions
Inspect lips:
- for color, moisture, cracking, or lesions; retract lips and note inner surfaace - african americans normally may have bluish lips and a dark line on gingival margin
Disease Causation Theories - Naturalistic
- forces of nature must be kept in balance - embrances idea of opposing categories or forces - yin and yang, hot and cold
low sodium diet
- fresh food over canned - no chips - ketchup
paranasal sinuses
- frontal - ethmoid - spenoid - maxillary - amplify voice and is why sound differently when sick. Help hair get clean, moist and warm
The interview allows?
- gather complete accurate data about the persons health state - establish trust - teach the person about their health - build rapport for a continuing therapeutic relationship - discuss health promotion and disease prevention
Inspection and Palpation: Skin - Color
- general pigmentation, freckles, moles, birthmarks - widespread color change
Summary Checklist: Head, Face, and Neck, including regional lymphatics examination - inspect and palpate the skin
- general size and contour - note any deformities - palpate temporal artery and temporomandibular join(TMJ) joint
Under the influence: violence
- goal: stay safe - if you feel threatened(trust your instincts, leave door open, make a way of escape, do not raise your voice, do not argue/reason with the person, act calm, unhurried)
Developmental Competence: Aging adult
- gradual rise in SBP common with aging; widening of pulse pressure(be alert for orthostatic hypotension) - left ventricular wall thickness increase - presence of supraventricular and ventricular dysrhythmias increases with age - age related ECG changes occur due to histologic changes in conduction system
Total population passed 321 million people in 2015 in US
- greater than one third of US residents were other than non-Hispanic Whites - Minority, or emerging majority, populations total 114.5 million people - Hispanics: largest and fastest growing group - Blacks: second largest population - Asians, American Indians, Alaska natives, native hawaiians, and other Pacific Islanders make up the third largest part of the population
Methods of wound measurement
- greatest length and width method - clock method - combination method: both the above combined - photo documentation - wound traacing
health effects of violence
- gynecolic problems, depression, low birth weight, substance use, chronic pelvic pain, unintended pregnancy, STIs, UTIs, poor health, improper brain development, cerebral palsy, arrest, anxiety, chronic diseases
Perception abnormalities
- hallucinations: perceptions for which there are no external stimuli - illusion: misperception of an actual existing stimulis
Rule of nines for burns calculation
- head and neck: 4.5% - trunk: 18% - upper limbs: 4.5% - lower limbs: 9% - front groin: 1% - add the front and the back together with percentages
Inspection and Palpation of the Neck: Head and neck symmetry
- head position is centered in midline, and accessory neck muscles should be symmetric - head should be held erect and still
Subjective Data: Health History
- headache(worst headache of their life?) - head injury(recently or chronic issue?, seizures?) - dizziness(light headed ness? vertigo? history of this? fluid behind ear? nausea/vomiting? heart rate?, mobility issues? decreased hearing?) - neck pain, limitation of motion(radiating down neck? slept on it funny? meningitis? nausea? vomiting? fever?) - lumps or swelling(swollen lymph nodes? swollen head structures? radiation? problems eating/drinking?, smoke?, alcohol use? thyroid issues?) - history of head or neck surgery(many forget surgeries) Going through each of these do the PQRST
Developmental Competence: Infants
- heart rate may range from 100 to 180 bpm immediately after birth - note findings that reflect heart status(pallor, cyanosis, RR) - may hear murmurs in immediate newborn period
Subjective data for breasts
- history of breast disease and or surgery - lumps or thickening(have you noticed it before? where is it? Has there been changes?) - discharge/rash(when did you notice it? color and consistency?) - swelling/trauma(when did it occur? - pain - axillary tenderness, lumps swelling, rash
Anterior Inspection - facial expression and level of consciousness
- if have patient with acute change in LOC think oxygen status - facial expression is appropriate
Note any white patches, nodules, or ulcerations:
- if lesions are present, or with any person over 50 years old or with a positive history of smoking or alcohol use, use your gloved hand to palpate area - place your other hand under jay to stabilize tissue and to "capture" any abnormality; note any induration
Assessing the neck "Carotid Artery"
- important in middle-aged to older adults or someone with cardiac disease - auscultate for bruit and feel for contour and amplitude - angle of jaw, middle of cervical area, base of area - press lightly with bell of stethoscope
Disease Causation Theories - healing and culture
- in addition to seeking help from health care providers, patients may also seek from folk or religious healers - hispanics or american indians may believe that cure is incomplete unless healing is carried out for body, mind, and spirit
Normal occlusion:
- in back, upper teeth rest directly on lowers - in front, upper incisors slightly override lower incisors
Infants and Children - inner ear starts to develop early in fifth week of gestation
- in early development ear is posteriorly rotated and low set - if maternal rubella infection occurs during first trimesters, it can damage organ or Corti and impair hearing - infants eustachian tube is shorter and wider and more horizontal than adults, so its easier for pathogens from nasopharynx to migrate through to middle ear
Prescription drug abuse - contributing factors to Rx abuse and opioid crisis
- increase in Rx for pain medication - marketing strategies to promote medications - misrepresentation of "addictive" nature - combination addictions: drinking and taking alcohol-interactive medications
Aging adults developmental competence - Pressure/pulse changes
- increase in systolic BP due to thickening and stiffening of arteries - left ventricular wall becomes thicker - heart doesn't compensate as easily
age-related macular degeneration
- increase seen in US adults over the age of 75 - more prevalent in Caucasians - risk factors(positive family history, smoking, hyperopia, light iris color, HTN, hypercholesterolemia, and female gender)
Otitis media increased effects
- increased ambulatory visits - persistent effusion may lead to hearing loss - genetic variation with regard to cerumen development
Under the influence: risk
- increased risk for overdose - accidents(31% of driving fatalities are alc related) - injuries - complex care(body systems affected by alc use)
Harms related to bad alcohol and substance use
- injury/trauma - criminal justice involvement - social problems - mental health consequences - increased absenteeism and accidents in the workplace
Rectal, tympanic, axillary temperature
- insert inch to inch and half in adult - rapid - least accurate
Summary checklist of nose
- inspect external nose for symmetry, any deformity, or lesions - palpation: test patency of each nostril - inspect with nasal speculum nasal mucosa, septum, and turbinates - palpate the sinus area
Health Promotion and Teaching Points for peripheral vascular disorder - foot care
- inspect feet daily(sensations are decreased) - maintain exercise to improve circulation - pay attention to seated positions during the day(no leg crossing) - always wear shoes(risk of injury and delay of healing: well fitted shoes that prevent injury) - no compression socks for PAD - vascular disease is elevating legs and not keeping them hanging, compression stocking
External eye structures Infants and Children
- inspect ocular structures - a neonate holds eyes tightly shut; do not pry them open; that just increases contraction of the obicularis oculi muscle - test vestibular function reflex(Doll's eye reflex will disappear by 2 months)
Inspection and palpation - nasal turbinates
- inspect turbinates - superior turbinate may not be in view - middle and inferior turbinates appear the same light red color as nasal mucosa; note any swelling but do not try to push speculum past it
Summary checklist for mouth and throat
- inspect with penlight: mouth, teeth and gums, buccal mucosa, palate and tonsils, and pharyngeal wall - palpate when indicated(For adults bimanual palpation of the mouth. In neonate, palpate for integrity of palate and assess sucking reflex)
pleural friction rub
- inspiration and expiration - low pitched, harsh/grating sound, continuous
coarse crackles
- inspiration(can extend into expiration) - low-pitched, wet bubbling sound
Peripheral vascular disease: arterial
- intermittent claudication, pain - no edema - no pulse or weak pulse, no drainage - round smooth sores - black eschar - location of sores on toes and feet
Why is domestic and family violence important?
- intimate partner violence is another important universal screening - legal responsibility(screening and implementing) - fulfills our nursing values(social injustice - advocate)
Interpersonal violence
- intimate partner violence(IPV): physical/sexual/emotional/psychological - child/elder abuse - mandatory reporter: suspicion - do not have to have objective proof
Abnormal respiratory patterns - biots
- irregular deep respirations, shallow respirations, and periods of apnea
What are some reasons it is beneficial to screen universally?
- it can lead to early interventions - alcohol use can often go undetected
Developmental competence: newborn infants
- lanugo: fine downy hair of newborn infant - vernix casoesa: thick, cheesy substance - sebum: holding water in the skin producing milia
Galant Reflex Response
- lateral flexion of trunk on side stimulation, elongation on the opposite
CN VI
- lateral rectus
Subjective data for assessment of peripheral vasculature and lymphatic system
- leg pain or cramps(PAD - intermittent claudication) - skin changes on arms or legs(pale, sore from not enough oxygen, and colder for arterial, redish color skin, toenails, warmer legs for venous issues) - swelling(venous) - lymph node enlargement - medications - smoking history
Status of immigrants entering the health care system
- legal permanent residents - naturalized citizens - undocumented aliens - refugees, requesting asylum, and parolees - legal nonimmigrant residents
Behavior
- level of consciousness - facial expression - speech - mood and affect
How to perform breast self-examination?
- lie down. press 3 middle fingers in a circular motion and use 3 levels of pressure. Follow an up and down pattern - sit up. Examine underarm with arm slightly raised - note surface changes with hands pushed on hips, shoulders hunched.
Internal Factors specific to you as the healthcare team member
- liking others - empathy - ability to listen - self-awareness
Teach Back Points
- limit the amount of info to 2-3 key points - rephrase if a client is not able to explain the info correctly - avoid asking "do you understand" or "do you have questions" - beware of words with multiple meanings
Steps for ABI for leg
- locate pulse in dorsalis pedis - apply BP cuff to ankle and use doppler on dorsalis pedis - inflate the cuff until signal is gone and release pressure until hear return signal. - posterior tibial artery same thing. - use highest number from posterior tibial and dorsalis pedis left or right for top number - calculate each side left and right
Structure of the breast
- located between 2nd and 6th rib - nipple is below the center of the breast - areola surrounds the nipple for a 1-2 cm radius
Developmental Competence - Infants and Children - Auscultation
- loud breath sounds - fine crackles are normal AT BIRTH ONLY(amniotic fluid - more in C section from no squeeze) - may hear other sounds due to small size
bronchial breath sounds
- louder than vesicular - high-pitched - hollow sounds - normal if auscultated over trachea - inspiration and expiration almost equal in duration with distinct pause in between
Infants and Young children otoscopic examination
- mandatory for any infant or child requiring care for illness or fever - timing is best towards end - parent hold and comfort child - positioning of child to get clear view of cancal - pinna down on infant or child younger than 3; match slope of ear canal
For infants and children health history questions
- maternal alcohol or drug use? - type of delivery?(vaginal or by cesarean section? any difficulty? use of forceps?) - growth pattern?(was it on schedule?)
Critical thinking
- means by which we learn to assess and modify, if indicated, before acting. Required for sound diagnostic reasoning and clinical judgement. - The final steps to critical thinking include evaluation and planning. Make sure you are on the right track. Final step is a comprehensive plan that is kept up to date.
Fraud detection methods - automated reviews
- medical record review not required - focus on non-covered service
What might alter MSE findings?
- medications - educational level - stress - health issues
bronchovesicular breath sounds
- medium-pitched intensity - inspiratory time is equal to expiratory time - higher pitched mixed with lower pitched - throughout lung fields, upper third of chest
Skin color is derived from three sources:
- melanin: brown pigment - carotene: yellow/orange pigment - red purple tones: underlying vascular bed
At risk drinking
- men is more than 14 drinks a week or more than 4 drink/events - women is more than 7 drinks a week or more than 3 drink/event
Reference Lines
- midclavicular - midsternal - lateral clavicular - mid axillary - posterior axillary - lateral axillary - mid scapular - front clavicular
Many new immigrants have only minimal understanding of the following:
- modern health care delivery system - modern medical and nursing practices and interventions - English language
vesicular breath sounds
- most common - soft with low pitch, even softer during expiration, rustling quality - inspiratory time is longer(3:1) - heard in most areas of lungs but most prominently heard at lung bases and periphery
Alcohol statistics
- most used/abused psychoactive drug - 10% of pregnant women consume alcohol - many people have alc related problems - 56% of Americans are current alcohol drinkers(greater than 18) - of these 40% were binge drinders(more than 5 drinks/occasion) - 11% heavy drinkers(binge a least 5/30 days)
Inspect and Palpation - inspect and palpate external ear: tenderness
- move pinna and push on tragus; they should feel firm, and movement should produce no pain - palpating mastoid process should also produce no pain
How to use incentive spirometer correctly
- move yellow piece to where patient needs to get bigger yellow piece - have patient sit up and exhale completely - seal mouth around mouthpiece tightly - inhale slowly and deeply making sure yellow indicator on side within normal range - keep inhaling until cant do it anymore - hold breath for 6 seconds and exhale slowly while allowing piston to fall completely - use 10 times every 1-2 hours while awake
What does someones diet have to do with the muscles in someones body?
- muscle is made up of protein - a malnourished patient will have muscle atrophy - check protein levels to help respiratory status
Internal anatomy of breasts
- muscles - ligaments - glandular/adipose/lymphatic tissue
Victim response
- need for privacy(work around someone not wanting to leave) - delayed reporting of sexual abuse is a common, normal reaction from someone who has experienced events - sexual abuse can cause intense feelings of embarrassment, fear and humiliation - many victims continue to have a relationship with their abuser(feel like it is their fault) - a victims view of the offenders actions change over time - victims may deny the abuse theyve suffered, or misrepresent parts of their story - do not think they are lying, our job to believe and investigate even with suspicion
Anterior Inspection - color and condition and quality of respirations
- no signs of cyanosis - retraction will mean they are working harder to breath - tripod position - respiratory rate(pattern, rate)
Subjective data with violence
- nonbias and photographic evidence(have to get consent) - unrealistic to document everything - subjective statements - statements as to who perpetrated the abuse, severe threats of harm - separate patient from parent, spouse, caregiver - follow protocol
Measurement of pulmonary function status - pulse oximeter
- noninvasive - a healthy person with no lung disease and no anemia SPO2 of 97-99%
Lacrimal Apparatus - tearing
- normally puncta drain tears into lacrimal sac - presence of excessive tearing may indicate blockage of nasolacrimal duct
Where can i put the sensor to get an accurate reading?
- nose, toe, forehead, earlobe - forehead and earlobe is good for those with temors or fat fingers - children is good on the toe
Visual impairment(VI)
- not being able to see letters on the eye chart at line 20/50 or below - expected to double in the US due to aging population - highest numbers seen in Caucasian women and older adults - Ethnic groups seeing emerging trends - African Americans and Hispanics - Visual screening crucial - safety concerns
Voice sounds
- not routine - supplemental assessment if abnormality is suspected - bronchophony, egophony, whisterped pectoriloqy
Inspection and Palpation of the Neck: Range of motion
- note any limitations - test muscle strength - observe for enlargement of glands and/or pulsations
Inspection and Palpation: Skin - color, note what?
- note color change over entire body skin, such as pallor(pale - pass out), erythema(red - worked out), cyanosis(blue - poor oxygenation), or jaundice(yellow-liver issues) - Note if color change transient or due to pathology
infants and young children ear exam
- note ear position difference - top of pinna should match an imaginary line extending from corner of eye to the occiput - ear should be positioned within 10 degrees of vertical
Inspect and Palpation - inspect and palpate external ear: External auditory meatus
- note size of opening to direct choice of speculum for otoscope; no swelling, redness, or discharge should be present - some cerumen usually present with color and texture variation
Summary Checklist: Head, Face, and Neck, including regional lymphatics examination - Inspect and palpate the face
- observe facial expresssion - cranial nerve VII: symmetry of movement - observe for any abnormal movements
Nasal septum inspection
- observe nasal septum for deviation - note any perforation or bleeding in septum
Epicanthal fold differences
- occurs frequently in Asian children and in 20% of whites - in non-Asians usually disappears by 10 years of age - give false appearance of malalignment, termed pseudostrabismus; yet corneal light reflex is normal
Abnormal palpation - unequal chest expansion
- one side is not rising symmetrically like the other - pneumonia, pleural fusion, trauma to chest cavity(fractured rib), pneumothorax
Health History Questions: Headache
- onset pattern characteristics - location pattern - pain characteristics - course and duration - precipitating factors - associated factors - alleviating factors - what makes it worse - presence of comorbidities - medication history - patient-centered care
Neck pain health history questions
- onset, location, associated symptoms, limitation of ROM, precipitating factors, stress - focus on patient-centered care
Health history questions: Head injury
- onset, setting, and description of injury - changes in levels of consciousness(loss of consiousness and or fall) - history of comorbidity - location of injury - pattern of symptoms(presence of associated symptoms) - treatment plan(emergency, hospitalization, and/or medication) - HEALTH PREVENTION
Although many people take medications that are not prescribed to them, we are primarily concerned with"
- opiods - benzos - stimulants - sleep aids - other assorted(clonidine, carisoprodol)
Cognition
- orientation(time, place, person, situation)(*3,4 etc) - attention span - recent memory - remote memory - new learning
Tests for newborn hearing screening
- otoacoustic emissions test - auditory brainstem response(ABR) test
Equipment needed for nose, mouth, and throat
- otoscope with short, wide-tipped nasal speculum - penlight - two tongue babies - cotton gauze pad, 4x4 inches - gloves
Two pairs of salivary glands accessible to examination on the face:
- parotid glands are in the cheeks over mandible, anterior to and below ear: the largest of salivary glands, they are not normally palpable - submandibular glands beneath mandible at angle of jaw
Lesions caused by trauma or abuse:
- pattern injury - hematoma: collection of blood outside blood vessel - contusion(bruise): type of hematoma
Aging adult visual acuity
- perform same exam as described in adult section - central acity may decrease, particulary after 70 years of age; peripheral vision may be diminished
Developmental competence pregnant women: what are third trimester common findings?
- peripheral pitting edema - varicose veins
Risk of breast cancer
- personal history of breast, ovarian, tubal, or peritoneal cancer - family history of these cancers - ancestry(jewish) associated with BRCA1 or 2 mutations - radiotherapy to the chest between age 10 and age 30 - history of alcohol use, obesity, and smoking - known carrier of a pathogenic mutation for a hereditary breast and ovarian cancer syndrome in self or Previous breast biopsy indicating high-risk lesion(atypical hyperplasia)
Vascular lesions - purpuric lesions
- petechiae: 1-3mm round, discrete, do not go away(pressure applied constantly, bleeding disorder - conjunctiva) - ecchymosis: large bruise greater than 3mm - purpura: Worsening version of ecchymosis and petechiae greater than 3mm, flat and red(scurvy, traumas)
Thought content abnormalities
- phobia - hypochondriasis - obession - compulsion: unwanted purposeful act - delusions: firm, fixed, false beliefs
HITS
- physically hurt you - insult you or talk down to you - threaten you with harm - scream or curse at you
Opiates
- pinpoint pupils, decreased BP, pulse, repirations, lethargy, slurred speech, dysphoria, inattention, impaired memory - withdrawal: dilated pupils, pooping, runny nose, fever, elevated BP, depression, nausea, vomiting, tremor
Snellen chart positioning
- place chart in well lit spot at eye level; position the person exactly 20 feet from chart; hand the person an opaque card with which to shield one eye at a time during test - if the person wears glasses or contact lenses, leave them on; remove only reading glasses - ask the person to read through chart to smallest line of letters possible; encourage trying next smallest lime also
Let parent help position child
- place infant supine on examining table, with arms restrained - older infant and toddler may be held on parent's lap
Vascular lesions - Hemangiomas
- port-wine stain(nevus flammeus) - strawberry mark(immature hemangioma) - cavernous hemangioma(mature - spongy feel)
Preparation of objective data for nose, mouth, and throat
- position a person sitting up straight with his or her head at your eye level - is the person wears dentures, offer a paper towel and ask the person to remove them - child may sit with caregiver
Neck vessels - inspect jugular venous pulse
- position a person supine anywhere from a 30-45 degree angle, wherever you can best see pulsations - observe for distention and visible pulse(central venous pressure)
Objective data - Preparing for the assessment: Sequence
- posterior and anterior - start with posterior then anterior
Structure of nails
- posterior nail fold - cuticle - lunula - lateral nail fold - nail plate - nail matrix - nail bed
Appearance
- posture - body movements - dress - grooming and hygiene - can be noted with general survey because they match
Culture affects choices parents make for children regarding the following:
- presumed cause of illness - first treatment tried - acceptability of treatments offered by clinicians
Assess and document what?
- prior abuse - interpersonal violence - childhood physical abuse - childhood sexual abuse - prior rape
Heart and Neck Vessels - Objective Data - Preparing for the assessment
- privacy - position(sitting up, laying on back for jugular veins) - sequence - infection control
Objective data - Preparing for the assessment: Privacy
- privacy(sports bra, mention when would do sensitive areas - under breast) - if someone knocks say, patient care. Close curtain and the door
Healthcare Communication
- promoting effective interpersonal communication - impact of ineffective interpersonal communication - maintaining open lines of communication - timely updates in organized manner
Dizziness health history questions
- provide a description of "feeling" in patient's own words - associated with change of position, nausea, and/or vomiting
Communication traps
- providing false assurance or reassurance - giving unwanted advice - using authority - using avoidance language - engaging in distancing - using professional jargon - using leading or biased questions - talking too much - interrupting - using "why" questions
Thyroid disorders: hypothyroidism
- puffy edematous face - periorbital edema - coarse facial features - course hair and eyebrows
Cocaine
- pupils dilated, tachycardia, elevated or lowered BP, weight loss, vomiting - dysphoric mood, fatigue, insomia, hypersomina
Aging adult - pupils
- pupils small in old age; pupillary reflex may be slowed - lens loses transparency and looks opaque
What are three qualities to consider when assessing pulse?
- rate - rhythm - force
Precordium Auscultation note what?
- rate and rhythm - identify S1 and S2 - listen for extra heart sounds(where, what did it sound like?)
Culture and Respect
- realize you must know heritage of yourself and patient - examine patient within cultural context - select simple questions and speak slowly - pace questioning throughout exam - encourage patient to discuss meaning of health and illness with you - check patient's understanding and acceptance of recommendations - touch patient within boundaries of his or her heritage
Cannabis
- reddened eyes, tachycardia, dry mouth, euphoria, pleasant sate of relaxation - no withdrawal symptoms with occasional use, chronic is irritability, sleep disturbances, weight loss, loss of appetite
Which of the following are additional guiding principles of MI?
- resist the righting reflex - understand your client's motivations - listen to your patient
Developmental Competence: Pregnant Women
- resting pulse rate of 10-15 bpm and drop in BP from normal pre-pregnancy level - palpation of apical impulse is higher and lateral compared with normal position - heart sound changes due to increased volume and workload
Different characteristics in right and left lung
- right lung is shorter because it is displaced by the liver - left lung is narrower because of the heart
Do and dont of collecting wound culture
- rinse wound with sterile saline solution. remove gloves, hand hygiene, clean gloves. swab the wound by gently rotating a sterile calcium alginate between fingers. swab the wound from margin to margin in a 10 point zig zag fashion. Use enough pressure to express fluid within the wone tissue - dont take specimen from exudate, dont use cotton tip swab, dont let swab touch fingers or other objects
Developmental Competence - Infants - Inspection
- rounded thorax with equal AP diameter - APGAR score - nose breathers - always count for one full minute(30-40 RR - higher if crying) - irregular resp with 10-15 sec periods of apnea - use abdominal muscles more
Developmental Competence - Aging Adult
- rounder thoracic cage with kyphosis - decrease in subcut. fat = easier to palpate bony prominences - costal cartilage calcifies with age = decrease chest expansion - faint with lung sounds
Sebaceous glands
- sebum: secreted lipid substance through hair follicles - lubricate skin and form emulsion
Heart sounds - S2
- second heart sound - closure of semilunar valves - end of systole and beginning of diastole DUB
Developmental competence: adolescents
- secretions from apocrine sweat glands increase - subcutaneous fat deposits increase - secondary sex characteristics
How to prevent and detect skin cancer
- seek shade when possible - wear sun protective clothing - wear sunscreen broad spectrum and water resistance, reapply every two hours
Braden Scale for Predicting Pressure Sore Risk
- sensory perception: ability to respond meaningful to pressure discomfort - moisture: degree to which skin is exposed to moisture - activity: degree of activity(shifting in chair too) - mobility: ability to change and control body position - nutrition: usual food intake pattern - friction and shear: Do you have to pull or lift them? Sliding against sheet can cause skin tear
Summary Checklist - Note presence of lesions
- shape, configuration, and distribution
DVT complications - clinical manifestations
- shortness of beath - decreased oxygen saturation - tachycardia - hypotension - sweating - sharp chest pain(most during deep breathing) - hemoptysis
Inspection and Palpation of the Neck: Trachea
- should be midline - palpate for any tracheal shift - note any deviation from midline
Sedatives
- similar to alcohol - withdrawal: anxiety or irritabililty, nausea, vomiting, malaise, tremor of hands
Nursing process: implement and evaluation
- similar to the scientific method - determine whether you achieved the outcome desired(met, unmet, partially met)
Objective data - Preparing for the assessment: Position
- sitting up - if patient cant sit up on own then get assistance or turn on their side
Summary Ear Examination - Inspect external ear
- size and shape of auricle position and alignment on head - note skin condition - check auricle and tragus for tenderness - evaluate external auditory meatus
How to check pupils with a penlight
- size(3-5 mm) - shape(round) - direct response(shine light in one eye to see if constricts) - consenual response(opposite eye and make sure constrict together - dim light - accomodation(move the closer to face and see if eyes constrict) - PERRLA(documentation)
Three things that help venous blood return to heart
- skeletal muscle contracting - valves functioning properly - lumen(diameter) is open and patent
Why are skin, hair, nails important?
- skin assessment and management is a major role and responsibility of the RN - largest organ system - immobility is a risk for skin breakdown among other risk factors
Complete physical examination
- skin assessment integrated throughout examination all throughout body(head to toe) - scrutinize the outer skin surface first before you concentrate on underlying structures - separate intertriginous areas(areas with skinfolds) such as under large breasts, obese abdomen, and groin - always inspect feet, toenails, and between toes
Inspection of the arms
- skin color and nail beds - symmetry - lesions or scars - clubbing Look at the top and bottom of arms
Inspect and Palpation - inspect and palpate external ear: skin condition
- skin color consistent with person's facial skin color - skin intact, with no lumps or lesions
Thyroid cartilage
- small palpable notch in upper edge(adams apple in males) - cricoid cartilage or upper tracheal ring - isthmus of the thyroid gland
Barriers to treatment of intimate partner violence
- societal stressors(lack of understanding) - legal status(deported) - lack of access to culturally appropriate care(interpreters)
Condition that is culturally defined
- some have no equivalent in a biomedical, scientific perspective - anorexia nervosa and bulimia are examples of cultural aspects of illness in dominant cultural population in North America
Posterior assessment - inspection: shape and configuration
- spine is straight - thorax is symmetric - breathing is symmetrical - ribs at 45 degree angle from spine
Pressure Ulcer, Decubitus Ulcer stages
- stage 1: Non-blanchable erythema - stage 2: partial-thickness skin loss, blistering, superficial - stage III: Full thickness skin loss, ulcerated - stage IV: full thickness skin/tissue loss - deep tissue pressure injury - PI caused by medical device
Virchow's Triad for DVT?
- stasis(blood not moving) - hypercoagulability(increased risk for clotting) - vessel damage Risk factors for DVT
Reading levels
- steriods decrease inflammation and suppress the body's immune system repsosne which dilates your airway and allows more room to take in oxygen(11th grade) - steroids help decrease swelling and open your airway to help you breathe(5th grade)
When an employee in a provider's office suspects fraudulent activity and uses OIG Hotline to report it, the employee should do which of the following?
- stop filing suspicious bills and claims - pursue knowledeable legal counsel - report and return overpayments - disengage professionally with the suspected perpetrator
objective data equipment needed
- strong, direct lighting, gloves, penlight, and small centimeter ruler
CN IV
- superior oblique
CN III
- superior rectus - inferior oblique - inferior rectus
Gum hypertrophy
- surface looks smooth and stippling disappears - may occur normally at puberty or during pregnancy(pregnancy gingivitis)
Developmental Competence - Infants and Children - Palpation
- symmetric chest expansion - encircle thorax with both hands
Palpation of the legs
- temperature - tenderness(when) - inguinal lymph nodes - pulses - edema - measure calves(unequal size do it and if redness and tenderness - measure largest area)
Palpation of the arms
- temperature - texture - turgor - capillary refill - edema - pulses - epitrochlear lymph nodes
Summary Checklist - Palpation of the skin, hair, and nails
- temperature and texture - edema, mobility, and turgor
Physiologic murmur
- temporary murmur - physiologic states that increase blood flow(pregnancy, anemia, fever, hyperthyroidism) - not associated with cardiovascular disease - heard at left 2nd to 4th intercostal space, heard at apex too
Extraocular muscle function
- testing for strabismus(squint, crossed eye) is an important screening measure during early childhood - test malalignment by corneal light reflex and cover test
Thought Processes, Content, and Perceptions
- thought processes(how do they think? Should be logical, conversing with you in complete thoughts)( - thought content(what are they thinking and is it logical?) - Perceptions(assess if patient is aware of reality)
Hair
- threads of keratin: hair shaft and bulb matrix - types of hair: vellus and terminal - follicle: cyclical with active and resting phases
Pregnancy changes for HEENT
- thyroid gland enlargement - hyperpigmentation - increased fluid - more stuffy
The terms of the contract(interview) include
- time and place of the interview - introduction of yourself and explanation of your role - purpose of the interview - how long it will take - expectation of participation for each person - presence of any other people - confidentiality - costs
Heritage consistency continuum
- traditional: living within norms of traditional culture - modern: acculturated to norms of dominant society
Inspection and Palpation: Nails - Color
- translucent nail plate to pink nail bed below - note ethnic variations
Closure of fontanels
- triangle-shaped posterior fontanel closes by 1 to 2 months - diamond-shaped anterior fontanel closes between 9 months to 2 years
Innocent murmur
- turbulent blood flow - during systole as blood is ejected from ventricles
Differing views of epilepsy
- uganda: contagious, untreatable - greece: source of family shame - mexican american community: evience of physical imbalance - hutterities: evidence of having endured trial by god
Abnormal findings: extraocular muscle dysfunction - cover test
- uncovered eye - covered eye
Why is SBIRT important?
- unhealthy and unsafe alcohol and drug use are major preventable public health problems resulting in more than 100,000 dealths each year - the costs to society are more than 600 billion annually - effects of unhealthy and unsafe alcohol and drug use have far-reaching implications for the individual, family, workplace, community, and the health care system
Why is this substance use assessment important?
- universal screening - substance abuse impacts every care area - the RN functions as an advocate for the client and communicates findings related to substance use that respects client autonomy, and human dignity
Alcohol
- unsteady gait, flushed face, sedation, relief, slurred speech, irritability, depression, talkativeness - withdrawal: uncomplicated, delirium
What are the quadrants of the breasts
- upper inner quadrant - upper outer quadrant - lower inner quadrant - lower outer quadrant - axillary tail of Spence
Eyelids
- upper lids normally overlap superior part of iris, and approximate completely with lower lids when closed - palpebral fissures horizontal in non-Asians; Asians normally have an upward slant
Inspection and Palpation: Skin - temperature
- use backs of hands to palpate person - skin should be warm, and temperature equal bilaterally; warmth suggests normal circulatory status - hands and feet may be cooler in a cool environment(hypothermia, hyperthermia)
Doppler Ultrasonic Probe
- use jelly to put on skin - describe rate, rhythm, and force - use doppler for chest compressions to make sure you can hear the pulse
aging adults developmental competence
- vision and hearing checked first - easier to misdiagnose - issues come along with older age, so have to know if its just age or an issue
Subjective Data
- vision difficulty: decreased acuity, blurring, blind spots - pain - strabismus, diplopia - redness/swelling - watering, discharge - history of ocular problems - glaucoma - use of glasses or constant lenses - patient-centered care
Additional Health History Questions - Aging Adults
- what changes have you noticed in your skin in past few years? - any delay in wound healing? - any change in feet: toenails, bunions, wearing shoes? - falling: bruises, trauma? - History of diabetes or peripheral vascular disease?"
Factors in consistent wound measurement
- when measuring length, your ruler should be placed over the longest length; head is at 12:00 and feet are at 6:00 - measure widest aspect of the wound perpendicular to the length - toes are at 6:00 and heels are at 12:00 - always measure in cm L*W*D - length may be smaller than width
Findings of Raynaud phenomenon
- white: lack of arterial blood flow - blue: little blood flow - red: vasodilation and areas refilled - precursor of autoimmune disorder
What is the big deal with cultural assessment?
- who are you meeting for the first time? - where does the patient come from? what is his or her heritage? - what is their cultural background: ethnicity and religion? - does the patient understand, speak, and read English? - what language do they understand, speak read? - what are their health and illness beliefs and practices?
Trachea
- windpipe - 10-11 cm - begins at level or cricoid cartilage(cartilage that surrounds trachea) - right and left main bronchus
Sending: Verbal Communication
- words you speak: vocalization - tone used in conversation
male breast
-Chiefly small nipple and areola -Overlie thin disc of undeveloped breast tissue -May be difficult to distinguish male breast tissue from surrounding muscles of chest wall
the working phase
-Data-gathering phase -Verbal skills include questions to patient and your responses to what is said
Transcultural expression of pain
-Expectations, manifestations, and management of pain are all embedded in a cultural context -Pain has been found to be a highly personal experience, depending on cultural learning, the meaning of the situation, and other factors unique to the person -Silent suffering has been identified as the most valued response to pain by health care professionals
Examples of bloodborne pathogens
-Hepatitis B virus (HBV) -Human immune deficiency virus (HIV) - Hep C
patency of nostrils
-Plug one nostril & sniff AND switch to other nostril
SA node (sinoatrial node)
-pacemaker of the heart(60-100bpm) -sets the heartbeat rate -located in the right atrium -causes atria to contract
Grading for Heart murmurs
0-6 Scale 0- can't hear 1-barely audible in quiet room 2-clearly audible but faint. 3-moderately loud/easy to hear 4-loud/palpable thrill 5-(4+)very loud/heard w/edge stethoscope off chest 6-(5+)loudest/heard w/edge stethoscope off chest.
What do rectal temperatures measure?
0.7-1 higher(0.4-0.5C) Most accurate
A score of 7 on the DAST would be considered a substantial level of risk. What additional actions need to take place?
0: no problems - none at this time 1-2: low level - monitor, reassess at a later data 3-5: moderate level - further investigation 6-8: substantial level - intensive assessment
Normal puberty - tanner stages for pubic hair men and women
1 - no pubic hair 2 - few pubic hairs 3 - too many too count 4 - full amount of pubic hair but none on thighs 5 - hair everywhere
You may normally see?
1+ or 2+ tonsils in healthy people, especially in children, because lymphoid tissue is proportionately enlarged until puberty
Blood flow through the heart
1-Superior & Inferior Vena Cava, 2-Rt Atrium, 3-Tricuspid Valve, 4- Rt Ventricle, 5-Pulmonary Valve, 6-Pulmonary Artery, 7- Lungs-pick up oxygen, 8-Pulmonary Veins, 9- Lt Atrium, 10- Mitral Valve (Bicuspid), 11-Lt Ventricle, 12- Aortic Valve, 13-Aorta, 14- Body
Nursing Process Steps
1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation
Example of Nursing Plan Interventions
1. Instruct patient to notify nurse immediately when chest pain occurs 2. Assess and Document patient response to medication
Blood pressure documentation should have the following:
1. Manual/Automatic 2. Position: Sitting, supine, standing 3. Cuff size: adult, large adult, child, thigh 4. Where you placed the cuff: Forearm, upper arm, thigh 5. Systolic/diastolic in mmHg
Nursing diagnoses
1. alteration in comfort (related to ..)(as evidenced by...) 2. alteration in respiration 4. alteration in skin integrity 5. Disturbed body image 6. Alteration in nutrition 7. potential for/acutual infection 8. Impaired oral mucus membrane 9. ineffective self-cafe
Normal respiration rate
10-20 breaths/min - watch chest rise and fall
Call your baby's healthcare provider if a baby's rectal or forehead temperature is?
100.4 or higher
--- ------ vertebra that makes up thoracic cage.
12 thoracic
The majority of adolescents have used alcohol or another drug by the?
12th grade
--- facial bones also articulate at sutures
14
the brief RCOPE
14 item assessment for use in clinical practice, helps practitioners understand the patients religious copign to enable them to integrate spirituality in treatment. Whether a patient uses positive or negative religious coping
Glandular tissue has
15-30 lobes
curved nail
160 degrees or less - christopher toenails
Adults ideal BMI range is
18.5 and 24.9
Danger Assessment Tool
19 item yes or no instrument - the more yes, the more serious the danger in the patients situation
Normally all 20 deciduous teeth are in by?
2 1/2
Cuff width should cover how much?
2/3 of the upper arm, and cuff bladder must completely encircle it.
Children have how many teeth?
20 decidious, or temporary, teeth that erupt between 6 months and 24 months of age - all 20 should appear by 2 1/2 years
Normal ABG: HCO3(metabolic)
22-26 - < 22 = acidosis - > 26 = alkalosis - bicarbonate
BMI overweight is considered
25-29.9
inspiration to expiration ratio
2:1 Inspiration may be longer, expiration may be longer, or they may be equal
Full breast development average of?
3 years - one breast may grow faster than the other(normal)
Pulse force three-point scale
3+ full, bounding 2+ normal 1+ weak, thread 0 Absent
The lung borders extend?
3-4 cm above the inner third of the clavicles. This is the apex of the lungs. Listen to lung sounds in this area
How do you know how high to pump the blood pressure cuff up to?
30 mmHg over usual systolic pressure
Obese BMI
30-39.9
Newborn's head measures about?
32-38 cm(average around 34 cm) and about 2 cm larger than chest circumference.
Normal ABG: PaCO2(respiratory)
35-45 - < 35 = alkalosis - > 45 = acidosis - carbon dioxide in the blood
Cellular metabolism requires a stable core or "deep body" temperature of a mean of
37.2C(99F)
Saliva present after ---- months of age and shows in excess with ----
3; teething children
Faces pain scale
4 y/o and older · Used in children 4-12 years · Patients point to face that represents pain · Score 0-10
What percent of people are below average health literacy?
43%, not every patient you see if going to understand the terms you are speaking. - average people speak at 6th grade level and health material is 10th grade level
Auscultation of Anterior Chest
5 spots side to side
Percussion of Anterior Chest
5 spots side to side
Nearly --- of what they do remember is recalled incorrectly
50%
Pulse in aging adults
50-95 beats/min
You cant use sunscreen in?
6 months or less
school-age child
6-12 years
Deciduous teeth lost beginning at age?
6-12; replaced by permanent, starting with central incisors
In resting adult, normal heart rate range(pulse) is?
60-100 bpm
Older adult age
61 and older
Normal ABG: PH
7.35-7.45 - PH < 7.35(acidosis) - PH > 7.45(alkalosis)
Most clients forget up to --- of their instructions as soon as you leave the room
80%
Normal ABG: PaO2
80-100 - oxygen dissolved in the blood
Height in aging adults
80s and 90s, many people shorter
Healthy person with no lung disease and no anemia normally has an SpO2 of
97% to 98%
What is the normal oral temperature in a resting person?
98.6(37C) - range of 96.4-99.1(35.8C-37.3C)
Mid upper arm circumference
< 10th percentile or > 95th = further work up
Waist/Hip circumference
> 1.0 in men > in women = increased risk for disease
Tachycardia and bradycardia
>100 bpm <60 bpm
Normal ABG: SaO2
>95% - oxygen saturation(hemoglobin binding sites)
Health Care Reform Act
A 2010 federal statute that increases the number of persons who have health care insurance in the United States and provides new protections for insured persons from abusive practices of insurance companies. - applies to all federally billed programs
Tympany
A bell-like noise when tapping the abdomen
Leukoedema
A benign lesion occurring on buccal mucosa is seen more often in blacks
Torus palatinus
A bony ridge running in middle of hard palate is seen in 20% to 35% of the US population
Fissure
A break in the skin that is a line that is a crack and can go into the dermis. Dry mouth and crack in corner of mouth
Rule of Nines for Burns
A calculation used to calculate the total body surface percentage of the body that is burned. - does the patient meet criteria to go to burn unit? patient is at risk for hypovolemic shock within first 24 hours.
A client has been diagnosed with a myocardial infarction that has damaged a part of the right atrium. The nurse monitors the client for:
A change in the rate and rhythm of the client's heartbeat - SA node
Deep Vein Thrombosis
A deep vein is occluded by a thrombus(clot) causing inflammation, decreased venous return and edema
Organic disorder
A disorder that is due to a known brain disease of a specific organic cause - alcohol and drug intoxication which is causing alteration in the brain - dementia
Orthostatic hypotension
A drop of 20 millimeters of mercury(mmHg) in your systolic blood pressure or a drop of 10 mmHg in your diastolic blood pressure within two to five minutes of standing up, or if standing causes signs and symptoms.
thyroid cartilage
A firm prominence of cartilage that forms the upper part of the larynx; the Adam's apple.
cricoid cartilage
A firm ridge of cartilage that forms the lower part of the larynx.
Epiglottis
A flap of tissue that seals off the windpipe and prevents food from entering.
A parent calls a peds office to make an appointment for her school age child. The nurse should instruct the parent to call the previous peds office and request that?
A form authorizing release of copies of the records be sent to her to sign and return
Teach Back
A method to confirm that you have explained to the client what they need to know or do, in a way the client understands - client understanding is confirmed when they explain the information back to you
Resonance
A phenomenon that occurs when two objects naturally vibrate at the same frequency
medication reconciliation
A procedure to maintain an accurate and up-to-date list of medications for all patients between all phases of health care delivery.
Wellness
an overall state of well-being or total health
Subjective
· Chief complaint · Start of the nursing process
Subjective Data
"told" by the patient and includes: · Chief complaint: direct quote(my abdominal area hurts) · History of present illness(OPQRSTU) · Family history · Patients own surgical history · Patients own medical history · Medical diagnoses · Medications · Review of systems
What does percussion do?
- Mapping out the location and size of an organ by exploring where the percussion note changes between borders of an organ and its neighbors - Signaling the density of a structure by a characteristic note - Detecting an abnormal mass if it is superficial - Eliciting a deep tendon reflex using the percussion hammer
Objective
- Physical assessment - Diagnostic findings
Disease based precautions - neutropenic
- gloves - gown - mask
Nursing process depends on our knowledge level and years of experience
- novice - competency - proficient - expert
Physical Assessment
An examination of the bodily functions and condition of an individual.
palpation: the dorsa(backs) of the hands and fingers
Best for determining temperature because the skin is thinner than on the palms
Objective
Core of the examination part of each body system chapter with skills, expected findings, and common variations for healthy people, as well as selected abnormal findings
palpation
Follows and often confirms what you noted during inspection. Applies your sense of touch to assess: texture, temperature, moisture, organ location and size, any swelling, vibration, pulsation, rigidity, presence of lumps, tenderness, pain
Needlestick Safety and Prevention Act
Revision to Bloodborne Pathogens standard that requires employers to minimize employees' exposure to blood through sharps injuries.
Objective data
The data you as the RN collect with physical exam techniques and other data from diagnostic testing - Example: · Subjective: "my throat hurts to swallow" · Objective: pharynx is erythematous and exudate is present
Nursing process: diagnosis
Uses subjective and objective data to determine a nursing diagnosis
infant
1 month to 1 year
How long does it take to develop competency?
2-3 years in which you can see actions in context of patient goals or plans of care.
Fall Risk
Based on our assessment we decide they are at risk for falls or injury. Do not want them walking without help or with device
Planning
Goals, interventions, additional diagnostic testing needed
HIPPA
Health Insurance Portability and Accountability Act of 1996. The purpose is to protect the privacy of patient health information. - privacy, security, and enforcement rule, and heath information technology for economic and clinical health eact(HITECH)
Subjective
Health history through questions(examiner asks) and explanation
What is RN practice regulated by?
NC board of nursing
What is assessment?
The foundation for the nursing process and practice. Collection of data about the patients health state.
Lab
This is where we go in hands on manikin or individual and perform assessments and will be recorded for online.
Health care language is important for what?
Your ability to act safely
Exposure can occur as the result of a
a needlestick, a cut from a sharp object, or contact of mucous membranes or broken skin with contaminated blood. Treat all human blood and body fluids as if they are infectious
Percussing over a body structure causes vibrations that produce characteristic waves that are heard as notes which are differentiated by:
amplitude(loud or soft), pitch(vibrations per second), quality, duration(time lingering) - More air(lungs) give a louder, deeper, and longer sound while denser more solid structures gives a softer, higher, shorter sound.
palpation - fingertips
best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps
Bloodborne Pathogen Standard
combined engineering and work practice controls, training, and other factors to minimize transmission of bloodborne pathogens in the workplace.
Nursing Process
five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating
Otoscope
funnels light into the ear canal and onto the tympanic membrane.
Ophthalmoscope:
illuminates the internal eye structures. Its systems of lenses and mirrors enables you to look through the pupil at the fundus of the eye, much like looking through a keyhole at a room beyond.
Wash hands frequently and properly. Soap and water is preferable but,
in its absence, use an alcohol hand sanitizer that is at least 60% alcohol to clean hands. The practice of "foaming in" and "foaming out" of patients' rooms is stressed at many facilities.
chronic illness
irreversible illness that causes permanent physical impairment and requires long-term health care
Ascultation
listening to sounds produced by the body, such as the heart and blood vessels and the lungs and abdomen.
Hyperresonance
lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax
Disease based precautions - droplet
mask, gown, gloves
Novice
no experience with a specified patient population and uses rules to guide performance.
What is RN practiced based on?
on Evidence(scientific and experiential) to protect our patients not necessarily just nursing professionals
Standard assessment behaviors improve what?
practice safety
What is RN practice guided by?
professional standards of practice
QSEN
quality and safety education for nurses is a national initiative to identify the competencies and knowledge, skills, and attitudes needed by all nurses to continuously improve the QS of health care.
dull
thudlike sounds are normally heard over dense areas such as the heart or liver
palpation: A grasping action of the fingers and thumb
to detect the position, shape, and consistency of an organ or mass
Shadow Health
virtual reality clinical setting, get to touch a patient with avatar, like a video game.
Anatomy of a room
· Bed/client positioning · Call system(telephone or call system) within reach · Telephone · Tv remote/lights · Bedside table · Kleenex/water
Toileting equipment
· Bedpan · Urinal · Urinary catheter · Bedside commode
Signage in room
· Bulletin board · NPO status · Fall risk
What does hourly rounding consist of?
· Care environment assessment · Client safety assessment · Client mental status/pain assessment
Assessment
· Collect Data: review of the clinical record, health history, physical examination, functional assessment, risk assessment, review of the literature · Use evidence-based assessment techniques · Document relevant data
Diagnosis
· Compare clinical findings with normal and abnormal variation and development events · Interpret data: identify clusters of clues, make hypotheses, test hypotheses, derive diagnoses · Validate diagnoses · Document diagnoses
Stages of diagnosis
· Cue recognition · Hypothesis formulation · Data gathering for hypothesis testing · Hypothesis evaluation · Critical thinking: identify assumptions and validation(reliability and accuracy)
Nursing diagnosis problems
· Include "related to" 1. The context of the problem · Include "As evidence by..." 1. The symptoms that provide the support for the selection of the problem · Actual problem already
Class 2 physical injury
· Ineffective airway clearance · Risk for aspiration · Risk for bleeding · Risk for falls · Risk for injury · Risk for thermal injury · Risk for urinary tract injury · Risk for peripheral neurovascular dysfunction · Risk for pressure ulcer · Risk for shock · Impaired skin integrity · Risk for impaired skin integrity · Risk for sudden infant death syndrome · Risk for suffocation · Impaired tissue integrity · Risk for impaired tissue integrity · Risk for trauma · Risk for vascular trauma
RN Practice State Law
· Plan and evaluating appropriate nursing acts · Teaching, assigning, delegating to our supervising other personnel · Collaborate with other health care providers in determining the appropriate health care for a patient but, subject to the provisions of G.S. 90-18.2, not prescribing a medical treatment regimen or making a medical diagnosis, except under supervision of a licensed physician · Implement the treatment and pharmaceutical regimen prescribed by any person authorized by State law to prescribe the regimen · Provide teaching and counseling about the client's health · Report and record the plan for care, nursing care given, and the client's response to that care · Supervise, teach, and evaluate those who perform or are preparing to perform nursing functions and administering nursing programs and nursing services · Provide for the maintenance of safe and effective nursing care, whether rendered directly or indirectly
Evaluation
· Progress toward outcomes · Conduct systematic, ongoing, criterion-based evaluation · Include patient and significant others · Use ongoing assessment to revise diagnoses, outcomes, plan · Disseminate results to patient ad family
Nursing diagnosis risks
· Risks for: · "Related to" 1. The context of the problem · Do not include "as evidenced by.." · Possible problem
Additional things in room
- PPE - Waste Basket - Sink - Bedside table - Chair - IV pole - Sharps container - Oxygen - Suction - Emergency equipment - emesis bags