Advanced Health Assessment Exam One: Quiz One, Quiz Two, Quiz Three, Quiz Four

Developmental Competence: Adolescence

Adolescence characterized by rapid physical growth and endocrine and hormonal changes Caloric and protein requirements increase to meet this demand, and because of bone growth and increasing muscle mass (and, in girls, the onset of menarche), calcium and iron requirements also increase. Increased requirements cannot be met by three meals per day; therefore, nutritious snacks play an important role in achieving adequate nutrient intake Childhood is the most active period in the life span with levels of activity decreasing.

Biculturalism and integration:

Allow for reciprocal change and maintaining ethnic identity; bounce between two worlds

External Ear auricle or pinna and external auditory canal

Auricle or Pinna • Movable cartilage • Serves to funnel sound waves into the external auditory canal External Auditory Canal • S-shaped in adult 2.5-3 cm long; extends to the tympanic membrane or ear drum • Cerumen (ear wax) secreted by modified sweat glands-keeps TM soft, bacteriostatic, protects against foreign bodies • Outer third is cartilage • Inner two-thirds is bone covered by thin sensitive skin • Drains into the parotid, mastoid, & superficial cervical nodes

COMPONENTS OF THE MENTAL STATUS EXAMINATION Four main headings of mental status assessment: A-B-C-T

1. Appearance 2. Behavior 3. Cognitive Function 4. Thought processes and perception

Ten Traps of Interviewing

1. Providing false assurance or reassurance 2. Giving unwanted advice 3. Using authority 4. Using avoidance language (patient has passed instead of patient has died) 5. Engaging in distancing 6. Using professional jargon (use appropriately, don't use if patient won't understand) 7. Using leading or biased questions (don't say you don't smoke do you because this will lead them to say no even if they do smoke) 8. Talking too much 9. Interrupting 10. Using "why" questions (why didn't you do this? negative connotation)

history- trigeminal neuralgia, goiter, thyroid function

Facial pain -Trigeminal neuralgia Coughing or difficulty swallowing -Goiter Change in texture of skin or nails, energy level, sleep habits, emotional stability, palpitations -Thyroid function

Ophthalmoscope: Fundus and Macula

Fundus • Light red to dark brown-red •No lesions Macula • 1 DD in size • 2 DD from the disc

The General Survey-Mobility

Gait • Feet should be shoulder-width • Foot placement accurate • Smooth and even • Maintain balance without assistance • Symmetrical movements (arm swing) Range of Motion • Full mobility for each joint • Movement - deliberate, accurate, smooth, & coordinated • No involuntary movement

THE FOUR UNRELATED WORD TEST

Highly sensitive and valid memory test Requires more effort than recall of personal or historic events, and avoids danger of unverifiable recall Assessment Process Pick four words with semantic and phonetic diversity; ask person to remember the four words. To be sure person understood, have him or her repeat the words. Ask for the recall of four words at 5, 10, and 30 minutes. Normal response for persons younger than 60 is an accurate 3- or 4-word recall after 5, 10, and 30 minutes.

Cardinal Features of Long-Term Weight Loss

Individualized and based on realistic patient goals Culturally sensitive Regular physical exercise • 4 to 5 times a week for 30 minutes Eating a low calorie, low fat diet • Caloric intake 1400 to 1500 kcal/day • Fat intake 20% to 25% of total calories Monitoring daily food intake • Food diary • Portion size • Weight

Nociception Pain Pathophysiology Modulation

Inhibits the pain message • Involves neurotransmitters • Endorphins • Enkephalins • Serotonin • Norepinephrine and more

Objective Data pain

Joints Note size, contour, and circumference of joint. Check active or passive range of motion. Joint motion normally causes no tenderness, pain, or crepitation. Muscle and skin Inspect skin and tissues for color, swelling, and any masses or deformity. Abdomen Observe for contour and symmetry. Palpate for muscle guarding and organ size. Note any areas of referred pain.

COMPONENTS OF THE MENTAL STATUS EXAMINATION BEHAVIOR

LOC - Person is awake, alert, aware of stimuli from the environment and within the self and responds appropriately and reasonably soon to stimuli . Facial Expressions - Appropriate to the situation and changes appropriately with the topic; comfortable eye contact unless precluded by the cultural norm Speech - Judge the quality of speech, noting that person makes sounds effortlessly and shares conversation appropriately. Pacing, articulation, and word choice

Developmental Competence: Pregnant Woman Mouth

May experience nasal stuffiness and epistaxis do to increased vascularity Gums may soften and be hyperemic Normal tooth brushing may cause bleeding

ASSESSMENT: Collecting subjective data: health history

Mental health assessment is inferred from the answers from the interview process Explain purpose, tell them they may refuse to answer any questions, ensure confidentiality, and be respectful Remember other body systems may affect mental status Regardless of source (whether physical, medication, outside source), lifestyle & functional level may be affected Some symptoms may invoke fear for serious conditions Be sensitive to these fears or client may shut down and not share important information

Cultural Assessment

No gold standard tool Never assume but always ask List of domains • Heritage • Health practices (any culture specific healers, CAM?, herbal) • Communication (preferred name, language, etc.) • Family roles and social orientation (who makes the decisions) • Nutrition (certain foods not allowed to have) • Pregnancy, birth/childrearing (how many chidlren, beliefs surrounding this?, some cultures don't immediately bond after birth) • Spirituality/religion • Death (particular ritual) • Health providers (prefer same sex providers)

Psychiatric mental illnesses

Organic etiology has not yet been established (e.g., anxiety disorder or schizophrenia) Mental status assessment documents a dysfunction and determines how that dysfunction affects self-care in everyday life.

COMPONENTS OF THE MENTAL STATUS EXAMINATION APPEARANCE: Appearance

Posture - Erect and position relaxed Body Movements - voluntary, deliberate, coordinated, and smooth, and even Dress - Appropriate for setting, season, age, gender, and social group Grooming & Hygiene - Congruence between grooming and a

Nutritional Consequences of Bariatric Surgery

Potential nutritional consequences and related dietary change as a result of surgical intervention. Malabsorption of protein and calories • Eat small nutrient dense meals. Malabsorption of vitamins and minerals • Taking supplements Weight regain • Avoid excess intake of calorically dense/liquid foods. Obstruction • Avoid chunks of food that could cause blockage.

Acculturation:

Process of adopting culture and behavior of the majority culture

Week One Objectives

Promote collaboration through a human connection with your classmates Define culture Identify barriers to access to care that may be attributed to a lack of cultural competency Describe the importance of cultural and linguistic competency as a national priority. Describe the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care Describe the important policies of the course

Function of the Skin

Protection • Temperature regulation • Identity • Fluid & electrolyte balance • Absorption • Excretion • Sensation (perception) • Immunity • Vitamin D synthesis

Standard Communication: Background

Provide pertinent history as it directly relates to patients current health status. ex. history MI

Developmental Competence: Infants

Same capacity for pain as adults By 20 weeks of gestation pathways in place 30 weeks due to immaturity of cortex and lack of conscious awareness. Inhibitory neurotransmitters are in insufficient until birth at full term ➢ Making preterm infant more sensitive to painful stimuli Preverbal infants at high risk for under treatment of pain ➢ Because of myths and beliefs that infants do not remember pain New research ➢ Poorly controlled pain in infants (daily heel sticks, venipunctures) can result in pain hypersensitivity later in life

Structure and Function: Ears

Sense Organ • Hearing • Equilibrium Three distinct parts • External Ear (directly assessed) • Middle Ear (not directly assessed) • Inner Ear (not directly assessed)

SCREEN FOR DEPRESSION DISORDER

Series of tools that can be used in the clinical setting Patient Health Questionnaire-2 (PHQ-2) Asks 2 questions about depressed mood and anhedonia (lack of interest). Serves as a screening tool to use full PHQ-9 tool PHQ-9 Series of 9 questions requiring adding column totals that relate to the frequency of occurrence of symptoms Higher the score, the greater the likelihood of functional impairment or clinical diagnosis.

Types of Headaches

Sinus Cluster Tension Migraine Tumor-related See page 265, Table 14-1

•Ethnicity:

Social group with shared traits

Standard Communication: Assessment

State pertinent assessment findings obtained with interpretation of data e. EKG

Romberg Test

Tests equilibrium Feet together and arms at side, close eyes for 20 seconds Check for swaying

Health

Balance of the person, both within one's being and in the outside world; certain beliefs that believes cause illness

•Acculturative stress:

Based on input from environment, social/interpersonal and societal; p. 14 categories for acculturative stress

Naturalistic or holistic

Believe that the forces of nature must be kept in balance • Example is yin/yang theory (Asian) and hot/cold theory (Hispanic)

COMPONENTS OF THE MENTAL STATUS EXAMINATION THOUGHT PROCESSES & PERCEPTIONS

Thought Processes - Should be logical, goal-directed, coherent, and relevant; should complete thoughts Thought Content - Should be consistent and logical Perceptions - consistently aware of reality; perceptions should be congruent with yours

Subjective Data Questions - Mouth & Throat: Family History

CA of the mouth, throat, nose or sinus?

Culturally competent

Caregivers apply a universal concept of understanding to all contexts of an individual's situation (including immigration status)

Subjective Data r/t Nutritional History

Changes in appetite, taste, smell, chewing, swallowing Recent surgery, trauma, burns, infection Chronic illnesses Nausea, vomiting, diarrhea, constipation Food allergies or intolerances Medications and nutritional supplements Patient-centered care Alcohol or drug use Exercise and activity patterns Family history

Objective Data -Mouth- Check and inspect

Check Check tongues strength Check Check taste Inspect Inspect hard & soft palates • Color • Integrity Inspect Inspect buccal mucosa • Color and consistency • Stenson's ducts (Parotid ducts) Inspect Inspect uvula • Color • Integrity

Collecting Four Types of Patient Data

Complete total health database Focused or problem-centered database. Follow-up database Emergency database

Metabolic Syndrome (MetS)

Diagnosed in the presence of 3 out of 5 biomarkers Waist circumference • Gender-based measurements Glucose level • Above 100 mg/dL or being treated for hyperglycemia High-density lipoprotein (HDL-C) • Gender-based measurements or being treated for hyperlipidemia Triglyceride (TG) level • Above 150 mg/dL or being treated for elevated TG Hypertension (HTN) • Systolic and diastolic parameters or being treated for HTN

Pain Patho

• Associated with the central and peripheral nervous systems • The source of pain stimulates peripheral nerve endings (nociceptors), which transmit the sensation to the CNS • Nociceptors are located body, skin, subcutaneous tissue, skeletal muscle, joints, peritoneal surfaces, pleural membranes, dura mater, & blood vessels walls

Biomedical or scientific

• Assumes cause and effect• Example is germ theory

Skin • Composed of three layers

• Epidermis • Dermis • Subcutaneous tissue

• Conjunctivitis

• Inflammation of the conjunctiva

Secondary Skin Lesions • Erosion

• Localized loss of epidermis with moist, slightly depressed base

Secondary Skin Lesions • Ulcer

• Localized loss or destruction of epidermis and underlying dermis, irregular shape, may bleed

Structure and Function of Throat: Throat (pharynx)

• Located behind the mouth and nose, serves as a muscular passage for food and air. • Nasopharynx, oropharynx, and laryngopharynx • Contain the tonsils • Palantine tonsils, linguinal tonsils and pharyngeal tonsils; palatine tonsils what we think when assessing and removing. pharyngeal is what we think of as adenoids

• Cataract

• Loss of transparency or cloudiness of the lens

Nail Inspection and Palpation

• Nail Inspection • Shape and Contour • Color • Nail grooming and cleanliness, nail color and markings, shape of nails • Nail Palpation • Assess texture and consistency, capillary refill p. 211

Abnormalities of the Optic Disc

• Papilledema • Glaucoma • Optic atrophy

Collecting Objective Data EYES

• Preparing the client • Explain test to client • Equipment • Snellen/E, near vision screener • Penlight •Opague card • ophthalmoscope

• Exophthalmos

• Protruding eyeballs

Production of Sounds • Basic principles

• Structure with more air produces louder, deeper sound compared with denser structure. • Variations occur in clinical practice based on individual anatomical differences.

Magicoreligious

• The world is an arena in which supernatural forces dominate • Good versus evil • Example is voodoo or witchcraft

RADIATING

•Does it go anywhere?

Defining Mental Status: Mental Health

"a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community" (WHO, 2010)

Defining Mental Status: Health

"is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (WHO, 2010)

Health History Sequence

-Biographic data • Source of history • Reason for seeking care • Present health or history of present illness • Past health • Family history • Review of systems • Functional assessment including activities of daily living (ADLs)

Normal vision requires 3 processes/disruption of any of the 3 can cause a visual disorder.

1. Formation of an image on the retina (refraction) 2. Stimulation of rods and cones 3. Conduction of nerve impulses to the brain

Ophthalmoscope: Retinal Vessels

1. Number = 4 pairs; one in each quadrant 2. Color = Artery brighter than veins 3. A : V Ratio = artery-to-vein is 2:3 or 4:5 4. Caliber = decrease in caliber as they extend to the periphery 5. A-V Crossing = Artery and vein may cross paths 6. Tortuosity = mild twisting in both eyes is usually congenital 7. Pulsations = seen in veins

Stages of Cognitive Development

1. Use the stage of cognitive development as a guide for facilitating communication 2. Consider the maturity level of the child; not all children the same age are in the same stage of cognitive development 3. Remember that a health care crisis can lead to regression

Evidence-Based Assessment

1850s: Florence Nightingale began a historical evolution with the concept of "research" (fresh air, hand washing, not the same research done today but it was based on observations) • 1970s: "Evidence-based medicine" term coined • Cochrane—systematic reviews of RCTs (archie cochrane (epidemiologist) realized needed systemic reviews of rct trials. noticed studies about corticosteroid use for preterm babies were not being utilized)(this has reduced infant mortality between 30-50%) • Evidence-based practice (EBP) • More than just the use of best-practice techniques • Integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences • Clinical decision making = best evidence from literature review + patient's own preference + clinician's experience/expertise + physical exam; p. 6 in book (often takes up to 17 years for research findings to be put into practice)

Interview People with Special Needs Threats of Violence

70% of nurses have reported physical or verbal abuse •Patients are the primary source of violence •Identify red flags (fist-clenching, pacing, history of recent drug use or recent bereavement) •Diffuse threatening behavior •Leave the door open, do not turn back, always position yourself between the person and the door •Do not raise voice, remain calm

JUDGMENT

Ability to compare and evaluate alternatives in a situation and reach an appropriate course of action Judgment about daily or long-term goals, the likelihood of acting in response to hallucinations or delusions, and capacity for violent or suicidal behavior. In the context of the interview By what a person says about job plans, social or family obligations, and plans for the future; job and future plans should be realistic, considering the person's health situation. Ask for the rationale for their health care, and how they decided about compliance with prescribed regiments; actions and decisions should be realistic.

The General Survey- Physical Appearance

Age • Should appear his or her stated age Sex • Development appropriate for sex and age • Transgender - what is the stage of transformation Level of Consciousness • Alert and oriented to person, place, time, & situation • Attends & responds to questions appropriately Skin color • Tone is even • Skin intact with no obvious lesions • Note any tattoos or piercing Facial Features • Symmeric with movement Overall appearance • Give a general statement

Demographic Differences

Age, poverty level, and household composition Number of relatives living in household is higher Number of multigenerational families is also higher African Americans, American Indians, and Alaska natives have a higher rate of grandparents caring for grandchildren Lowest household income •African Americans •Hispanics All groups exceed the national poverty level (14.8% in the U.S.) Low educational attainment contribute to the poverty level Low educational and poverty level contributes to disability

Risk Factors for Hearing Loss

Aging, especially due to many years of exposure to sounds that can damage inner ear cells Heredity, with genetics that are related to susceptibility to ear damage Occupational loud noises as regular part of the working environment Recreational noises and exposure to explosive noises Ototoxic medications Illnesses, especially with high fever Noise exposure Smoking Cardiovascular risk factors Genetic and family susceptibility Premature birth Hypoxia during birth Rubella, syphilis or certain other infections in pregnant mother Inappropriate use of ototoxic drugs during pregnancy Neonatal jaundice, which can damage the otic nerve in a newborn baby •Infectious diseases such as meningitis, measles, mumps, and chronic ear infections in childhood as well as in later life •Head injury or injury to the ear •Wax or foreign bodies blocking the ear canal

Interview People with Special Needs Anxiety

Almost all ill people have some anxiety •Normal response •Take the time to listen and do not act in haste will help ease some of the anxiety

Complex Regional Pain Syndrome (CRPS)

Also known as reflexive sympathetic dystrophy (RSD) • Chronic progressive nerve condition • Complex interaction of sensory, motor, autonomic nervous system, and immune system • Equally seen in gender, usually around ages 40 to 60 Key feature is an innocuous stimulus. • Presents with burning pain, swelling, stiffness, and discoloration of the affected extremity Treatment • High doses of medications (e.g., prednisone, amitriptyline, pregabalin, clonidine) to decrease symptoms • Physical therapy to regain limb function

ABNORMAL FINDINGS

Altered level of consciousness Speech disorders (look in textbook) Mood and affect abnormalities (flat affect) Anxiety disorders Delirium, depression, and dementia Thought process abnormalities Thought content abnormalities Perception abnormalities Characteristics of eating disorders Childhood mental disorders p. 75-82 (go through these and be familiar)(on quiz)

Developmental Competence: The Aging Adult pain

Although pain should not be considered a "normal" part of aging, it is prevalent. ➢ Older adults with history of comorbidities— should anticipate pain. ➢ Older adults often deny having pain • for fear of dependency, further testing or invasive procedures, cost, and fear of taking painkillers or becoming a drug addict. ➢ Observe for changes in functional behavior and/or behavioral cues. ➢ Comorbidity of dementia may prevent patient from identifying and describing pain—observe behaviors —use PAINAD scale.

SCREEN FOR ANXIETY DISORDERS

Anxiety and depression are the two most common mental health disorders seen in individuals seeking health care. Generalized anxiety disorder scale (GAD-7) Consists of 7 itemized scale Higher the score, greater the likelihood. First 2 questions relate to core anxiety. Greater or equal than 3 indicates diagnosis.

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? Coping strategies • Do you take any steps to protect your ears, such as headphones or earplugs?

History- Any lumps or lesions and head or neck surgery

Any lumps or lesions • Recent infection • Radiation? • Smoking • Alcohol • Difficulty swallowing • Thyroid problems • Possible cancer History of head or neck surgery • Type of surgery • Reason for • Response to

MENTAL STATUS EXAMINATION: aphasia, symptoms of psychiatric mental illness, known illnesses or health problems, medications

Aphasia Impairment of language ability secondary to brain damage Symptoms of psychiatric mental illness Especially with acute onset Known illnesses or health problems: Such as alcoholism or chronic renal disease Medications: Side effects of confusion or depression

Developmental Competence: The Aging Adult

As people age, they are at increased risk to develop make undernutrition or overnutrition. Major risk factors for malnutrition in older adults: • Poor physical or mental health, social isolation, alcoholism, limited functional ability, poverty, and polypharmacy Normal physiologic changes in aging adults that directly affect nutritional status include • poor dentition, decreased visual acuity, decreased saliva production, slowed gastrointestinal motility, decreased gastrointestinal absorption, and diminished olfactory and taste sensitivity. Decrease in energy requirements due to loss of lean body mass and increase in fat mass • Age-related loss of muscle mass—Sarcopenia • Sarcopenic obesity—low muscle mass with excess fat

SCREENING FOR SUICIDAL THOUGHTS

Assess for possible risk for harm if the person expresses feelings of sadness, hopelessness, despair, or grief. Begin with more general questions and proceed if you hear affirmative answers. It is very difficult to question people about possible suicidal wishes for fear of invading privacy Risk is far greater skipping these questions if you have the slightest clue that they are appropriate; you may be the only health professional to pick up clues of suicide risk. For people who are ambivalent, you can buy time so the person can be helped to find an alternate remedy. Share any concerns you have about a person's suicide ideation with a mental health professional.

Assessment: Point of Entry in an Ongoing Process

Assessment • Collection of data about a person's health status (Step one in the nursing process) • Consist of two types of data • Subjective data ( What is said; what can be done without your hands; SYMPTOMS) • Objective data (What you observe via inspection, percussion, palpation, or auscultation; SIGNS) • Forms the database which can be used as a yardstick for measuring the effectiveness of care. • Purpose - allows for a clinical judgment or diagnosis to be made. • If inadequate or not done correctly can lead to adverse effects • Ongoing process - circular as opposed to linear (think nursing process)

Week Two Objectives

At the end of this week, the student will be able to: Discuss the role of assessment as the starting point of all models of clinical reasoning. Describe the use of diagnostic reasoning and the nursing process in clinical judgment. Differentiate between novice, proficient, and expert practitioner. Describe the use of critical thinking in diagnostic reasoning and clinical judgment. Differentiate first-level, second-level, and third-level priority problems. Use a conceptual framework to guide nursing practice. Contrast medical diagnosis with nursing diagnosis. Consider life cycle and cross-cultural factors when performing a health assessment. Discuss the importance of high-level assessment skills Describe the basic characteristics of culture and the steps to cultural competence. Describe the concept of heritage consistency. Explain the concept of ethnicity. Discuss the influence of religion and spirituality on health and illness perception. Discuss areas of potential cultural conflicts between nurses and patients of different ethnic groups. Discuss components of the health belief system and their influence on health practices and illness expressions. Examine the sources that influence the culture and beliefs the student embraces. Provide care that reflects an acceptance of the patient as a unique individual. Demonstrate the ability to establish the parameters for a health interview. State the factors that affect communication. Describe the phases of an interview. State the 10 traps of interviewing. Discuss the meaning of common nonverbal modes of communication. Modify communication techniques as indicated by each patient's developmental stage, special needs, or cultural practices and discuss working with and without an interpreter to overcome communication barriers. State the purpose of the complete health history. List the categories of information contained in a health history and describe the data or information that must be gathered for each category of a health history. Describe the eight critical characteristics included in the summary of each patient's symptom. Relate developmental care during a health history for a child or older adult. Define the behaviors that are considered in an assessment of a person's mental status and describe relevant developmental care related to the mental status examination. State the purpose of a mental status examination. List the four components of mental status assessment and complete a Mini-Mental State Examination. Discuss developmental care for infants, children, and aging adults. Identify current statistics related to alcohol use and abuse. Identify risk factors associated with increased alcohol use and identify current statistics related to drug use and abuse. Incorporate assessment tools for the use of alcohol and drug abuse into the assessment of patients in the healthcare environment. Identify and assess substance abuse in individuals across the lifespan. Recognize health care professionals' role as mandatory reporters of abuse. Discuss the health effects of violence. Describe the use of the Abuse Assessment Screen (AAS) when one is screening for intimate partner violence (IPV). Explain the aspects of assessment and history taking for suspected abuse and describe the components of the physical examination of the known survivor of IPV or elder abuse and use correct forensic terminology. Examine the increasing problem of adolescent relationship violence. Discuss the importance of procedures for both written and photographic documentation of IPV and elder abuse. Assess the risk of homicide when working with suspected IPV cases. Determine what steps to take if a patient denies IPV but abuse is still suspected.

Blood Pressure Factors

Average BP in young adult is 120/80 mm Hg BP Varies based on • Age • Sex • Time of day due to Diurnal rhythm • Weight • Exercise • Emotions Other factors • Caffeine • Nicotine • Pain • Temperature • Position of person or arm; stress can affect

Infants and Children: Developmental Competence Vital signs

BP is not normally checked in children less than 3 years of age. Whenever possible, avoid rectal route and take a tympanic, inguinal, or axillary temperature. Infant: reverse order of vital signs to respirations, pulse and temperature Preschooler: consider normal fear of body mutilation may increase with any invasive procedure School-age: Promote cooperation by explanation and participation in handling equipment Adolescent: Same consideration as with adults

Pain Assessment: Infants and Children

Because infants are preverbal and incapable of self-report, pain assessment is dependent on behavioral and physiologic cues. • It is important to underscore understanding that infants do feel pain. • Children 2 years of age can report pain and point to its location but cannot rate pain intensity. • It is helpful to ask parent or caregiver what words the child uses to report pain. Rating scales can be introduced at 4 or 5 years. • Faces Pain Scale-Revised (FPS-R) is an example. • 6 drawings of pain intensity from "no pain" on right (0) to "very much pain" on left (10) • Realistic facial expressions used p. 169

CONCEPTUAL FOUNDATIONS: Must have the following features to be considered a mental disorder

Behavior or psychological syndrome or pattern Reflect an underlying psychobiologic dysfunction Clinically significant distress or disability Must not be merely an expected response (reaction to death) Not primarily a result of social deviance or conflicts with society

Developmental Competence

Beliefs can impact delivery of care delivery and treatments • Parenteral perceptions of illness • Cultural taboos (ex. administration of blood to jehova witness) Values held by dominant U.S. culture influence perception of aging population • Old at 65 • Limit work •Cultural shock for older immigrants

Culture and Genetics (Mouth)

Bifid uvula A condition in which uvula is split either completely or partially; occurs in 10% of some American Indian groups Cleft lip and cleft palate Most common in Asians, intermediate in whites, and least common in blacks Torus palatinus A bony ridge running in middle of hard palate is seen in 20% to 35% of the US population. Leukoedema A benign lesion occurring on buccal mucosa is seen more often in blacks. Dental caries Infectious process leading to tooth decay due to interaction of bacteria is on the rise. Increased risk for dental disease Due to socioeconomic status, lack of access and comorbidities Complications r/t periodontal disease Linked to type 2 diabetes Increased incidence of oral cancers Linked to HPV and changes in sexual norms

Developmental Competence: Infants and Children for head and neck

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. Closure of fontanels -• Triangle-shaped posterior fontanel closes by 1 to 2 months. • Diamond-shaped anterior fontanel closes between 9 months and 2 years. 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 During infancy, trunk growth predominates •so that head size changes in proportion to body height. Facial bones grow at varying rates •In toddler, mandible and maxilla are small and nasal bridge is low.. Lymphoid tissue •Well developed at birth and grows to adult size when the child is 6 years old In adolescence •facial hair also appears on boys at this time: first on upper lip, then on cheeks and lower lip, and last on the chin. •noticeable enlargement of the thyroid cartilage occurs, and with it, the voice deepens.

Culturally sensitive

Caregivers possess some basic knowledge of populations in which they provide care

Health History: History of Present Health Concern Using COLDSPA

Character Onset Location Duration Severity Pattern Associated Factors; Dr. Koch likes oldcarts better (a=aggravating or relieving factors, r=radiation, t=treatment tried.)

DEVELOPMENT COMPETENCE AGING ADULTS

Check sensory status, vision, and hearing before any aspect of mental status. Confusion is common and is easily misdiagnosed. Presence of delirium can have serious affects. Overall presence of dementia has decreased Determination of delirium versus dementia must be evaluated when cognitive impairment is present upon examination of the older adult

Developmental Competence: Aging Adults Ears

Cilia become stiff • Which can cause cerumen to accumulate thus reducing hearing; Cerumen is drier because of atrophy of apocrine glands • Impacted cerumen is a common but reversible cause of hearing loss in older people Presbycusis: type of hearing loss that occurs with aging • Gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve • Onset occurs in the 50s and slowly progresses • First loss of high-frequency tones • Ability to localize sound is impaired • Worse when there is a lot of background noise is present • Affects men more often • Lower prevalence in AA

Collecting Objective Data head and neck

Client preparation • Ask the client to remove all clothing and jewelry • Have the client sit comfortably Equipment • Small cup of water • stethoscope

Mental disorder

Clinically significant behavioral emotional or cognitive syndrome that is associated with significant distress or disability involving social, occupational, or key activities

SUPPLEMENTAL MENTAL STATUS EXAMINATION: Mini-Mental State Exam (MMSE)

Cognitive functioning only Set of 11 questions takes ~ 5 to 10 minutes to administer Used for both initial and serial measurement (therefore can show worsening) Detect dementia and delirium and differentiate these from psychiatric mental illness. Normal mental status average 27; scores between 24 and 30 indicate no cognitive impairment

AGING ADULTS - NEW LEARNING

Cognitive functions: new learning In people of normal cognitive function, age-related decline occurs in performance in the Four Unrelated Words Test. Persons in the eighth decade average two of four words recalled over 5 minutes and will improve performance at 10 and 30 minutes after being reminded by verbal cues. The performance of those with Alzheimer disease does not improve on subsequent trials.

AGING ADULTS - ORIENTATION

Cognitive functions: orientation Many aging persons experience social isolation, loss of structure without a job, change in residence, or some short-term memory loss. Aging persons may be considered oriented if they know generally where they are and the present period. Consider them oriented to time if year and month are correctly stated. Orientation to place is accepted with correct identification of the type of setting (e.g., the hospital and name of town).

The Process of Communication: Sending

Communication • Exchanging of information • More than talking & hearing • Also based upon behavior (conscious and unconscious) Sending • Verbal communication • Words you speak • Tone used • Nonverbal communication • Body language (posture, gestures, facial expressions, eye contact, etc.) • More reflective of truer feelings. • Can help interview recognize importance of unconsconscious messages

Pain Health History

Consider these questions (cont.) ➢ Relieving factors ➢ Exacerbating factors ➢ Any treatments ➢ Anything else Personal / Past Health History ➢ Any previous pain experiences ➢ Any special meaning related to this pain

Critical Thinking and the Diagnostic Process: Nursing Process

Consist of six steps • Assessment: Collecting subjective and objective data • Diagnosis: Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral) • Outcome Identification (individualize to patient - cultural & realistic - timeline) • Planning: Determining outcome criteria and developing a plan • Implementation: Carrying out the plan • Evaluation: Assessing whether outcome criteria have been met and revising the plan as necessary; nursing process used to be five step but outcome identification added.

Characteristics of Palpation

Consistency • Soft, hard • Filled with fluid Mobility • Fixed • Mobile Moisture • Wet • Dry Pulse Strength • Strong, weak • Full, Bounding • Thready Shape • Regular • Irregular Size • Small • Medium • Large Temperature • Warm • Cold Texture • Smooth • Rough

DEVELOPMENTAL COMPETENCE INFANTS AND CHILDREN

Covers behavioral, cognitive, and psychosocial development and examines how child is coping with his or her environment Follow A-B-C-T guidelines as for adults, with consideration for developmental milestones Abnormalities often problems of omission; child does not achieve expected milestone Parent's health history, especially sections on developmental history and personal history, yields most of mental status data.

Head- cranium

Cranium • Houses and protects the brain and sense organs • Consist of 8 bones • Frontal • Parietal • Temporal • Occipital • Ethmoid • Sphenoid Immovable sutures • Coronal • Sagittal • Lambdoid

Cultural Factors and Dietary Practices

Cultural factors that must be considered: Cultural definition of food Frequency and number of meals eaten away from home Form and content of ceremonial meals Amounts and types of foods eaten and regularity of food consumption Knowing person's religious practices r/t food enables you to suggest improvements or modifications that do not conflict with dietary laws. Other issues are fasting and other religious observations that may limit a person's food or liquid intake during specified times.

How to become a culturally competent practitioner

Cultural sensitivity Cultural appropriate Cultural competent Cultural care

SCREENING TESTS FORINFANTS AND CHILDREN

Denver II screening 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 to develop in behavioral, language, cognitive, and psychosocial areas. An additional language test is the Denver Articulation Screening Examination. "Behavioral Checklist" for school-age children, ages 7 to 11, is tool given to parent along with the history. Covers five major areas: mood, play, school, friends, and family relations It is easy to administer and lasts about 5 minutes.

Anthropomorphic Measures

Derived weight measure Percent usual body weight—formula calculation Body mass index—practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition Waist-to-hip ratio Assesses body fat distribution as an indicator of health risk Waist circumference (WC) alone predicts health risk. Arm span or total arm length Useful in situations where height is difficult to measure Serial assessment Made at routine intervals weekly, biweekly, or monthly dependent on patient population.

DEVELOPMENTAL COMPETENCE: Infants and children

Difficult to separate and trace the development of just one aspect of mental status in children, because all aspects are interdependent Critical issues r/t substance abuse, suicide, and impact of mental health diagnoseS and/or individuals receiving treatment (suicide higher in rural areas compared to urban areas; increased access to firearms and less access to mental health services)

The General Survey-Behavior Dress and Personal Hygiene

Dress • Appropriate for weather • Appropriate for culture and age • Clean and fits well Personal Hygiene • Clean and groomed (for age, job, & socioeconomic status) • Hair groomed • Makeup appropriate (age & culture); musky body odor could indicate diabetic uncontrolled, alcoholic smell, etc.

Organic disorders

Due to brain disease of known specific organic cause (e.g., delirium, dementia, alcohol and drug intoxication, and withdrawal)

Developmental Competence: Adulthood

During adulthood, growth and nutrient needs stabilize. Most adults are in relatively good health but influence of lifestyle factors can lead to development of disease. • Lifestyle factors such as cigarette smoking, stress, lack of exercise, excessive alcohol intake, and diets high in saturated fat, cholesterol, salt, and sugar and low in fiber Adult years, therefore, are an important time for education to preserve health and to prevent or delay onset of chronic disease. Adult emergence of Metabolic syndrome is a concern leading to increased cardiac risk(elevated blood pressure, elevated sugar, fat around waist).

Abnormal Findings

Dwarfism • Hypopituitary dwarfism • Achondroplastic dwarfism Gigantism (before puberty)(robert wadlow) versus acromegaly (after puberty)(andre the giant)(hyperpituitarism) Anorexia nervosa (see themselves as fat no matter how skinny) Endogenous obesity—Cushing's syndrome (excessive cortisol, weight gain, moon face, muscle wasting) Marfan syndrome (hyperextensibility of joints, arm span bigger) Review these syndromes*

Traditional Treatments and Folk Healers

EAch culture has its own healers who usualy speak the native language -Hispanic: curandero, espiritualista, yerbo, or partera -black: hougan, spiritualist, old lady -American Indian: shaman, medicine woman, medicine man -Asian: herbalists, acupuncturists, bone setters -Amish: braucher Healing is not complete unless body and mind are healed -Division of these is a western concept Use of alternative, comp., or traditional therapies; not going into what these are.

Subjective Data Ears

Earache Infections Discharge Hearing loss Environmental noise Tinnitus Vertigo Patient-centered care

Ways to Improve Health Literacy Teach back

Easy •Has patient repeat teaching in their own words •Verifies understanding

FACTORS AFFECTING MENTAL HEALTH

Economic & Social factors Unhealthy lifestyles Exposure to violence Personality factors Spiritual factors Cultural factors Changes in structure & function of neuro Psychosocial development

Obesity Statistics

Estimated 17% of children and adolescents, ages 2 to 19 66% of adults in United States are either overweight or obese. For children, overweight defined as body mass index (BMI) equal to or greater than 95th percentile based on age- and gender-specific BMI charts For adults Overweight defined as BMI of 25 or greater Obesity defined as BMI of 30 Being overweight during childhood and adolescence associated with increased risk for becoming overweight during adulthood

Whisper Test

Evaluation of hearing acuity Have client place a finger on the tragus of one ear (this is not the ear you are testing) Shield your lips and whisper a two-syllable word 1 to 2 feet behind the client Repeat on the other ear

SUPPLEMENTAL MENTAL STATUS EXAMINATION: Montreal Cognitive Assessment (MoCA)

Examines more cognitive domains, more sensitivity to mild cognitive impairment Free and takes ~ 10 minutes to do A total score of 30 with a score of ≥ 26 considered normal

Objective Data: External Ear: external auditory meatus and external canal

External auditory meatus • Note size of opening • Should be no swelling, redness, or discharge • May see cerumen External Canal • Note any redness or swelling; lesions, foreign bodies or discharge • If discharge note color and odor • If discharge on speculum clean before placing in other ear • If wears hearing aid note if there is any irritation to canal

Structure and Function: Eyes

Eye transmit visual stimuli to the brain Organ for vision Set in the orbit (round, hollow area formed by bones) Cushioned by fat Bones and fat provide protection

External Structures of the Eye

Eyelids upper and lower Lateral and medial canthus Eyelashes, conjunctiva Lacrimal apparatus Extraocular muscles

The General Survey-Behavior

Facial Expressions • Maintains eye contact • Expression appropriate for the situation (dependent on culture) Mood and affect (flat, seem upset?, etc.) • Comfortable and cooperative • Interacts pleasantly Speech • Clear articulation • Speech Pattern • Fluent & even paced • Conveys ideas clearly • Word choice appropriate

Interview

First point of contact and most important part of the data collection Purpose •Gain an understanding of the patient's beliefs, concerns, and perception of their individual health state Allows for the gathering of subjective data Allows for the awareness of some objective data such as physical appearance, posture, ability to carry on a conversation, and demeanor; if dont get this may get diagnosis wrong

Priority Problems Level

First-level priority • Emergent, life-threatening, and immediate Second-level priority • Next in urgency, requiring attention so as to avoid further deterioration Third-level priority • Important to patient's health but can be addressed after more urgent problems are addressed. Collaborative problems • Approach to treatment involves multiple disciplines; use critical thinking. triage.

SCREENING TESTS FOR Adolescents

Follow same A-B-C-T guidelines as for adults

SCREENING TEST FOR AGING ADULTS

Follow same A-B-C-T guidelines for the younger adult with these additional considerations. Behavior: level of consciousness Glasgow Coma Scale is useful in testing consciousness in aging persons in whom confusion is common. Gives numerical value to person's response in eye-opening, best verbal response, and best motor response Avoids ambiguity when numerous examiners care for same p

Cultural Competence

Foods and eating customs are culturally diverse, and each person has unique cultural heritage that may affect nutritional status. Immigrants commonly maintain traditional eating customs long after language and manner of dress of adopted country become routine. Newly arriving immigrants may be at nutritional risk for a variety of reasons. Impact from prior country and unfamiliarity with new country Period of adjustment required that is impacted by socioeconomic and cultural factors.

Additional Nutritional History

For adolescents, obtain information about your present weight. use of anabolic steroids or other agents to increase muscle size and physical performance. overweight and obesity risk factors. age first started menstruating. For pregnant women, obtain information about number of pregnancies and pregnancy history. food preferences when pregnant. (pica?) For the aging adult, obtain information about prior dietary history in ages 40's and 50's. factors affecting present dietary intake. vitamin D and calcium intake

PQRST Method of Pain Assessment

For each of the initials a series of questions are asked to help qualify patient's self-report of clinical symptoms ➢ P = Provocation/palliation ➢ Q = Quality/quantity ➢ R = Region/radiation ➢ S = Severity scale ➢ T = Timing

COMPONENTS OF THE MENTAL STATUS EXAMINATION

Full mental status examination is a systematic check of emotional and cognitive functioning. Usually, mental status can be integrated within the context of the health history interview. You will collect ample data to be able to assess mental health strengths and coping skills and to screen for any dysfunction.

Structure and Function of Mouth: Three pairs of salivary glands

Function is to secrete saliva (moistens food, starts digestion, and cleans and protects the mucosa) 1. Parotid gland Located within the cheek in front of the ear Stensen's duct opens on the buccal mucosa opposite 2nd molar 2. Submandibular gland Located beneath mandible at the angle of jaw Wharton's duct runs Located in floor of mouth and opens at either side of frenulum 3. Sublingual gland Smallest, almond-shaped Located in the floor of mouth under tongue Many small openings along sublingual fold under tongue

Review of Systems

General -usual weight, recent weight change, weakness, fatigue, fever Skin -rashes, lumps, sores, itching dryness, color change, changes in hair or nails Head -headache or head injuries Eyes -Vision, glasses, last exam, pain, redness, tearing , vision problems Ears -hearing, tinnitus, vertigo, earaches, infection, drainage, use of hearing aides Nose and sinuses -frequent colds, nasal stuffiness, discharge, itching, hay fever, nosebleeds, sinus problems Mouth and gums -condition of teeth and gums, bleeding gums, dentures, last exam, sore tongue, dry mouth, frequent sore throats or hoarseness Neck -lumps or swelling, goiter pain, stiffness Breast -lumps, pain, discharge, self-exams Respiratory -cough, sputum color quantity), hemoptysis, wheezing, asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleurisy, last cxr Cardiac -heart trouble, HTN, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, edema, last EKG or other exam Gastrointestinal: problems swallowing, heartburn, appetite, nausea, vomiting, bowel habits, jaundice, liver or gallbladder problems Urinary: frequency, polyuria, nocturia, burning or pain, blood in urine, urgency, problems with stream, infections, stones, and incontinence Genital male: hernias, discharge or sores from penis, testicular pain or masses, sexual dysfunctions, any sexually transmitted diseases and tx, sexual preference Genital female: age of menarche, regularity, duration of periods, amount of bleeding, any abnormal periods, or bleeding after intercourse, last period, discharge or itching, any sexually transmited disease and tx, sexual preference, birth control methods, number of pregnancies, delivers, abortions peripheral vascular- leg cramps, varicose veins, past history of blood clots musculoskeltal- muscle of joint pains, stiffness, arthritis, gout, swelling, redness, pain or tenderness, ROM Neurological- fainting, blackouts, seizures, weakness, paralysis, numbness, tingling, or tremors hematologic/immunologic- anemia, easy bruising or bleeding, past transfusions and any reactions to them, status to HIV infrection, any autoimmune disorders Endocrine- thyroid trouble, heat or cold intolerance, excessive sweating, diabetes, excessive thirst or hunger, polyuria psycholbiolic- nervousness, tension, mood, memory (depression, anxiety, medication use?)

Developmental Competence The Aging Adult

General Survey • Physical Appearance • Posture • Gait Measurement • Weight • Height

Developmental Competence Infants and Children

General Survey - interpret based on age & development • Physical appearance • Body Structure • Mobility • Behavior • Parental Bonding Measurements • Weight • Length or height (length is measurement lying down and height standing up) • Head circumference (done until age of 2)

Head- face and glands

Head • Face • Consist of • Muscles • Facial movement and expressions • Salivary Glands • Parotid Gland • Located on each side of the face • Anterior & inferior to the ears, behind the mandible • Submandibular Glands • Inferior to the mandible, underneath the base of the tongue • Temporal artery • Located behind the eye and the top of the ear

THE HEAD

Head (skull) • Cranium • Face Neck • Muscles and cervical vertebrae • Blood vessels • Thyroid gland Lymph nodes

Objective Data head and palpate

Head Inspection for size, shape, & configuration •Should be symmetrical, round, erect, & midline without lesion Head Inspection for involuntary movement •Neurological disorders may cause horizontal jerking Palpate the head •Lesions or lumps may indicate recent trauma

DETERMINANTS OF HEALTH AND HEALTH DISPARITIES

Health Status • Influenced by several related factors • These factors are known as the Social Determinants of health (SDOH) • Affect a person from preconception to death • Goal of Healthy People is to eliminate disparities SDOH 1. Neighborhood and built environment 2. Health and health care 3. Social and community context 4. Education 5. Economic stability (factor that has the greatest influence)

Structure and Function of Mouth: Floor of mouth

Horseshoe-shaped mandible bone, tongue, and underlying muscles Tongue: striated muscle has a crosswise pattern It can change shape and position • Papillae: rough, bumpy elevations on its dorsal surface • Ventral surface: smooth, shiny and has prominent veins • Frenulum: midline fold of tissue connecting tongue to floor of mouth Because it can change shape and position this allows it functions in mastication, swallowing, cleansing teeth, and the formation of speech Functions in taste sensation

Abnormal Findings BP

Hypotension • Normotensive adults ˂ 95/60 • Hypertensive adults ˂ average reading but > 95/60 • Children ˂ expected value for age • Seen in acute myocardial infarction (AMI), shock, hemorrhage, vasodilation, and/or Addison's disease Primary HTN • See BP Guidelines (Page 159) • ACC/AHA Task Force • JNC-8 Guidelines • Cardiovascular risk stratification -Smoking, dyslipidemia, diabetes mellitus, above 60 years of age, gender (men and postmenopausal women), and family history of cardiac disease

Objectives for Week Five At the end of this week, the student will be able to: Quiz 4

Identify the external anatomic features of the eye. Describe the internal anatomy of the eye. Name the functions of the ciliary body, the pupil, and the iris. Describe the compartments of the eye. Identify the structures viewed through the ophthalmoscope. Define pupillary light reflex, fixation, and accommodation. Identify age-related changes in the eye AND discuss the three most common causes of decreased visual functioning in the older adult. Incorporate health promotion concepts when performing an assessment of eyes. List the anatomic landmarks of the external ear. Describe the tympanic membrane and its anatomic landmarks. List the functions of the middle ear. State the functions of the inner ear that can be assessed Differentiate among the types of hearing loss AND relate the anatomic developmental differences that alter hearing. Incorporate health promotion concepts when performing an assessment of the ears. Name the functions of the nose. List the anatomic landmarks of the external nose. AND describe the nasal cavity. Name the paranasal sinuses and their functions. Identify the structures of the oral cavity AND list the functions of the mouth. Identify the effects of some of the age-related changes that take place in the mouth. Incorporate health promotion concepts when performing an assessment of the nose, mouth, and throat.

IMMIGRATION

Immigrants May have minimal understanding of healthcare resources • May not speak English • May not be literate Population 42.2 million immigrants in 2014 = 13.2% of the population • Number of foreign born in U.S. has quadrupled since 1960s • Number of foreign born in U. S. expected to double by 2065; Need interpreter if can not speak english

CULTURAL ASSESSMENT

Imperative to build relationships with your patients Serious errors can be made if omitted You must be open to people who are different Self-awareness Integral part of forming a full assessment; each patient has individual needs. should not be omitted. For instance patients that take genseng can erase the digoxin levlel. Herbal remedies must be assessed.

Subjective Questions: Infections and Discharge

Infections • Any ear infections? As an adult or in childhood? • How frequent were they? How were they treated? 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?

Types of Pain Assessment Tools

Initial pain assessment ➢ Clinician asks patients eight questions concerning location, duration, quality, intensity, and aggravating/relieving factors. ➢ Furthermore, clinician adds questions about manner of expressing pain and effects of pain that impairs one's quality of life. Brief pain inventory ➢ Clinician asks patient to rate pain within past 24 hours on graduated scales (0 to 10) with respect to its impact on areas such as mood, walking ability, and sleep. Short-form McGill Pain Questionnaire ➢ Clinician asks patient to rank list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain.

Objective Data -Mouth- tongue

Inspect tongue (all aspects) •Color, moisture, size, & texture? •Any fasiculations (tremors)? •Is it midline? •Assess the ventral surface •What does the frenulum look like •Wharton ducts (Opening from the submandibular) •Any patches or ulcerations? Any nodules? Palpate tongue •Check any lesions •Is there any induration?

Types of Violence

Intimate Partner Violence (IPV) •10 million / year •33% female and 25% males report abuse by IP Intimate Partner (IP) •Any partner with whom the person has a close relationship IPV •Can be current or former partner •Four main categories

MENTAL STATUS EXAMINATION

It is necessary to perform a full mental status examination when any abnormality in affect or behavior is discovered and in certain situations listed as below When initial screening Suggests an anxiety disorder or depression Behavioral changes Memory loss, inappropriate social interaction Brain lesions Trauma, tumor, cerebrovascular accident, or stroke

COMPONENTS OF THE MENTAL STATUS EXAMINATION MOOD & AFFECT

Judge by body language and facial expression and by direct questioning. Mood should be appropriate to a person's place and condition and should change appropriately with topics; person is willing to cooperate.

DEVELOPMENTAL COMPETENCE: Aging adults

Leaves mental status intact but slower response times Age-related changes in sensory perception can affect mental status along with chronicity of disease process (presence of comorbidity). Grief and despair surrounding these losses can affect the mental status and can result in disability, disorientation, or depression. Older adulthood contains more potential for losses.; vision and hearing can affect mental status. older adults have grief and despair surrounding losses that can lead to depression, at risk for isolation

Developmental Competence: Aging Adult Mouth

Loss of subcutaneous fat gradually begins during middle adult years this may make the nose appear more prominent Atrophic tissues ulcerate easily increasing risk for older people for infections, such as oral moniliasis and malignant lesions. Natural tooth loss exacerbated by inadequate dental care, poor oral hygiene, and tobacco use can lead to malocclusion leading to further tooth loss and pain. Diminished sense of taste and smell decreases an aging person's interest in food and may contribute to malnutrition. Trouble with mastication can lead to dietary pattern changes which may place the older adult at risk for nutritional deficits (protein, vitamins, and minerals).

Health History Reason for seeking health care

Major health problem or concern should be in patient's own words; chief complaint ("")

Cultural Differences in Pain

Make sure to review methods of working with an interpreter if assessing patients from a different culture and/or who speak a different language to avoid misunderstanding. ➢ Perform a thorough pain assessment examination on all patients. ➢ Lack of outward pain "symptom" or expression does not indicate an absence of pain. Most research conducted on racial differences and pain has focused on disparity in management of pain for various races. Poorly treated pain leads to increased physiologic and psychological costs. ➢ Pain and expression of pain are influenced by social, cultural, emotional and spiritual concerns

Functional Assessment

Measures a persons self care ability self esteem, self concept activity and exercise sleep and rest (sleep aids use) nutrition and elimination (last 24 hour diet; problems with constipation, diarrhea, etc.) interpersonal relationships and resources (support system) spiritual resources (what resources and how does it influence health) coping and stress management (loss of family, loss of job etc) personal habits (smoking when start how often when start, alcohol) illicit or street drugs (prescription pain killers, cocaine, meth, etc.) environment and work hazards (live by self, safe in home, electricity, etc) intimate partner violence (do you feel safe at home, etc.) occupation health; (clean house, grocery shop, etc.)

DEFINING MENTAL STATUS

Mental status Cognitive functioning Emotional functioning Mental Health Essential part of one's total health Not just the absence of mental disa

CONCEPTUAL FOUNDATIONS

Mental status cannot be examined directly like the characteristics of skin or heart sounds. Mental health assessment is inferred from the answers from the interview process and the individual's behaviors Consciousness, language, mood, and affect Orientation and attention Memory and abstract reasoning Thought process, through content, and perception

AGING ADULTS - SMSE

Mini-Cog Reliable and quick instrument to screen for cognitive impairment in healthy adults Consists of three-item recall test and clock-drawing test Tests person's executive function, including ability to plan, manage time, and organize activities, and working memory Those with no cognitive impairment or dementia can recall the three words and draw a complete, round, closed clock circle with all face numbers in correct position and sequence and hour and minute hands indicating time you requested.

Developmental Competence: Infants pain

Most pain research on infants has focused on acute, procedural pain. ➢ Limited understanding of how to assess chronic pain in infants: • There is no one assessment tool that adequately identifies pain in infants. • Using a multidimensional approach for whole infant is encouraged. • Changes in facial activity and body movements may help assess pain.

Additional History for Aging Adult

Mouth dryness? What medications? Loss of teeth? Any food difficulties? Any dentures? Change in sense of taste?

Health History Biographic data

Name Address Phone Gender Relationship status (support system) Race and ethnic origin Occupation (usual and present)(if they had injury what did they do compared to what capable of doing now) Primary language Source of history and reliability General appearance well or ill Any special circumstances (interpreter) Educational level Religious or spiritual practices

Developmental Competence Aging Adult

No evidence that they perceive pain to a lesser degree or that they have diminished sensitivity to pain ➢ Common experience for those 65 years of age and older • Not normal a process of aging • It indicates pathology or injury. ➢ Never be considered something to tolerate in one's older years • Many wrongfully assume pain is expected in aging, which leads to less in appropriate treatment

Summary Checklist: Nose, Mouth, and Throat Examination

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. 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

MENTAL STATUS EXAMINATION: Educational and behavioral level:

Note factor as normal baseline Stress responses observed in social interactions, sleep habits, drug and alcohol use

Eating Pattern Questions

Number of meals/snacks per day? Kind and amount of food eaten? Fad, special, or alternative diets? Where is food eaten? Food preferences and dislikes? Religious or cultural restrictions? Able to feed self?

Defining Nutritional Status

Nutritional status refers to the degree of balance between nutrient intake and nutrient requirements. Affected by many factors, including physiologic, psychosocial, developmental, cultural, and economic factors Optimal nutritional status Achieved when sufficient nutrients are consumed to support day-today body needs and any increased metabolic demands due to growth, pregnancy, or illness Under nutritional status Occurs when nutritional reserves are depleted or when nutrient intake is inadequate to meet day-to-day needs or added metabolic demands Over nutritional status Caused by consumption of nutrients, especially calories, sodium, and fat, in excess of body needs; malnourished can be underweight or overweight

OLD CARTS

O = ONSET L= LOCATION D = DURATION C = CHARACTERISTICS A = AGGREVATING = ALLEIVATING = ASSOCIATED R = RELEIVING = RADIATING T = TIME S = SEVERITY

Objective Data: Clinical Signs Observation of general appearance

Obese, cachectic (fat and muscle wasting), or edematous, can provide clues to overall nutritional status • More specific clinical signs and symptoms of nutritional deficiencies can be detected through physical examination and laboratory testing. • Observe for clinical signs which are late manifestations of malnutrition, only in areas in which rapid turnover of epithelial tissue (skin, hair, mouth, lips, and eyes) are nutritional deficiencies readily detectable. • Signs may also be non-nutritional in origin. • Laboratory testing is necessary to make clinical diagnosis.

Classification of Malnutrition

Obesity Marasmus (protein-calorie malnutrition) Kwashiorkor (protein malnutrition) Marasmus/Kwashiorkor mix p. 191

Respirations

Observe without the client knowing • Maintain your position of counting radial pulse & count respirations • Count for 30 seconds or a full minute if you suspect an abnormality • Avoid 15-second interval • Expect an increase in response to exercise or anxiety Consider • Rate • Rhythm • Depth

Summary Checklist: Nutritional Assessment

Obtain a health history relevant to nutritional status. Elicit dietary history, if indicated. Inspect relevant systems (integument, musculoskeletal, and neurologic) for clinical signs and symptoms suggestive of nutritional deficiencies. Measure anthropometric parameters as indicated. Review relevant laboratory tests. Offer health promotion teaching.

Additional History for Infants and Children

Obtaining dietary histories from responsible person/caregiver Obtain relevant questions r/t gestational nutrition. infant breastfed or bottle-fed. child's willingness to eat what is prepared. overweight and obesity risk factors.

COMPONENTS OF THE MENTAL STATUS EXAMINATION COGNITION

Orientation - Time, place, person (also situation) Attention Span - check person's ability to concentrate (may be impaired if anxious, fatigued, or intoxicated) Recent Memory - Assess by 24-hour diet recall or when they arrived Remote Memory - Ask about verifiable past events (birthday or historical event). This can be lost with some disease processes like dementia New Learning - Can be tested by 4 unrelated words test

Pain Assessment Tools

Pain is multidimensional in scope, encompassing physical, affective, and functional domains. ➢ Many tools developed ➢ Select pain assessment tool based on its purpose, time involved in administration, and patient's ability to comprehend and complete tool. • Rate and evaluate all pain sites. • Use assessment tool consistently. • Reassessment of pain following intervention is critical in determining clinical response to therapy. • Standardized overall pain assessment tools are more useful for chronic pain conditions or particularly problematic acute pain problems.

Types of Pain Assessment Tools Continued rating scales

Pain rating scales are one-dimensional and are intended to reflect pain intensity. ➢ Pain rating scales can indicate a baseline intensity, track changes, and give some degree of evaluation to a treatment modality. ➢ There are different subtypes that use numbers, verbal description, visual analog, or descriptor scale. ➢ Selection of pain rating scale is based on patient understanding and age of development. Numeric rating scales patient to choose a number that rates level of pain, with 0 being no pain and highest anchor 10 indicating worst pain. Verbal descriptor scales have the patient use words to describe pain. Visual analog scales have the patient mark the intensity of the pain on a horizontal line from "no pain" to "worst pain." Descriptor scales in which patients are asked to indicate their pain by using selected pain term words

Sources of Pain

Pain sources based on their origin (location) ➢ Visceral pain originates from larger interior organs. • Stems from direct injury to organ or from stretching of organ from tumor, ischemia, distention, or severe contraction • Pain impulse transmitted by ascending nerve fibers along with nerve fibers of autonomic nervous system • Presents with autonomic responses such as vomiting, nausea, pallor, and diaphoresis ➢ Deep somatic pain comes from sources such as blood vessels, joints, tendons, muscles, and bone. • Injury may result from pressure, trauma, or ischemia. • Described as aching or throbbing • Usually well localized and able to be identified • Like visceral pain it can be accompanied by nausea, sweating, tachycardia, and HTN.

Neuropathic Pain

Pain that does not adhere to typical phases seen in nociceptive pain Due to a lesion or disease ➢ Implies an abnormal processing of pain message ➢ Difficult to assess and treat ➢ Seen often long after injury heals Possible causes ➢ Diabetes mellitus ➢ Herpes zoster (shingles) ➢ HIV/AIDS, sciatica ➢ Trigeminal neuralgia ➢ Phantom limb pain > Chemotherapy

Objective Data - Sinuses

Palpate Sinuses • Frontal • Maxillary Percussion for tenderness • Frontal • Maxillary Transilluminate sinuses (older technique) • Checking for fullness

Structure and Function: Sinuses

Paranasal sinuses: air-filled pockets within the cranium Communicate with the nasal cavity and have the same ciliated mucous membrane Helps lighten the skull's weight Serve as resonators for sound production Makes mucus Openings are narrow and occluded easy This may cause inflammation or sinusitis.

Abnormalities Caused by Nutritional Deficiencies

Pellagra Niacin deficiency Scorbutic gums Vitamin C deficiency Follicular hyperkeratosis Vitamin A and/or linoleic acid deficiency Bitot's spots Vitamin A deficiency Rickets Vitamin D and calcium deficiency Magenta tongue Riboflavin deficiency

Chronic Pain Behaviors

Persistent (Chronic) pain behaviors ➢ Often live with experience for months and years ➢ Adaptation occurs over time. • Clinicians cannot look for or anticipate the same acute pain behaviors to exist in order to confirm a pain diagnosis. ➢ Shows more variability than acute pain behaviors • Higher risk for under detection ➢ Associated behaviors: • Bracing, rubbing • Diminished activity • Sighing • Change in appetite

Pain Objective Data Preparation

Physical examination process can help you understand the nature of the pain. • Is it an acute or chronic condition? • Physical findings may not always support patient's pain complaints, particularly for chronic pain syndromes. • Pain should not be discounted when objective, physical evidence is not found. • Based on the patient's pain report, make every effort to reduce or eliminate pain with appropriate analgesic and nonpharmacologic intervention. American Pain Society • Important to establish a diagnosis for the cause of acute pain is a priority but symptomatic treatment should be started during the investigation process. • Patient comfort will better lead to cooperating with diagnostic procedures.

U.S. DEMOGRAPHICS

Population exceeded 321 million in 2015 • 61.6% of the population identified as non-Hispanic whites • Minority, or emerging majority accounts for 38% • Hispanics: largest and fastest growing group • Blacks: second largest population • Asians, Those that identify as more than two ethnic groups, American Indians, Alaska Natives, Native Hawaiians, and other Pacific Islanders make up the third largest part of the population

Developmental Competence: pregnant female and aging adult

Pregnant female -Thyroid gland enlarges slightly during pregnancy as a result of hyperplasia of tissue and increased vascularity. 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.

Objective Data: Mouth- preparation

Preparation Have person set up straight with head at your eye level. If they wear dentures have them remove them.

Expected Changes with Aging Ears

Presbycusis common after 50 years of age Negative self-image with hearing aid Elongated earlobes with linear wrinkles Harder cerumen builds as cilia in ear canal become more rigid Coarse, thick wire like hair may grow at ear canal entrance Eardrum appears cloudy

History- previous head or neck problem or radiation therapy

Previous head or neck problem • May cause chronic pain • Limited movement Radiation therapy • Linked to thyroid cancer

Health History: Past Health

Problems at birth childhood illnesses accidents or injuries serious or chronic illnesses previous hospitalizations (medical and psychiatric) surgical history (when, who did it, where, any complications, what) obsteric history (how many times pregnant, how many full term, preterm, miscarriages, complications, etc.) immunizations (ensure current) last exam date (eyes checked, dental check, etc) allergies (environmental, food, medication) current medication (med rec, bring in meds) drug history/use of alcohol and/or tobacco

Standard Communication: Situation

Provide a brief description of pertinent patient variables, demographics, clinical diagnosis, and location. ex. chest pain

Cultural care

Provision of health care across cultural boundaries considering where the patient lives and the health problems

Adolescent

Psychosocial review of symptoms (help maximize communication) • Goal is to maximize communication • Uses the HEEADSSS • Home environment ex. who lives with you? can you talk to anyone about stress? • Education and employment • Eating • Activities peer-related • Drugs- do any of your friends or family members use drugs? • Sexuality • Suicide/depression • Safety from injury; p 60-61

Review of systems

Purpose of ROS -evaluate past and present state of each body system - double checks in case any significant data was omitted in PHI (pt may remember a surgery they had later on) -evaluate health promotion practices Done in an organized manner -head to toe approach Use medical terms to chart but not ask questions do not include objective data; if state abnormal pap smear then chart that but don't put in results.

Nutrition Screening

Quick first step method to obtain data Parameters include weight and weight history, conditions associated with increased nutritional risk, diet information, and routine laboratory data. A variety of valid tools are available for screening different populations. Admission Nutrition Screening Tool validated for use by nurses in hospital settings Nutrition Screening Initiative form designed and validated in outpatient, geriatric population Individuals identified at nutritional risk during screening should undergo a comprehensive nutritional assessment, which includes the following: Dietary history and clinical information Physical examination for clinical signs and anthropometric measures Laboratory tests

Temperature Scales

Reporting temperature • Use Celsius • Report temperature and route Use this conversion • Degrees C = 5/9 (F − 32) • Degrees F = (9/5 × C) + 32 Familiarize • Know both scales Note it is far easier to learn to think in centigrade scale than to take time for paper-and pencil conversions.

Communicating with Other Professionals

Requires mutual respect and collaboration Ineffective communication leads to negative outcomes; tell everything you know about the patient; SBAR

Characteristics of Percussion

Resonance -Part air and part solid tissue -Hollow -Normal lung Hyper resonance -Mostly air -Booming -Lung with emphysema Tympany -Enclosed air -Drum like -Puffed-out cheek, air in bowel Dullness -Mostly solid tissue -"thud" sound -Liver, spleen, heart Flatness -Very dense tissue -Flat -Muscle, bone

Developmental Competence: Infants and Children Mouth

Salivation begins @ 3 months Babies may start drooling before they learn to swallow Teeth begin to develop in utero (both sets) Number of teeth Children have 20 deciduous, or temporary, teeth that erupt between 6 months and 24 months of age. All 20 should appear by 2½ years. Deciduous teeth lost beginning at age 6 through 12; replaced by permanent, starting with central incisors Nose develops during adolescence, along with other secondary sex characteristics. This growth starts at age 12 or 13, reaching full growth at age 16 in females and age 18 in males.

Abnormalities of Head and Neck

cushings and acromegaly, etc.

Nails • Grow from the

cuticles

• Largest organ of the body

Skin

Standard Communication: Recommendation or Request

State what you need or want for the patient in terms of medical treatment and/or assistance ex. MONA, labs, etc.

The General Survey-Body Structure

Stature • Height normal for age and genetic Nutrition • Weight normal range for height & body build; even fat distribution Symmetry • Body parts equal and proportionate Posture • Erect standing as age-appropriate • Plumb line- goes through anterior ear shoulder, hip, patella, ankle. exception for this is toddlers with protuberatnt abdomen. or others who are older and have khyphosis

Neck

Structure • Muscles • Ligaments • Cervical vertebrae Contains • Hyoid bone • Several major blood vessels • Larynx • Trachea • Thyroid gland

Structure and Function of Mouth: teeth, gums

Teeth Adult have 32 permanent teeth Consist of crown, neck, & root Gums Collar of the teeth

Pain Receptors

The nociceptors are responsive to different stimuli • Mechanosensitive nociceptors responds to mechanical sensations • Thermosensitive nociceptors responds to heat or cold • Polymodal nociceptors responds to noxious stimuli that is mechanical, thermal, or chemical in nature

Tinnitus and Vertigo Questions

Tinnitus 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 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?

Developmental Competence: Pregnancy and Lactation

To support synthesis of maternal and fetal tissues sufficient calories, protein, vitamins, and minerals must be consumed. National Academy of Sciences (NAS) recommends weight gain of • 25 to 35 lb for women of normal weight. • 28 to 40 lb for underweight women. • 11 to 20 lb for overweight women

Risk Factors for Oropharyngeal Cancer

Tobacco product use Heavy ETOH use Chewing betel nuts HPV (certain types) UV light exposure (lip) Male Fair skin Poor oral hygiene, diet, nutrition Weakened immune system

Subjective Data: Pain

Unpleasant sensory and emotional experience associated with actual or potential tissue damage ➢ Pain is always subjective. ➢ Pain is whatever the experiencing person says it is, existing whenever he or she says it does. ➢ Subjective report is the gold standard of pain assessment ➢ Diagnosis from physical examination findings cannot be made exclusively, although these findings can lend support

Infants and Children: Temperature: Rectal

Use • Infants • When other routes are not feasible Position • Supine or side-lying, with knees flexed to abdomen (hold) • Separate buttocks • Insert lubricated probe 2.5 cm (1 in) • No deeper risks rectal perforation • Measure higher in infants and young children than in adults (100° F) at 18 months. • May see elevation • Late afternoon • After vigorous playing • After eating

Nutrition Screening Methods

Various methods for collecting current dietary intake information are available. 24-hour recall Food frequency questionnaire Food diaries or records—3 days typically used Direct observation of feeding with documentation Use of standardized dietary guidelines can help to determine adequacy of diet. ChooseMyPlate Dietary Guidelines Dietary Reference Intakes (DRIs)

Usual Weight Questions

What is your usual weight? 20% below or above desirable weight? Recent weight change? How much lost or gained? Over what time period? Reason for loss or gain?

The Procedure: Thigh Pressure

When BP measured at arm is excessively high, compare it with thigh pressure to check for coarctation of aorta (congenital form of narrowing). Particularly in adolescents and young adults Normally thigh pressure higher than that in arm If possible, turn person to prone position on abdomen. Wrap large cuff around lower third of thigh, centered over popliteal artery on back of the knee. Auscultate popliteal artery for reading. Normally systolic value is 10 to 40 mm Hg higher in thigh than in arm, and diastolic pressure is same.

Nonverbal Behaviors of Pain

When individual cannot verbally communicate pain, you can (to a limited extent) identify pain using behavioral cues ➢ Recall that individuals react to painful stimuli with a wide variety of behaviors. Behaviors are influenced by ➢ nature of pain (acute versus chronic) ➢ age ➢ cultural and gender expectations

Competency

building on two to three years of clinical experience. see actions in the context of patient goals or plans

Developmental Competence: Infants and Children

Time from birth to 4 months of age is most rapid period of growth in life cycle. Infants double their birth weight by 4 months and triple it by 1 year of age. Breastfeeding is recommended for full-term infants for first year of life because breast milk is ideally formulated to promote normal infant growth and development and natural immunity. Fat, calories, and essential fatty acids are required for proper growth and central nervous system development.

•Assimilation:

Unidirectional in linear fashion•

Culturally appropriate

caregivers apply knowledge to provide a given person with the best possible health care

proficient

adding to time and experience. understand the patient situation as a whole rather than individual parts-apply long term goals

expert

attained mastery of an area of learning. performs clinical judgement using intuititive analysis

Family health history

health problems among relatives (living or deceased) causes of death among relatives ages at time of death those at risk may need to seek screening earlier standard tool to display information is a genogram Culture: other questions if new to U.S. (under biographical data ask when came to us and from what country, refugee?, torture?, blood products?, religious needs, immunizations given in native country (ex. vaccine for TB, they will test positive on skin tests), what is health perception, nutritional status, etc.); p 49

Abnormal Findings: Pediatrics

hydrocephalus • Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head down syndrome • Most common chromosomal abnormality with characteristic facial abnormalities • Upslanting eyes with inner epicanthal folds • Flat nasal bridge and small, broad nose • Protruding thick tongue and ear dysplasia • Broad neck with webbing and small hands with single palmar crease plagiocephaly • Positional or deformational due to sleeping position craniosynotosis •Premature closing of one or more cranial sutures that leads to head malformation atopic (allergic) faces •A variety of presentations seen in children who have chronic allergies •Include exhausted face, allergic shiners, Morgan lines, central facial pallor and allergic gaping fetal alcohol spectrum disorders •Narrow palpebral fissures, epicanthal folds, thin upper lip, and midfacial hypoplasia 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

Techniques of Communication Phases of the interview: Introductory

keep it short and formal (discuss type of questions being asked. explain confidentiality, explain why taking notes, ensure patient comfortable and has privacy. establish rapport)

Secondary Skin Lesions

modification of primary lesion

DURATION

oHow long have they had the symptoms. oAll of the time or does it come and go

TREATMENT

oWhat have you done to treat the symptom? oResponse to any treatment oHave you been treated for this in the past?

ONSET

oWhen did it start (give options like weeks, months, years) oWas it an abrupt onset or gradual? oWhat were they doing when the symptoms began? oDoes anyone else you are in contact with have the same symptoms

Vascular Skin Lesions

p 231

Nociception Phases

p. 162

Tool: CRIES

p. 172

Tool: FLACC

p. 172

Steps of the Nursing Process

pg 3

CHAPTER 3 THE INTERVIEW

powerpoint

CHAPTER 6 SUBSTANCE USE ASSESSMENT

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Chapter 1 Nose, Mouth, and Throat (Sinuses)

powerpoint

Chapter 10 Vital Signs

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Chapter 11 Pain Assessment

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Chapter 12 Nutrition Assessment

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Chapter 14 Assessing Head and Neck

powerpoint

Chapter 15 Eyes

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Chapter 16 Ears

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Chapter 2 Cultural Assessment

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Chapter 4 The Complete Health History

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General Survey and Measurement

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HISTORY

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CHAPTER 5 MENTAL STATUS ASSESSMENT

powerpoint;

Chapter 7 Domestic and Family Violence Assessment

powerpoint; United States •20 people per day abused IP •50% of female homicide killed by a current/former intimate partner •5 children per day die Joint Commission standards to assess for: •Intimate Partner Violence (IPV) •Child abuse •Elder abuse

Chapter 13 Skin, Hair, and Nails; Start of Quiz 3

powerpoint; Introduction • Integument=skin; integumentary=referring to the skin • The skin's appendages=refers to hair, nails, & glands located in the skin

Assessment Techniques and Safety in the Clinical Setting. Quiz Two begins

powerpoint; ch. 8

CHAPTER 1 EVIDENCE-BASED ASSESSMENT

powerpoint; use the information you get from history and assessment to deermine diagnosis and so on. also think of what info can help you for health promotion.

Leukoplakia

precancer

Lifestyle and Health Practice head and neck

smoke or chew tobacco, use alcohol •Increases risk for head and neck cancer Wear helmet when riding bike, horses, or othe sports •Increase risk for injury What kind of recreational activity •Contact or aggressive increase risk for injury Posture •Poor posture exacerbate head or neck pain Head or neck problems interfere with relationship •Activities of daily living

Novice

starting out in an area of learning. uses rules to guide performance

Cheilosis

vitamin b2 deficiency

Pain

• "an unpleasant sensory and emotional experience, which we primarily associate with tissue damage or describe in terms of such damage" (International Association for the Study of Pain [IASP]. • "Pain is whatever the person says it is" (McCaffery & Pasero, 1999)(cancer patients were being undertreated)

Primary Skin Lesion • Nodule

• 0.5-2 cm • Solid, elevated, hard or soft lesion • Keloid scar

Older Adult Abuse and Neglect

• 10% of Americans ≥60 have experienced abuse • 5 million / year (1 in 14 reported) • Usual perpetrator is a family member in 60% of cases (probably not all reported) • Forms of older adult abuse • Physical abuse: intentionally assaulted, injured, threatened, or restrained • Sexual abuse or abusive sexual contact: any sexual contact against one's will • Psychological or emotional abuse: includes verbal and nonverbal behaviors intended to humiliate, isolate, or affirm control • Neglect: failure of caregiver to meet basic older adult needs • Financial abuse or exploitation: unauthorized use and/or improper use of older adult's funds/resources • Mandatory reporting

Structure and Function of Sinuses: • Paranasal Sinuses

• 4 pairs • Frontal - can be examined • Maxillary - can be examined (won't mature full y until get teeth) • Ethmoidal - not visible • Sphenoidal - not visible • Ethmoid and Sphenoid present at birth ? see textbook • Decrease weight of the skull • Act of resonance chambers during the speech; textbook: Only the maxillary and ethmoid sinuses are present at birth. The maxillary sinuses reach full size after all permanent teeth have erupted.

Child Abuse and Neglect

• 683,000 / year • Defined at state and federal level • The Child Abuse Prevention and Treatment Act • Federal definition of abuse and neglect • Recently amended to include sex and human trafficking • Enhance protection for infants with Fetal Alcohol Spectrum Disorder • General definitions • Neglect: failure to provide for children's basic needs • Physical abuse: nonaccidental injury that leads to harm of a child • Sexual abuse: fondling, sexual acts, exploitation, and trafficking • Emotional abuse: pattern of behavior that harms a child's sense of self-worth or development • State laws may expand upon federal definition -know your laws; Green Bear (local MO advocate program)

DEFINING ILLICIT DRUG USE

• 7 Categories • Marijuana • Cocaine • Heroin • Hallucinogens • Inhalants • Prescription drugs used nonmedically • Methamphetamines • 10% of those report use of illicit drugs • Marijuana most common • Facing epidemic of prescription drug abuse and opioid-related deaths • Drug overdose rates now exceed MVA rates • Many opioid abusers switch to heroin (opioids a little harder to get now) • Factors that contribute to crisis • Increase use in pain meds (first undermedicated for pain and then started overprescribing) • Aggressive marketing • Misleading marketing

Primary Skin Lesion • Vesicle

• < 0.5 cm, Raised lesion filled with clear fluid • Chicken pox

Primary Skin Lesion • Papule

• < 0.5 cm, Solid, elevated, circumscribed lesion • Elevated nevus (mole), molluscum, wart

Primary Skin Lesion • Plaque

• > 0.5 cm • Papules coalesce to form surface elevation wider than 1 cm • Scaling-psoriasis

Primary Skin Lesion • Tumor

• > 2 cm, Firm or soft, deeper into dermis • Raised above the surface of the skin • May be benign or malignant • Large lipoma or carcinoma

Children Assessment

• Adapted to include information specific for age and developmental stage • Biographic Data • Source of History • Reason for Seeking Care (quotations but in parents words unless child old enough to tell you)(ex. brought child in who looks pale and parent knows a child who was diagnosed with leukemia so is probably scared) •Present health or history of present illness; interpreter used?

Integumentary System adolescents and pregnant women

• Adolescents • apocrine glands enlarge and become more active --> increased sweating, body odor. • Sebaceous glands increase sebum production --> oily skin, acne. • Coarse terminal hair begins to develop in axillae and pubic regions; and facial regions of males. • Pregnant Women • Striae • Linea nigra • Chloasma • Vascular spiders

Nociception Pain Pathophysiology Perception

• Affected by emotional status • Involves the hypothalamus and limbic system (an emotional aspect of pain perception) • Frontal cortex (rational interpretation and response); person becomes aware of pain

Substance Abuse: Adolescents

• Alcohol slows brain development and maturity levels • Increase use of alcohol causes • Risky sexual behaviors • Academic problems • Injuries • Problems in adulthood

The Older Adult communication

• Always address by surname • Avoid first names and elderspeak • Diminutive (honey, sweetie, etc.) • Plural pronouns (we / our) • Interview will take longer • They have lived a long time and have a lot to say • May need longer to respond • May have physical limitations • May have impaired hearing • Touch is important for older adult

Production of Sounds • Characteristics of sounds

• Amplitude (intensity)—loud or soft sound • Pitch (frequency)—number of vibrations per second • Quality (timbre)—subjective difference • Duration—length of time sound lingers

Subjective Questions: Earache

• Any earache or other pain in ears? • Location: Does it feel close to surface or deep in head? Does it hurt when you push on ear? • 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? • Any accompanying cold symptoms or sore throat? Any problems with sinuses or teeth? • Ever been hit on ear or on side of head or had any sport injury? Ever had any trauma from a foreign body? • What have you tried to relieve pain?

• Skin Lesions

• Any variation from normal structure • Usually how disease are discovered • Not necessarily sign of disease • Ex: Freckles

Vision Subjective Data

• Any vision difficulties • Changes in vision (sudden or gradual / blurry or decrease acuity) • See spots or floaters • Have blind spots • See halos or rings (narrow-angle glaucoma) • Any double vision (diplogia) • Strabismus • Pain or itching, pain with bright lights (sudden may be emergency) • Redness or swelling • Excessive watering (one or both eyes) • Any discharge • Trouble seeing at night or trouble climbing stairs • Any previous problems with eyes or vision • Any eye surgery • Any past eye treatment (was it successful or not) • What medications are they taking • Last eye examination • Amsler's test • Prescription for corrective lenses • Wear contacts • Tested for glaucoma - G • Any vaginal infections at birth - P

Health Assessment • Consider these questions pain

• Are you experiencing now or in the last 24 hours • Ask for description of pain • When did it start • Where is it located, does it radiate • How long does it last, does it reoccur • What were you doing when it started • Is it continuous or intermittent

Health History Questions: Headaches

• Ask about • 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

Health History Questions: Head Injury

• Ask about • onset, setting, and description of injury. • changes in levels of consciousness. • loss of consciousness and/or fall • history of comorbidity. • location of injury. • pattern of symptoms. • presence of associated symptoms. • treatment plan • emergency, hospitalization, and/or medication.

Techniques of Communication Phases of the interview: Closed

• Asks for specific information leading to a yes or no • Each has a different place and function in the interview; give options is pain crushing, dull, etc.; use rephrasing to ensure you are understanding what patient is saying; use well placed phrases like nodding or uhuh to show that you are listening. also can infer to elicit accurate information but do not be leading. also provide infomration if patient asking questions.

• Evaluate Vision Cont • Positions Test

• Assess eye muscle strength & CN function • Have client focus on object (pencil or finger) ~ 12 inches away • Move object through all six cardinal positions • Observe eye movements • Should see smooth, symmetrical movement in all six directions • https://www.youtube.com/watch?v=ldiNRvLhQ3A • Note any nystagmus may be indicative of MS or brain lesion; Extraocular muscle innervation: LR6 SO4, all the rest is CN III; superior rectus moves eye up and out, inferior rectus down and out, lateral rectus moves eye laterally and medial rectus moves eye medially.; superior oblique moves eye down and in, inferior oblique up and in (Oblique moves Opposite)

• Evaluate Vision Cont • Perform corneal light reflex

• Assess parallel alignment of the eye • Shine a light toward the person's eyes ~ 12 inches away • Direct the person to stare straight ahead at your nose • Note the reflection of the light on the corneas, it should be in the exact same spot on each eye •If not then it indicates • Asymmetry due to eye muscle weakness or paralysis

Palpation

• Assessing the characteristics of an organ or body part by touching and feeling it with the hands or fingertips • Uses 3 different parts of the hand • Fingertips or pads: fine discriminations • Ulnar or palmar surface: vibrations, thrills, fremitus • Dorsal (back) surface: temperature • Fingers and thumb - position, shape, and consistency of an organ or mass • Assesses • Texture, temperature and moisture • Organ location and size • Swelling, vibration, pulsation or crepitation • Rigidity or spasticity • Presence of lumps or masses • Presence of tenderness or pain

Neck assessment landmarks

• Assessment landmarks • Anterior triangle • Located under mandible • Anterior to the sternocleidomastoid • Posterior Triangel • Located between the trapezius & sternocleidomastoid

Chronic Nonmalignant Pain

• Associated with a specific cause not cancer such as such as arthritis, low back pain, or fibromyalgia • Usually more than 6 months

Astigmatisms, blepharitus, diabetic retinopathy

• Astigmatisms • Blurred vision due to irregular shape of cornea or curvature of the lens • Blepharitus • Staphylococcal infection of the eyelid • Diabetic retinopathy • Progressive damage of the retina due to complication of diabetes • Leading cause of blindness

Additional History for Infants and Children Ears: 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?

Sebaceous Glands

• Attached to hair follicles • Present over most of the body • Not on the palms & soles • Secret sebum • Waterproofing the skin and hair

Objective Data: auscultate thyroid gland

• Auscultate only if you find an enlarged thyroid gland • May hear a blowing or swishing sound in hyperthyroidism • Place the bell of the stethoscope over the lateral lobes of the thyroid gland, ask the client to hold his/her breath

Expanding the Concept of Health • Culture and genetics

• Awareness of the emerging minority • Diversity and incorporation of "cultural health rights"; different beliefs about medicine that is not congruent with western medicine. need to respect.

•Hordeolum (sty)

• Bacterial infection of hair follicle

Culture and Genetics Cultural Considerations on Sexual Orientation

• Be aware of heterosexist bias • Many same-sex couples are in a monogamous, committed relationship • Ask the same question to a homosexual couple as a heterosexual if appropriate • Do not make assumptions about a person's sex based on his or her appearance; for example if lesbian couple don't say you don't use birth contorl do you? just ask if birth control is or have ever been used

Culture and Genetics Cultural Considerations on Gender

• Be careful not to violate cultural norms with male-female relationships • Ask what is the norm; ex. provider to patient. some cultures require male to male provider or female to female provider

Equipment

• Be prepared to have all necessary equipment in place before starting examination. • Perform hand hygiene. • Protective equipment including but not limited to gloves • Measurement of vital signs requires platform scale (with height attachment), stethoscope, sphygmomanometer, and thermometer. Pulse oximetry reading can be included. • Otoscope, ophthalmoscope, penlight, and pocket vision screener • Skinfold calipers, skin marking pen, and tuning fork • Nasal speculum, tongue depressor, and cotton balls • Flexible tape measure and ruler, sharp object (split tongue - blade), reflex hammer • Bivalve vaginal speculum, materials for cytology, lubricant, and fecal occult blood materials

Nociception Pain Pathophysiology • Transduction

• Begins with a stimulus from a tissue injury or damage • Results in an inflammatory process which activates the release of cytokines and neuropeptides from the leukocytes • This causes vasodialtion, increase blood flow, & edema, and further release of bradykinin, serotonin and histamine which exacerbates the process

Behavioral Manifestations of Hearing Loss- Infants and young children

• Behavioral manifestations of hearing loss: • Child is inattentive in casual conversation. • Reacts more to movement and facial expression than to sound • Facial expression strained or puzzled • Frequently asks to have statements repeated • Confuses words that sound alike • Has accompanying speech problem • Appears shy and withdrawn and "lives in a world of his or her own" • Frequently complains of earaches • Hears better at times when environment more conducive

Temperature

• Between 96.0o F - 99.9o F (average 98.6o F) • Can be taken at various anatomical sites • Affected by • Diurnal Cycle • Lowest in early morning • Ovulation • Strenuous exercise • Age • Decreases with age: 95.0o F - 97.5o F in the elderly Hypothermia-prolonged exposure to cold, hypoglycemia, hypothyroidism, starvation Hyperthermia-infection, malignancies, trauma, blood/endocrine/immune disorders; 96.4-99.1 (in book average), oral, rectal, temporal, tympanic. can be reported in either celsius or F, should be reported in celsius, report how temp obtained, conversion chart in book

Measuring Blood Pressure

• Blood pressure measured with stethoscope and aneroid sphygmomanometer • Subject to drift • Must be recalibrated yearly • Inflatable cuff with rubber bladder covered by a cloth • Width qual 40% of arm Circumference • Length 80% of arm circumference (if off wont get accurate reading)

Interview People with Special Needs Behavior depends on the drug used

• CNS Depressant (alcohol, benzos, opioids -heroin, methadone, morphine) • Slows brain activity • Impairs judgment, memory, intellect, performance, and motor coordination • Stimulants (Cocaine, Amphetamines) • Intense high • Agitation and paranoid behavior • Hallucinogens (LDS< ketamine, PCP) • Bizarre and inappropriate behavior • Violent behavior with superhuman strength & insensitivity to pain • Ask simple direct questions • Nonthreatening; avoid confrontation • Top priority is what drug, when, & how much • Initially -defensive and in denial; need to wait until; may have to wait for detox to get questions answered

Hearing Disorders: • Conduction impairments

• Can be caused by blockage of the external or middle ear (e.g., cerumen, foreign bodies and tumors & even ruptured TM) • Otosclerosis—inherited bone disorder involving irregularity of the stapes; it first appears as tinnitus (ringing) then progresses to hearing loss • Otitis—ear inflammation caused by infection; can produce swelling and fluids that block sound conduction

• Determining category of the lesion

• Can be done with penlight • Elevated - cast shadows outside their edges • Papule - sm, firm, raised lesion • Plaque - large, raised lesion • Vesicle - blister • Pustule - pus-filled lesion • Crust - scab • Wheal(hive) - raised, firm lesion with a light center • Flat - do not cast shadows • Macule - flat, discolored region • Depressed - cast shadows inside their edges • Excoriation - missing epidermis, as in a scratch wound • Ulcer - craterlike lesion • Fissure - Deep crack or break

External Structures of the Eye: canthus, plapebral fissure, eyelids

• Canthus • Medial contains • Puncta (allows drainage) • Caruncle (contains sebaceous glands) • Plapebral Fissure - opening between the eyelids • Eyelids • Closed • Upper & lower should touch • Open • Upper should be b/t the iris & top of pupil • Lower lid should rest on the lower border of iris; p 275

Categories of IPV

• Categories • Physical violence: force resulting in injury or death • Sexual violence: attempted or completed acts without permission • Stalking: repeated unwanted attention through various methods (social media, physical stalking, etc.) • Psychological aggression: emotional abuse of an aggressive nature (verbal or nonverbal communication) • Also includes teen dating violence • Can be physical, sexual, psychological, or emotional • Youths who experience this are more likely to experience mental health issues and/or participate in unhealthy behaviors. • sexting or cyber abuse can be a means of access

Internal Structure of the Eye: Chambers

• Chambers • Aqueous Chambers • Anterior Chamber • Located between the cornea & iris • Contain watery fluid (aqueous humor) • Posterior Chamber • Located between the iris & the lens • Contain watery fluid (aqueous humor) • Vitreous Chamber • Located in the area behind the lens • Largest chamber • Contains a gelatinous fluid (vitreous humor)

Internal Structure of the Eye: Middle layer

• Choroid • Pigmented vascular layer prevents scattering of light • Front part of this layer made of iris (colored part of eye) and the ciliary muscle • The pupil is the hole in the center of the iris • Contraction of iris muscle dilates or constricts pupil • Lens • transparent body behind the pupil; focuses light rays on the retina

Skin Cancer

• Classic signs: • A - asymmetry • B - irregular borders • C - variation in color • D - diameter > pencil eraser • E - elevation

A Safer Environment

• Cleanliness of your equipment • Hand Hygiene • Before and after patient care • Protocols for washing hands • Use protective equipment as needed • Gloves • Gowns • goggles

Collecting Objective Data

• Client Preparation • Ask the client to remove all clothing and jewelry • Have the client sit comfortably • Ensure privacy • Maintain comfortable room temperature

Otoscope Examine

• Client seated; head tilted slightly away from you • Use largest speculum possible • Use your thumb & fingers of opposite hand to • Pull auricle gently up and back (adult), down and back (child) • Insert speculum gently approximately ½ inch • Do not touch the canal with the speculum • Do before you check hearing (may have an impaction)

Focused or problem-centered database

• Collect "mini" database, smaller scope and more focused than complete database • Assessment of a specific client problem • Already have a database for patient (previous comprehensive assessment ex. earache, belly ache. not necessarily full head to toe you focus on problem

Nursing Assessment

• Collecting Subjective Data • History of present health concern • Past health history • Family history • Lifestyle and health practices

Nursing Assessment

• Collecting Subjective Data • History of present health concern • Past health history • Family history • Lifestyle and health practices

Consider Inspection

• Color, pattern, size, location, consistency, symmetry, movement, behavior, odors and/or sounds

Developmental Competence: Adults: otosclerosis

• Common in young adults • Conductive hearing loss • Between ages of 20 and 40 • Hardening of the bones (gradual) condition • Causes footplate of stapes to become fixed in oval window • Impeding the transmission of sound • Leading to progressive deafness

Culture

• Complex phenomenon • Includes attitudes, beliefs, self-definitions, norms, roles, and values • Transmitted through socialization or enculturation • Process of being raised within a culture; acquiring the norms, values, and behaviors of that group Universal phenomenon; yet unique •Includes all knowledge, beliefs, customs, and skills •Some within may have other beliefs and values •Subculture-customs or values that differ from the main group •Race = self-identification and is typically a social construct (we identify people as coming from a certain race based on looks)(looking to change term for race to ethnic group); some cultures will do home remedies before seeking medical care. how symptoms are displayed varies with culture

External Structures of the Eye: eyelids

• Composed of skin and muscles • Striated & smooth • Purpose • Protection • Foreign objects • Limit amount of light • Upper lid • Contains the tarsal plate (meibomian glands= oily lubrication) • Bigger than the lower lid and more movable

Integumentary System

• Composed of the following • Skin • Hair • Nails • Glands • Sebaceous • Sweat

Chronic Malignant Pain

• Compression of nerves • Damage from surgery, radiation, chemotherapy, or tumor growth

Nonverbal Skills

• Congruency between verbal and nonverbal communication reinforces the message. • Non-congruency between verbal and nonverbal communication leads to nonverbal being "truer"

The Clinical Setting General Approach

• Consider your and the patient's emotional state • Usually, anxious due to the anticipation of the exam and unknown outcome • Try and make them feel more comfortable more reliable data will be obtained because it will be closer to the person's natural state Hands On • Measurement and vital signs

Hair

• Consist of layers of keratinized cells • Found over most of the body • Areas that are hairless • Lips • Nipples • Soles & palms • Labia minora • Penis

Abnormalities of Retinal Vessels and Background

• Constricted arteriole • Copper wire arteriole • Silver wire arteriole • Arteriovenous nicking • Arteriovenous tapering • Arteriovenous banking • Cotton wool patches (due ot lack of blood flow see this kind of patches from like diabetes or htn) • Hard exudate • Superficial retinal hemorrhages • Deep retinal hemorrhages • Microaneurysms; p 315

Pulse

• Created by the shock wave of the contraction of the ventricles travelling along the arterial fibers • Consider • Rate • Rhythm • Amplitude (force) • Contour • Elasticity

Assessing for Risk for Homicide

• Danger assessment (DA) • This 19-item yes/no instrument • It starts with a calendar • To show women how frequent and severe the violence (previous year) • No cut-off score • But the more yes answers, the > the danger; p 109 and 110

Techniques of Communication Phases of the interview: Working

• Data-gathering phase • Verbal skills include questions to the patient and your responses to what is said. (what is developmental stage?) • Two types of questions • Open-ended • Asks for narrative information • Used to elicit the clients' feelings • "How", "What"

The Opioid Epidemic

• Declared Public Health Emergency in 2017 • Strategy to combat epidemic • Effective against pain but can cause serious side effects • Consider risks versus benefits • Opioid receptors connect with mu-opioid receptors throughout the body. • Pain relief • Euphoria • Physical dependence. • Practice management concerns • Pain management principles • Patient and provider education; should have narcan ready

• Complete total health database

• Describes current and past health state and forms baseline to measure all future changes. • Health history • Physical status • First entry into the health care system and periodically • Frequency is determined by age, risk factors, health status, health promotion practices and lifestyle

Hair develops

• Develops within the hair follicle • Growth occurs at the base • Hair root lies hidden in follicle; visible part of hair called shaft • Arrector pili—specialized smooth muscle that produces "goose pimples" and causes hair to stand up straight

Vascular Skin Lesions • Telangiectasias

• Dilation of cutaneous blood vessels • Usually linear configuration • Liver cirrhosis • Pregnancy/estr ogen • Chronic sun damage • Connective tissue disease

Health Care Disparities Among Vulnerable Populations

• Disparities affect • Those with a disadvantage • Social • Economical • Environmental • Vulnerable Populations • Ethnic & racial minority • Those with disabilities • LBGT community• Measured by comparing differences • Few differences are biologic (hypertension is greater in african americans but this is not necessarily genetics it is due to outside factors)

Chronic

• Does not stop when the injury heals • It persists after the predicted trajectory • Outlasts its protective purpose • The level of pain intensity does not correspond with the physical findings. Unfortunately, many patients with chronic pain are not believed. ➢Often labeled as malingers, attention seekers, drug seekers, and so forth

• Ptosis

• Dropping eyelid

Secondary Skin Lesions • Fissure

• Dry or moist linear cleft in skin surface with abrupt edges • Due to chronic inflammation • Cheilosis, athlete's foo

Pain Classification

• Duration • Location • Etiology • Severity

Note to Examiner

• 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

• Sweat Glands two types

• Eccrine glands • Over the entire body • Secretion of sweat & thermoregulation • Apocrine • Located near hair follicles (axillae, perineum, & areolae) • Nonfunctional until puberty • Secrete a milky sweat • Responsible for body odor

Setting

• Ensure comfortable room temp • Quiet private room with adequate lighting • Clean & working equipment • Wash hands prior to & after assessment • Wear gloves • Follow standard precautions • Place patient in a comfortable position

The Process of Communication: Internal & External Factors: External

• Ensure privacy • Avoid interruption • Physical environment • Dress • Note-taking- don't be so engrossed in this that you seem disintered in patient

Developmental Competence: PAINAD Scale

• Evaluates 5 common behaviors • Breathing, vocalization, facial expression, body language, and consolability • Quantified behaviors in category 0 to 2 • Total score metric 0 to 10 • Score of 4 or more requires treatment. in book.

Hearing Loss Questions

• Ever had any trouble hearing? • Onset: Did loss come on slowly or all at once? • Character: Has all your hearing decreased or just on hearing certain sounds? • In what situations do you notice loss: conversations, using the 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? • Ever had any trouble hearing? • Have you recently traveled by airplane? • Do you have a family history of hearing loss? • Efforts to treat: Do you have any hearing aid or other device? Anything that helps 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?

Collecting Objective Data Equipment for Assessment

• Examination light and penlight • Magnifying glass • Centimeter ruler • Wood's light • Examination gown or drape • Braden Scale For Predicting Pressure Sore Risk • PUSH Scale to Measure Pressure Ulcer Healing

Developmental Competence Ears- • Infants and young children

• Examination of the external ear is similar to that described for adult, with addition of examination of position and alignment on head • Note ear position. • Top of pinna should match an imaginary line extending from corner of eye to the occiput. • Also, ear should be positioned within 10 degrees of vertical.

History of Present Health Concern head and neck

• Experiencing dizziness, lightheadedness, spinning, blurred vision or LOC? • Description of feeling • Associated with change of position, nausea, and /or vomiting • Any neck pain • Possible muscle or spine problems, sign of stress or tension, or meningeal irritation • Older adults may have arthritis and decrease ROM • Difficulty moving head or neck?\ • Muscle or joint problems

Subjective Data/Lifestyle and Health Practice EYEs

• Exposed to chemicals, smoke, dust or other substance that may harm eyes • Wear sunglasses when outside • Has vision loss affected ADLs • What type of visual aids do you use • Diet & supplements • Smoke/how much/ how long

External Structures of the Eye: Extraocular muscles

• Extraocular Muscles • Six muscles that control six directions of eye movement • 4 rectus for straight movement (superior, inferior, lateral, and medial) • 2 oblique for diagonal movement (superior & inferior) • Innervation supplies by 3 cranial nerves: •III-oculomotor (superior oblique) •IV-trochlear (all other muscles) • VI-abducens (abducts the eye; controls the lateral rectus); according to book: The abducens nerve (CN VI) innervates the lateral rectus muscle (which abducts the eye); the trochlear nerve (CN IV) innervates the superior oblique muscle; and the oculomotor nerve (CN III) innervates all the rest—the superior, inferior, and medial rectus and the inferior oblique muscles.

Vascular Skin Lesions • Ecchymosis

• Extravasation of RBCs outside cutaneous vessels • > 3 mm in size • Bruise

Vascular Skin Lesions • Petechiae

• Extravasation of RBCs outside cutaneous vessels • Tiny capillary hemorrhages • 1-2 mm in size

External Structures of the Eye: eyelashes, conjunctiva, lacrimal apparatus

• Eyelashes • Filter dust & dirt • Conjunctiva-thin, transparent membrane • Palpebral-lines the inside of the eye • Bulbar-lines the eyelids • Lacrimal apparatus- • Lacrimal glands produces tears & lubricates the eye • Lacrimal canal/ducts - drain into the nasal meatus; p 275

Head- face

• Face • Consist of 14 bones • Maxilla • Zygomatic (cheek) • Interior conchae • Nasal • Lacrimal • Palatine • Vomer • Mandible (only movable bone)

Objective Data facial inspection and palpation

• Facial Inspection for symmetry, features, movement, expression, & skin condition • Palpate the temporal artery • Palpate the temporomandibular joint • Pain, swelling, decrease RIM may indicate TMJ

Verbal Responses: Assisting the Narrative

• Facilitation—encourages patient to say more • Silence—directed attentiveness • Reflection—echoes to help express meaning • Empathy—names a feeling and allows its expression • Clarification—asking for confirmation • Confrontation—clarifying inconsistent information • Interpretation—makes association to identify cause or conclusion • Explanation—informing person by sharing factual and objective information • Summary—provides conclusion based on verified information which in turn identifies that the interview process is closing

Lymph Nodes of the Head and Neck

• Filter lymph • Remove bacteria & foreign substances • Produce lymphocytes & antibodies • Usually found in clusters • Varies in size • Usually not palpable • If overwhelmed with microorganisms they become swollen & tender • Cancer = swollen but not tender

Primary Skin Lesion• Macule

• Flat, colored lesion, < 1cm • Freckles

Primary Skin Lesion • Patch

• Flat, colored lesion, > 1 cm • Mongolian spot

Infants and Children: Blood Pressure Continued for children

• For children • BP classified as 90th and 94th percentiles is elevated • ≥l 95th percentile is elevated for adolescents • Children younger than 3 • Use an electronic BP device that uses oscillometry (Dinamap) It gives digital readout for systolic, diastolic, and MAP and pulse. • Or use a Doppler

Pulse Amplitudes

• Force of pulse strength • Scale • 0: Absent • 1+: Weak, thready (diminished - easy to obliterate) • Indicates low stroke volume • 2+: Normal (obliterate with moderate pressure) • 3+: Full, Bounding (unable to obliterate or requires firm pressure) • Indicates increased stroke volume • Stroke volume • Volume of blood pumped out of the left ventricle of the heart during each systolic cardiac contraction; p 143

Successful Interviews allow you to:

• Gather complete and accurate data about a person's health • Establish trust -showing acceptance and leading to greater data sharing • Teach the person about their health state • Build rapport • Discuss health promotion and disease prevention

The Clinical Setting

• General Approach • Consider your emotional state and that of the person being examined. • The patient is usually anxious due to the anticipation of being examined by a stranger and the unknown outcome of the examination. • If anxiety can be reduced, the person will feel more comfortable, and data gathered will more closely describe the person's natural state. • Measurement and vital signs • Have patient change into an examination gown. • Maintain privacy and respect. • Perform hand hygiene. • Provide explanations. • Begin with the person's hands as point of initial contact. • Concentrate on one step at a time—avoid distractions. • Examination sequence—offer health teaching • Provide explanations. • Summarize findings for person.

• Scalp and Hair inspection and palpation

• General color and condition • Cleanliness, dryness or oiliness, parasites • Texture • Amount and distribution of scalp, body, axillae, and pubic hair • Lesions

Health History -Review of Body Systmes

• General overall health state (lost weight, gain weight, fever, etc.) • Skin, hair, nails (moles, bruising, hair loss, etc.) • Head (headache, injury, dizziness) • Eyes (visual problems, eye exam recent, blurred vision, floaters, blind spots, vision worsened, reddnes or swelling, hx of cataracts or glaucoma, glasses?) • Ears (ear infections, discharge, ear check, hearing loss, etc.) • Nose and sinusesm(nosebleeds, obstructions, allergies, smell okay, etc.) • Mouth and throat (bleeding gums, toothache, hoarseness, difficulty swallowing, tonsillectomy, dental appointment) • Neck (any lumps, enlargement, etc.) • Breast (pain, last mammogram, breast exam, surgeries, rash, etc.) • Axilla • Respiratory (asthma, emphysema, wheezing, cough, what color sputum, chest xray, TB) • Cardiovascular (chest pain, irregular heart beat, shortness of breath, last EKG, last cardiac enzyme test) • Peripheral Vascular (swelling, n/t, discoloration, etc.) • Gastrointestional (intolerance, difficulty swallowing, n/v/d, gallbladder issues, laxative use) • Urinary (signs or symptoms of urinary tract infection, kidney stones, incont., etc.) • Genital (penis: testicular pain, discharge, testicular self exam; vagina: when did you get your period, are you regular, vaginal discharge or itching, how old at menopause, last pap smear) • Sexual Health (ask all patients about this, having intercourse, satisfaction, ED, vaginal dryness, contraceptives use, tested for STDs, hx of STDs) • Musculoskeletal (injuries, stiffness, pain to joints) • Neurologic (seizure, stroke, motor weakness, etc.) • Hematologic (bleed easily, infections?) • Endocrine (hx of diabetes, thyroid issues-ask for signs and symptoms)

Working with (and without) an Interpreter

• Greatest challenge • Patients with language barriers experience more negative health outcomes • Need a bilingual interpreter • Even those who speak English may need an interpreter • Do not use relative or friend • Violate confidentiality • May not understand medical terminology

Expanding the Concept of Health • Health Promotion and disease prevention

• Guidelines for prevention of health-related problems due to personal behavior

Objective Data • Vital Signs

• HR, RR, BP, Temp • Indicators of health • Data that is trended throughout patient experiences in multiple clinical practice settings • Follow stated facility guidelines for monitoring • Use nursing judgment to warrant additional assessment • Usually if abnormal something is wrong • Pain is now considered the "fifth vital sign"; pulse oximetry?

Vital Signs

• Hands-on physical examination begins with vital signs. • Provide data that reflect body systems status • Cardiovascular • Neurologic • Peripheral vascular • Respiratory

Subjective Data for Substance abuse

• Hard to collect if actively intoxicated • Ask about alcohol use 1. Do you sometimes drink beer, wine, or other alcoholic beverages? If the answer is yes, then ask screening question about heavy drinking days, such as "How many times in the past year have you had five or more drinks a day (for men) or four or more drinks a day (for women)? • Also ask • On average how many days a week do you have an alcoholic drink • On a typical drinking day how, many drinks do you have 2. Use Screening tools such as • The Alcohol Use Disorders Identification (AUDIT) • Helpful with ED & trauma because it is sensitive to current problems (doesn't dwell on past issues) • Cut down, Annoyed, Guilty, Eye-opener (CAGE)(have you every thought about cutting back on drinking, are you annoyed by questions about your drinking, do you feel guilty about your drinking, and do you drink in the morning as an eye opener)(book doesn't go into CAGE as much. maybe p. 53) 3. Assess for alcohol use disorders using the diagnostic criteria • Ask, "In the past 12 months :• "Has your drinking repeatedly caused or contributed to the following?" • Risk for bodily harm, relationship trouble, role failure, and/or run-ins with law • "Have you not been able to stick to drinking limits, or have you repeatedly gone over them?" • Not stuck to drinking limits, not been able to cut down, shown tolerance, signs of withdrawal, kept drinking despite problems, spent a lot of time drinking or anticipating or recovering from drinking, spent a lot of time on drinking, spent less time on other matters • Ask about use of illicit substances: • "Do you sometimes take illicit drugs or street drugs, such as marijuana, cocaine, hallucinogens, narcotics?" • If yes, ask, "When was last time you used drugs, and how much did you take that time?; p 89

Additional History for Infants and Children: • 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? • NOTE: 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

Culture and Genetics

• Headache • Leading cause of acute pain and lost productivity • Classified by etiology and often misdiagnosed • Chronic migraine • More than 15 days per month • Gender difference • More common in females than males with peak in midlife seen equally • Ethnic difference • More prevalent among Caucasian and Hispanic population • Various etiological theories proposed

History of Present Health Concern head and neck

• Headache • Head Injury • Dizziness • Neck pain, limitation of motion • Lumps or swelling • History of head or neck surgery

Assessment of Child Abuse and Neglect

• Health care providers • Monitor for signs of abuse and neglect during visits • Provide anticipatory guidance (try to prepare parents for milestones that can be challenging like terrible twos) • Use developmental screening tools • Identify risk for abuse • Parent/caregiver teaching and education • Documentation • When documenting findings of child abuse and neglect • Use words the child uses (if child calls genitals by certain word then use this word) • Remember the possibility that the abuser may be accompanying the child (if child verbal try to separate for certain questions) • If child is nonverbal, use reports of caregivers. • Know your institutional protocol for obtaining history in cases of suspected child maltreatment • Some protocols may delay a full interview until it can be done by a forensically trained interviewer.; Bright Futures- all development appropriate milestones

The General Survey- Measurement Height and BMI

• Height • Use wall-mounted device or the pole on scale • Headpiece should be aligned with the top of head • No shoes, standing straight, looking forward • Feet, shoulder, & buttocks touching wall • Body Mass Index • Marker for optimal health • Identifies those at risk for CV disease; pg 129; bmi tells if normal body weight or overweight or obese, the bmi in book doesn't show dfference in gender

Common Errors in BP Measurement

• High reading causes • Taking when physiologically active, following activity, or emotionally labile • Cuff to small • Reinflating cuff during the procedure • Leads to low readings • Decreased inflation • Too large cuff size • Can lead to high or low readings—examiner/observer error • Position of arm or leg • Improper cuff size • Deflating cuff too quickly

Past Health History

• History of sunburns as a child (potentiona for future skin cancer) • Previous problems with (skin, hair, or nails) • Recent hospitalizations or surgeries • Allergic skin reactions • Fever, N/V, GI or Respiratory problems? • Pregnant, menstrual periods regular? • History of anxiety or depression

Patient-Centered Care Questions Ears

• How do you clean your ears? • Last time you had your hearing checked? • If hearing loss was noted • 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?

Cultural and Genetics Violence

• IPV occurs in all cultures • Higher in minorities • Common theme that causes barriers • Societal stressors • Like poverty increases difficulties in daily struggles and conflict in relationships • Past discrimination leads to reluctancy to seek healthcare • Legal status • Immigration status -fear of deportation • Violence Against Women Act (AWA) provides legal support. • Lack of access to culturally appropriate care (some cultures women rely on men for financial support so that can be barrier to get help) • Traditional roles foster dependency • Need for bilingual cultural interpreters in clinical practice settings

Health Effects of Violence

• Immediate and long-term effects • Most obvious immediate is injury (increase in yearly cost for 15 years)(for instance if brain injury sustained) • Long-term abuse leads to chronic health problems (CV, endocrine, immune, & GI) • Women • Gynecologic problems • Negative effects during pregnancy • Preterm, low birth weight, and perinatal death (miscarriage) • Sexual abuse • Reproductive problems, infections, & UTIs • More likely to suffer from mental health problems • Depression, suicide, PTTS, and substance abuse • Children are more apt to have ongoing poor health as they age • brain development, Cerebral Palsy, learning delays, and higher risk for chronic disease • Increase risk for teen arrest, pregnancy, & criminal behavior as adult

Infants and Young Children- • Otoscopic examination for child being treated for chronic otitis media

• In a child being treated for chronic otitis media, you may note the presence of a tympanostomy tube in central part of eardrum. • This is inserted surgically to equalize pressure and drain secretions. • Finally, although condition is not normal, it is not uncommon to note a foreign body in a child's canal, such as a small stone or a bead.

Nociception Pain Pathophysiology • Transmission

• Initiated by this inflammatory process • Conducts impulses to the spinal cord

Dermis

• Inner layer of skin • Deeper & thickest layer • Composed of loose connective tissue • Contain the dermal papillae • Connect the dermis to the epidermis • Responsible for fingerprints • Contain collagen, elastic fibers, nerve endings, & lymph vesssels • Location of sebaceous glands, sweat glands, & hair follicles

Epidermis Stratum Germinativum

• Innermost layer of epidermis • Cells undergo mitosis/reproduction • These cells"specialize" which help provide protection by self repair • Barrier against infection • Called the "pigment layer" • Produces melanin (responsible for pigmentation which gives the skin color) • Melanocytes - pigment producing cells

Objective Data: External Eye Structures- eyebrows, eyelids and eyelashes

• Inspect Eyebrows • Inspect eyelids & eyelashes • Position of palpebral fissure (ethnic differences, asian) • Assess the ability of eyelids to close • Note the position of the eyelids in comparison with the eyeball • Note • Turnings • Color • Swelling • Lesion • Discharge • Eyelashes distributed evenly; p 307

Objective Data-Nose- internal nose

• Inspect the internal nose • Mucosa • What is the color? Moisture? Any swelling? Discharge? Bleeding? Or Foreign objects? • Septum any deviation? Any bleeding or perforation? • Inferior and middle turbinates should be the same color as nasal mucosa. Any swelling? Any polyps or growths?

Objective data neck inspection and palpation

• Inspect the neck position, symmetry, lumps or masses • May indicate enlarged thyroid, tumor, or inflammation • Inspect the movement of neck structures • May indicate thyroid problem • Note limitations • Test strength • Inspect cervical vertebrae • Should be able to see only C7 • Inspect ROM • May indicate spasm, inflammation, or arthritis • May be sign of meningitis

Objective data: • Inspection of Internal Ear

• Inspect the tympanic membrane for shape, consistency, and landmarks • Should see landmarks • Should be shiny, pearly-gray color and translucent • Should see cone-shape light reflex • Should see malleus, umbo, manubrium, & short process • Annulus looks whiter and denser • TM should be flat & pulled in the center; flutter with insufflation • Should be intact • May see scarring

Objective Data: External Ear

• Inspection and palpation of external ear • Inspect the auricle, tragus, and lobule for size, shape, position, lesions/discoloration, and discharge. • Ears should be equal bilateral with no swelling or thickening • Skin color consistent with facial skin color, no lesions or lumps (Darwin's tubercle normal variance) p. 324 • Palpate the auricle and mastoid process for tenderness • Pinna & tragus should feel firm • No pain from the auricle or over the mastoid process

Auscultation Sounds Classified as:

• Intensity (loud/soft) • Pitch (high/low) • Duration (length) • Quality (musical, crackles, wheezed, etc.) Descriptive terms • Harsh • Blowing • Crackling • Loud • Distant • Soft

Blood Vessels

• Internal jugular veins & carotid arteries • Located bilaterally, parallel & anterior to sternomastoid muscles • External jugular vein • Lies diagonally over the surface of these muscles • DO NOT compress bilaterally

Functional Assessment Children

• Interpersonal Relationships (do parents work outside of the home, adopted?, etc.) • Within the family • Friends (support system, school life) • Activity and Rest • Economic Status • Home Environment (access to outside areas, age appropriate toys) • Environmental Hazards (stairs in home, baby proof) • Coping/Stress Management • Habits (drug use preteen) • Health Promotion

Developmental Competence Tips with parent or caregiver

• Interviewing the parent or caregiver of a child or children • You need to develop rapport with two people • Greet both by name • Don't say, mom or dad • Avoid nonjudgmental questions when asking about milestones • Focus on both individuals so as to encourage participation • Be aware of nonverbal cues as children are very keen to these • Contact during the interview can help with the examination

Structure and Function of Nose: •Internal nose: nasal cavity & nasal septum

• Kiesselbach's area (lots of blood suply) located in the anterior part of the septum • Superior, middle, and inferior turbinates • Located on the lateral walls of the cavity • Increase the surface area • Under each tubinate is a cleft, the meatus is named for the turbinate above • Sinus drain into the middle meatus • Contain the Olfactory nerve (CN I)

Korotkoff Sounds

• Korotkoff V sound is used to determine diastolic pressure for all age-groups • When a variance greater than 10 to 12 mm Hg exists between phases IV and V, record both phases along with systolic reading (e.g. 142-98/80); table 10.3

Inner Ear

• Labyrinth fluid filled organ for equilibrium & hearing • Bony labyrinth filled with perilymph • Subdivided into • Vestibule • Semicircular canals (receptors for balance) • Cochlea - sense organ for hearing • Membranous labyrinth filled with endolymph • Vestibular nerve & Cochlear nerve join to form the Acoustic or vestibulocochlear nerve (CN VIII) • Not accessible for direct examination but functions can be accessed

Equilibrium

• Labyrinth sends information to the brain about the position of the body • Three semicircular canals •If inflamed, it sends wrong information to the brain, causing vertigo and a staggering gait

COMPLETING A CULTURAL ASSESSMENT

• Lack of cultural knowledge is a challenge to providing high-quality care • Cultural self-Assessment • Leads to cultural sensibility -deliberate proactive behavior by health care providers who examine cultural situation through thoughtful reasoning, responsiveness, and discreet interactions

Thyroid Gland

• Largest endocrine gland • Produces the thyroid hormones which are responsible for metabolic rate • Surrounded by the trachea, thyroid cartilage, hyoid bone • Two lateral lobes connected by the ischium

Basic Characteristics of Culture

• Learned from birth • Shared by all members of the same cultural • Adapted to specific conditions • Dynamic and ever changing

Substance Abuse: Objective Data

• Less sensitive than self-report • Laboratory Data • Gamma glutamyl transferase (GGT) • Carbohydrate -deficient transferring (CDT) • Serum aspartate aminotransferase (AST) (any liver damage from alcohol) • Mean corpuscular volume (MVC) • Phosphatidylethanol (Peth) • Breath Alcohol

Vision

• Light must pass through the cornea, aqueous humor, lens, and vitreous humor before reaching the retina • The cornea & lens refract (bend) light on to the retina • The image is upside down & reversed left to right •Nerve impulse leaves the eye through the optic nerve; the point of exit is free of receptors and is therefore called a blind spot •Visual interpretation occurs in the visual cortex of the cerebrum

The Process of Communication: Internal & External Factors: Internal

• Liking others—using a "genuine" approach • Empathy—being understanding and sensitive to others feeling's • Ability to listen—being an active not passive listener • Self-awareness—what are your "implicit bias"

Auscultation

• Listening with a stethoscope for normal and abnormal sounds generated by organs and structures such as the heart, lungs, intestines, and major arteries • Fit and quality of the stethoscope is important. • Diaphragm—flat edge, high pitched sounds • Bell—deep, hollow cuplike shape, soft pitched sounds • Turnable diaphragms—allows you to listen to both high pitched and soft pitched sounds

• Cervical Vertebrae (C1-C7)

• Located in posterior neck • Supports the cranium • C7 palpated easily when neck is flexed • Landmark for finding other vertebra

Nails

• Located on distal phalanges of fingers & toes • Hard, transparent plates • Parts • Nail body - visible part of the nail • Nail root - lies in a groove and is hidden by the cuticle (fold of skin) • Lunula - cresent-shape white area nearest the root called "little moon" • Nail bed - located under the nail, layer of epithelium; changes color with a change in blood flow

Normal variations in nail structure

• Longitudinal ridges - common in light skin people • Pigmented bands - common findings in dark skin people

Inspection

• Look at the patient as a whole first, then each system • Begins when you first see the patient (general survey) • Always come first • The systematic and thorough observation of the patient and specific areas of the body using your senses of vision, smell, and hearing to inspect. • Guidelines for inspection • Area being inspected needs to be exposed • Look before touching • Compare symmetry • Use adequate lighting • Provide a warm room for the examination; as soon as lay eyes on patient begins

Subcutaneous Tissue (Adipose)

• Loose connective tissue • Connects skin to underlying tissue • Below the dermis • Function • Stores fat for energt • Provides insulation • Cushion • Nutrient • Removal of waste • Allows for increased mobility

Ear Infections- Acute otitis media

• Loss of light reflex and bony landmarks, redness, bulging, and loss of mobility on insufflation (pneumatic otoscopy)

• Strabismus

• Malalignment of the eyes • The eyes do not look at the same place at the same time • Two types • Esotropia tuns inward toward the nose • Exotrophia turns outward away from the nose

Electronic Health Record (EHR)

• Mandated to improve quality and safety • Don't let the computer screen become a barrier • Biomedical, psychological, and emotional information may not always be captured • Establishing rapport & a trusting relationship

Assessment of Child Abuse and Neglect: Medical history

• Medical history • Obtained away from parents if verbal • Important part of the examination • Any hospitalizations, recent injuries, delay in seeking care • Chronic medical conditions -easy bruising • History of substance abuse • History of financial strain • Methods of discipline • Any specific cultural practices • Spooning -Coining • Cupping

Integumentary System • Infants

• Mongolian Spot • Café' au lait Spot • Erythematous states • Beefy red flush • Harlequin color • Erythema toxicum • Cyanotic conditions • Acrocyanosis • Cutis marmorata • Jaundice • Carotenemia • Moisture • Vernix • Texture • Milia • Thickness • Mobility and Texure • Vascularity or Bruising • Hair • Nail p. 213

Infants and Children: Blood Pressure

• Monitor yearly for 3 and older • Monitor more frequently for younger children at risk • Use correct cuff size for accurate measurement • Cuff width needs to be two thirds of upper arm • Bladder must completely encircle it • Use a pediatric-sized endpiece on stethoscope (or use bell) • Allow crying infant to become quiet for 5 to 10 minutes before measuring the BP, if possible (otherwise may elevate the systolic pressure by 30 to 50 mm Hg) • Use phase V Korotkoff for diastolic reading in children • Height more strongly correlated with BP than age • New charts • Avoid misclassification of children as normotensive or hypertensive who are at extremes of normal growth.

The Aging Adult

• More older adults 60-64 are drinking (50.9%) • As the population ages the number drinking will also go up • Increase risks associated with alcohol use • Decrease in liver function, body water, & kidney function • Increase concentration of alcohol in the blood • Due to the above • Lose of muscle mass • Multiple medication • Increase risks for • Falls • Depression • GI problems • Toxic reactions • Fatal overdoses

Health Literacy

• More than just the ability to read • Includes the ability to understand and follow directions, navigate the health care system, and communicate concerns • A patient can be literate but not have health literacy • Involves the use of quantitative information and remembering directions • Low literacy leads to adverse health outcomes • Tools for determining literacy • Several available but time consuming • Not one particular is recommended. • Follow employment policy

Neck muscles

• Muscle (paired muscle) • Sternocleidomastoid rotates and flexes the head • Trapezius extends the head and moves the shoulder • Allows movement • Provide support to the head and neck • Cranial nerve 11th • Shrugging of the shoulders

Objective Data Violence

• Must do head-to-toe for suspected abuse • No scientific accuracy for dating bruises with certainty • Red (12-36) • Purple-blue to bluish-green • Greenish-brown to brownish-yellow • Fades away • Older adult bruising • Medication • Abnormal blood • Nutritional supplements • Suspected Abuse Labs • CBC and Chemistry (BUN, Creatinine, protein, and albumin) • LFTS and Coags • UA • Be aware of normal range of findings based on developmental age. • Visual examination of the entire body is required. • Abuse may be hidden under clothing. • Atypical bruising pattern or bruise in the shape of an object • Significant injury observed in non-mobile individual • Use appropriate terminology r/t bruising. • Maintain consistency for accurate interpretation. • Include baseline laboratory testing • CBC with platelet count, basic blood chemistries, serum LFTs, coagulation panel and UA; children who start cruising are going to have some bruising but if you have a baby who is nonmobile then bruises would be suspicious, or bruises in odd places

EXAMINATION SEQUENCE OF STEPS: Data Collection

• Need to assess accurately to assure validity • Most basic function assess first • Consciousness • Language

Interview People with Special Needs Acutely Ill People

• Need to combine interview with physical assessment • Focus on pertinent information only (HPI, Meds, Allergies, Last meal, basic health state)

Hearing Disorders: • Nerve impairment (Sensorineural) and Mixed Hearing Loss

• Nerve impairment (Sensorineural) • Presbycusis—progressive nerve deafness associated with aging • Progressive nerve deafness can also result from chronic exposure to loud noise • Meniere's disease—chronic inner ear disorder characterized by tinnitus, nerve deafness, and dizziness • Ototoxic drugs • Mixed Hearing Loss • Combination of conductive and sensorineural in the same ear

Assessment of Older Adult Abuse and Neglect

• No specific tool • USPSTF & others recommend routine screening • Assessment of abuse or neglect in cognitively challenged persons is complicated. • Older adult Elder Abuse Suspicion Index can be used in cognitively intact patients • Includes 6 questions • 1-5 questions asked of the patient • 6 question answered by the physician • Need to consider all types of abuse • Financial • Physical • Emotional • Sexual; p. 104

Structure and Function of Nose

• Nose • First part of the respiratory track • Made of bone and cartilage • Receives, filter, warm, & moisten air • Consists of an external portion covered with skin and an internal nasal cavity • External nose: a bridge, tip, and two oval openings called nares

Subjective Data Questions - Nose

• Nose and Sinuses • Nasal drainage /discharge? Continuous? Is it watery, purulent, mucoid, bloody? • Frequent colds (URI) any unusually frequent or severe colds? How often? • Sinus pain/pressure? Sinusitis? Treatment? • Trauma any blow to nose? Can you breathe through your nose? • Nosebleeds? How often? How much? Color? Clots? What nostril? Aggravating factors like picking or scratching? Treatment? •Allergies or hay fever? What allergies? How was it dx? What makes it worse? Can you avoid exposure? • Change in ability to smell? •Nasal stuffiness? • Breathing?

Objective Data -Mouth- uvula, tonsils, pharyngeal wall

• Note any odor • Assess the Uvula • Characteristics • Position • Say "aah" • Inspect tonsils • Color & size • Presence of exudates or lesions? • Grade • Inspect the posterior pharyngeal wall • Note color of throat • Any exudates or lesions? • Say Ahh?

Objective data • Palpating the lymph nodes

• Note the following • Size = < 1 cm • Shape = round • Delimitation = position usually discrete • Mobility = should be mobile, fixed with cancer • Consistency = soft, hard and firm with disease (1 side cancer) • Tenderness = indicates infection • Location = common lymph node sites

Developmental Competence: Infants and Children: Otitis media

• Obstruction of eustachian tube or passage of nasopharyngeal secretions into the middle ear • One of the most common illnesses in children • Risk factors to acute OM • 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 • Decreased ambulatory visits • Persistent effusion may lead to hearing loss • Genetic variation in cerumen • Wet cerumen: honey brown (more typical in this area) to dark brown (african american and european) and moist • Dry cerumen: white, flaky, and dry (asian)

• Some variations represent injury of disease

• Onycholysis - loosing of the nail from the bed • Pitting - seen in psoriasis

What to look into for Children

• Operations or Hospitalizations • Reason for care, age at admission, length of stay, treatment and/or intervention • Hospital facility location, physician/provider, type of surgery, date, reaction to hospitalization • Immunizations or Allergies • CDC recommendations per established guidelines according to age • Indicate allergen and response• Obtain information to discriminate between food allergy and food intolerance. • Medications • Include information about prescribed, OTC, and/or herbal therapy • Obtain information r/t vitamin supplements • Dosage, schedule, and clinical indication • Developmental History (milestones, growth, use Brightfutures for milestones)(what words saying at one years old, etc.) •ROS- same as an adult (may be to young to have had a vision screening but if old enough ask)

Inspection Instruments used

• Ophthalmoscope • Penlight • Nasal • Vaginal specula

Internal Structure of the Eye optic disc and retina vessels

• Optic disc • Cream-colored , circular area • Where optic nerve enters eye • Can be seen with the opthalamoscope • Retina Vessels • 4 sets of arterioles & venules; p 278

Infants and Young Children: • Otoscopic examination

• Otoscopic examination is not performed at birth because canal is filled with amniotic fluid and vernix caseosa; after a few days the TM is examined. • During first few days, TM often looks thickened and opaque; may look "injected" and have mild redness from increased vascularity. • TM also looks injected in infants after crying. • Position of eardrum is more horizontal in neonate, making it more difficult to see completely and harder to differentiate from canal wall. • By 1 month, drum is in the same oblique (more vertical) position as in older child, and examination is a bit easier • Pneumatic bulb attachment enables you to direct light puff of air toward TM to assess vibratility. • Rubber tip on end of speculum gives a better seal. • Give a small pump to bulb (positive pressure), and then release bulb (negative pressure). • Normally TM moves inward with a slight puff and outward with a slight release. • Normally TM is intact.

Epidermis

• Outer layer of skin • Composed of tightly packed epithelial cells • Has 4 layers • Stratum corneum (dead, keratinized cells = waterproof) • Stratum lucidum • Stratum granulosum • Stratum germinativum (undergoes mitosis, contains melanin)

ALCOHOL USE AND ABUSE

• Over half of Americans 18 and older report being current alcohol drinkers • Binge drinking (≥ 5 drinks/occasion) is on the rise • Most abused psychoactive drug • Use of alcohol on the rise • Highest increase in women, older adults, racial/ethnic minorities • Morbidity and mortality show the adverse consequences of alcohol use • 4th leading cause of preventable death • Large number of medications are interactive with alcohol •Increase ED visits and hospital admissions • Increases risks for cancers and other chronic diseases

TRANSCULTURAL EXPRESSION OF PAIN

• Pain definition is culturally determined • Pain variations and expressions of pain differ in cultures • Some will complain of pain • Others will not

Objective data palpate trachea and thyroid

• Palpate the trachea • Asymmetry may indicate atelectasis or tumor • Palpate the thyroid • Asymmetry may indicate a mass

Secondary Skin Lesions • Scar

• Permanent fibrotic skin changes due to damage to dermis • Atrophic vs. hypertrophic

The Procedure: Arm Pressure

• Person may be sitting or lying, with the bare arm supported at heart level • Palpate brachial artery with the cuff deflated • Center cuff 2.5 cm (1 in) above brachial artery & evenly wrap the cuff around the arm • Palpitate brachial or radial artery • Inflate the cuff until obliteration of artery pulsation • Go about 20 to 30 mm Hg beyond obliteration • Deflate cuff quickly and completely • Place stethoscope diaphragm / bell over brachial artery • Rapidly inflate cuff to highest predetermined level • Then deflate the about 2 mm Hg per heartbeat to allow a slow and even deflation • Note when you hear first sound, muffling of sound, and point of no sound

Interview People with Special Needs How to handle different behaviors

• Personal Questions • Do not have to answer but can when appropriate • Sexually Aggressive • Do not tolerate • Set strong verbal boundaries • Crying • You did not hurt the person (an important topic that stirs emotion) • Reassure that they should not feel embarrassed • Do not move on until crying has subsided • Anger (for instance patient upset for long wait. deal with this first. ask why and apologize for the wait) • Do not take personally •ask about anger and deal with it before asking about health topic

Nonverbal Communication

• Physical appearance • Patient: Inattention to dressing or grooming what does it say? (patient always dressed nice and then all of sudden not. what does that mean?) • Provider: Professional dress• Posture • Patient: Open or closed: What does this say • Provider: Calm / relaxed posture.• Gestures • Nodding in agreement • Not bouncing or fidgeting with items • Facial expression • Reflects emotions • Does it agree with what is being said • Are you attentive, sincere, and interested Eye Contact • Lack of suggests shyness, depression, or intimidation • Do not fixate or stare • Be mindful of cultures that do not do this Voice • Be aware of the tone • Can convey sarcasm, disbelief, sympathy, or hostility Touch • Can be easily misunderstood • Do not use until you are sure of how it will be received

Cultivating Your Senses

• Physical examination requires all senses • Sight • Smell • Touch • Hearing • Assessment Techniques (in this order) • Inspection • Palpation • Percussion • Auscultation (order changes with abdominal assessment)

• Blunt Percussion

• Place one hand flat on the body & using the fist of the other hand strike the back of the hand that is flat on the body • Used to detect tenderness over organ

Objective Data Preparation: Ear

• Position sitting up straight with head at eye level • Occasionally ear canal partially filled with cerumen, which obstructs view of TM • 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 lowpulsatile dental irrigator or WaterPik. • Direct fluid to posterior wall; leave space around irrigator tip for water to escape. • Do not irrigate if history or examination suggests perforation or infection. C

Developmental Competence • Order of the developmental stage is more important than the chronological age

• Position, preparation, and sequence will vary across the life cycle • Infants and toddlers • Preschool, school-age child and adolescent • Aging adult • The Sick Patient • May need to alter the position • Adapt assessment to patient; pg 120-124 an ex. assessment of infant will require parent cooperation. if baby sleeping then start by listening to lungs and leave procedures that will upset them for last such as looking in ears

The General Survey-Body Structure position and body build

• Posture Continued • Plumb line • Position • Sitting comfortably with arms at sides and head turned toward the examiner. • Body Build - contour • Arm span- should equal the height • Body length- head to pubis is that same distance from pubis to sole of feet • Note any physical deformities

• Names of the lymph nodes

• Preauricular • In front of ear • Postauricular • Superficial to mastoid process • Occipital • At the base of the skull • Submental • Midline, behind tip of mandible • Submandibular • Halfway between angle and tip of mandible • Tonsillar • Under angle of mandible • Superficial cervical • Overlying sternomastoid muscle • Posterior cervical • In posterior triangle along edge of trapezius muscle • Deep cervical • Deep under sternomastoid muscle • Supraclavicular • Just above and behind clavicle, at sternomastoid muscle • Need to know in case of infection

Children Past Health History

• Prenatal, perinatal, and postnatal status (any complications) • Obtain all pertinent data relative to childbirth experience • Childhood illnesses • Listing of age, types, and potential complications • Serious Accidents or injuries • Age of occurrence, types of injury, treatment, and/or possible complications • Serious or chronic illnesses • Age of onset, types of diseases, treatment, and or possible complications

presbyopia, hyperopia, myopia

• Presbyopia • "old-age sightedness" •Normal loss of ability to focus on objects close up due to aging •Hyperopia • Farsightedness •Myopia •Nearsightedness

Guidelines for auscultation continued

• Press diaphragm firmly over area being assessed • Hold bell lightly over area being assessed to listen for low-pitched sounds • Eliminate extra noise. • Keep environment warm and warm your stethoscope. • Avoid listening over hairy body areas. • Never listen through a patient's gown or clothing. • Avoid your own artifact

History of Present Health Concern

• Problems (rashes, lesions, dryness, oiliness, drainage, bruising, swelling, pigmentation) • Changes in lesion appearance (birthmark or moles) • Ability to feel (pain, pressure, touch, temperature) • Experiencing any (pain, itching, itch, tingling) • Medications taking • Body odor / excessive perspiration • Hair loss or changes • Nail changes; p 200-202; for children- rashes or sores, ever have jaundice, birthmarks?, any allergies, reactions to food, diaper rash, any exposure to infectious disease, any nail or hair disruption such as nail biting, delayed wound healing, acne in adolescents, diabetic specific

Violence Documentation

• Provide detail • Non-biased progress notes, injury maps, and photographic evidence • Transcribe verbatim (document the exact words patient uses) • Information received from individual • Physical exam • Thorough documentation using forensic technology terms see Table 7.1 • Provide digital photographic documentation in the medical record • Obtain consent • May have to separate (when asking if afraid of harm will want to separate) • The patient from the parent, spouse, and/or caregiver- follow protocol

Abnormalities of External Eye

• Ptosis • Drooping of the eyelid • Exophthalmos • Bulging eyes • Entropion • Inward turned lower eyelid • Ectropion • Outward turned lower eyelid • Chalazion • Infection of the meibomian gland • Blepharitis • Inflammation of the eyelids or eyelashes • Conjunctivitis • Inflammation of the conjunctiva • Diffuse episcleritis • Inflammation of the sclera • Hordeolum • Sty; p 305

Infants and Children: Pulse, Heart Rate, and Respirations

• Pulse • Infants & toddlers palpate or auscultate an apical rate • Children 2 & older use radial site. • Count for a full minute • Heart rate fluctuates more with emotion, exercise, & illness than adults • Respirations • Infants - watch abdomen for movement (more diaphragmatic than thoracic) • Most accurate is a sleeping respiratory rate • Count for a full minute

Measurement of Oxygen Saturation

• Pulse oximeter • Noninvasive method to assess SpO2 • Attached sensor to finger or ear lobe • Healthy person • Normal SpO2 of 97% to 98%. • If lower O2 levels ear lobe probe more accurate

Visual Reflexes*

• Pupillary light reflex (CN II & CN III) • Bright light causes immediate constriction •Direct reflex - constriction occurs in eye exposed* •Indirect or consensual - light in one eye causes constriction in the other* •Accommodation • Functional reflex •Allows eyes to focus on near objects •Will see simultaneous convergence of eyes & constriction of pupils • https://www.youtube.com/watch?v=jJO-E8cQ62Q • Can be impaired by drugs, alcohol, fatigue, & inattention

Primary Skin Lesion • Pustule

• Pus-filled vesicle

Emergency database

• Rapid collection of data often compiled concurrently with lifesaving measures. • Very rapid assessment • The major and only concern is to determine the status of life-sustaining physical functions; usually obtain health history before assessment but in emergency do it at same time and are just trying to save life.

Pulse Rate

• Rate • Normal (60-100) • Slow ˂ 60 (Bradycardia) • Fast > 100 (Tachycardia) • Varies with age, gender • Rhythm • Regular or Irregular

Structure and Function of Mouth: • First part of the digestive tract

• Receives food-ingestion • Taste • Preparation for digestion • Speech • Cranial Nerves V, VII, IX, & XII assist with these functions • Also, an opening for the airway • Formed by the lips, cheeks, hard and soft palates, uvula, and the tongue and its muscles. • Oral cavity contains tongue, teeth, gums, and the openings of the salivary glands.

Family History skin

• Recent illness, rash or skin problem or allergy • Skin cancer • Keloids p 229

Internal Structure of the Eye: •Innermost Layer

• Retina •Contains rods (receptors for night vision) and cones (receptors for day vision and color vision) • 3 kinds of cones • red • green • blue •Cones less numerous than rods

The General Survey Measurement • Waist Circumference

• Risk factor for disease • At waist instead of hips = high risk for DM2 and heart disease • Waist circumference measured in inches at smallest circumference below rib cage and above iliac crest • Hip circumference measured in inches at largest circumference of buttocks • Note the measurement at end of normal expiration.; apple shape versus pear shape. apple shape higher risk of cardiac issues

Testing Hearing Acuity- Infants and young children

• Room should be silent and baby contented; make a loud sudden noise; you should note these responses: • Newborn: startle (Moro) reflex, acoustic blink reflex • 3 to 4 months: acoustic blink reflex, infant stops movement and appears to listen, halts sucking, quiets if crying, cries if quiet • 6 to 8 months: infant turns head to localize sound; responds to own name • Preschool and school-age child: child must be screened with audiometry

Internal Structure of the Eye: External Layer

• Sclera • Tough outer coat; "white" of eye • Cornea is transparent part of sclera over iris

Internal Structure of the Eye: The eye •3 Layers of eyeball

• Sclera •Choroid •Retina

Interview People with Special Needs Hearing Impaired

• See not as a disability • Some will not let you know they have a hearing problem you will have to guess from cues • Ask preferred method of communication

Integumentary System Older adults

• Senile lentigines • Keratoses • Seborrheic Keratosis • Actinic Keratosis • Moisture • Thickness • Epidermis thins • Hair • Decrease in axilla and pubic areas (decrease hormone functioning) • Chin hair • Male pattern baldness • Gray hair results from decrease in functioning melanocytes • Nail growth slows • Sebaceous and sweat glands decrease in activity. • Increased permeability of the epidermis • Dermis: less elastic and shrinks --> epidermal wrinkles

Tympanic Membrane

• Separates the external ear from the middle ear • Ear drum, translucent, pearly gray, oval, and pulled in at the center by one of the middle ear ossicles (malleus) • Visible through or on the TM • Handle and short process of the malleus • Umbo base of the malleus • Cone of light (reflection of the otoscope) • Pars flaccida (top; small & slack) • Pars tensa (bottom; thicker & more taut) • Annulus the outer fibrous rim of the TM; p. 318

Orthostatic or (Postural) Vital Signs

• Serial measurements of pulse and blood pressure • Done when you • Suspect volume depletion • Has hypertension or taking antihypertensive • Reports fainting or syncope • Procedure • Supine for 3 minutes then take BP (baseline), have patient sit and take BP and then have patient stand and take BP • To be orthostatic • ≥ 20 mm Hg SBP • ≥ 10 mm Hg DBP; table 10.4

National Cultural and Linguistic Standards

• Set of 15 standards • Blueprint to improve quality of care • Goal is to eliminate health disparities • Title VI Civil Rights Act 1964 • Limited English Proficiency (LEP) cannot be denied services • LEP • Leads to decreased quality of care • Providing assistance with communication decreases adverse health outcomes

Internal Structure of the Eye: shaken baby syndrome

• Shaken baby syndrome • Multiple hemorrhages of the retina from child abuse

Spiritual Assessment

• Should use an assessment tool • FICA (Faith, importance/influence, community and address/action) • See page 20 • To assess coping with loss use • Brief RCOPE (Religious Coping) • The score of each item ranges from 1 ('not at all') to 4 ('a great deal'), and the total score ranges from 7 to 28 for each subscale; the higher the score, the stronger the PRC and NRC, respectively. PRC items rely on a secure relationship with God, whereas NRC items reflect religious struggle that grows out of a more tenuous relationship with God(Paikaet al., 2017, p. 3); higher the score secure relationship with God and negative religious struggle

Objective Data

• Skin Inspection • General skin coloration • Pallor • Erythema • Cyanosis • Jaundice • Note any distinctive odor • Color variations • Skin breakdown • Primary, secondary, or vascular lesions

Pigmentation

• Skin color changes • Pink flush indicates increased blood volume or increased blood oxygen • Cyanosis—bluish gray color indicates decreased blood oxygen level • Vitiligo—patchy light skin areas resulting from acquired loss of epidermal melanocytes • Albinism - partial or total lack of melanin pigment in skin & eyes; hereditary

Primary Skin Lesion • Cyst

• Soft, raised, encapsulated lesion • Filled with semi- solid contents • Sebaceous cyst

Subjective Data Questions - Mouth & Throat

• Sores or lesions? How long? Have you had it before? Is it one or more? Are they associated with stress, season change, or food? How treated? • Sore throat? How frequent? When did it start? Is it associated with cough, fever, fatigue, decreased appetite, HA, hoarseness, or postnasal drip? Worse in the morning? Humidity level? Dust or smoke at work? Any documented strep? Treatment? • Bleeding gums? How long? • Toothache? Sensitivity? Lost teeth? • Hoarseness? Voice change? Lump feeling? Vocal for job? Any hoarseness? • Dysphagia? How long? Food gets trap? Any pain? • Altered taste or change in taste? • Smoking, alcohol consumption? How long with tobacco products? How much alcohol? What? When was you last drink? • Patient Centered • How often do you brush and floss? Last examine? Any foods problematic? Any dental appliance?

Hearing

• Sound waves are collected by the external ear and strike the tympanic membrane and cause it to vibrate • This vibration is transmitted to the ossicles • The stapes vibrates and causes the oval window to vibrate • Vibration of the oval window causes the perilymph in the bony labyrinth of the cochlea to move, which causes the endolymph in the membranous labyrinth of the cochlea or cochlear duct to move • This movement of endolymph stimulates hair cells on the organ of Corti (spiral organ) to generate a nerve impulse • The nerve impulse travels over the cochlear nerve, which becomes a part of cranial nerve VIII. Eventually, nerve impulses reach the auditory cortex and are interpreted as sound

• Test visual fields for gross peripheral vision • Confrontation Test

• Stand facing person, approximately 2 feet away • Have client cover left eye, while you cover right eye • Look at each other with the uncovered eye • Extend your left arm at the midline between you and the person, and slowly move one finger or pencil upward from below until the client sees your finger. Do this from several directions • https://www.youtube.com/watch?v=GMyj_8wdIyQ

Follow-up database (ongoing or partial assessment)

• Status of all identified problems should be evaluated at regular and appropriate intervals • Ongoing assessment on a regular basis • Mini-overview • Hospital shift assessment. ex. pt that is coming back for rechecks of blood pressure for patient with hypertension. comprehensive check should already be done with first initial appointment

OBJECTIVE DATA

• Study of the whole person, covering general health state and any obvious physical characteristics • General survey begins at the moment of your first encounter (tells you about general health, do they look ill?) • Introduction • As you proceed • General Survey • Physical Appearance • Body Structure • Mobility • Behaviour; p. 125

Health Assessment Pain

• Subjective Data • Description of pain quoted • Questions • Location • Intensity • Quality • Pattern • Precipitating factors • Pain relief • Effects on daily activity • Coping strategies • Emotional response

Closing the Interview

• Summary and closing • Summarizing information obtained during the working phase • Validating problems and goals with the client • Identifying and discussing possible plans to resolve the problem with the client • Making sure to ask if anything else concerns the client and if there are any further questions • Summarize the information • Thank the patient • Give opportunity for the patient to ask questions

Lifestyle and Health Practice

• Sunbathe and skin precautions • Self examines • Exposure to chemicals • Long periods of sitting & lying • Exposure to extreme temperature • Body piercings or tattoos • Routine skin care • Foods and fluids • Smoking or drinking • Normal activities affected by skin problems • Relationship affected by skin problems • How much stress?

Primary Skin Lesion • Wheal

• Superficial, raised, erythematous, irregularly shaped papules or plaque • Mosquito bite, allergic reaction

Screening Women for Alcohol Problems

• TWEAK questions -combination of items from other questionnaires • Ask • Tolerance: How many drinks can you hold? Or how many drinks does it take to make you feel high? • Worry: Have close friends or relatives complained about your drinking in the past year? • Eye-opener: Do you sometimes take a drink in morning when you first get up? • Amnesia: Has a friend or family member told you about things you said but could not remember? • Kut down: Do you sometimes feel the need to cut down on your drinking?

Percussion

• Tapping a portion of the body to determine if there is tenderness or to elicit sounds that vary according to the density of underlying structures • Elicit pain • Determine location, size, & shape • Determine density • Detect abnormal masses • Elicit reflexes

The Aging Adult VS

• Temperature • Less likely to have a fever but at greater risk for hypothermia • Less reliable index of health state • Sweat gland activity is also diminished • Pulse • Normal range of heart rate is 60 to 100 bpm • Rhythm may be slightly irregular • Respirations • Decrease in vital capacity and decreased inspiratory reserve volume • May note shallower inspiratory phase • Increased respiratory rate. • Blood pressure • Widened pulse pressure as the heart pumps against a stiffer aorta causing an increase in SBP • Often both systolic and diastolic pressures increase

• Skin Palpation

• Temperature • Moisture • Texture • Thickness • Edema • Mobility and turgor • Vascularity or Bruising • Lesion

Objective Data: • Evaluate Vision

• Test distant visual acuity • Snellen hanging wall chart read with the patient standing at a distance of 20 feet • Normal vision 20/20 with or without corrective lenses • Test near visual acuity • Handheld vision card read 14 inches from eyes • Each eye is tested independently (one is covered while the other is used to read) • The patient should be allowed to wear their glasses and the results are referred to as "corrected vision" • Normal acuity is 14/14 with or without corrective lenses

• Evaluate Vision Cont • Perform the Cover

• Test for deviation in alignment •Ask the person to stare straight ahead •Cover one eye •As it is covered, note the uncovered eye (should remain fixed) •Uncover the covered eye and observe it for movement •If movement indicates eye muscle weakness exists

• The Skin's Response to Stress and Inflammatory response:

• The Skin's Response to Stress • Wound-disrupts normal continuity. Inflammation: mechanism to destroy bacteria. Characterized by: redness, edema, heat, pain. • Inflammatory response: • Insult/injury→bleeding which soon stops 2o clotting. Histamines are released→vasodilation→increased permeability→large amounts of fluid entering and exiting the wound site→edema. Edema→pressure on nerves and outer tissues→pain. fluid dilutes harmful substances and brings oxygen and nutrients. Increased blood flow→warmth, red. Clots in the interstitial fluid slows or walls off the spread of infection. • Pus = a creamy fluid containing WBC and bacteria. • Scab = dehydrated blood clot.

Blood Pressure

• The pressure exerted on arterial walls • Varies with the cardiac cycle • Highest with systole-ventricular contraction • Lowest with diastole-ventricular relaxation • Expressed as a fraction systolic/diastolic • Affected by several factors • Cardiac Output • Distensibility of the arteries PVR • Blood volume • Blood velocity • Blood viscosity; book lists other factors

Diagnostic Reasoning

• The process of analyzing health data and drawing conclusions to identify diagnoses • Uses a hypothetico-deductive model with four components • attend to initially available cues (pieces of information). • formulate diagnostic hypotheses (tentative explanation of cues).( what are we speculating) • gather relevant data. • evaluate each hypothesis with ongoing data collection.

The Clinical Setting next steps

• Then change into a gown • Maintain privacy • Perform hand hygiene • Provide explanations • Begin with person's hands as a point of initial contact • Concentrate on one step at a time— avoid distractions • Examination sequence—offer health teaching • Provide explanations a • Summarize findings for person

An Interview is a contract between you and your patient: Contract terms

• Time and place (includes physical) • Introduction and explanation of role • Purpose • How long it will take • Expectation • Prescence of others (do you want family with you or not?) • Confidentiality (unless reportable by law) • Cost (can not always say for sure of cost)

Purpose of Health History

• To collect subjective data • It is what the patient tells you • Types of subjective data • Sensations • Symptoms • Feelings • Perceptions • Desires • Preferences • Beliefs • Ideas • Values • Personal information

Developmental Competence: Infants Tool pain

• Tools used to assess pain in infants: • CRIES • Measures postoperative pain in preterm and term neonates • Examines physiologic and behavioral indicators on 3 point scale • FLACC • Nonverbal tool used for infants and young children up to age 3 • Assesses 5 behaviors of pain (facial expression, leg movement, activity level, cry, and consolability)

Epidermis Stratum corneum

• Tough, outer layer • Cytoplasm of cells replaced by keratin • Keratin • Tough, waterproof, protein material • Protective quality • Cells at this layer are dead & flake off

Family History

• Triptans • Opioids • Hormone Meds • Caffeine Meds • NSAIDS Headaches when you take the following meds • Genetic disposition History of head or neck cancer • Family association History of migraines

Ophthalmoscope

• Turn the ophthalmoscope "on" •Ask client to remove eyeglasses and fix gaze straight ahead & upward •Darken room for best view •Hold in right hand with index finger on lens wheel, use your right eye to examine client's right eye •Hold in left hand with index finger on lens wheel, use your left eye to examine clients left eye •Begin 10 to 15 inches from client • Keep red reflex in site • Steadily move close to the eye • Start diopter at 0 and adjust the diopter setting to bring the ocular fundus into sharp focus • Red numbers (negative & are for nearsighted eyes) • Black numbers (positive & are for farsighted eyes •As you move in note any opacities • Cataracts appear as opaque black areas against the red reflex •Continue until your foreheads almost touch

Development of Pathologic Pain

• Two main pathways • Nociceptive • Neuropathic processing • They present differently • Response to therapy different • Need accurate pain assessment • To develop plan of care • non-pharmacologic • pharmacologic

Middle Ear

• Tympanic cavity air-filled cavity located in the temporal bone • Separated from the external ear by the TM • Separated from the inner ear by the oval and round windows • Contains the Ossicles that transmit sound • Malleus • Incus • Stapes • Eustachian tube • Equalizes pressure on both sides of the TM • Connects to the nasopharynx

Infants and Children: Temperature

• Tympanic measurement (TMT and TAT) • Useful with toddlers who squirm or preschoolers not yet able to cooperate for oral temperature • Rapid - over before they know it • Axillary route safer and more accessible than rectal route • Accuracy and reliability questioned • Place tip well into axilla, and hold arm close to the body • Oral route • Usually at age 5 or 6, when they can keep their mouth shut (some younger can) • Use an electronic thermometer if possible • Unbreakable and it registers quickly

Subjective Data Violence

• US Preventative Task Force Guidelines (USPTF) • All women of childbearing age (14 to 46) should be screened. • Insufficient evidence to support screening of older adult or vulnerable adults • No current recommendations for children • Early detection is the key in terms of prevention of long-term complications. • Health care providers are mandatory reporters

Visual Field Defects

• Unilateral blindness • Bitemporal hemianopia (tumor or lesion can cause; parial blindness) • Lesion in optic nerve • Lesion of optic chiasm • Left superior quadrant anopia • Right visual field loss; p 310

Diagnosing Substance Abuse

• Use Gold standard • Criteria in DSM-V • Problems underdiagnosed in both hospital and primary settings • Usually not recognized until development of serious complications; table 6.2 (criteria for diagnosis of substance abuse)

• Indirect percussion

• Use index or middle finger of non- dominant hand. Place it over area to be percussed. Hyperextend the middle finger (the pleximeter) • Place distal joint and tip firmly against the person's skin. Only distal joint and tip of middle finger should be touching the person's skin • Use quick, light, firm strikes with the tip of the middle finger of the dominant hand against the distal end of the nondominant hand • Deliver one to three taps then move to another area

Guidelines for palpation

• Use light palpation first <1 cm • Moderate palpation second < 1-2 cm • Deep palpation third <2.5-5 cm (more advanced practice. where we are at now) • Saving tender areas for the last • Bimanual (two hands used to feel such as pelvic exam) • Have clean, warm hands with short nails • Follow standard precautions • Use pad of fingers to palpate pulse, texture, size, shape, crepitus

Assessment of Intimate Partner Violence

• Use of open-ended questions • "Tell me what happened." • Interview separately (if can't get away without drawing suspicion then listen for cues) • Listen for cues • Does it match • Is the story straight • Know the law and be prepared to report • Normalize questions, ask each patient • History questions (ask do you feel safe at home) • Prior hospitalizations • Treatment for injuries • Delayed treatment (red flag) • Circumstance behind injury (does it match up with story)

• Direct percussion

• Use one or more fingertips to tap over area being percussed • Used to elicit tenderness

Screening Aging Adults

• Use the SMAST-G questionnaire for older adults who report social or regular drinking of any amount of alcohol. • Older adults have specific emotional responses and physical reactions to alcohol. • 10 questions with yes/no responses that address these factors • Zero to 1 point a low-risk 4. Advise and Assist • Consequences of substance abuse are so debilitating • State your conclusion and recommendation clearly

Rinne Test

• Use tuning fork and place the base on the client's mastoid process. • When the client no longer hears the sound, note the time interval, and move the tuning fork in front of the external ear. When the client no longer hears the sound, note the time interval. • Normal findings • Air Conduction 2X that of Bone Conduction (AC 2X BC) • Conductive hearing loss: BC ≥ AC • Sensorineural hearing loss: findings may be normal, AC > BC or no sounds heard

Weber Test

• Use tuning fork placed on the center of the head or forehead • Ask whether the client hears the sound better in one ear or the same in both ears • Equal lateralization or NO lateralization • Conductive hearing loss: lateralization to the affected/bad ear • Sensorineural hearing loss: lateralization to the unaffected/good ear • Normal = sound equal in both ears

Clinical Institute Withdrawal Assessment (CIWA)

• Used for those experience alcohol withdrawal • Most sensitive objective measurement • Measures the progress of withdrawal • Assessment • Vitals signs • Consist of 10 criteria with range of 0-7 except orientation 0-4 • Total 0-7; you can assess every 4 hours for 72 hours • <8 for 72 hours; then you can discontinue assessments; p 94-95

Doppler

• Used to enhance BP and pulse measurement • Handheld transducer picks up changes in sound frequency demonstrated as a whooshing sound. • Apply gel to probe • Turn Doppler on • Touch probe to skin perpendicularly to artery • When you hear whooshing, you have located the artery, may need to move the probe around • If you push too hard, artery will be occluded = no sound • Inflate cuff until sounds disappear and then increase 20 to 30 mm Hg further • Slowly deflate cuff, noting when first whooshing sounds appear (SBP)

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 Technique

• Using pads of the first three fingers, palpate radial pulse at flexor aspect of wrist laterally along radius bone until strongest pulsation is felt • If the rhythm is regular, count beats for 30 second X 2 • Most accurate for normal or rapid regular rhythms • If irregular • Count for a full minute • Assess pulse for rate, rhythm, force, and elasticity.

Hair • Two types

• Vellus Hair (peach fuzz) • Short pale & fine • Present over most of the body • Helps with thermoregulation • Terminal Hair (scalp & eyebrows) • Darker & coarser • Puberty initiates growth in other places • Color varies with the amount of pigmentation

Primary Skin Lesion • Bulla

• Vesicle > 0.5 cm in diameter • Large blisters

Expanding the Concept of Health Holistic Health

• View the mind, body, and spirit as interdependent & function as a whole • Notes that health is impacted by both internal and external factors • Includes: lifestyle behaviors, culture & values, family & social roles, self-care behaviors, job-related stress, developmental tasks, and failures & frustrations of life

The General Survey-Measurement

• Weight • Use a standardized balance or electronic standing scale • Remove shoes and heavy outer clothing • When repeated weights are necessary • ~ same time of day & type of clothing • Record weight in kilograms and pounds • Show person recommended range for height • Compare current weight with previous • Recent weight loss may be explained by successful dieting • May be a sign of illness • Weight gain usually reflects too many calories and a sedentary lifestyle • Weight gain may be fluid retention though

Lifestyle Modifications for HTN Prevention and Management

• Weight loss • Limit alcohol • Increase aerobic exercise • Reduce sodium intake • Maintain adequate sources of dietary potassium, calcium and magnesium • Stop smoking -Reduce saturated fats and cholesterol

Assessment of Intimate Partner Violence: Screening Tools Used

• What tool is used in your facility • Screening may be a single question "Do you feel safe at home?" • USPTF have examined several for validity • HITS -4 questions • Can also be used to screen for adolescents dating violence • STaT- 3 questions

• Arcus senilis

• White arc around iris

Subjective Data

• Who can provide subjective data? • Only the patient • Who can verify subjective data? • Only the patient • Can provide clues to physiologic, psychological or sociologic problems • May reveal strengths and risks • Requires effective interviewing skills • Used in combination with objective data to form the database • Provides a complete picture of the patient; combined with objective data to come up with diagnosis

The Process of Communication: Receiving

• Words must be interpreted by the receiver (patient) • They may not understand the message as you intended • Past experience • Culture • Self-concept • Physical & emotional state

• Xanthelasma

• Yellow nodules around eyes from fat deposits; may indicate lipid profile abnormal

Ear Infections- Otitis media with effusion (serous otitis)

• Yellow or amber fluid behind the TM, mobile TM, air bubbles sometimes seen

Spirituality

•Broader term that encompasses something larger than one's own existence with a belief in transcendence

CHARACTERISTICS

•Burning, stabbing, aching •Describe symptoms

Vision Health Assessment

•Collecting Subjective Data •History of present health concern • Past health history • Family history • Lifestyle and health practices

Ophthalmoscope: optic disc

•Color = creamy yellow-orange to pink • Shape = Round or oval •Margins = Distinct and sharply demarcated (nasal edge may be fuzzy) •Cup-disc ratio = Width not more than ½ the disc diameter; brighter yellow than the rest of the disc

Abnormalities of Cornea and Lens

•Corneal abnormalities •Corneal scar •Pterygium (lesion from corner of nose into eye) •Lens abnormalities •Nucleus cataract •Peripheral cataract

Substance Abuse: Pregnancy

•Dangers to fetus •Cause of Fetal Alcohol Syndrome •Physical, learning, & behavioral problems •No amount is safe

Glaucoma, macular degeneration, nystagmus, retinal detachment, subconjuctival hemorrhge

•Glaucoma •Damage of optic nerve from increased pressure in the eye that leads to blindness •Macular degeneration •Nystagmus •Retinal detachment • Subconjuctival hemorrage

Subjective Data/Family History Eyes

•History of eye problems or vision loss in family

Developmental Competence: Infants and Children Ears

•Inner begins development in 5th week of gestation • Maternal infections in the first trimester can damage the Organ of Corti and cause impariment (Rubella) •Remember tube is shorter & wider; more horizontal (slope opposite than adults) • Easy for pathogens to enter • Puts them at increased risk for infection

Summary Checklist: 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. •Otoscopic examination • External canal—redness or swelling • Cerumen discharge, foreign bodies, or lesions •Inspect tympanic membrane • Color, characteristics, position, and integrity • Test hearing acuity

Objective Data-Nose- external nose

•Inspect external nose • Color, shape, consistency, symmetry? Any deformity? Any injury? • Palpate external nose • Tenderness? •Check patency of airflow •How is the sense of smell?

Objective - External Eye Structure Eversion of the Upper Eye Lid

•Inspect for • Color change • Swelling • Lesions • Foreign body

Objective Data -Mouth- lips, teeth, gums

•Inspect lips • Consistency and color? Any craking? Any lesions? •Inspect Teeth • Number, color, & condition • Repairs • Note alignment •Inspect gums • Color and consistency? Any swelling? Any bleeding?

Clinical Signs of Substance Use Disorders

•Intoxication: maladaptive behavioral changes due to effects on CNS from substance •Abuse: daily or recurrent use such that impairment and decreased functioning has occurred leading to ongoing problems •Dependence: physiological reliance •Tolerance: requires more to get the desired effect •Withdrawal: cessation of substance leads to physiological effects; p. 95-96

Abnormalities of Iris and Pupil

•Irregularly shaped iris •Miosis = constricted and fixed pupils •Mydriasis = Dilated and fixed pupils •Anisocoria = uneven pupils

Ways to Improve Health Literacy Oral Teaching

•Keep it simple (short sentences, two-syllable words when appropriate) •Use regular words not medical jargon.

Objective Data: External Eye Structures- other structures

•Observe for redness, swelling, discharge, or lesions •Observe the position and alignment of the eyeball in the eye socket. •Inspect the bulbar conjunctiva and sclera. •Inspect the palpebral conjunctiva. •Inspect the lacrimal apparatus. • Palpate the lacrimal apparatus. •Inspect the cornea and lens. (look for cloudiness, rough exterior, ring, etc) •Inspect the iris and pupil. • Test pupillary reaction to light. • Test accommodation of pupils.

Religion

•Refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, as well as the attendance of regular services. •Shared experience into which people or born or adopt to assist in meeting one's spiritual needs

Internal Structure of the Eye

•Sclera, cornea, iris, ciliary body, •Pupil, lens, choroid, retina, optic disc •Physiologic cup, retinal vessels •Anterior chamber, posterior chamber

THROUGHOUT

•Set tone and redirect •Do not lead but give options

Ways to Improve Health Literacy Written Materials

•Should be at a 5th-grade level or below •Use of 12-point font •No all caps •Use headings and subheadings

The Interview •History Taking

•Systematic approach of doing it the exact same way, every single time, as best you can •Not being rigid about it but just having a general flow.

ASSOCIATED SYMPTOMS

•Think of other systems affected based on your differential diagnoses.

LOCATION

•Very important •Be Specific •ABD for example

Vision: Visual field

•Visual Field • what a person sees with one eye • 4 Quadrants: upper temporal, lower temporal, upper nasal, lower nasal • Each eye sees a different view •Binocular vision = two-eyed vision •Visual Cortex fuses the 2 different images visual cortex provides depth perception or 3- dimensional vision

ALLEVIATING FACTORS

•What makes it better

RELEIVING FACTORS

•What makes it better

AGGREVATING FACTORS

•What makes it worse

Objective Data: Internal Eye Structures

•Will need to use the ophthalmoscope •Inspect the optic disc •Inspect the retinal vessels (bigger emerge from disc and gradually decrease in size. look if artery and vein cross path, any pulsation, any torturous vessels) •Inspect retinal background (should be light red to dark brown red) •Inspect fovea and macula •Inspect anterior chamber; look at cup to disc ratio; p 314

Pain can be classified by its duration

➢ Acute ➢ Chronic (persistent) ➢ Duration provides information r/t underlying mechanisms and treatment decisions.

Neuropathic Pain Diagnosis

➢ Cannot be identified by x-ray, CT scan, or MRI because it is at the neurochemical level ➢ Need an electromyography and nerve-conduction studies ➢ Abnormal processing of a pain impulse continued by peripheral, or CNS Proposed mechanisms ➢ Spontaneous and repetitive firing of nerve fibers, almost seizure like in activity ➢ Central neuron excitability ( wind-up) ➢ Minor stimuli causes significant pain

Pain sources based on their origin

➢ Cutaneous pain derived from skin surface and subcutaneous tissues • injury is superficial, with a sharp, burning sensation. ➢ Referred pain felt at a particular site but originates from another location • Both sites are innervated by same spinal nerve, and it is difficult for brain to differentiate point of origin. • Referred pain may originate from visceral or somatic structures. • Various structures maintain their same embryonic innervation. • It is useful to have knowledge of areas of referred pain for diagnostic purposes.

Nociception Pain

➢ Develops from stimulation of functioning and intact nerve fibers in the periphery and CNS ➢ Triggered by outside force as a result of actual or potential damage ➢ Nociception pain can be divided into four phases: • Transduction • Transmission • Perception • Modulation

Acute Pain Behaviors

➢ Involve autonomic responses ➢ Protective purpose ➢ Individuals experiencing moderate to intense levels of pain may exhibit the following behaviors: • Guarding, grimacing • Vocalizations such as moaning, agitation, restlessness, stillness • Diaphoresis, • Change in vital signs

Acute pain

➢ Short-term and self-limiting: • Often follows a predictable trajectory, and dissipates after an injury heals • Usually associated with a recent injury • Less than 6 months ➢ Self-protective purpose: • Acute pain warns of actual or potential tissue damage

Pain: Gender differences are influenced by societal expectations, hormones, and genetic makeup.

➢ Traditionally, men have been raised to be more stoic about pain, and more affective or emotional displays of pain are accepted for women. ➢ Hormonal changes are found to have strong influences on pain sensitivity for women. ➢ Women are two to three times more likely to experience migraines during childbearing years, are more sensitive to pain during premenstrual period, and are six times more likely to have fibromyalgia.

Breakthrough pain

➢ Transient spike in pain level with moderate to severe intensity in an otherwise controlled pain syndrome ➢ Can result from: • End of dose medication failure (wearing off before time for next dose)(can change frequency) • Result of incident or episodic pain (pain controlled but now pt) ➢ Treatment: • Shorten interval dosing and/or increase medication ➢ Experience of pain is a complex biopsychosocial mechanism. • More clinical research is needed. • Rely on patient report as best indicator of pain

Older adults have additional fears about

➢ becoming dependent, undergoing invasive procedures, taking pain medications, and having a financial burden. ➢ Most common pain-producing conditions for aging adults include • pathologies such as arthritis, osteoarthritis, osteoporosis, peripheral vascular disease, cancer, peripheral neuropathies, angina, and chronic constipation. ➢ Dementia does not impact ability to feel pain, but it does impact person's ability to effectively use selfreport tools.