Exam 1: Review
Describe communication techniques that enhance data collection.
Active listening concentrates on patient responses and subtleties; avoid formulating the next question during responses, avoid making assumptions about patient responses. Facilitation uses verbal and nonverbal phrases to encourage patients to continue talking further (uh huh, go on). Clarification is used to gather more information. Restatement is repeating what patients says in different words to confirm interpretation. Reflection is repeating what patient said and encourages elaboration or more info. Confrontation is used when inconsistencies are noted between patient report and nurse's observations; use tone of voice to convert confusion or possible misunderstandings (diet and exercise, still gaining weight, help me understand). Interpretation is used to share conclusions drawn from data; patient may confirm, deny, or revise. Summary condenses and orders data to clarify sequence of events for patient; emphasizes data related to health promotion, disease protection, and resolving health problems.
Identify communication strategies that aid in managing awkward moments in an interview.
Answering personal questions: brief direct answers, share experiences that support patient, enhance relationship and increase credibility. Silence: necessary for patients to reflect and gather courage to address painful topics or issues; feedback that patient is not ready to discuss topic or that the approach needs to be evaluated; become comfortable with silence.
Demonstrate/recognize techniques of auscultation.
Auscultation is listening to sounds within body; nurse commonly uses stethoscope to facilitate auscultation. Stethoscope is used for auscultation to block out extraneous sounds when evaluating condition of heart, blood vessels, lungs, and intestines. Listen for sound and characteristics: Intensity, pitch, duration, and quality. Concentrate; sounds may be transitory or subtle: Selective listening is isolating specific sounds, such as air during inspiration, or a single heart sound. Optimize quality of auscultation findings: Best to auscultate in quiet room where noises cannot interfere.Stethoscope must be placed directly on skin because clothes obscure or alter sounds. If patient is cold and shivers, involuntary muscle contractions may interfere with normal sounds. Friction of body hair rubbing against diaphragm could be mistaken for abnormal lung sounds (crackles).
Describe the use of auscultation as a physical examination technique.
Auscultation is listening to sounds within body; nurse commonly uses stethoscope to facilitate auscultation. Stethoscope is used for auscultation to block out extraneous sounds when evaluating condition of heart, blood vessels, lungs, and intestines. Listen for sounds and characteristics: intensity, pitch, duration. Concentrate: sounds may be transitory or subtle. Selective listening is isolating specific sounds, such as air during inspiration, or a single heart sound.
Describe when to use open-ended, close-ended, and directive questioning.
Begin with open-ended questions to encourage a free-flowing, open response: focus on questions about patient's health; may need to refocus questions if patient is unable to focus on topic or takes excessive time. Close-ended questions yield more precise data; give patient options for response. Directive questions lead patient to focus on one set of thoughts; most often used in reviewing systems and evaluating functional status.
Describe the purpose of and methods for measuring blood pressure. (Technique /cuff selection/ explain what BP represents, define korotkoff sounds, recognize ranges for orthostatic pressure, classification of htn)
Blood pressure is force of blood against arterial walls. It reflects relationship between cardiac output and peripheral resistance. Cardiac output is volume of blood ejected from heart each minute. Peripheral resistance is force that opposes flow of blood through vessels; when arteries are narrow, peripheral resistance to blood flow is high, and reflected in elevated blood pressure. Blood pressure is dependent on velocity of blood, intravascular blood volume, and elasticity of vessel walls.Blood pressure measured in millimeters of mercury (mm Hg). Systolic blood pressure is maximum pressure exerted on arteries when ventricles eject blood from heart. Diastolic blood pressure represents minimum amount of pressure exerted on vessels when ventricles of heart relax. Blood pressure is recorded with systolic pressure written on top of diastolic pressure (e.g., 130/76), but it is not a fraction. Pulse pressure is the difference between systolic and diastolic pressures and normally ranges from 30 mm Hg to 40 mm Hg. Orthostatic blood pressures are a series obtained when the patient is lying, sitting, and then standing. Indirect measurement is done by auscultation with sphygmomanometer and stethoscope or with noninvasive blood pressure monitor. Blood pressure categories in the new guideline are: Normal: Less than 120/80 mm Hg; Elevated: Systolic between 120-129 and diastolic less than 80; Stage 1: Systolic between 130-139 or diastolic between 80-89; Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg; Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage. Hypotension < 95/60 in normotensive adults Less than average reading but higher than 95/60 Less than expected value for age in children Second Korotkoff sound is a swishing sound heard as cuff continues to deflate. Third Korotkoff sound is a softer thump than first. Fourth Korotkoff sound is muffled and low pitched as cuff is further deflated. Fifth Korotkoff sound marks cessation of sound and indicates artery completely open. Manometer pressure noted at fifth Korotkoff sound is diastolic pressure.
Distinguish the purposes of comprehensive and focused health assessments.
Comprehensive health history: performed during a hospital admission, with an initial clinic or home visit, or when the patient's reason for seeking care is for relief of generalized symptoms such as weight loss or fatigue; requires more time because a complete database is being established; biographic data-initial visit, reason for seeking care, present health status, past medical history, family history, personal and psychosocial history, and review of body systems. Focused health assessments (problem-based assessment): includes data that are limited in scope to a specific problem; must be detailed enough that the nurse is aware of other health-related data that might affect the current problem.
Describe the components of a health assessment.
Conducting a health history (collecting subjective data), performing a physical examination (collecting objective data), and documenting findings. The amount of information collected by the nurse during a health history and the extent of the physical examination depend on setting, situation, patient's needs. and nurse experience.
Recognize tests for EOM
Cover test: Cover one eye, FIRST look for steady gaze on uncovered eye, Remove cover & look for movement Normal - eye should stare straight ahead, Weakness = phoria, Tropia v phoria; ALSO CALLED: 6 Cardinals Fields of Gaze, lead patient thru 6 fields, note parallel tracking of eyes, Note any nystagmus - tremor-like movement best seen near iris, Note any lid lag - white rim of sclera; b/t lid & iris
Describe and recognize abnormal findings that may be identified by examination of the skin, hair, and nails. Include techniques for persons of color (tables listed in Bb and key terms)
Cyanosis: Grayish-blue tone, especially in nail beds, earlobes, lips, palms, soles of feet Ecchymosis: dark red, purple, yellow, or green color, depending on age of bruise Erythema: Reddish tone with evidence of increased skin temperature secondary to inflammation Jaundice: Yellowish color of skin, sclera of eyes, fingernails, palms, oral mucosa Pallor: Pale skin color that may appear white Petechia: Lesions appear as small, reddish purple pinpoints Rash: May be visualized and felt with light palpation Scar: Narrow scar line
Define terms related to findings for head, eyes, ears, nose throat in the context of health history questions
Describe sensation of dizziness you are experiencing: When did it begin? How often? How long? Dizziness is a feeling of faintness. Vertigo is a sensation that the environment is whirling around. ; Describe noise you are hearing. Is it ringing, hissing, crackling, or buzzing? When did it begin? Ringing of ears (tinnitus) is a sensation or sound heard only by affected individual and can manifest with a variety of sounds or sensations. Does sound occur continuously, or come and go? If it comes and goes, does it occur with certain activities, or at the same time of day? Pattern of symptoms may provide clues to cause. ; Migraine is second most common headache syndrome in the United States and can occur in childhood, adolescence, or early adult life; young women are most susceptible. Clinical findings: Starts with aura from vasospasm of intracranial arteries; throbbing unilateral distribution of pain. May be accompanied by depression, restlessness, irritability, photophobia, nausea, or vomiting. May last up to 72 hours. Cluster headache: Most painful of primary headaches. Common from adolescence to middle age. Clinical findings: Intense episodes of excruciating unilateral pain. Lasts 30 minutes to 1 hour and may repeat daily for weeks with some remissions or 6 to 12 weeks with remissions for 1 or more years. Pain is burning, drilling, stabbing behind one eye. May be accompanied with unilateral ptosis, ipsilateral lacrimation, nasal stuffiness, and drainage. Tension headache: Most common headache experienced by adults between 20 and 40 years of age. Clinical findings: Usually bilateral; may be diffuse or confined to frontal, temporal, parietal, or occipital area. Onset may be gradual and last for several days. May be accompanied by contraction of skeletal muscles of face, jaw, and neck. Patients frequently describe as feeling of tight band around their heads. Cataract is opacity of crystalline lens from denaturation of lens protein caused by aging and may be congenital or caused by trauma. Clinical findings:Cloudy or blurred vision; glare from headlights, lamps, or sunlight; and diplopia. May also report poor night vision and frequent changes in prescriptions for glasses. A cloudy lens can be observed on inspection. Glaucoma is a group of diseases that increases intraocular pressure and damages optic nerve, leading to blindness. Two types of glaucoma: Open-angle and closed-angle; Sensorineural hearing loss (SNHL) caused by structural changes, disorders of inner ear, or problems with auditory nerve: SNHL accounts for more than 90% of hearing loss; Epistaxis is bleeding from nose, recognized as one of most common problems of nose: Common causes of nosebleeds include forceful sneezing or coughing, trauma, picking of nose, or heavy exertion. Some nosebleeds occur spontaneously without an obvious causative event. Clinical findings: Bleeding due to high vascularity; most occur anterior of septum; Thyroid disorders: Hyperthyroidism is a condition associated with excessive production and secretion of thyroid hormone; Graves' disease, a familial autoimmune disorder, is most common cause. Thyroid disorders: Thyroid cancer is most common type of endocrine malignancy.
Describe the use of percussion as a physical examination technique.
Evaluate size, borders, and consistency of internal organs. Detect tenderness. Determine extent of fluid in a body cavity. Direct percussion: strike finger or hang directly against patient's body, evaluate adult sinus by directly tapping finger on sinus, elicit tenderness over kidney by striking costovertebral angle (CVA) directly with fist. Indirect percussion requires both hands; methods can vary by system being assessed. Distal aspect of middle finger is used over the skin to strike the distal interphalangeal joint with the tip of the middle finger of the dominant hand; force of the downward snap of the striking finger comes from flexion of the wrist; rebound quill to avoid muffling of the vibration. Five percussion tones: tympany is loud, high-pitched sounds heard over abdomen; Resonance is heard over normal lung tissue; hyperresonnace is heard in overinflated lungs, as in emphysema; dullness is heard over liver; flatness is heard over bones and muscle.
Identify the components of a general inspection.
General inspection begins the moment nurse meets patient. Initial impressions guide nurse to areas requiring further examination. Physical appearance and Hygiene: Does patient appear healthy? Any obvious findings such as tremors or facial drooping? Does patient appear close to stated age?Note that patient may appear older or younger than stated age due to drug and alcohol use, excessive sun exposure, chronic disease, and endocrine disorders. Note color and condition of skin. Any variations or obvious presence of lesions? Is patient clean and well groomed or disheveled? Any odors detected? Body structure and position:Stature and height appropriate for age. Nutritional status: Well nourished, cachectic, obese. Body symmetry and positioning. Body movement: Note how patient moves. Use of assistive devices. Are there limitations in range of motion? Are there any involuntary movements such as a tremor or tic?Emotional and mental status and behavior:Note alertness, facial expressions, tone of voice, and affect. Does patient maintain eye contact as culturally appropriate? Does patient converse appropriately? Are facial expressions and body language appropriate for conversation? Is clothing appropriate for weather? Is behavior appropriate?
Identify the rationale for using personal protective equipment during a physical examination.
Gloves: are single-use items and should be used for invasive procedures including contact with sterile sites, non-intact skin or mucous membranes, and for all activities that have been assessed as carrying a risk of exposure to blood, body fluid or infectious respired aerosols or droplets. Apron/gown: Aprons are single-use items and must be worn when in close contact with patients, materials or equipment that pose a risk of contamination with blood or body fluids. Fluid-repellent gowns must be worn when there is an extensive risk of the splashing of blood or body fluid onto the skin or clothing of health workers. Mask/respirator, when worn: When there is a risk of blood or body fluid splashing onto the eyes and face of the health worker, To protect against respired infectious aerosols/droplets. Hands must be washed
Describe appropriate inspection, palpation, and positioning techniques used in the examination of the head, eyes, ears, nose, and throat.
Head: Head and neck contain multiple structures: Skull encloses brain. Facial structures include eyes, ears, nose, and mouth. Neck structures include: Upper portion of spine Esophagus Trachea Thyroid gland Arteries Veins Lymph nodes; Skull is a bony structure that protects brain and upper spinal cord: Contains special senses of vision, hearing, smell, taste. Comprises six bones fused at sutures. Covered by scalp tissue typically covered with hair. Face comprises 14 bones: Mandible articulates with temporal bone to form temporomandibular joint. Facial muscles innervated by cranial nerves V (trigeminal) and VII (facial). Eyes: External ocular structures: External eye is composed of eyebrows, upper and lower eyelids, eyelashes, conjunctivae, and lacrimal glands. Palpebral fissure is opening between eyelids. Conjunctivae are two thin, transparent mucous membranes, between eyelids and eyeball. External ear Auricle or pinna and external auditory ear canal composed of cartilage and skin. Helix is prominent outer rim. Concha is deep cavity in front of external auditory meatus. Lobule is bottom portion of ear. Auricle serves three main functions: Collection and focus of sound waves. Location and direction of sound. Protection of external ear from water and dirt. Hearing: Sound waves reach cochlea by middle ear causing movement of hair cells. Sensory hair cells transmit impulses through nerve receptors and vestibular nerve branch of acoustic nerve, CN VIII. Transmit to temporal lobe of the brain, where sound is interpreted. Conductive loss Mechanical External or middle ear cerumen, perforated tympanic membrane Sensorineural loss Perceptive Patho of inner ear, CN VIII, or auditory area of brain Nerve degeneration Ototoxic drugs Neck: Cervical spine Sternocleidomastoid muscle Hyoid bone Larynx Trachea, Esophagus Thyroid gland Lymph nodes Carotid arteries Jugular veins, Neck formed by cervical vertebrae, supported by ligaments, and SCM and trapezius muscles: Allow extensive movement within neck. Mobility greatest at C4-5 or C5-6. Neck muscles and bones form triangles: Anterior (medial borders of SCM muscle and mandible). Posterior (trapezius muscle, SCM muscle, clavicle). Thyroid gland: an important endocrine gland straddles trachea in middle of the neck Synthesizes and secretes thyroxine (T4) and triiodothyronine (T3), which are hormones that stimulate rate of cellular metabolism
State the purposes of a health history.
Health history = subjective data Database used to create a plan, prevent disease, resolve problems, and minimize limitations.
Differentiate between health promotion and health protection.
Health promotion: behavior motivated by the desire to increase well-being and actualize human health potential; central component of health care; begins with health assessment, nurse assess patients health status, health practices, and risks Health protection: behavior motivated by desire to avoid illness, detect illnesses early, and maintain functioning when ill.
Describe the purpose of and methods for measuring heart rate, including characteristics (strength/amplitude)
Heart rate: Palpation of arterial pulses provides valuable information about cardiovascular system. Pulse determines heart rate and rhythm: Heart rate is number of times in a minute a pulsation is felt. (beats) Rhythm refers to regularity of pulsations or time between each beat. Pulses also provide important information on strength of pulse and perfusion of blood to various parts of the body. To take a pulse, place fingers over artery and feel for pulsations and rhythm: Use finger pads of index and middle fingers; apply firm pressure over pulse, but not so hard that pulsation is occluded. If rhythm is regular, count number of pulsations for 30 seconds and multiply by 2. If pulse rhythm is irregular, note any odd rhythm, and count pulsations for full minute. Document irregular pulse when recording vital signs. Radial artery is most frequently used to measure heart rate because accessible and easily palpated: Radial pulse found at radial side of forearm at wrist. Brachial and carotid arteries are common alternative sites to assess pulse rate: Brachial pulse is located in groove between biceps and triceps muscles, in bend of elbow. Carotid pulse is found along medial edge of sternocleidomastoid muscle in lower third of neck. Heart rate can also be assessed by auscultating heart, which is known as apical pulse, and counting heart sounds for 1 minute. Located over the fifth intercostal space at the mid clavicular line. Must use a stethoscope to auscultate heart rate.
List common errors in BP measurement and result
High: patient's legs are cross during measurement, positioning the patient's arm below the level of the heart, using a cuff that is too narrow for the extremity, wrapping the cuff too loosely or unevenly, deflating the cuff too slowly (slower than 2-3 massaging Hg per second), reinflating the cuff without completely deflating it, failing to wait 1 to 2 minutes before obtaining a repeat measurement Low: positioning the patient's arm above the level of the heart, using a cuff that is too wide, not inflating the cuff enough, deflating the cuff too rapidly (faster than 2-3 mm Hg per second), pressing the diaphragm too firmly on the brachial artery
How does the nurse facilitate the discussion to determine the patient's beliefs?
How does the patient define health; beliefs about attaining and maintaining health; view of responsibility for health, health behaviors currently practiced, and unhealthy behaviors patients are willing to change; health expectations based on life experiences: self, family, friends, and culture
Describe age-related and situational variations in the health history.
Infants, Children and adolescents: Pediatric health history similar to that of adult. Additions of pregnancy, prenatal care, growth and development, behavioral status, as applicable. Most data are obtained from adult accompanying child, but should include child as much as appropriate for age. Nurse determines if an adult or pediatric database format is appropriate for adolescent. Nurse determines whether to interview adolescent alone or with parent present. Pregnancy: Comprehensive health history is obtained at first prenatal visit, establishes baseline data, special emphasis on data that may impact pregnancy outcomes Older adults: Incorporation of various age-related questions and functional status questions. May not be necessary to collect data on childhood immunizations or develop a genogram. Many older adults have multiple symptoms, conditions, medications, and a long past health history. Time needed to complete interview may be much longer.
Discuss health promotion practices and related health history questions that are pertinent to the skin, hair, and nails
Inspect the skin, palpate the skin, inspect and palpate the scalp and hair, inspect facial and body hair, inspect and palpate the nails, inspect and palpate skin lesions, inspect lesions using a wood's lamp
Order and technique for exam for lymphatic system (Head & Neck)
Lymphatic system: an extensive vessel system, is major part of immune system, which detects and eliminates foreign substances from body, Vessels allow flow of clear, watery fluid from tissue spaces into circulation. Nodes are small, oval clusters of lymphatic tissue that filter lymph and engulf pathogens, preventing potentially harmful substances from entering the circulation Greatest supply is in head and neck You should be familiar with direction of drainage patterns of lymph nodes, Lymph nodes in head categorized as: Preauricular, postauricular, occipital, parotid, retropharyngeal (tonsillar), submandibular, submental, and sublingual. Lymph nodes in neck are found in chains: Named according to relation to SCM muscle. Include anterior and posterior cervical chains, sternomastoid nodes, and supraclavicular nodes.
Review the normal ranges of vital signs across age groups (Adult and school age child)
Newborn: Heart rate: 120-160, Average 140, Respiratory rate: 30-60, BP: 60-90/20-60 Toddler: Heart rate: 90-140, Average 110, Respiratory rate: 24-40, BP: 80-112/50-80. School-Age Child: HR: 75-100, Average 85, Respiratory rate: 18-30, BP: 84-120/54-80, Adolescent: HR: 60-90, Average 70, Respiratory rate: 12-16, BP: 94-139/60-79; Adult: HR: 60-100, Average 70, Respiratory rate: 12-20; BP: 110-139/60-79
Describe normal findings for the lymph nodes
Normal nodes feel movable, discrete, soft, mobile and nontender—document & note location Abnormal matted together, not mobile, not smooth, and tender; If enlarged or tender, check area they drain for source of the problem; they often relate to inflammation or neoplasm in head and neck; Follow up on or refer your findings; an enlarged lymph node, particularly when you cannot find the source of problem, deserves prompt attention; 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
Describe expected findings derived from the examination of the head, eyes, ears, nose, and throat.
Note general size and shape. Assess shape: place fingers in person's hair and palpate scalp. Skull normally feels symmetric and smooth. Cranial bones that have normal protrusions are forehead, lateral edge of parietal bones, occipital bone, and mastoid process behind each ear; There is no tenderness to palpation. Palpate temporal artery above zygomatic (cheek) bone between eye and top of ear. Palpate temporomandibular joint as the person opens the mouth; Facial structures always should be symmetric. Note: facial expression and appropriateness to behavior or reported mood, symmetry of eyebrows, palpebral fissures, nasolabial folds, and sides of mouth abnormal facial structures (coarse facial features, exophthalmos, changes in skin color or pigmentation), or abnormal swellings involuntary movements (tics) in facial muscles; normally none occur; Symmetry, Head position is centered in midline, and accessory neck muscles should be symmetrical, Head should be held erect and still; Trachea. Normally, trachea is midline; palpate for any tracheal shift; Space should be symmetric on both sides. Note any deviation from midline Thyroid gland. Difficult to palpate; check for enlargement, consistency, symmetry, and presence of nodules; If enlarged, auscultate thyroid for presence of bruit, which occurs with accelerated or turbulent blood flow, indicating hyperplasia of thyroid (e.g., hyperthyroidism)
Discuss variables that affect the measurement of vital signs.
Number of patient-related factors affect blood pressure and should be kept in mind when interpreting blood pressure measurements. Age: From childhood to adulthood there is gradual rise. Gender: After puberty, women usually have a lower blood pressure than men; however, after menopause, women's blood pressure may be higher than men's. Race: Incidence of hypertension is twice as high in black Americans as in whites. Diurnal variations: Pressure is lower in early morning and peaks in late afternoon or early evening. Emotions: Anxiety, anger, or stress may increase blood pressure. Pain: Acute pain may increase blood pressure. Personal habits: Caffeine or smoking within 30 minutes before measurement may increase reading. Weight: Obese patients tend to have higher blood pressures than nonobese patients.
Describe variations of technique/findings for infants/children/elderly
ORDER: Respirations; Watch abdominal movement in sleeping infant; Palpate or auscultate apical in infants & toddlers;Take pulse for one full minute in children. Temps; Use noninvasive routes when possible. When febrile, rectal measure preferred. Choose equipment correctly for infants/children;Pediatric diaphragm & bell for stethoscope; Allow crying infant to quiet for 5-10 min before pulse, BP; Temp is decreased in elders. Less reliable as an indication of illness; Pulse. Rhythm becomes irregular, Respirations become more shallow. Expect elevated SBP; no change in DBP; Widening pulse pressure
Demonstrate/recognize techniques of percussion.
Percussion performed to: Evaluate size, borders, and consistency of internal organs. Detect tenderness. Determine extent of fluid in a body cavity. Direct percussion Strike finger or hand directly against patient's body. Evaluate adult sinus by directly tapping finger on sinus. Elicit tenderness over kidney by striking costovertebral angle (CVA) directly with fist. Indirect percussion requires both hands; methods can vary by system being assessed. Place the distal aspect of the middle finger of the nondominant hand against the skin over the organ being percussed and strike the distal interphalangeal joint with the tip of the middle finger of the dominant hand. Force of the downward snap of the striking finger comes form rapid flexion of the wrist. Rebound quickly to avoid muffling of the vibration. Five percussion tones:Tympany is loud, high-pitched sound heard over abdomen. Resonance is heard over normal lung tissue. Hyperresonnace is heard in overinflated lungs, as in emphysema. Dullness is heard over liver. Flatness is heard over bones and muscle.
Describe the use of inspection as a physical examination technique.
Physical exam begin with inspection: visual exam and body, including movement and posture. Data obtained by smell are also a part of inspection. Examination of every body system includes technique of inspection. Patient is draped appropriately to maintain modesty while allowing sufficient exposure for exam. Adequate lighting is essential. Patient should be thoroughly observed with a critical eye. Concentration without distraction avoids overlooking potentially important data. Inspection may seem easy to master, but practice is necessary to develop skill. Use of equipment may facilitate inspection of certain body systems: penlight, otoscope, opthamoscope, and vaginal speculum.
Demonstrate/recognize techniques of inspection.
Physical exams begin with inspection: Visual exam of body, including movement and posture. Data obtained by smell are also a part of inspection. Examination of every body system includes technique of inspection. Patient is draped appropriately to maintain modesty while allowing sufficient exposure for exam; adequate lighting is essential. Patient should be thoroughly observed with a critical eye. Concentration without distraction avoids overlooking potentially important data. Inspection may seem easy to master, but practice is necessary to develop skill. Use of equipment may facilitate inspection of certain body systems: Penlight, otoscope, ophthalmoscope, and vaginal speculum.
Distinguish between pupillary light reflex, consensual reflex, and corneal light reflex
Pupillary light reflex: normal constriction of pupils when bright light shines on retina When one eye exposed to bright light, a direct light reflex occurs, constriction of that pupil; and a consensual light reflex, simultaneous constriction of other pupil
Define PERRLA (what does each letter represent and the meaning of the term)
Pupils Equal, Round, React to Light, Accommodation (adaptation of eye for near vision, accomplished by increasing curvature of less through movement of ciliary muscles, although lens cannot be observed directly, convergence (motion toward) of the axes of the eyeballs and pupillary constriction; Pupils constrict when focusing on a close object, pupils dilate when focusing on a distant object, even the name helps you remember the expected findings
Discuss techniques used for measurement of respiratory rate.
Respiratory rate involves counting number of ventilatory cycles and inhalation and exhalation, each minute. Men usually breathe diaphragmatically, increasing movement of abdomen. Women tend to be thoracic breathers, noted with movement of chest. Count respiratory rate when patient is unaware to prevent self-conscious changing of breathing rate or pattern. Other factors that increase respiratory rate are fever, anxiety, exercise, and high altitude. Note rhythm, depth, and effort of breathing: Rhythm is pattern or regularity of breathing and described as regular or irregular. Depth described as deep (full lung expansion with full exhalation), normal, or shallow. Observe effort that goes into breathing also. Normal breathing should be even, quiet, and effortless when patient is sitting or lying down
Identify the positions used for examination of the patient.
Sitting: sitting upright provides full expansion of lungs and better visualization of symmetry of upper body parts Supine (lying on back): this is the most normally relaxed position, it provides easy access to pulse sites Dorsal recumbent (lying on back knees up): this is used for abdominal assessment because it promotes relaxation of abdominal muscles Lithotomy (lying on back, legs up, genitalia exposed): provides maximal exposure of genitalia and facilitates insertion of vaginal speculum Sims (lying on side, knees on side): flexion of hip and knee improves exposure to rectal area Prone (lying on front): used to access extension of hip joint Lateral recumbent (lying on side): aids in detecting murmurs Knee-chest (lying on front, rectum up): provides maximum expose of rectal area
Describe tests for visual acuity
Snellen: 20 ft Eye level Test one eye/time OD, OS, OU Wear corrective lenses Record as fraction NL: 20/20 If pt missed a letter 20/20 Ex. 20/100 Snellen E or shape chart Test near vision in patients over 40 Hold a Jaeger or Rosenbaum card screener 14 in. from eye Test one eye at a time Normal = 14/14 Confrontation: Quick measure of peripheral vision (PV) Compare pt's PV with your own Test Right & Left fields for one eye at a time
Define standard precautions
Standard Precautions apply in all health care settings: Hand hygiene is the single-most important component to reduce infection transmission. Utilize personal protective equipment as necessary. Proper management of patient care equipment is essential. Be mindful of latex allergies: Health care professionals are at risk for developing latex allergies because of frequent exposure. Patients may also have a latex allergy Ask!
Describe appropriate inspection the examination of the skin, hair, and nails.
Start with a general survey, noticing the color of the skim, general pigmentation, vascularity or bruising, and lesions or discoloration Not any unusual odors. Next inspect and palpate the skin more closely, moving systematically from the head and neck to the trunk, arms, legs, and back. In a head-to-toe assessment, you can examine the skin in conjunction with other body systems. Before you begin, be sure to have adequate lighting so subtle changes are not missed. Be alert for cuts, bruises, scratches, and welts that may indicate interpersonal violence, especially when the explanation for their cause does not seem to fit the lesions observed.
Distinguish between objective and subjective data.
Subjective data = health history collected during interview; info about patient's current state of health, medications, previous illnesses and surgeries, family history, and review of systems. Symptoms = primary source data Objective data = signs; a physical examination involving the collection of objective data; palpation, inspection, percussion, auscultation; height, weight, BP, temp, pulse, respiratory rate
Palpation technique for assessment of thyroid
Symmetry Range of motion Lymph nodes Trachea Thyroid gland Posterior approach Anterior approach Auscultate thyroid for bruit, if enlarged; Range of motion; Note any limitation of movement during active motion When neck is supple, motion is smooth and controlled Test muscle strength and status of cranial nerve XI Look for swelling below angle of jaw; note thyroid gland Note any obvious pulsations; carotid artery creates brisk localized pulsation just below angle of the jaw
List steps of symptom analysis.
Symptom analysis: a systematic way to collect data about the history and status of symptoms; not all individuals seeking health care have a specific problem or illness, thus recording a history of present illness or a symptom analysis is not always indicated. Onset: when did the symptoms begin? Location: Where are the symptoms? Duration: How long do the symptoms last? Characteristics: Describe the characteristics of the symptoms. Aggravating and Alleviating factors: What affects the symptoms? Related Symptoms: Are other symptoms present? Treatment: Describe self-treatment before seeking care. Severity: Describe the severity of the symptom.
Define the term assessment in the context of the nursing process.
The first and foundational step is assessment, defined as a collection of "comprehensive data pertinent to the patient's health and/or situation." The assessment and subsequent analysis of data are preformed by nurses in all settings.
Identify situations in which appropriateness of the chosen health assessment approach varies.
The term context refers to circumstances or situations associated with and event or events. The phrase context of care refers to the circumstances or situations related to the health care delivery; Setting, environment, physical, psychological Comprehensive health assessment: hospital admission Problem-based focused assessment: ER, sore throat Episodic assessment: Follow up screening, mammogram
Describe the equipment used during a physical examination.
Thermometer: Measure body temperature; three types:Electronic: Calculates and displays temperature on digital screen within 15 to 30 seconds. Tympanic: Temperatures are obtained by placing a probe into ear; studies have shown widely varying results. Temporal artery: Utilizes infrared technology; studies demonstrate a high level of accuracy. Stethoscope: Auscultates sounds within body not easily audible to human ear. Four types of stethoscopes: Acoustic - most common. The acoustic stethoscope transmits sound waves from the source through the tube to the ears: Does not magnify sound but blocks extraneous sound, making difficult sounds easier to hear. Four components: Earpieces, binaurals, tubing, and head with diaphragm and bell. Head includes two components: Diaphragm is flat surface with rubber or plastic ring: Used to hear high-pitched sounds such as breath sounds, bowel sounds, and normal heart sounds. Structure screens out low-pitched sounds. Bell constructed in concave shape: Used to hear soft, low-pitched sounds such as extra heart sounds or vascular sounds (bruit). Should be pressed lightly on skin with just enough pressure to ensure a complete seal around bell. Blood pressure: Measures arterial blood pressure indirectly (noninvasively). Sphygmomanometer consists of gauge to measure pressure, a cuff enclosing an inflatable bladder, and bulb with valve used to inflate and deflate bladder within cuff . Cuff sizes vary. It is necessary to ensure the correct size is utilized for accurate results. Stethoscope is used to auscultate blood pressure. Pulse ox: Highly accurate noninvasive measurement estimates arterial oxygen saturation in blood. Consists of LED probe emitting light waves that reflect off oxygenated and deoxygenated hemoglobin molecules circulating in blood.Reflection used to estimate percentage of oxygen saturation in arterial blood and pulse rate. Sensor taped to ear, finger, or toe. Visual Acuity: Snellen chart is wall chart placed 20 feet from patient: 11 lines of letters decreasing in size. Letter size indicates visual acuity from 20 feet. Tests one eye at a time. Provides visual acuity number. Top number = distance from chart. Bottom number = distance person with normal vision should be able to read line. E chart used for young children and non-English-speaking patients: Scored same as Snellen. Jaeger and Rosenbaum charts are commonly used to evaluate near vision: Rosenbaum consists of numbers, Es, Xs, and Os in graduated sizes. Held 14 inches away, one eye tested at a time. Visual acuity is measured same as Snellen. Opthamoscope: is an instrument consisting of series of lenses, mirrors, and light apertures to inspect internal eye structures: Head consists of lens selector dial and aperture settings. Lens selector dial adjusts lenses that control focus; unit of strength for each lens is diopter. Positive and negative lenses compensate for myopia or hyperopia in both nurse's and patient's eyes and permit focusing at different places within patient's eye. Otoscope: Otoscope consists of magnification lens, light source, and speculum inserted into auditory canal to inspect external auditory canal and tympanic membrane. Choose largest size speculum that fits into patient's ear canal. Pneumatic attachment produces small puffs of air against tympanic membrane to evaluate fluctuation of tympanic membrane in children. Penlight: Provides focused light source for inspection. Penlight has many uses during a physical assessment. Used to illuminate inside of mouth or nose, highlight a lesion, or evaluate pupillary constriction. Light transmitted from otoscope may be substituted as a focused light source. Nasal Speculum: Spreads opening of nares to inspect internal surfaces of nose. Two instruments may be used as a nasal speculum: Simple nasal speculum is used in conjunction with penlight to inspect lower and middle turbinates of the nose. Gently squeezing handle of speculum causes blades of speculum to open and spread nares. Second type is broad-tipped, cone-shaped device that is placed on the end of an otoscope. Tuning fork: has two purposes: Auditory screening and assessment of vibratory sensation. High-pitched tuning fork with frequency of 500 to 1000 hertz (Hz) should be used to estimate hearing loss in range of normal speech (300 to 3000 Hz). For neurologic vibratory evaluation, a pitch between 100 and 400 Hz should be used. Sharply strike tuning fork on heel of hand. Reflex hammer: Used to test deep tendon reflexes. Percussion (reflex) hammer consists of a triangular rubber component on end of a metal handle: Flat surface commonly used when striking tendon directly. Pointed surface used to strike tendon directly or to strike a finger, which is placed on a small tendon such as patient's biceps tendon. Neurologic hammer can also be used to test deep tendon reflexes; similar to percussion hammer, but the rubber striking end is rounded on both sides. Doppler: Doppler uses ultrasonic waves to detect and amplify difficult-to-hear vascular sounds such as fetal heart tones or peripheral pulses. Coupling gel is applied to patient's skin; then transducer is slid over skin surface until blood flow is heard in earpieces. As blood in vessels ebbs and flows, Doppler picks up and amplifies subtle changes in pitch; the resulting sound that the nurse hears is a swishing, pulsating sound. Volume control may further amplify sound. Goniometer: Determines degree of flexion or extension of joint. Two-piece ruler jointed in middle with a protractor-type measuring device. Placed over joint; as individual extends or flexes joint, degrees of flexion and extension are measured on protractor. Calipers: Measure thickness of subcutaneous tissue to estimate amount of body fat. Different models may be used for different points on body. Most frequent location is posterior aspect of triceps.
Discuss the importance of draping the patient during a physical examination.
This helps maintain modesty while allowing sufficient exposure for exam.
Delineate types of data that belong under each of the following sections of a health history.
Types of health history: Comprehensive health history establishes complete database. Problem-based or focused health assessment includes data limited to the scope of problem.Episodic or follow-up assessment focuses on specific problems for which patient is already receiving treatment. History of Present Illness: Chief complaint or presenting problem: Brief statement regarding purpose for visit. Recorded in direct quotes from patient. Multiple reasons: List and prioritize. Patient may not give reasons until comfortable. Patient condition determines next step. Urgencies require expediency. Bibliographic data delayed. Data analysis to determine cause and to develop plan. Include all of the following:SymptomologyOnset, location and duration, related and alleviating factors, attempts at self-treatment. Present and Past health status: Present history focuses on the patient's acute and chronic conditions: Current health conditions; Medication reconciliation; Allergies Past health assessment focuses on important health history: Childhood illnesses; Surgeries; Hospitalizations Accidents or injuries Immunizations Obstetric history Last examinations Family History: Blood relatives: Biologic parents, aunts, uncles, siblings, children, and spouse. Identify genetic, familial, environmental factors that might affect current or future health status; ask about specific diseases. Psychosocial status: General statement of feelings about self Family and social relationships Diet and nutrition Functional ability Mental health Personal habits: Tobacco, alcohol, illicit drugs. Health promotion activities Environment Review of systems: Past and present health of each body system. Conduct symptom analysis when patient indicates presence of symptoms. Define medical terms, when necessary. Additional health promotion data may be collected during review of systems. In a comprehensive health assessment, you will ask most of the questions. In a focused health assessment, you ask questions about systems related to reasons for seeking care. Individual systems review: General symptoms, Integumentary system, Head and neck, Breasts, Respiratory system/chest, Cardiovascular system, Gastrointestinal system, Urinary system, Reproductive system, Musculoskeletal system, Neurologic system
Describe the use of palpitation as a physical examination technique.
Use of hands to feel texture size, shape, consistency, location of certain parts, and identify painful or tender areas. Requires nurse to move into personal space. Gentle touch, warm hands, and short nails to prevent discomfort or injury to patient: touch has cultural symbolism and significance. State purpose, manner, and location of touching. Wear gloves when palpating areas where contact with body fluids is possible. Palmar surface of fingers and finger pads are more sensitive than fingertips, better to determine position, texture, size, consistency, masses. fluid, crepitus. Ulnar surface of hand to fifth finger is most sensitive to vibration. Dorsal surface is better for assessing temperature. Using palmar surfaces of fingers may be light or deep and controlled by amount of pressure.
Demonstrate/recognize techniques of palpation.
Use of hands to feel texture, size, shape, consistency, location of certain parts, and identify painful or tender areas. Requires nurse to move into personal space.Gentle touch, warm hands, and short nails to prevent discomfort or injury to patient: Touch has cultural symbolism and significance. State purpose, manner, and location of touching. Wear gloves when palpating mucous membranes or other areas where contact with body fluids is possible. Palmar surface of fingers and finger pads are more sensitive than fingertips. Better to determine position, texture, size, consistency, masses, fluid, crepitus. Ulnar surface of hand to fifth finger is most sensitive to vibration. Dorsal surface is better for assessing temperature.
Relate location of lymph nodes to area/direction of drainage
Using a gentle circular motion of finger pads, palpate lymph nodes; Beginning with pre auricular 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
Describe communication techniques that diminish data collection.
Using medical terminology confusing to patient; patient may not understand question or may be embarrassed to request clarification and therefore may give inaccurate responses. Expressing value judgements, interrupting them patient is talking, having an authoritarian or paternalistic demeanor, asking "why" questions that may threaten patient and make him or her defensive.
