Nursing Exam 4

PATIENTS WITH A MASTECTOMY: Woman who have had a mastectomy require the same breast assessment as all other women (CBE & monthly Breast Awareness). Many women experience anxiety or fear as they worry about the recurrence of cancer or metasis. In addition to examining the remaining breast in the usual manner, the nurse should assess the mastectomy site and the scar because malignancy recurrence is possible at the:

scar site.

Elevated, firm circumscribed area less than 1 cm in diameter Wart (verruca), elevated moles, lichen planus, cherry angioma, neurofibroma, skin tag:

Primary Skin Lesions: papule

Gynecomastia

- male enlargement of the breasts Slight during puberty With aging (increase in size)- decreasing testosterone Assess with the patient in sitting position Palpate axilla

Gait refers to the mechanics of walking. To sum it up, ask yourself . . .

"does the gait have a regular rhythm and is it equal bilaterally?"

When the patient shrug the shoulders or turn the head during the interview, the spinal accessory nerve ______ is in tact.

Spinal accessory nerve (XI) ABNORMAL FINDINGS: An absence or difficulty in turning the head may indicate a CN XI abnormality.

Guidelines for assessment of the breasts:

- Research has not shown a clear benefit of regular physical breast exams done by either a health professional (clinical breast exams) or by women themselves (breast self-exams). - Rather than Breast Self-Exam: the nurse instructs the patient in Breast awareness, how their breasts normally look and feel.

Safe Medication Administration:

(review med administration exam notes)

When to perform an assessment of the genital in the order of Head to Toe Assessment?

- Usually not assessed unless the nurse needs. - further assessment of elimination status - to assess skin integrity - to identify the urinary meatus when placing a Foley catheter, indwelling or intermittent - to provide hygiene to the patient's perineum

- When to perform in the order of Head to Toe Assessment? - Usually not assessed unless the nurse needs:

- further assessment of elimination status - to assess skin integrity - to identify the urinary meatus when placing a Foley catheter, indwelling or intermittent - to provide hygiene to the patient's perineum

Nursing Diagnosis (ICNP nursing diagnoses related to hygiene)

1. Hygiene self-care deficit - SOB with activity, strong body odor, unkempt hair, patient admits that he is not able to care for himself "like he used to" 2. Readiness for enhanced self-care - Patient is able to get out of bed and stand at sink, patient is expressing a desire to be independent in ADLS. 3. Ineffective health maintenance - Impaired ability to understand, cognitive changes, poor hygiene, unkempt appearance, halitosis 4. Risk for impaired skin integrity 5. Risk for infection 6. Impaired tissue perfusion

Partial Bed Bath:

A partial bed bath is performed when ONLY PART OF THE BODY IS WASHED. Some patients want to wash their hands and face before breakfast. Others need perineal care after using the bedpan. Many patients can independently perform parts of the bath but need help with washing their back and feet. After assessment, the nurse may decide to do a partial bath if a patient has extremely dry skin. Many older adults find that a complete bath daily causes excessive drying of their skin. If a patient cannot tolerate a complete bed bath because of weakness or activity intolerance, the nurse washes only the areas where skin problems could develop or are causing discomfort.

Alterations in Structure and Function Affecting Hygiene Care:

A. Ulcers, incisions and wounds B. Decreased sensation C. Alopecia D. Pediculosis E. Nails F. Oral cavity G. Self care alterations H. Diversity considerations

Inversion and eversion are limited to the:

ANKLE NOT THE SAME AS ABDUCTION AND ADDUCTION.

Routine Techniques for Neurological Assessment:

ASSESS mental status and level of consciousness. EVALUATE speech. NOTICE cranial nerve functions. OBSERVE gait. EVALUATE extremities for muscle strength and tone.

The elbow, knee, and ankle all share which type of joint:

Hinge joint

When hair follicles completely die, . . .

alopecia (absence or loss of hair) develops

Additional nipples are present at birth along the embryonic milk line what is this called:

Supernumerary Nipples

PATIENTS WITH A MASTECTOMY: The mastectomy site and axilla should be iINSPECTED for:

Color Rash Irritation Visible edema Thickening Lumps Lymphedema - edema of upper extremity on affected side, due to resection of lymph nodes.

The wrist and toes share which type of joint:

Condyloid

The hand/fingers have which type of joint:

Condyloid hinge

Reddish-purple , non-blanchable spot of variable size. Cause: trauma to the blood vessel resulting in bleeding under the tissue:

Ecchymosis (Bruise)

Techniques for examination of the breast include:

INSPECT both breasts INSPECT the skin of the breasts INSPECT the areolae INSPECT the nipples

Skin, nails, hair, sweat glands, and sebaceous (oil) glands form the:

Integumentary system

ABNORMAL FINDINGS IN MUSCLE STRENGTH: Fasciculation

Involuntary twitching movements of a localized muscle group. (similar to twitching of eyelids) Note by inspection or palpation. Etiology: - Medication side effects - Cerebral palsy - Neuralgia - Polio

Lesions that form a line (poison iv, contact dermatitis)

Linear lesion patter

Primary lesions:

freckles, patches, and comedones (acne)

Hypotonicity

having abnormally low tension or tone, esp. of the muscles.

Secondary lesions:

injury to skin, scar

Mucous membranes of the lips, nostrils, anus, urethra, and vagina join seamlessly with the:

skin

Inspect the client in the standing position - Scoliosis

lateral curvature of the spine. School nurses can screen this in students Curvature of the spine may create asymmetry of the asymmetry of the shoulders. S shaped curvature

If a patient has been on bed rest doing these types of motions will keep the joints:

limber, supple, and moveable for when they return to their normal activities.

Range of motion is active when the client can

perform it unassisted.

EARLY SIGNS OF MELANOMA: ABCDEF

A - ASYMETRY (NOT ROUND OR OVAL) B - BOARDER (POORLY DEFINED/IRREGULAR BOARDER) C - COLOR (UNEVEN, VARIEGATED) D - DIAMETER (USUALLY GREATER THAN 6 MM) E - ELVATION (RECENT CHANGE FROM FLAT OR RAISED LESIONS) F - FEELING (SENSATION OF ITCHING, TINGLING, OR STINGING WITHIN THE LESION)

ABNORMAL FINDINGS ON INSPECT the skin for localized variations in skin color: Melanoma

Melanoma: The nurse should be familiar with abnormal characteristics of pigmented moles that might point to melanoma. Moles located below the waist or on the scalp or breast ARE RARELY NORMAL MOLES. Vitiligo is an acquired condition associated with the development of unpigmented patch or patches: it is common in dark-skinned races and throughout to be an autoimmune disorder. Localized areas of hyperpigmentation may be associated with endocrine disorder (pituitary adrenal) and autoimmune disorders (systemic lupus erythematosus)

Assessment of Intellectual Function:

Memory Knowledge Abstract Thinking Association Judgement

INSPECT the scrotum for color, texture, surface characteristics, and position:

Move the penis out of the way with the back of your hand (or ask the patient to hold the penis out of the way) while you inspect the scrotum. The scrotal sac is divided in half by the septum; the two sides appear asymmetric. Left testicle is lower than the right because of longer spermatic cord. Scrotal skin is more deeply pigmented and has a coarse appearance (without lesions) than the body skin. the color should be consistent. Rugae present and hairless Small bumps on the scrotal skin are known as sebaceous cysts or sebaceous glands; they are considered a normal finding. Scrotum rises when environmental temperature is cold Lowers when temperature is hot or when client is febrile (fever) ABNORMAL FINDINGS: Scrotal lesions or scrotal redness (either generalized or isolated) is considered abnormal and may indicate an infection. Excessive differences between the right and left sides are an abnormal finding.

___________ _________ are surfaces that line the passages and cavities of the body, such as nasal, oral, vaginal, urethral, and anal cavities. The outer layer of ________ ________ is composed of epithelial cells? Guess

Mucous membranes

EVALUATE extremities for muscle strength and tone:

Muscle strength may be apart of the musculoskeletal or neurologic system assessment. Ask the patient to flex the muscle being evaluated and resist when you apply opposing force against the muscles. Expect muscle strength to be 5/5, bilaterally symmetric, with full resistance to opposition. -Ask patient to squeeze your hands -With your palms of hands on bottom of feet, ask patient to push down on your hands -Compare both arms (patient flexes forearm against resistance offered by nurses hand = compared right to left extremities) (Patient extends forearm against nurses hand to assess strength of patients hand against hers) (hand strength is also compared by clients grasp of both of nurses hands) -Compare both legs -Strength should be equal bilaterally ABNORMAL FINDINGS: Note muscle weakness (less than 5/5). Paralysis is lack of voluntary movement or movement that is spastic or flaccid. Spastic paralysis occurs with pyramidal tract injury that occurs after a spinal cord injury or cerebrovascular accident (CVA). Flaccid paralysis is the lack of muscle tone and deep tendon reflexes that may occur from spina bifida.

INSPECT muscles for equal symmetry and size

Muscles should appear relatively symmetric bilaterally of extremities. (No person has exact side-to-side symmetry). Muscle circumference can be measured with a cloth or paper tape measure to provide a baseline for future comparisons and make side - to - side comparisons. The dominant side usually is slightly larger than the nondominant side. To ensure consistency of measurement, record the number of centimeters ABOVE or BELOW the joint where the muscle was measured. (or include diagram) ABNORMAL FINDINGS: Atrophy (muscle wasting) of muscle mass bilaterally may indicate lack of nerve stimulation such as a spinal cord injury or malnutrition. Unilateral muscle atrophy may be from disease, from pain of movement, or after removal of a cast. Fasciculations (muscle twitching of a single muscle group) may be caused by adverse effects of drugs. Fasciculations are localized, whereas spasms (involuntary muscle contractions) tend to be more generalized.

Age - related variations of Neurological Assessment: Older Adults

Assessing the neurologic system of an older adult usually follows the same procedure as for the younger adults. Tests for balance and gait of older adults are often assessed to identify those at risk for falls.

G. Self-Care Alterations:

Assessing the patient's level of ability to perform skills such as self-bathing helps the nurse devise an appropriate plan of care and assist the patient plan of care and assist the patient when needed.

Assessment Skin, Hair, Nails, and Oral Activity: BOX 27.3 Health Assessment Questions

Assessment of kin occurs before and during hygiene care. Before care, the nurse asks if the patient has noticed dry skin, rashes, skin changes, or sores. The nurse observes the condition of the exposed skin and notes body odors. During a complete bed bath. the nurse has the opportunity to objectively assess the skin for changes, performing inspection and palpation to note the color, texture, warmth, and intactness of the skin and related structures. After inspection, the nurse documents the skin assessment and calculates the "Braden" score to document the patient's risk for impaired skin integrity. While gathering the health history, the nurse observes the patient's hair for cleanliness and grooming. Poor hygiene practices or self-care deficits are indicated by oily, matted, or tangled hair. Inspection of a patients hair may reveal dandruff = scaling and flaking of scalp skin) or head lice. While assessing the patients peripheral vascular status, the nurse observes the condition of the fingernails and toenails. The nails are assessed for color, thickness, cracking, odor, and capillary refill. Inspection of the oral mucosa and teeth is part of a complete head -to- toes assessment. By inspecting the condition of the patients mouth, the nurse assesses oral hygiene. Broken or missing teeth, red gums halitosis, and open sores are all indications of altered oral health and poor oral hygiene. The nurse assesses for excessive dryness, the color of the oral mucosa, and presence of any sores.

Pre-assessment of muscle strength, joints, and range of motion nursing interventions include:

Assist patient to supine position in bed. HEAD OF BED MAY BE ELEVATED FOR PATIENT COMFORT. Raise bed to comfortable working height for the nurse. REMEMBER to return the bed to the lowest position when all assessments are complete

HIPS SUPINE PALPATE the hips for stability and pain/tenderness:

Assist the patient in a supine position. Use the iliac crests as landmarks. Palpate iliac crests to determine if they are symmetric. Findings should be bilaterally symmetric hips that are stable and painless. With the client in supine: - Palpate for tenderness ABNORMAL FINDINGS: Osteoarthritis or hip dislocation may cause pain and hip instability.

With patient in SUPINE TEST the hips for muscle strength:

Assist the patient to a supine position. Ask him or her to attempt to raise the legs while you try to hold them down. Evaluate one leg at a time, noting if the response is bilaterally strong and if you are unable to interfere with the movement. . Use the criteria from Table 14-3 for grading muscle strength. It should be 5/5 or normal bilaterally. ABNORMAL FINDINGS: An unequal response, weak response, muscular spasm, and pain may be caused by joint or muscle inflammation, trauma, or injuries.

Hygiene and Personal Care

Assisting patients with hygiene (practices such as cleanliness that promote and preserve health) is an essential part of patient care. The hospitalized patient may depend on the nurse for basic care that is usually completed independently at home. These practices vary according to personal habits, cultural beliefs, ethnic customs, and age. During patient care, the nurse communicates with the patient, assesses the skin, and observes for any abnormalities. Bathing cleans the skin, removes organisms that can cause infection and odor, provides comfort and contributes to the patient's health and well-being.

Epidermis:

Avascular = direct blood supply. Outermost layer from which dead cells slough off. Keratinization = in which keratin (a protein) is deposited, causing cells to become flat, hard, and waterproof. Hair shafts Sweat glands Melanocytes = located in the basal cell layer of the epidermis, secret melanin, which provides pigment for the skin and air and serves as a shield against ultraviolet radiation.

During hygiene care, the nurse cleanses all areas of the integumentary system to maintain healthy tissue, reduce body odor, and enhance comfort. Cleansing rides the skin of

microorganisms that can cause infection and odor.

The salivary glands of the mouth secrete:

mucus, enzymes, and a watery fluid, which mix to form saliva.

Range of motion is passive when the client needs assistance to

perform the motions.

Always explain the procedure to the patient before you begin. Let her know that you will be touching her breasts and be sure to obtain her permission before you begin the examination. Initially

position the patient so she is sitting on the examination table facing you. provide privacy Direct light source Explain to patient that you will be performing a breast exam. Ask permission to touch breasts Ask patient to remove clothing above waist Place patient in a sitting position Embarrassment experienced by the examiner- consider the therapeutic benefit of the clinical breast exam to client She should be sitting erect with her gown dropped to the waist.

Male Perineal Care:

provided during a bath or incontinence episode. some cultures it is taboo for an unrelated female to touch male genitals. If patient or family request same sex, it is honored. A male patient may have an erection during care, which is a normal response to tactile stimulation = ignore it or return later to complete care. Document is part of hygiene care. Document any redness, drainage, odor, edema, or skin changes,

Diarthrodial joints are further classified by their type of movement. Only the diathrodial joints have one or more:

ranges of motion (Table 14-1)

Documentation of hygiene care:

redness drainage odor edema skin changes

Ambu bag is a:

resuscitator bag that is used to assist ventilation.

Located in the dermis, sebaceous glands, secret an oily substance called:

sebum that keeps the hair and skin soft. If left unwashed, hair becomes oily as a result of these secretions.

The Bartholin Glands are:

small and round, located in either side of the introitus, at approximately the 5 and 7 o ' clock positions. The ducts of the Bartholin's glands open onto the sides of the vestibule in the space between the hymen and the labia minora. The ductal openings are usually not visible. During sexual excitement Bartholin's glands secrete a mucoid material into the vaginal orifice for lubrication.

Nails arise from the epidermis and are composed of keratinized epithelial cells. They grow from the nail matrix. Unlike skin, nails do not slough off and must be cut. Normal nails are:

smooth and pink

Crepitus

the crackling sound produced by bone fragments or articular surfaces rubbing together.

Skin is composed of three layers that are functionally related:

the epidermis; the dermis; and the subcutaneous layer, also known as the hypodermis.

Vascular lesions:

Bruising Telangiectasia: permanent dilation of blood cells, a fine, irregular line. Cherry angioma: bright red dot on face, neck, and trunk these increase in size and number with advanced age.

Breast Awareness is:

- Is a form of secondary prevention - American Cancer Society recommends that patients know how their breasts normally look and feel, known as Breast Awareness. Teaching Breast Awareness to patients - Recommended for all women > age 20 yrs., monthly - Palpation while lying down using the vertical strip method - Inspect in front of mirror with hands on hips - Palpation of axilla with same arm raised slightly

Pre-Assessment techniques before assessing patients Neurologic system:

- Knock of door first - Wash hands and introduce yourself to the patient. - Explain to the patient what it is that you are going to be doin.

ASSESSMENT OF SPECIFIC REGIONS OF THE MUSCULOSKELETAL SYSTEM BEGINS:

Gait Shoulders Arms, elbows, hands Hips Legs, knee, and feet

Female Internal Structures:

Vagina, Uterus, Fallopian Tube, and Ovaries

BENIGN BREAST DISEASE (noncancerous breast conditions):

account for 90% of clinical breast problems.

ABNORMALITIES OF GAIT: Kyphosis

exaggerated thoracic curve occurs with osteoporosis

Planning (nursing process related to hygiene): During the planning stage of the nursing process, the nurse prioritizes identified hygiene-related nursing diagnoses based on patient needs and recognized risks. Nursing care plans are developed for each nursing diagnosis after considering the patients self abilities, available resources, and family involvement. Setting realistic goals helps the nurse develop a plan of care that will enable the patient to meet goals. Collaboration with other health care professionals, patients, and families is necessary when setting long-and-short term goals.

- "Patient will accept assistance with hygiene within 24 hours." - "Patient will perform 100% of ADLS while hospitalized." - "Patient will remain free of body odors during hospitalization."

Bones of Skull and Neck

- 6 bones of cranium (one frontal, two parietal, two temporal, and one occipital) are fused together. - The face consists of 14 bones that protect facial structures. - bones are immobile and are fused at sutures, with the exception of the mandible (allowing movement of jaw up, down, in, out, and from side to side) - Neck is supported by the cervical vertebrae, ligaments, and the sternocleidomastoid and trapezius muscles.

Cultural and Ethnic variations of Hair

- African Americans - fine or thick, curly - Curly facial hair in men may cause razor bumps - Asians, Pacific Islanders, Native Americans - straight, coarse hair - Asian and Native American men have less body and facial hair - Native American females have balding patterns: men do not

- Nurse's preparation for a perineal exam ( genitalia exam)

- Ask patient to empty bladder - Provide privacy for patient by pulling curtain around bedside - She should be instructed to undress and put on a gown. Some women may be more comfortable wearing their socks. - Tell patient in advance what you are will do next during exam (what you are doing, what you are seeing or feeling, and how long). Touch the inner aspect of her thigh before you touch the external genitalia. (do not be tentative with touch, once contact is made, maintain it throughout the procedure) - KNOW woman may feel apprehensive about having their genitalia examined, especially if the nurse is a male. If necessary, arrange female assistant. - Assist patient to the dorsal recumbent position. Lithotomy position for an internal vaginal exam comes under Advanced Practice nursing. - completely cover sheet over the patients lower abdomen and upper legs, exposing only the vulva for examination. - Push sheet down so you can see the woman's face as you proceed. - Ask if she would like her head elevated so she can see you better if embarrassed or uncomfortable. - Perform hand hygiene - Don exam gloves

TSE procedure - www.cancer.org Testicular Self Examination - Secondary

- Best time to do TSE - during or after a shower - Teach patient to palpate 1 testicle at a time, using thumb and fingers - Patient should note any hard or smooth rounded lumps, change in size, shape or consistency of testicle - Like BSE, goal of this secondary prevention is detection of a change from the normal

BOX 27.4 INTERPROFESSIONAL COLLABORATION AND DELEGATION: HYGIENE CARE

- Collaboration with colleagues is necessary when a patient requires a caregiver of the same sex for personal care because of cultural or religious reasons or personal preference. - Family members or friends need to be involved in goal setting if the patient needs assistance with self-care activities after discharge from the hospital. - Some aspects of personal care and hygiene may be DELEGATED TO AN UNLICENSED ASSISTIVE PERSONNEL AFTER ASSESSMENT OF THE PATIENT AND SPECIFIC INSTRUCTION. - Interprofessional collaboration with physical therapists for assessment of the patient's motor abilities and with occupational therapists for evaluation of the patient's activities of daily living may be necessary.

Routine Techniques in each specific musculoskeletal region the nurse performs the skills of:

- INSPECTION of skeleton and extremities. - INSPECTION of muscles. - PALPATE bones, joints, and muscles. - OBSERVE/GUIDE range of motion and adjacent muscles. - TEST muscle strength and compare sides.

Client Safety in the Hospital:

- Orientation: of patient (are they awake, alert, oriented x3) - Call Bell: within arm reach of the patient (teach them how to use the call bell to alert the nurse) - Lighting: sometimes patients prefer lights off but this could be hazardous to the patient. - Bedside Commode: want to make sure that it is close enough for the patient to get to it but not too close to bump into or fall over. - Side Rails: A MUST top 2 side rails always need to be up. Patient uses to turn in bed. can put one of the bottom side rails up if the nurse thinks it will keep the patient from not getting out at one side of the bed. WE CAN NEVER PUT UP ALL 4 SIDERAILS UNLESS WE HAVE A DOCTORS ORDER IT IS CONSIDERED A RESTRAINT. JERRY CHAIR not considered restraints but we can be alerted when an un-oriented patient tries to move from a chair or bed. - Breaks need to always be engaged. Only take the break off if you are moving the bed to put a patient onto the stretcher. If they were going down for some kind of test. If u release the break a very loud alarm goes off. - When A PATIENT gets into or out of a wheelchair LOCKS MUST BE ONE.

Pre-assessment nursing interventions and PPE required for a Musculoskeletal exam include:

- Perform hand hygiene - DON PPE of Protective Eyewear = Goggles, Safety glasses, Shield - Exam gloves - Position patient sitting at the edge of the bed OR standing position.

Preparing for the Male Examination Nursing Interventions for Assessment:

- Perform hand hygiene - Don exam gloves, if not already completed - Ask or assist patient to a supine position - Raise bed to comfortable working height for nurse - Remember to return bed to lowest position when all assessments are complete. - Men may feel apprehensive having, especially if the nurse is female. - This may be seen as an invasion of privacy rather than accepted as a necessary component of examination. - As a nurse you must be aware of these concerns and approach the genitalia examination in a professional, matter-of-fact way, projecting confidence throughout the examination.

Functions of the Skin

- Provides protection to the body from microbial invasion - Retains fluids and electrolytes in the body - Provides body with sensory input re: temperature, hot surfaces - Production of Vitamin D - Excretion of sweat, urea and lactic acid - Can repair itself when injured - Can provide clues to a disease

With the client supine: PALPATE the knees for contour, tenderness, and edema:

-First palpate the suprapatellar pouch on each side of the quadriceps with the thumbs and fingers of both hands. Compare one side to the other. (knees should feel smooth) -With the knee flexed to 90 degrees, palpate over the medial and lateral aspects of the tibiofemoral joint space -Palpate the popliteal space (Joint should feel firm and smooth) ABNORMAL FINDINGS: Edema, heat, or pain may occur from rheumatoid arthritis, osteoarthritis, or bursitis. (Tenderness and Edema is abnormal)

Client Stressors = Risk for injury Psychological

Depression Anxiety Developmental Decreased agility Poor vision Decreased mobility

Male A & P

2 Testicles - Oval shaped - Smooth - Rubbery texture Scrotum - Has rugae (wrinkles) - Darker pigmentation than overall skin color - Maintains temperature of testicles to promote sperm viability Penis - Urethral meatus should be located at the tip of the penis - Male breast undergoes very little development after birth.

Reduction of Procedure - Related and Equipment - Related Events:

A break in sterile technique or contamination of a Foley catheter during insertion may result in a catheter associated urinary tract infection (CAUTI). Catheter-associated UTIS are considered to be reasonably preventable errors for which the cost of treatment is no longer covered. Nasogastric tube for temporary tube feedings. If the correct placement of the tube is not verified radiologically before administering feedings or the tube becomes dislodged during the course of the routine care, aspiration pneumonia may result. Injuries = improper equipment maintenance/malfunction If routine quality-control checks on equipment such as blood glucose meters are not performed, inaccurate readings and inappropriate insulin coverage, with associated hyperglycemia or hypoglycemia. Radiation diagnostics or treatments = Lead Stay far away from radiation source for as long as possible check radiation badge.

Complete Bed Bath:

A complete bed bath is performed for patients who are bedridden or depend totally on others for care. Nurses or Unlicensed assistive personnel (UAP) wash the patient and perform passive range-of-motion exercises as appropriate. Assessment of the patients tolerance of this activity is essential before the bath. Equipment used during the bath is facility-specific and tailored to patient needs. Some facilities use bath basins, wash clothes, towels, and soap or skin cleanser, whereas others use prepackaged bath cloths. The packages contain several, premoistened, disposable, no-rinse cloths that can be used instead of soap and water.

Neurological System Assessment

A concept related to this chapter is Intracranial Regulation. The nervous system controls body functions through voluntary and autonomic responses to external and internal stimuli. Structural divisions of the nervous system are the central nervous system (CNS), which consists of the brain and spinal cord; the peripheral nervous system; and the autonomic nervous system.

D. Pediculosis:

A contagious scalp infection, pediculosis, is caused by Pedicullus humanus capitis. This disorder is more commonly known as head lice. Transmission occur through CONTACT with infested personal items such as combs, hats, or linens. Symptoms of pediculosis are: itching and redness of scalp if left untreated = secondary bacterial infection.

Problem - Based History - Problems with Daily Activities

ADLS Which activities are limited? To what extent are your daily activities limited? How do you compensate for this limitation? - Bathing - (getting in and out of the tub, turning faucets on or off) - Eating - (preparing meals, pouring, holding utensils, cutting food, bringing food to your mouth, *DYSPHAGIA* = swallowing, drinking) - Dressing - (buttoning, zipping, hooking your brassiere, pulling a dress or skirt over your head) - Toileting - (urinating, defecating, ability to raise or lower yourself onto or off of the toilet) - Grooming - (shaving, brushing teeth, brushing or combing hair, washing and drying drying hair, applying makeup) - Moving around - (walking, going up or down stairs, getting in or out of bed, getting out of the house) - Sleeping - (getting into and out of bed, moving in bed) - Communicating - (writing, talking, using the telephone) Any impair mobility or function may interfere with the persons ability to perform self-care activities. The nurse asks the patient to identify which activities: - are impaired ? - to what extent ? - how her or she compensates ?

INSPECT the skin for localized variations in skin color:

ALMOST all healthy individuals have natural variations in skin pigmentation. A common intentional localized variation in skin color is a tattoo. IF a tattoo present, its location and characteristics of the surrounding areas should be examined and documented. NORMAL LOCALIZED VARIATIONS OF THE SKIN PIGMENTATION INCLUDE THE FOLLOWING: Pigmented nevi (moles): Mole are most commonly located above the waist on sun-exposed body surfaces (chest, back, arms, legs, and face). They tend to be uniformly tan to dark brown, less than 5 mm in size. can be raised or flat, clearly defined oval shape with boarder. Freckles: Freckles are small, flat, hyperpigmented macules that may appear anywhere on the body, particularly on sun exposed areas of the skin. (face, arms, back) Patch: A patch is an area of darker skin pigmentation that is usually brown or tan and typically is present at birth (birth marks). Some of these patches pade, but many do not change over time. Striae: Striae are silver pink "stretch marks" secondary tp weight gain or pregnancy. - weight gain - pregnancy

Lymphedema is a localized:

Accumulation of lymph fluid in the interstitial spaces caused by removal of the lymph nodes.

F. Oral Cavity:

Alterations in the health of the oral cavity can affect the patients ability to chew or overall health. Sores anywhere in the oral cavity, gingivitis (inflammation of gums), and broken or missing teeth create problems with chewing. Certain medications cause the mouth to be dry, creating discomfort for the patient. Halitosis = unpleasant breath odor (may result from poor dental hygiene, fungal or bacterial infections, and complications of medical conditions such as diabetic ketoacidosis or renal failure. Oral health = diligent oral hygiene

Disorders of the Central Nervous System: Craniocerebral Injury (Head Injury)

Any injury to the scalp, skull, or brain that is sufficient to alter normal function can result in craniocerebral injury. Open head injuries result from fractures or penetrating wounds; closed head injuries result from blunt head injury producing cerebral concussion or contusion. Clinical Findings: - residual deficits in memory, cognition, and motor and sensory abilities depend on the extent of injury to the brain.

A. Ulcers, Incisions, and Wounds:

Any interruption in the skin, which is the body's first line of defense, may lead to infection. Excessively dry skin can lead to cracks and openings in the integumentary system. Excoriation = (red, scaly areas with surface loss of skin tissue) occurs in patients whose skin is exposed to bodily fluids such as stool, urine, or gastric juices. Excoriation also occurs in areas where skin rests on skin such as in the = AXILLA (armpit), under large, pendulous breasts, or in abdominal folds.

Then move on to HIPS As the patient STANDS (anatomical position) INSPECT the hips for symmetry: What range of motion is done here while the patient is in a standing position?

Ask the patient to STAND. Look at the symmetry of the hips anteriorly and posteriorly. The hips should be the same height and symmetric. You may need to move the patient's clothing aside to visualize the hips. ABNORMAL FINDINGS: Asymmetric hips may occur from curvature of the spine, hip deformities, or unequal leg length. ROM HYPERTENSION DONE HERE - Hyperextension: Move leg behind the body.

INSPECT the shoulders and cervical, thoracic, and lumbar spine for alignment and symmetry:

Ask the patient to stand; while you stand to his or her side, observe the cervical concave, the thoracic convex, and the lumbar concave. Looking for symmetry, equal height, and equal contour. Note the landmarks on the back: spinous processes protruding slightly at C7 and T1, paravertebral muscles, and the alignment across the iliac crests at L4 and the posterior superior iliac spine at S2. (Ask the patient to touch the toes. Move behind the patient to inspect the spine.) EXPECTED FINDINGS: Expected concave and convex curves should be present. Vertebrae should be aligned, indicating a straight spine. Shoulders should be level or at equal heights, indicating symmetry. Posterior thoraces should be symmetric when patient touches his or her toes. ABNORMAL FINDINGS: - Kyphosis - Lordosis - Scoliosis

OBSERVE gait for conformity, rhythm, and symmetry: (Gait - the mechanism of walking)

Ask the patient to walk across the room and back. EXPECTED FINDINGS: Conformity = (ability to follow gait sequencing of both stance and swing if right foot goes forward so does the left arm, if the left foot goes forward so does the right arm.) Rhythm = (regular, smooth rhythm with movement of swing on both limbs) Symmetry = (length of leg swing: smooth swaying; and smooth, symmetric arm swing) When unequal leg length is suspected, measure the leg from the anterior superior iliac spine to the medial malleolus, crossing the knee on the medial side. FIG 14-14 page 286 ABNORMAL FINDINGS: An unstable or exaggerated gait, limp, irregular stride length, arm swing that is unrelated to gait, or any other inability to maintain straight posture or asymmetry of body parts requires further assessment. Pain, immobile joints, and muscle weakness are usually unilateral and cause asymmetric abnormalities in gait. Disorders of the neurologic system such as rigidity or cerebellar diseases cause symmetric abnormalities in gait.

Specific regions of M-S System: Arms OBSERVE the elbows for range of motion:

Assess pronation and supination of the elbow by having the patient rotate the hand's palms up and palms down. Movement should be bilaterally equal and without pain. The patient should demonstrate pronation and supination while keeping the lower arm flexed 90 degrees at the elbow. term-56 ABNORMAL FINDINGS: Limitation of motion, asymmetry of movement, or pain at the elbow may require further evaluation.

Assessment of each cranial nerve individually is an advance practice nursing skill and is usually performed when the nurse suspects an abnormal finding of general cranial nerve function. The assessment here is assessment of all cranial nerve functions in a more generalized approach: SENSORY NOTICE cranial nerve functions:

Assesses sensory functions - what is felt by the patient. Assess motor functions - voluntary movement by patient. Assessing cranial nerves is not performed ordinarily during a routine examination. They are assessed when you suspect an abnormal finding of one or more of the cranial nerves. However, you collect data about the expected cranial nerve functions during the interview. If you notice the following expected findings, you document "CN II-CN XII grossly intact"

The hips andshoulderhas which type of joint:

Ball and socket

Bathing and Skin Care:

Bathing and skin care are essential components of patient care. The amount of assistance patients need depends on their self-care abilities. Hygiene teaching can be incorporated throughout care. There are many method of bathing a patient, depending on the setting and the equipment available. Individual bathing preferences should be taken into account when planning bathing care. Bathing removes dead skin, bacteria, and body fluids that build up on the skin. Keeping the skin clean and dry can help prevent problems caused by breakdown of the skin. Bathing provides comfort and is a therapeutic intervention; it offers relaxation and skin benefits such as prevention of maceration = breakdown of skin caused by fluids) and infection caused by breeding microorganisms. After the bath, the nurse documents the type of care performed, date and time, skin assessment, and the patients current position, ability to assist, and response to bathing. QSEN FOCUS: Patient - centered hygiene care integrates an understanding of patient and family preferences and values, coordination of care, provision of physical comfort, and emotional support. The nurses elicits the patients values and preferences when planning care.

Palpation Results of: - Bones: - Joints: - Muscles:

Bones - Tenderness = should be absent. Joints - Tenderness = should be absent. - Heat = should be absent. - Edema = should be absent. Muscles - Tenderness = should be absent. - Heat = should be absent. - Edema = should be absent. - Tone = should be equal bilaterally, well developed.

EXAMINE stool characteristics and presence of occult blood: Slowly removed the gloved finger from the patients rectum. Inspect the gloved finger for color and consistency of stool. It should be brown and soft. Use a GUAIAC TEST TO EVALUATE FOR OCCULT BLOOD. A NEGATIVE RESPONSE IS EXPECTED: Stool color and significance:

Bright red blood - bleeding from hemorrhoids or lower rectum Tarry black - Upper intestinal bleeding Excessive iron supplementation Bismuth ingestion Pepto bismol Light gray or tan - obstruction of liver or gallbladder, biliary tract (obstructive jaundice) Pale yellow - malabsorption syndrome ABNORMAL FINDINGS: ALSO REPORT presence of blood, pus, mucous, or abnormal color of stool.

Dentures:

Care of dentures (artificial teeth) should be performed at least every morning and evening. The nurse or UAP performs this procedure for patients who cannot clean their own dentures. Denture care is performed wearing gloves.

Lateral View: Cervical Concave, Thoracic Convex, and Lumbar Concave Normal Curves:

Cervical concave and Lumbar concave curves mirror each other (both have the same curvature) while the Thoracic convex has an opposite curvature in comparison to the cervical and lumbar areas.

Palpation with continuous contact:

Circular Method: place the finger pads of your middle three fingers against the outer edge of the breast. Press gently in small circles around the breast until you reach the nipple. Try not to life your fingers off the breast as you move from one point to another. Wedge Method: Place the finger pads of your three middle fingers on the areola and palpate from the center of the breast outward. Return your fingers to the areola and again palpate from the center outward, covering another section of the breast (in a spokelike fashion). Repeat this until the entire breast had been covered. Vertical Strip Method: Place the finger pads of your middle three fingers against the top outer edge of the breast. Palpate downward and then upward, working your way across the entire breast.

Specific regions of M-S System: Arms INSPECT the joints of the wrists and hands for symmetry, alignment, and number of digits:

Compare the right wrist and hand with the left. They should be symmetric. The hand with five digits is aligned with the wrist, and the fingers are aligned with the wrist and forearm. Symmetry Contour = No deformities Equal # of digits bilaterally ABNORMAL FINDINGS: Missing fingers are recorded. Osteoarthritis may cause Bouchard nodes in the proximal interphalangeal (PIP) joints, whereas Heberden nodes form in the distal interphalangeal (DIP) joints. Swan-neck and boutonniere deformities of interphalangeal joints may be related to rheumatoid arthritis.

Lesions that merge and run together over large areas (pityriasis rosea):

Confluent lesion pattern

Age - related variations of Neurological Assessment: Infants and Children

Neonates and infants have age-dependent reflexes that are assessed. Children's motor development is compared with standardized tables of normal age and sequences of motor development. Assessment of older child and adolescent follows the same procedures as for adults and reveals similar expected findings.

Eye care:

Eye care is part of the bathing routine. Eyes are washed with plain water from the inner to the outer canthus, using a different part of the washcloth for each eye. If the patient has dry, crusty drainage around the eyes or on the eyelids, a washcloth moistened with warm water or gauze moistened with saline can be applied. For patients whose eyes do not totally close at night, an eye patch and prescribed eyedrops may be necessary to prevent corneal drying. - Visual aids (glasses/contact lenses know the type of lenses) - Prosthetic eye (removed for cleaning)

Client Stressors = Risk for Injury Physiological

Dizziness Poor oxygenation Incontinent Confusion

General Health History - Present Health Status

Do you have any chronic disease? Loss of bone density or osteoporosis? - Chronic disease may affect mobility and activities of daily living. Reduction in weight - bearing activities contributes to loss of bone density and osteoporosis. Osteoporosis may lead to a decrease in height. Do you take any medications? If yes, what do you take and how often? Are you taking medications as they were prescribed? - Both prescription and over-the-counter medications should be documented. Patients may not report musculoskeletal problems if they are being treated successfully with over-the-counter and/or prescription medications. Have you noticed any changes in your ability to move around or participate in your usual activities? Have you noticed any changes in your muscle strength? What do you do to adapt to these changes? - If there are changes, they can be diagnosed and treated an early stage, or they can generate a discussion about hoe to prevent further changes. The health care provider needs to determine how the patient is adapting to these changes to determine their impact on his or her quality of life.

Hair:

Each hair consists of a root, a shaft, and a follicle (the root and its covering) Papilla = capillary loop that supplies nourishments for growth. Melanocytes within the hair shaft provide color.

PATIENT EDUCATION AND HEALTH LITERACY = ALOPECIA

Educate patients undergoing treatments (chemotherapy) that cause alopecia about when hair loss will occur, special care of the scalp, and protection of the skin. Arrange referrals to beauticians or barbers affiliated with the health care facility for patients who want to have their cut shorter before hair loss begins. Provide resources such as where the patient can obtain a wig or find a support group. Make available to patients any information on community agencies that may be helpful in providing care during chemotherapy.

TABLE 14-1 RANGE OF MOTION FOR DIARTHRODIAL JOINTS: - ELBOW - WRIST

Elbow: - Flexion: Bend elbow so lower arm moves toward its shoulder joint and hand is level with shoulder. - Extension: Straighten elbow by lowering hand. - Hyperextension: Bend lower arm back as far as possible. Not all elbows hyperextend. Wrist: - Flexion: Move palm toward inner aspect of the forearm. - Extension: Move fingers so fingers, hands, and forearm are in the same plane. - Hyperextension: Bring dorsal surface to hand back as far as possible. - Radial flexion: Bend wrist medially toward thumb. - Ulnar flexion: Bend wrist laterally toward fifth finger; referred to as radial/ulnar deviation.

Nails:

Epidermal cells converted into hard keratin plates. Nails assist in grasping small objects and protect the finger tips from trauma. Composed of a free edge, the nail plate, and the nail root. lunula = new nail growth at root Under nail plate is highly vascular, providing cues to oxygenation status and blood perfusion.

With the client in supine: OBSERVE/guide the knee for range of motion:

Evaluate the range of motion by having the patient flex the knees. If the knee is able to hyperextend, it should reach 15 degrees from the extended position (midline). Flexion Extension POSSIBILTIY Hyperextend ABNORMAL FINDINGS: A decrease in the range of motion may occur as a result of arthritis, trauma, or ligament, tendon, or meniscus injury.

PALPATE the breasts for tissue characteristics: FINDINGS and ABNORMAL FINDINGS

FINDINGS: the breast should feel firm, smooth, and elastic without the presence of lumps or nodules. Typically it should be nontender on palpation. After pregnancy or menopause the breast tissue may feel softer and looser. During the premenstrual period the patients breasts may be engorged, be slightly tender, and have generalized nodularity. Most women have a firm transverse ridge along the lower edge of the breast termed the INFRAMAMMARY RIDGE. This firm ridge is normal and should be mistaken for a breast mass. ABNORMAL FINDINGS: During the breast palpation include masses or isolated areas of tenderness or pain. Conditions that may cause lumps or masses include breast cancer, fibroadenoma, and fibrocystic changes to the breast. Breast engorgement (in patients who are not pregnant or premenstrual) is also an abnormal finding. - Dimpling or retraction of skin. - Lumps

Fall Prevention:

Falls = are events in which an individual unintentionally and through the force of gravity drops to the ground, floor, or some other lower level. Despite the need for comprehensive fall prevention programs, many interventions are simple and involve manipulation of the environment by the nurse to meet patient needs. FOR EXAMPLE, the call light should be kept within reach and the patient reminded how to use it with each interaction so the patient can call for help. Frequently used items should be kept close to the patient to prevent reaching. *Making hourly rounds ensures that patient needs are met and reduces patient falls in hospital settings.* *Patients who are at high risk for falling should be placed in rooms close to the nurses' station, and pressure-sensitive alarms can be used to alert staff about attempts to get out of bed Ex. Jerry Chairs" * SOME PATIENTS MAY REQUIRE A 24 HOUR SITTER FOR OBSERVATION. Some facilities also have virtual video monitoring to reduce the likelihood of falls. Nurses can intervene in the care environment to promote patient safety bY ensuring that BREAKS ARE ALWAYS APPLIED ON BEDS AND THAT SAFETY LOCKS ARE EMPLOYED ON WHEELCHAIRS. Using the brakes on beds and wheelchairs prevents the device from moving if a patient tries to get to a standing position w/o assistance. Other environmental adaptions that have been made in many health care facilities include the installation of grab bars near toilets and in showers so that patients who are unsteady have something sturdy to hold on to.

Risk Factors for Breast Cancer:

Females 99% more likely than in males. 1 in 8 cases < age 45: 2 in 3 cases > age 55. Caucasian women have slightly higher incidences than African Americans. African American woman have more deaths from disease and incidence < age 45. History of disease in 1st degree relative: 1 relative with breast cancer = 2x at risk. 2 relatives with breast cancer = 3x at risk. Personal history of breast cancer. Exposure to radiation treatments to the chest at a young age. Menarche (onset of menstruation) before age of 12 years. Patients who have dense breast tissue (sometimes hard to visualize on monography) MODIFABLE RISK FACTORS: Daily alcohol intake (2-3 drinks/day) Overweight and obese 1st baby after age 30. History of nulliparity (no pregnancies) History of nulliparity (no pregnancies) Estrogen replacement for > 5 years post menopause Diethylstilbestrol (DES) taken by the female patient (clients daughter at risk also) - Client daughter at risk also = drug no longer used. if seen in patient we will screen for breast cancer.

Brest Tissue Abnormalities: Fibrocystic: Fibroadenoma: Cancerous:

Fibrocystic changes to the breast: (noncancerous) multiple benign mases within the breast caused by ductal enlargement and the formation of fluid-filled cysts, commonly seen among middle-aged women. Clinical Finding: Typically cyst manifest as one or more palpable masses that are rounded, well-delineated, mobile, and tender. Fibroadenoma: (noncancerous) This is a common benign breast tumor among YOUNG women that consists of glandular and fibrous tissue. Clinical Findings: small, solitary, firm, rubbery, nontender lump. This tumor does not change premenstrually. Cancerous: unilateral, irregular shape, fixed (non-moveable), non-tender. Lymph node may be palpable in the axilla.

TABLE 14-1 RANGE OF MOTION FOR DIARTHRODIAL JOINTS: HANDS/FINGERS

Fingers: - Flexion: Make a fist - Extension: Straighten fingers. - Hyperextension: Bend fingers back as far as possible. - Abduction: Spread fingers apart. - Adduction: Bring fingers back together. - Opposition: client can touch thumb to base of each finger of same hand.

Unstageable ulcer:

Full-thickness tissue loss ulcer covered by slough (yellow, tan, gray-green, or brown) and or eschar (tan, brown, or black) True depth of the wound cannot be determined until the slough and/or eschar is/are removed to expose the base of wound.

Specific regions of M-S System: Arms TEST for muscle strength of fingers:

First ask the patient to extend and spread the fingers (both hands) while you attempt to push them together. The response should be symmetric to full flexion and extension, without discomfort and with sufficient muscle strength to overcome the resistance you apply. Next have the patient grip (squeeze) your first two fingers on each hand. The response should be bilaterally equal, and the grip tight and full flexion. Some nurses cross their hands for the patient to grip the fingers so the patients right hand is gripping the nurses right hand. This maneuver helps the nurse remember on which side the patient may have deficits. ABNORMAL FINDINGS: Weak muscle strength and impaired range of motion may accompany rheumatoid arthritis and osteoarthritis. Fractures of metatarsals or phalanges may weaken the muscle strength.

GUIDE CLIENT VERBALLY THROUGH RANGE OF MOTION OF SHOULDERS: OBSERVE the shoulders for range of motion and symmetry. NOTICE any crepitation or report of pain:

Flexion: Raising arm from side position to above head. Extension and hypertension: Ask the patient to extend the arms straight up beside the ears. bilaterally equal and cause no discomfort. Ask the patient to hyperextend the arms backward. bilaterally equal and cause no discomfort. Abduction and adduction: Ask patient to lift both arms laterally over his or her head. Then ask the patient to swing each arm across the front of the body. External rotation: To test external rotation, have the patient place the hands behind the head with elbow out. Movement should be bilaterally equal and without discomfort. Internal rotation: To test internal rotation, ask the patient to place the hands at the "small" of the back. movements bilaterally equal and without discomfort. ABNORMAL FINDINGS: Limited range of motion, pain with movement, crepitation, and asymmetry may require further evaluation. Degenerative joint changes or sports injuries may impair range of motion.

OBSERVE the toes range of motion:

Flexion: curling of toes Extension: Straightening of toes Abduction: Fanning of toes Adduction: brings toes back together

TABLE 14-1 RANGE OF MOTION FOR DIARTHRODIAL JOINTS: - FOOT/ANKLES

Foot: - Dorsiflexion: Move foot so toes are pointed upward. - Plantar flexion: Move foot so toes are pointed downward. - Inversion: Turn sole of foot medially. - Eversion: Turn sole of foot laterally. Ankle: - Flexion: Bring heel back toward back of thigh (point toe) - Extension: Return heel to floor.

E. Nails:

Fungal, bacterial, and viral infections of the fingernails and toenails occur that cause discoloration or thickening of the nails. Some patients have a decreased ability to heal due to poor circulation. Any cut in the skin can lead to an ulcer in these patients. An order from the primary care provider (PCP) may be necessary for nail trimming, or a podiatrist may be consulted.

Lesions that are scattered all over the body (herpes varicella)

Generalize

(Before sending patient home, get an assessment of their environment) Fall Assessment:

Get a good assessment of the home environment from the client/family. Mobility issues = walkers/devices used always. Identify clients at risk. Home hazards assessment (interior & exterior environment) Risk for fall

The feet have which type of joint:

Gliding joint

Safety During Patient Hygiene: (Bed Bath)

Good body mechanics Raise the bed (at the waist) Have supplies on the bedside table and within reach Have ALL SUPPLIES NEEDED you do not want to leave the patient at any time. If making an occupied bed - ASK FOR HELP (easier for you and safer for patient) LOWER THE BED WHEN BATH AND OCCUPIED BED CHANGE IS COMPLETED. Place the call bell within patients reach.

Specific Regions of M-S System: Arms TEST the arms for muscle strength: ARMS TRICEPS BICEPS Can client pull against nurse's resistance? 0-5 scale

Have the patient hold the arms up while you are try to push them down. Remember to compare one side with the other. They should be strong bilaterally, preventing you from moving them out of position. To test triceps muscle strength, ask the patient to extend the arm while you resist by pushing it to a flexed position. Expected stretch is recorded as 5/5. To test bicep strength, have the patient try to flex the arm while you try to extend his or her forearm. You should be unable to move the arm out of position, and strength should be equal bilaterally, documented as 5/5. ABNORMAL FINDINGS: unequal response, weak response, muscular spasm, and pain may be caused by joint or muscle inflammation, trauma, or injuries.

ASSESS mental status and level of consciousness:

Greet the patient. The patient is expected to turn toward you and respond appropriately. Ask the patient his or her name? Where he or she is? What is todays date? to assess knowledge of person, place, and time. Oriented x3. While taking the patients history, you gather data about his or her mental status. Patient should be able to respond appropriately. Patient can use clock and orientation board in hospital room in acute care settings. ABNORMAL FINDINGS: Patient who do not know their name or location are disoriented. Patients may be awake (aroused), but not aware (unable to respond to questions). For example, patients in a persistent vegetative state are not conscious, they are awake, but unable to speak or respond to any questions. Those who require excessive stimulation or even painful stimuli to respond have a decrease in level of consciousness. A change in level of consciousness is the first sign of impaired cerebral function. MENTAL STATUS (abnormalities) Patient does not know name (orientation to person) Patient does not know where they are (orientation to place) Patient does not know the day, date, or time of day (orientation to time) CONSCIOUSNESS STATUS (abnormalities): Patient does not arouse to voice or light touch Nurse must provide excessive stimuli to awaken Nurse may need to provide firm pressure to patient nailbeds or rub sternum to elicit a patient response

INSPECT the pubic hair and skin over the mons pubis and inguinal area for distribution and surface characteristics:

Hair distribution varies but usually covers an inverse triangle with the base over the mons pubis: some hair may extend up midline toward the umbilicus. Some women shave their pubic hair as a matter of preference. When this is the case, it is considered a normal variation. The skin should be smooth and clear. ABNORMAL FINDINGS Note any male hair distribution (diamond-shaped pattern), patchy loss of hair, or absence of hair in any patient over 16 years of age. Observe for presence of skin lesions or infestations (nits or lice) of skin or pubic hair. Monilial infections are red, eroded patches with scaling and pustules and are associated with immobility, systemic antibiotics, and immunologic deficits.

INSPECT pubic hair for distribution and skin for general characteristics:

Hair distribution varies widely but is normally in a diamond-shaped pattern that may extend to the umbilicus. The hair should appear coarser than scalp hair. It should be free of parasites; and the skin should be intact, smooth, and clear. ABNORMAL FINDINGS: Note patchy growth, loss, or absence of hair; distribution of hair in a female pattern (triangular, with the base over the pubis); nits or pubic lice; scars; lower abdominal or inguinal lesions; or a rash. Tinea cruris ("jock itch") is a common (fungal infections) found in the groin that appears as large, clearly marginated, red patches that are pruritic. (Monilial infections) are red eroded patches with scaling and pustules and are associated with immobility, systemic antibiotics, and immunologic deficits.

Appendages:

Hair, nails, and glands (the eccrine sweat glands) are considered appendages. There structures are formed at the junction of the epidermis and the dermis.

TEST shoulders and neck muscles for strength, movement, and symmetry:

Have the patient turn his or her head to the side against your hand: repeat wit the other side. Observe the contraction of the opposite sternocleidomastoid muscle and note the force of movement against your hand. Movement should be smooth, and muscle strength should be strong and symmetric. ABNORMAL FINDINGS: Weakness or pain when pushing against your hand or asymmetry may require further evaluation. Evaluate the spinal accessory nerve (CN XI) for movement. Ask the patient to shrug his or her shoulders upward against your hands. Contraction of the trapezius muscles should be strong and symmetric. ABNORMAL FINDINGS: Unilateral or bilateral muscle weakness or any pain or discomfort may required further evaluation.

Nursing Problem - Based History for Headaches Loss of consciousness (dizziness)

Headache: Describe your headaches. What do they feel like? Where do you feel the pain? How long do they last? How often do you have them? - These questions analyze the symptoms of headaches to help determine the cause. Headaches may be related to compression from tumors or increased intracranial pressure of ischemia from impaired circulation within the brain. (migraine, cluster, and tension) Have you had any recent surgeries or medical procedures such as spinal anesthesia or lumbar puncture? - A transient headache can occur after some diagnostic tests, such as a lumbar puncture. When the patient is in an upright position, the loss of CSF creates tension on the meninges, causing a headache. Loss of Consciousness (dizziness) When did you lose consciousness, have a blackout or faint, or feel that you were not aware of your surroundings? Did the change occur gradually or suddenly? Can you describe what happened to you just before you lost consciousness? Were there other symptoms associated with the change of consciousness. - Loss of consciousness may be caused by cardiovascular disorders. It is also associated with drugs; psychiatric illness; or metabolic diseases such as hypoxia, liver, or kidney failure, or diabetes mellitus.

Reduction of Pathogen Transmission:

Health care - associated infections (HAIs) formerly called nosocomial infections. Key to prevention of pathogen transmission among patients and health care workers is the use of standard precautions, which are practiced with all patients to avoid exposure to blood and other body fluids (urine, stool, sputum, gastric acid), which are all assumed to be infectious. The primary precaution is using proper handwashing or hand - sanitizing techniques before and after each patient contact and procedure. Another important precaution is donning protective equipment.

Fall Prevention at Home:

Health teaching for patients discharged to or residing in the home should include environmental interventions for fall prevention: - Remove obstacles from walking paths (clutter, throw rugs, cords, dog toys, baby toys) - Ensure adequate lighting in areas such as bathrooms, halls, and stairways. - Keep assistive devices (canes, walkers) within reach. - Use assistive devices consistently and properly when moving. - Repair loose or uneven floor and stairway surfaces. OR MINIMIZE THROW RUGS. - Install and maintain handrails and grab bars (firmly securable grab rails specifically in bathroom) - Use devices such as long-handled grabbers rather reaching or stooping. - Keep frequently used items within reach. - Maintain floor surfaces that are dry and free of debris. - Non- slip tread stairs. - Good lighting within stairway. - Enough head room in stair way. - Steps that are free of cracks, holes, and looseness. - Patients should be aware of environmental challenges, such as in-ground slope and unevenness in walking surfaces and curbs. When going out into community settings, patients should be encouraged to take their assistive devices along all occasions and properly use them. - Reminders may be important for those who tend to leave canes or walkers in the care when they are "only going a short distance".

Sweat glands are an accessory organ of the skin and produce a water-like substance. These glands are activated by:

Heat Nervousness Stress Sweat can produce a foul-smelling body odor.

Dermis:

Highly vascular connective tissue = provides a rich supply of blood. Blood vessels dilate and constrict in regulation of body temperature and blood pressure. supports the outer layer. Contains sensory nerve fibers that react to touch, pain, and temperature. The arrangement of connective tissue enables the dermis to stretch and contract with body movement.

OBSERVE the hips for range of motion while patient is in SUPINE position:

Hip (Flexion) with knee flexed: With patient in supine position, ask him or her to alternately pull each knee up to the chest. Hip (Flexion) with leg extended: Next have the patient raise the leg to flex the hip as far as possible without bending the knee. Raises straight leg 90 degrees. Extension: Return leg next to the opposite leg. External rotation: To test external hip rotation (Patrick test), ask the patient to place the heel of one foot on the opposite patella. Apply gentle pressure to the medial aspect of the flexed knee as the patient externally rotates the hip until the knee or lateral thigh touches the examination table. Repeat the procedure with the other hip. Internal rotation: Ask the patient to flex the knee and turn medially (inward) as you pull the heel laterally (outward). Repeat the procedure with the other hip. Abduction and adduction: Ask the patient to move one leg laterally with the knee straight to test abduction and medially to test adduction. Repeat the procedure with the other leg. Hyperextension: Assist patient to a prone position. Test hyperextension of the hip by raising the leg upward with the knee straight. Repeat the procedure with the other leg. This assessment can ALSO be performed with the patient in the standing position. ABNORMAL FINDING: Osteoarthritis and hip dislocation impair the hip range of motion. Vertebral compression of spinal nerves may cause back or leg pain during hip flexion with leg extension.

Specific regions of M-S System: Arms PALPATE the elbows for pain, edema, temperature, and nodules:

Hold the patients lower arm in your nondominant hand while using the pads of the thumb and fingers of the dominant hand to palpate the olecranon process and lateral epicondyle. Repeat the procedure on the other side. The elbows should have no pain, edema, heat, or nodules. ABNORMAL FINDINGS: Edema, nodules, point tenderness, and heat may occur in rheumatoid arthritis. Point tenderness is pain felt when pressure is applied to one location. Nodules from rheumatoid arthritis are rubbery, whereas nodules from gout are firm.

Routine Techniques for Male Breast:

INSPECT the breasts and nipples for symmetry, color, size, shape, rashes, and lesions.

Female Genitalia System Routine Techniques:

INSPECT the pubic hair and skin over the mons pubis and inguinal area. INSPECT AND PALPATE labia majora, labia minora, and perineum. INSPECT urethral meatus, vaginal introitus, and perineum. INSPECT AND PALPATE the sacrococcygeal area INSPECT the perianal areas and anus.

Male Genitalia Routine Techniques:

INSPECT the pubic hair. INSPECT and PALPATE the penis. INSPECT the scrotum. INSPECT the inguinal region and the femoral area. INSPECT and PALPATE the sacrococcygeal areas. INSPECT the perianal area and anus.

Routine Techniques for Skin, Hair, and Nails:

INSPECT the skin PALPATE the skin INSPECT and PALPTE the scalp and hair INSPECT facial and body hair INSPECT and PALPTE nails

Judgement:

If there were a fire in the house how would you react to the situation: Patient: Run (good judgement) Patient: Watch Tv (bad judgement)

Memory: contains 3

Immediate recall: Ask the patient to repeat the names of three unrelated objects that are spoken slowly such as "dog" "cloud" and "apple" Recent memory: Give the patient a short time to view four or five object and tell him or her that you will ask about these object in a few minutes. After about 10 minutes ask the patient to names the object. All object should be remembered. Remote memory: Ask the patient about his or her mothers maiden name, high school attended, or a subject of common knowledge. Impaired memory occurs with various neurologic and psychiatric disorders, such as anxiety or depression. Loss of immediate and recent memory with retention of remote memory suggests dementia.

Proper Use of Restraints:

In light of all the negative consequences that can result from the use of physical restraints, it is easy to conclude that they may do more harm than good for the patient. Nurses should employ as many RESTRAINT FREE ALTERNATIVES as possible before requesting orders for and applying a physical restraint. After all restraint-free alternatives have been exhausted and consultation with other members of the interprofessional care team (geriatrician, geriatric clinical nurse specialist, nurse practitioner, and psychiatrist) has been unsuccessful in identifying other means of keeping the patient safe, several steps should be carefully following before restraints are applied.

INSPECT and PALPATE with axillae for evidence of enlarged lymph nodes, rash, lesions, or masses ABNORMAL FINDINGS

Infections in he breast, arm, and even the hand may cause lymphatic drainage into the axillary area. Enlargement and tenderness of lymph nodes in the axilla may indicate such an infection. Hard, fixed nodules or masses may suggest metastatic carcinoma or lymphoma. Mastitis = infection of breast Carcinoma or Lymphoma

AGAIN, for repetition state the NORMAL FINDINGS of inspection and palpation of labia majora (outer), labia minora (inner), and clitoris:

Inspect for pigmentation and dry or moist mucosa Mucosal color is slightly darker than overall skin tone Smooth without lesions Moist Tell patient that you will be spreading labia before doing so Palpate the labia with thumb and finger Should feel smooth, without nodules Visualize the vaginal orifice - May have irregular edges. - Tissues at orifice should be moist. (we will not be getting into a deeper assessment of cervix just external assessment of genitalia)

PERFORM hand hygiene INSPECT the skin for general color:

Inspect the skin for general color and uniformity of color. The skin color should be consistent over the body surface, with the exception of vascular areas such as the cheeks, upper chest, and genitalia, which may appear pink or have a reddish - purple tone. = prone to blushing NORMAL RANGE OF SKIN COLOR VARIES FROM WHITISH PINK, TO OLIVE TONES, TO DEEP BROWN. Sun exposed areas may show evidence of slightly darker pigmentation. ABNORMAL SKIN COLOR MAY BE EVIDENCE OF LOCAL OR SYSTEMIC DISEASE. COMMON ABNORMAL FINDINGS OF PARTICULAR IMPORTANCE INCLUDE CYANOSIS, PALLOR, AND JAUNDICE: Hypopigmentation = also known as albinism (a complete absence of pigmentation; pale white skin tone is noted over the entire body surface) Hyperpigmentation = (increased melanin deposition) may be an indication of an endocrine disorder (addisons disease or liver disease)

after inspecting the vaginal orifice, then move on to INSPECTION of the urethral meatus, vaginal introitus, and perineum for positioning and surface characteristics:

Inspect the urethral meatus and the tissues immediately surrounding it. It is located above the vagina. There should be a midline location of an irregular opening or slit close to or slightly within the vaginal introitus. The vaginal introitus may appear as a thin vertical slit or a large orifice with irregular edges from the hymenal remnants; the tissues should appear moist. The posterior skin surface of the perineum between the vaginal introitus and the anus should appear smooth and soft and without lesions or discoloration. If the patient has had episiotomy, a scar (midline or mediolateral) may be visible. (from childbirth). As you get down to the anal/rectal area you will check for hemorrhoids. The normal is there are no distended vessels/absences of hemorrhoids. ABNORMAL FINDINGS: Note any discharge from the surrounding (Skenes) glands or the urethral opening, polyps, inflammation, discolored or foul-smelling vaginal discharge, bleeding or blood clots, edema, skin discoloration indicative of tissue bruising, or lesions. NOTE scars, skin tags, lesions, fissures, lumps, or excoriation

COMPARISONS OF HERNIAS: direct hernia

Less common; occurs most frequently in males over age 40; uncommon in women. The sac herniates through the external inguinal ring. The hernia is located in the Hesselbach triangle region. It rarely enters the scrotum. The patient has a bulge in the Hesselbach triangle area that is usually painless. The hernia pushes against the nurse's fingertips when the patient bears down. The hernia may decrease when the patient lies down.

OBSERVE joints for deformity:

Joint deformities are possible in any joint of the body, though they are most commonly found in the hands, as the hands contain a large amount of joints that are in near - constant use. Deformities in your joints can have many causes: Two of the most common causes are rheumatoid arthritis and osteoarthritis. ABNORMAL FINDING: Joint being enlarged

COMPARISONS OF HERNIAS: femoral hernia

LEAST COMMON HERNIA; occurs most frequently in women. The sac extends through the femoral ring, canal, and below the inguinal ligament. There is pain in the inguinal area. The right side is more frequently affected than the left side. Pain may be severe.

Positions for Rectal Examination:

Left lateral Sims position Knee-chest position Standing position

ABNORMAL FINDINGS of inspecting the peri-rectal area:

Lesions associated with sexually transmitted diseases appear on or around the anus. Anal Fissures = cut in the rectal area

F. Diversity Considerations:

Life Span: - infants and young children depend on others to care for their hygiene needs. - Skin become thinner, drier, and less elastic with age, making older adults more susceptible to skin breakdown. Gender: - Proper perineal care is an important step in preventing urinary tract infections, especially in women. The female urethra is shorter than the male urethra and is closed to the anus. - Providing perineal care for a patient of the opposite sex should be done with sensitivity to the patients feelings. If the nurse approaches personal care with a professional attitude and communicates the importance of the procedure, the patients comfort level is likely to increase. Culture, Ethnicity, and Religion: - In some cultures, male nurses may be prohibited from performing perineal care or examining private areas of a female patients body. Similar cultural restrictions may be true for a female nurse caring for male patients. - Cultural traditions and religious beliefs affect hygiene practices. North American and many other cultures consider it common to shower or bathe daily. In other cultures, bathing weekly is the norm. - A beard in certain cultures indicates that a man is married. - Women of some cultures shave their axillae (armpits) and legs. In other regions of the world, women do not shave these areas. The nurse should always consult with the patient or family before shaving or cutting a patients hair. - People of African descent tend to have hair that is drier and requires less frequent washing. Diability: - Patients with disabilities that affect mobility and range of motion may depend on the nurse for bathing, hygiene, and personal care. Morphology: - Obesity creates unique concerns for the nurse providing hygiene care. Areas on the body where skin touches skin, such as in abdominal folds, under breasts, in the axilla, and the groin areas, are prone to accumulation of moisture and CHAFING (inflammation due to friction). This can lead to skin breakdown and bacterial or fungal infections. - It may be difficult for the nurse to move and position obese patients for bathing and care. Use of mechanical lift equipment is necessary to ensure patient safety and avoid health care team injuries.

Cyanosis Light vs Dark Skin:

Light: Grayish blue tone, especially in nail beds, earlobes, lips, mucous membranes, palms, and soles of feet. Dark: Ashen - gray color most easily seen in the conjunctiva of the eye, oral mucous membrane, and nail beds.

Pallor Light vs Dark Skin:

Light: Pale skin color that may appear white. Dark: Skin tone appears lighter than normal; light-skinned African Americans may have yellowish-brown skin; dark - skinned African Americans may appear ashen; specifically evident is a loss of underlying health red tones of the skin.

Jaundice Light vs Dark Skin:

Light: Yellowish color of skin, sclera of eyes, fingernails, palms of hands or oral mucosa. Dark: Yellowish-green color most obviously seen in sclera (do not confuse with yellow eye pigmentation, which may be evident in dark-skinned patients) palms of hands, and soles of feet.

Petechiae Light vs Dark Skin:

Light: lesions appear as small, reddish-purple pinpoints. Dark: Difficult to see; may be evident in the buccal mucosa of the mouth or sclera of the eye.

Palpation of Breast Tissue - Mass characteristics identified note:

Location Size Shape Consistency Tenderness Mobility Borders (regular or irregular) Retraction of external skin present

COMPARISONS OF HERNIAS: indirect hernia

MOST FREQUENT TYPE OF HERNIA; my occur in both sexes and in children (mostly males). Sac herniates through the internal inguinal ring; can remain in the inguinal canal, exit through the external canal, or pass into the scrotum. The patient usually complains of pain with straining. The hernia may decrease when patient lies down.

ABNORMAL FINDINGS of inspection and palpation of the rectum:

Masses Polyps Nodules Tenderness Presence of blood, pus, mucus on exam glove

INSPECT facial and body hair for distribution, quantity, and texture:

Men generally have noticeable hair present on the lower face, neck, ears, chest, axilla, and back, shoulders, arms, legs, and pubic region. - Pubic hair pattern = upright triangle to the umbilicus Females present on limbs, axillae, pubic area, and around nipples. - Pubic hair pattern is an inverted triangle - Finer hair on back, face, and shoulders. ABNORMAL FINDINGS: Hair loss on the legs may indicate poor peripheral perfusion. Thinning of the eyebrows is a prominent finding of hypothyroidism. Hirsutism (hair, face, body, and pubic area excessive hair growth) may be a sign of endocrine disorder. Pubic hair distribution that deviates from typical gender patterns may indicate a hormonal imbalance.

INSPECT the nipples for position, symmetry, surface characteristics, lesions, bleeding, and discharge:

Most women's nipples protrude, although some may appear to be flat or actually inverted. All should be considered normal if they have remained unchanged throughout adult life and the nipples are symmetric bilaterally. Nipple inversion (a nipple that is recessed as opposed to protruding) can be normal or an abnormal finding. Consider it normal if it is not a new finding and if it can be everted with manipulation. (A female who has not breastfed a child, may be inverted) ABNORMAL FINDINGS: Nipples that point in different directions or those that are not symmetric should be considered abnormal, recent nipple inversion or nipple retraction (a nipple that is pointing or pulled in a different direction) suggest malignancy, and the patient should be referred for further evaluation. Nipples are normally smooth and intact without evidence of crusting, lesions, bleeding, or discharge. Note presence of supernumerary nipples, which are considered a normal variation although uncommon. These nipples look similar to pink or brown moles and generally appear along the embryonic "milk line". ABNORMAL FINDINGS: Deviations from normal include nipple edema, redness, pigment changes, ulceration or crusting, erosion or scaling, and wrinkling or cracking. A red, scaly nipple with discharge and crusting the lasts more than a few weeks could indicate PAGETS disease. Nipple discharge is usually considered an abnormal finding. - Not pointing in same direction - New onset of nipple inversion - Thickening of nipple - Discharge from nipple in absence of lactation.

An alternate 0-5 scale to rate muscle strength:

No evidence of movement= 0 Trace of movement= 1 Full range of motion, but not against gravity= 2 Full range of motion against gravity but not against resistance= 3 Full range of motion against gravity, some resistance, but weak= 4 Full range of motion against gravity, full resistance= 5

(FUNCTIONAL LEVEL SCALE) FOR MUSCLE STRENGTH: No movement = Evidence of slight movement = Complete range of motion (movement); pt. cannot hold up extremity (cannot overcome gravity) = Complete range of motion (movement); pt. can hold up extremity (can overcome gravity) = Complete range of motion (movement) + overcomes gravity + pt can resist NURSES hand BRIEFLY. = Complete range of motion (movement) + overcomes gravity + pt. can fully resist nurses hand = Know that 5/5 is normal: client can lift limb off of the bed ( against gravity), and flex limb against resistance by nurse. A score of 1 means slight movement of limb by patient, but not able to lift limb up, not able to pull against examiner's resistance.

No movement = 0/5 Evidence of slight movement = 1/5 Complete range of motion (movement); pt. cannot hold up extremity (cannot overcome gravity) = 2/5 Complete range of motion (movement); pt. can hold up extremity (can overcome gravity) = 3/5 Complete range of motion (movement) + overcomes gravity + pt can resist NURSES hand BIREFLY. = 4/5 Complete range of motion (movement) + overcomes gravity + pt. can fully resist nurses hand = 5/5

Assessment of Breasts

Not part of the head to toe assessment of patients in acute care setting. Nurses teach patients techniques in Breast Awareness as a secondary prevention. Not limited to the female gender. Patient's having had mastectomy for diagnosis of cancer still need to have breast awareness.

Implementation and Evaluation (nursing process related to hygiene): Interventions:

Nursing care plans for hygiene-oriented nursing diagnoses are tailored to patients' specific needs. Plans contain interventions focused on cleanliness, comfort, and prevention of injury or infection. Side benefits of assisting patients with their personal care include the opportunity to thoroughly assess each patients skin and communicate with the patient in a therapeutic manner. Patient and family education regarding proper hygiene practices and assessment of the patients home situation occur during this time.

Usually the area where confusion first becomes apparent is:

ORIENTATION TO TIME ANOTHER ABNORMAL FINDING.

BEGIN GENERALIZED ASSESSMENT OF M-S SYSTEM: INSPECT skeleton and extremities for alignment and symmetry.

Observe the patient standing upright, palms facing forward = ANATOMICAL STANDING POSITION. - Observe the patient from the Anterior (front), Posterior (back), and Lateral (side) view. - The patient should stand erect with a spine that is straight. - Use the umbilicus and spine (vertebral columns) as landmarks for the midline. Then compare the right and left of the umbilicus. - Example: Compare the height of the shoulders and arms bilaterally. The body should appear relatively symmetric when one side is compared with the other. - Even contour of the shoulders. - Level scapulae and iliac crests. - Alignment of the head over the gluteal folds. - Symmetry and alignment of extremities. - The spine should be straight with expected curvatures (cervical concave, thoracic convex, and lumbar concave) - Knees should be in a straight line between the hips and ankles. - The feet should be flat on the floor and pointing directly forward. ABNORMAL FINDINGS: Irregular posture or any asymmetry or misalignment warrants further assessment. Note any deviations in the curves of the cervical, thoracic, and lumbar spine.

Specific regions of M-S System: Arms OBSERVE range of motion of wrists and hands:

Observe the range of motion of wrists and hands. Ask patient to: - Bend the hand up to the wrist = hyperextension - down at the wrist = flexion - Flex just the fingers up at the metacarpophalangeal joints = hyperextension - Flex just the fingers down at the metacarpophalangeal joints = flexion - Place palms flat on the table and turn them outward and inward (ulnar deviation and radial deviation). - Spread fingers apart = finger abduction - Make a fist = finger flexion - Touch the thumb to each finger (opposition) and to the base of the fifth finger (able to perform all motions) = Finger extension: thumb to each finger tip and to base of little finger. ABNORMAL FINDINGS: Unequal response, weak response, muscular spasm, and pain may be causes by joint or muscle inflammation.

Fire:

One example is a no-smoking policy that does not permit smoking on the facility's property or allows it only outside the facility in designated areas. Oxygen is flammable and should not be used near an open fire. Fire evacuation drills and practice in the use of fire extinguishers should be conducted with enough frequency to ensure that health care professionals are prepared to properly respond in the event of a fire.

Evaluation:

Ongoing The focus of the care plan is on helping the patient gain self-care abilities and move toward independence. Diligent hygiene nursing care is needed for the dependent patient whose care plan includes as much assistance as is necessary for good hygiene practices.

When the patient walks in the room, sees a chair, and sits down . . . . what nerve is intact?

Optic nerve (CN II) ABNORMAL FINDINGS: if the patient bumps into furniture, squints, or needs assistance to locate a chair, it may indicate a vision problem.

Oral care:

Oral care is an essential nursing intervention that provides patient comfort, removes plaque and bacteria, reduces the risk for tooth decay, and decreases halitosis. Oral care includes = brushing the teeth, tongue, flossing, rinsing the mouth and cleaning dentures. When helping a dependent patient with oral care, the UAP or nurse always wears gloves. Teeth should be brushed several times daily using fluoride toothpaste. Encourage patients to floss their teeth daily at home. If patients have a difficult time grasping or maneuvering the toothbrush, adaptive equipment such as large-handle toothbrush may be necessary. The patient may find that using an electric toothbrush at home makes brushing easier. Performing oral care for patients who are dependent cleans the teeth and moistens the oral mucosa. Documentation of oral care includes the procedure, date and time, patient's tolerance, and findings of unusual sores, bleeding, or tenderness.

Patients with Special Needs (oral care):

Patients who are to receive nothing by mouth orders NPO or are receiving oxygen are susceptible to drying of the oral mucosa. Unconscious or intubated patients may not be able to swallow their own saliva. Oral care should be provided EVERY 2 HOURS FOR THESE PATIENTS BY USING A TOOTHBRUSH AND A SMALL AMOUNT OF WATER OR A MOISTENED TOOTHETTE, WHICH IS A DISPOSABLE FOAM SWAB THAT IS USED FOR ORAL CARE. unconscious patients are at risk for aspiration, and oral care procedure is modified for them. Patients who have gone under chemotherapy for cancer have special oral care needs.

B. Decreased Sensation:

Patients with neurologic deficits, such as peripheral neuropathy due to diabetes, may not be able to identify extremes of hot and cold. The nurse should monitor the temperature of bath water for patients with decreased sensation. Burns may result of skin is exposed to extremely hot water during bathing.

BOX 25.7 Alternatives to Physical Restraints:

Orient the patient to the surroundings, and explain all care-related interventions. Relocate the patient to a room near the nurses' station. Use-pressure sensitive and motion-sensitive bed and chair alarms consistently. Tabs and bed-check alarm systems can be used in the bed or chair. Ensure that alarms and sensors are properly placed and functioning and perform battery checks according to facility protocol. Encourage the family and significant others to spend time w the patient. Minimize the environment stimuli (noise, bright lights) Provide distractions based on patient preferences (music, television, doll to hold) Provide complimentary and alternative therapies: - Promote relaxation through gentle massage. - Use aromatherapy to relax the patient. Assess for sources of agitation, and ensure that the patients basic needs are met (food, fluids, toileting, pain, or discomfort relief, sleep, ambulation) Obtain an order for a 24hr sitter (UAP) Cover or disguise tubes or drains with clothing, or wrap intravenous sites with gauze so that they are kept out of patients site. Use untied, cloth-padded protective mitts on the patients hands to prevent the patient from removing tubes or drains.

INSPECT and PALPATE the labia majora, labia minora, and clitoris for pigmentation and surface characteristics: Labia Majora (outer) Labia Minora (inner)

PROCEDURE: Gently touches the patient on the inner thigh and tell her that you are going to spread the labia apart. Spread the labia majora to view the inner surface of the labia majora, labia minora, and the surface of the vestibule. NORMAL FINDINGS: The skin pigmentation of the labia majora should be darker than the patients general skin tone; and the tissues may appear shriveled or full, gaping or closed, usually symmetric, with a smooth skin surface and a dry or moist texture. The tissue should appear symmetric and without drainage, lesions, or sores. The clitoris is located midline between the labia minora. It is normally a smooth, pink, and moist cylindric structure about the size of an eraser head. ABNORMAL FINDINGS: Observe for signs of inflammation, edema, excoriation, leukoplakia, (white patches), ulceration, drainage, lesions, nodules, and marked asymmetry. Inflammation, irritation, excoriation, vaginal discharge, and pain are abnormal findings. Discoloration or tenderness may be the result of traumatic bruising. NOTE any enlargement, atrophy, inflammation, lesions, or discharge.

Problem - Based History - Pain

Pain Where do you feel the pain? When do you first notice it? Is it related to movement? Describe how it feels. How severe is the pain on a scale of 0 to 10, with 10 being the worst pain possible? - Back pain is the most common musculoskeletal complaint followed by knee pain and shoulder pain. Pain felt in and around the joint and accompanied by edema, warmth, and erythema indicates inflammation. Bones pain typically is described as "deep", "dull, "boring", or "intense". Bone pain frequently is not related to movement unless the bone is fractured, in which case the pain is described as "sharp". Muscle pain is described as "cramping". Did the pain occur suddenly? When during the day do you feel it? - Sudden onset of pain and erythema in the great toe, ankle, and lower leg suggests gout (also called gouty arthritis). Pain from rheumatoid arthritis and tendonitis may awaken the patient, especially when he or she is lying on the affected limb. Patients with osteoarthritis experience pain with weight-bearing that is relieved by rest. Does the pain move? Can you show me where it moves? Has there been any injury, overuse, or strain of muscles or joints? Were you ill before the onset of pain? - Muscle pain usually is localized, whereas nerve pain may radiate. Some disorders causing migratory arthritis, in which pain moves among joints (acute rheumatic fever, leukemia, or juvenile arthritis). Viral illnesses can cause muscle aches and pain (myalgia). What makes the pain worse? Does it change according to the weather? - Learning what makes the pain worse may help diagnose the disorder. Arthritis pain may become worse with changes in barometric pressure. Movement usually makes joint pain worse except in rheumatoid arthritis, in which movement may reduce pain.

Rectal Exam INSPECT the perianal area and anus for color and surface characteristics: (pubic area and labia)

Place patient in a left lateral Sim's position. Rectum should appear tightly closed with increased pigmentation and coarse skin; no lesions should be present, and the skin should be intact. The anus should be closed tightly. Differentiate hemorrhoids from other lesions. If a lesion is seen, identify the location of the abnormality in terms of the position of a clock, with 12 o'clock position being toward the symphysis pubis and the 6 o'clock position toward the sacrococcygeal area. Ask the patient to bear down. While the patient is straining, observe for the presence of internal hemorrhoids, polyps, tumors, and rectal prolapse. NONE SHOULD BE SEEN.

INSPECT and PALPATE with axillae for evidence of enlarged lymph nodes, rash, lesions, or masses: Patient is sitting

Palpation of lymph nodes in the axilla is included with clinical breast examination because lymph nodes are accessible and may provide clues regarding the presence of inflammation or lesions. Small masses and/or tumors may first evident by detection of a slight abnormality within the axilla. Procedure: (if the patient has a rash or an open lesion in the axilla, wear examination gloves.) You must have short fingernails to prevent injury to the patient. Instruct the patient to relax both arms at her sides. Using your left hand (if you are right-handed), life one of the patients arms and support it so her muscles are loose and relaxed. While in this position, use your right hand to palpate that axilla. Reach your fingers deep into the axilla and slowly and firmly slide your fingers along the patients chest wall, first down the middle of the axilla, then along the anterior border of the axilla, and finally along the posterior border. Then turn your hand over and examine the inner aspect of the patient upper arm. Repeat the same palpation in the opposite axilla. During all maneuvers position the patients arms with your other hand to maximize the examining area. In all positions palpate for areas of enlargement, masses, or lymph nodes or isolated area of tenderness. Findings: Lymph nodes or masses should not be palpable in the axillae or they should be small, soft, mobile, and nontender. There should be no evidence of lesions or rashes.

Disorders of the Central Nervous System: Parkinson's Disease

Parkinson's disease is a chronic and progressive movement disorder resulting from the degeneration of the dopamine producing neurons in the substantia nigra of the basal ganglia. Clinical findings: - tremors of the face, jaws, hands, arms, and legs, - bradykinesia - rigidity - postural instability - other manifestations include masklike facies, trunk forward flexion, muscle weakness, shuffling gait, and finger pill-rolling tremor.

C. Alopecia:

Patients may have alopecia due to hereditary factors, certain illnesses, or the effects of drugs such as those used in chemotherapy. This condition may affect the patients self-esteem. Collaboration with a beautician or barber may be needed if a patient is actively losing hair as a result of treatment. Special care should be given to the scalp.

Sink Bath:

Patients who are ambulatory may prefer to wash while standing or sitting in front of a bath basin or sink. Patients may still need assistance with their legs, feet, and back. Assessment of the patients ability to ambulate and wash independently is necessary.

ASSESS the anal sphincter for muscle tone:

Perform this procedure when decreased tone or pain reported. Withdraw your fingers from the rectum slowly and evaluate the characteristics of the anal tone with the middle finger. The anus should tighten evenly around the examination finger. ABNORMAL FINDINGS: Note the presence of rectal stricture. A hypotonic sphincter can occur with neurologic deficits, following rectal surgery, or with anal/rectal trauma (especially associated with frequent anal sex). Hypertonic sphincter may be associated with lesions, inflammation, scarring, or anxiety related to the examination. EXTREME PAIN with anal palpation almost always indicates a local inflammation such as fissures, fistula, or cyst.

Perineal Care:

Perineal care, or personal care, involves cleaning the genital area, urinary meatus, and anus. This care is particularly important for patients who are dependent or incontinent or those who have a urinary catheter. The caregiver always wears gloves to provide perineal care due to the risk for exposure to bodily fluids. Patients recoverin from perineal or genital surgery and women who are menstruating require diligent care to prevent infections and odors. SITZ BATH = baths for soaking a patients parineal are are sometimes used therapeutically after perineal surgery or childbirth to cleanse the area. Patients who can perform personal care independently should be allowed to do so after the nurse assesses their abilities and risks for complications. Perineal care is provided during a bath or shower but may be necessary more frequently, especially for incontinent patients. Patients are sometimes embarrassed to depend on others for personal care. A professional approach and caring attitude can allay a patients anxiety. Documentation after personal care includes the type of procedure performed, the date and time, skin-related issues, incontinence, drainage or odors, catheters or dressings, and the patients self-care abilities and response to the procedure. THIS DOCUMENTATION IS INCLUDED EVEN IF PERSONAL CARE WAS DONE AS PART OF A COMPLETE BATH.

PALPATE the breasts for tissue characteristics: Patient is supine

Position: the preferred position for breast palpation is supine with a small pillow or towel placed under the shoulder on the same side as the breast to be examined. Instruct the patient to place her arm over her head. The combination of the slight shoulder elevation and the arm positioning flattens the breast tissue evenly over the chest wall. A sitting position may be used if the patient has difficulty lying down, if she young and has very small breasts, or if the she has very large breasts, making palpation difficult in a supine position. Procedure: Using the finger pads of the first two or three fingers of your examining hand, gently, firmly, and systematically palpate all quadrants of the breast and the tail of SPENCE. Use a systematic approach to breast palpation that begins and ends at a designated point. This ensures that all areas of the breast are palpated. Several motions may be used for breast palpation, although one study suggests the vertical strip approach as the preferred method. Press firmly enough to feel the underlying tissue but not so firmly that the tissue is compressed against the rib cage. Do not life your fingers from the chest wall during the palpation because this breaks the continuity of the palpation. Instead gently slide your fingers over the breast tissue, moving along the designated pattern of palpation. If the sitting position is used for a woman with very large breasts, ask the patient to lean forward slightly and position your hands between the breasts. While supporting the inferior side of the breast with one had, palpate the breast with the other hand, starting at the top of the breast, and slowly slide the finger pads down the breast. Repeat the technique until all breast tissue of the both breasts are examined. If a mass is identified, specifically palpate the mass for characteristics, including its location, estimated size, shape, consistency, tenderness, should be included when assessing a mass are illustrated in Box 16-1. Transillumination may be used to confirm the presence of fluid in superficial masses.

ABNORMAL FINDINGS of inspecting the pubic area and labia:

Presence of lice Skin lesions Inflammation of mucosa Edema to labia Ulcerations Vaginal discharge Nodules Bruising

Vesicle greater than 1 cm in diameter Blisters, pemphigus vulgaris, lupus erythematosus, impetigo, drug reaction.

Primary Skin Lesions: Bulla

Elevated, superficial lesion; similar to a vesicle but filled with purulent fluid: Impetigo, acne, folliculitis, herpes simplex:

Primary Skin Lesions: Pustule

Elevated, irregular-shaped area of cutaneous edema; solid, transient, variable diameter. Insect bites, urticaria, allergic reaction, lupus, erythematosus:

Primary Skin Lesions: Wheal

A flat, circumscribed area that is a change in the color of the skin; less than 1 cm in diameter Freckles, Flat moles (nevi), Petechiae, Measles, Scarlet Fever:

Primary Skin Lesions: macule

Bed making:

Providing the patient with a clean, dry bed that is free of wrinkles is a basic comfort nursing measure. Bed linens may be changed after a bed bath. If the bed is not soiled, the nurse may wait until the patient is sitting in a chair or off of the nursing unit for testing. A lift may be used to temporarily lift the patient off the bed surface if the patient is on bed rest. Making an unoccupied bed is easier on the nurse or UAP and the patient. if it is not possible to move the patient out of bed, the nurse can change the linens with the patient lying in bed. When making an occupied bed, the nurse should have all linens in the room before beginning the procedure. Making the bed can be done during or after the bath or after perineal care for incontinence.

Assessment of Cranial Nerve Function: Recall from HNEENT assessment - PERRLA

Pupils Equal size Round Reactive to Light and Accommodation Mydriasis = dilated > 6 mm Miosis = constricted < 2 mm CN III Oculomotor, CN IV trochlear, CN VI abducens

Many health care facilities use the fire emergency response defined by the acronym RACE:

R, Rescue: All patients in immediate danger, and move them to safe areas. A, Activate: The manual - pull station or fire alarm, and have someone call 911. C, Contain: the fire by closing doors, confining the fire, and preventing the spread of smoke. E, Extinguish: the fire if possible after all patients are removed from the area. Measures are taken to contain (C) or prevent the spread of smoke and fire, which include closing doors and turning off oxygen. Patients receiving mechanical ventilation should be disconnected and provided with manual respiration with an Ambu bag. After all patients are removed from the area, an attempt may be made to extinguish (E) the fire if it is small enough. However, an attempt to extinguish a fire should not be made if personal or patient safety would be compromised in the process.

Ear Care:

Routine ear care is accomplished during bathing. Washing the ear with a washcloth and soap is sufficient for most patients. If the patient has a buildup of wax, or cerumen, the PCP may order special oil drops to soften the wax before irrigating the ear canal. Do not try to remove the wax using cotton-tipped applicator because it can push the wax further in the ear canal. Many patients wear hearing aids to amplify sound. These small electronic devies are expensive and must be kept dry. Handle hearing aids carefully, and clean them with a dry cloth. When not in use, they are stored in a container labeled with the patients name. PAGE 511 BOX 27.9

EVIDENCE - BASED PRACTICE AND INFORMATICS (ORAL CARE DURING CANCER THERAPY):

Routine oral hygiene reduces the severity and incidence of oral problems during cancer therapy. Patients should tell the primary care provider (PCP) or oncologist if they have the following: - changes in taste or smell - dry mouth - pain when eating hot or cold foods - trouble eating or swallowing - white spots in the mouth - sores on the lips or in the mouth Basic guidelines include the following: - brushing with a soft-bristle brush and baking soda or fluoride toothpaste after meals and before bedtime. - rinsing the oral cavity frequently with a baking soda, salt, and water mixture. - applying a lip balm to keep the lips from dying. - taking frequent sips of water or sucking on ice cubes to keep oral mucosa moist. - Avoid alcohol including mouthwash that contains alcohol. - Avoiding drinking citrus juices and tomato juice.

Irregular - shaped, elevated, progressively enlarging scar: grows beyond the boundaries of the wound: Keloid formation following surgery:

Secondary Skin Lesions: Keloid

Thin to the thick fibrous tissue that replaces normal skin following injury or laceration to the dermis: Healed wound or surgical incision:

Secondary Skin Lesions: Scar

Nursing Health History of Reproduction: - Sexual History - Problems with Menstruation

Sexual History: Are you currently in a sexual relationship? If yes, do you prefer relationships with men, women, or both? In which type of sex do you engage (penile-vaginal, penile-anal, recipient anal, oral)? How frequently do you engage in sexual activates? Are you and your partner(s) satisfied with the sexual relationship? Do you communicate comfortably about sexual activity? Do you or your partner(s) have multiple partners? How many sexual partners have you had in the past 3 months? How do you protect yourself from STD? Do you use a protective barrier such as a condom every time you have intercourse? Are you currently using any birth control measures? If so, which type(s)? How effective do you think it (they) has (have) been? Do you have any difficulty with the birth control measures? Do you use birth control measures every time you have intercourse? How old were you when you first had intercourse? Was it by choice? Have you ever been forced into sexual acts as a child or an adult? If so, how has this impacted you and your partner? Do you or your partner (s) frequently use drugs or alcohol before you engage in sexual activity? Have you ever traded sex for drugs, alcohol, or food? Problems with Menstruation: What kinds or problems with menstruation are you experiencing? Have you noticed clotted blood during your period? If so, when did it begin? Is it becoming worse over time? Do you have cramps or other pains associated with your period? Do they occur each month? What relieves the discomfort? Do the cramps or pain interfere with your normal activities? Do you ever have spotting between periods? Do you have unexplained vaginal bleeding? Do you have unexplained vaginal bleeding? Do you have any other problems or symptoms before menses such as headaches, bloated feeling, weight gain, breast tenderness, irritability, or moodiness? Do they seem to be associated with your periods, or do they occur at other times? Do they interfere with your routine activities?

Hair care:

Shampooing a patient's hair and cleansing the scalp increases comfort and provides a sense of well-being. Patients who are weak or debilitated may be unable to follow their usual grooming routine, and their hair may become oily and matted. Routinely combing or brushing a patients hair during morning and evening care helps prevent tangling. Shampooing can be accomplished during a shower for patients who use a stand-up shower or shower chair. For bedridden patients, a variety of shampooing methods exist, depending on the equipment available in each facility. The nurse can pad the bed with waterproof pads or use a shampoo basin. Some facilities have no-rinse shampoos, which are lathered in and toweled dry. Other shampoo caps have a shampoo solution in them. The cap is applied and the hair is lathered under the cap and then dried with a towel. Documentation of hair includes the assessment of the patient's scalp and tolerance for the procedure. If the patient is being treated for pediculosis, the medicated shampoo may be documented on the medication administration record.

Shaving a patient:

Shaving a patient may be part of hygiene care. Many men shave their faces daily. Beards or mustaches should NOT be shaved off without the consent of the patient or the family. Grooming of beards and mustaches is part of daily hygiene care. These areas can be washed with soap and water and rinsed well during the bath. If the hair id long, it can be combed out to remove tangles. Some women shave their legs and axillae during bathing or showering. Many older women have facial hair that they prefer to shave. The nurse or UAP can provide assistance with this grooming task when the patient is weak or debilitated. Some patients have their own electric razor, or an inexpensive hospital-supplied electric razor can be used. RAZORS SHOULD NOT BE SHARED. If the patient's condition permits, shaving can be accomplished with a disposable razor. Having a clean-shaven face or legs boosts the patient's self-esteem. Document the data and time, body part shaved, type of razor, and skin issues observed during or after shaving.

Musculoskeletal System

Skeletal Muscles - composed of muscle fibers that attach to bones to facilitate movement. Joints- articulations where two or more bones come together, They help hold the bones firmly whole allowing movement between them. - Joints are classified in two ways: by the type of material between them (fibrous, cartilaginous, or synovial) and by their degree of movement. Immovable joints are synarthrodial (the structure of the skull); slightly movable joints are amphiarthrodial (symphysis pubis) and freely movable joints are diarthrodial (the knee and the distal interphalangeal joint of the distal fingers) - further classified by their type of movement. Ligaments and Tendons - The difference between ligaments and tendons is more functional than structural. Ligaments are strong,dense, flexible bands of connective tissue that hold bones to bones. They can provide support in several ways: by encircling the joint, gripping it obliquely, or lying parallel to the bone ends across the joint. They can simultaneously allow some movements while restricting others. Conversely, tendons are strong, nonelastic cords of collagen located at the ends of muscles to attach them to bones. Tendons support bone movement in response to skeletal muscle contractions. Cartilage and Bursae- Cartilage is a semismooth, gel-like tissue that is strong and able to support weight. The upper secen paries of the ribs are connected directly to the sternum by costal cartilage. The flexibility of the cartilage allows the thorax to move when the lungs expand and contract. Cartilage also allows respiratory passage such as the nose, larynx, trachea, and bronchi. Bursae are small sacs in the connective tissue adjacent to selected joints such as the shoulders and knees. Each bursa is lines with synovial membrane containing synovial fluid, which acts as a lubricants to reduce friction when a muscle or tendon rubs against another muscle, tendon, or bone.

Nursing History for Skin/Extremity Assessment:

Skin Lesion

Chair Shower:

Some LONG - TERM PATIENTS are washed in the shower while sitting in a shower chair. A shower chair is durable, waterproof, and easily disinfected. It allows nurses or UAPs to wash patients in the shower who are physically dependent or cognitively impaired. Shower hairs have an open seat so that perineal care can be completed. Some shower chairs have hydraulic lifts making it easier for the caregiver to clean all areas of the body. Showering is a more efficient method of cleansing and is usually completed on a scheduled basis for dependent patients in long-term care. For patients with dementia or other cognitive impairments, an individualized bathing routine must take into account their former bathing preferences, current abilities and limitations, and responses to environmental stimuli. Adapting the routine to the patient helps maintain a calm environment. A soft voice, soothing music, and a warm room help the patient relax.

Shower:

Some hospital rooms or units are equipped with stand-up showers for patients who are strong enough to shower independently. The nurse assesses the patient and checks PCP orders to determine whether it is safe for a patient to shower.

Nose care:

Some patients need specialized care for the nose to provide comfort and remove secretions. The nurse may have to remove mucus secretions from the nares of patients who are unable to blow into a tissue. Removing moist secretions is accomplished by using suction. Removing dried mucus is performed using a moistened, cotton-tipped applicator. The applicator should never be inserted into the nostril FURTHER THAN THE DEPTH OF THE COTTON TIP. If a patient is on oxygen by a nasal cannula, the nasal passages may become dry. Humidifying the oxygen can help alleviate this problem. Patients with nasogastric feeding or suction tubes may have crusting around the tube. The crusting may be gently removed using saline on gauze or a cotton-tipped applicator. If tape is being used to hold the tube in place, the tape should be removed daily during cleaning of the area.

ABNORMAL FINDINGS IN MUSCLE STRENGTH: Paralysis - Lack of voluntary movement. 2 types???

Spasticity = involuntary contraction of muscles due to spinal cord injury or cerebrovascular accident (CVA) - stroke Flaccidity = involuntary lack of muscle tone due to spina bifida congenital (present at birth) defect of spine.

Pressure Ulcer Stages: Intact skin with nonblanchable redness, usually over a bony prominence. The are may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. May be difficult to detect in individuals with dark skin tones.

Stage I

Pressure Ulcer Stages: Partial-thickness loss dermis (skin loss). Presents as a shiny or dry shallow open ulcer with pink wound bed without slough or bruising. Appears like a blister, excoriation, abrasion.

Stage II

Pressure Ulcer Stages: Full- thickness tissue loss with damage to the necrosis of subcutaneous tissue: Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. may include undermining and tunneling

Stage III

Pressure Ulcer Stages: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present within the wound bed. Undermining and tunneling often present. May have purulent drainage:

Stage iV

PALPATE the posterior neck, spinal processes, and paravertebral muscles for alignment and pain (shoulders and spine):

Stand behind the patient. Use the pads of the thumbs and fingers for palpation. The posterior neck and spine should be straight and painless. (NOTE: having patient hunch his or her shoulders forward and slightly flex the neck may help your palpation) ABNORMAL FINDINGS: (Misalignment) may be caused by muscle weakness. Pain may be caused by inflammation such as myositis or herniated vertebral disk. (Tenderness) is abnormal as well.

INSPECT the breasts, noting size, symmetry, and shape: Patient sitting, arms at sides, then above head, then arms on hips.

Start by inspecting the breasts with the patient sitting with her arms at her sides. Breasts may be slightly unequal in size. Breast size may vary significantly, but symmetry or only slight asymmetry is considered normal. The breast shape should be smooth, convex, even, uniform color, venous pattern equal bilaterally, smooth skin texture. Gently lift each breast with your fingers and inspect the lower and outer aspects for dimpling, retraction, or bulging. ABNORMAL FINDINGS: Note evidence of marked asymmetry of breast size or shape. Significant and rapid changes in the size of one breast could indicate an inflammatory process or a growth. Dimpling, retraction, or bulging could indicate a malignancy.

Disorders of the Central Nervous System: Bells Palsy (facial drooping)

Sudden muscle weakness on one side of face. (facial muscle weakness, drooling, or dry eyes) Bells palsy may be a reaction to a viral infection. Sensory: Abnormality of taste or sensitivity to sound.

PALPATE the skin for texture, temperature, moisture, mobility, turgor and thickness:

TEXTURE: The skin should be smooth, soft, and intact, with an even surface. Expected variations include calluses over the hands, feet, elbows, and knees. ABNORMAL TEXTURE: Excessive dryness, flaking, cracking, or scaling of the skin may occur secondary to environmental conditions or may be signs of systemic disease or nutritional deficiency. (look for areas of maceration, discoloration, or rashes under skinfolds). TEMPERATURE: The skin temperature is best evaluated using the dorsal aspect of your hands. The skin should be warm. The skin temperature should be consistent for the entire body with the exception of the hands and feet, which may be cooler, particularly in a cool environment. ABNORMAL TEMPERATURE: Cool Skin: Generalize cool or cold skin is an abnormal finding and may be associated with shock or hypothermia. Localization of cold skin, particularly in the extremities, may be an indication of poor peripheral perfusion. Hot Skin: Generalized hot skin is a reflection of hyperthermia. This may be associated with a fever, increased metabolic rate (hyperthyroidism), or exercise. Localized areas of skin that are hot may reflect an inflammation, infection, traumatic injury, or thermal injury such as sunburn. MOISTURE: The skin is normally dry. There should be minimal perspiration or oiliness, although increased perspiration may be an expected finding associated with increased environmental temperatures, strenuous activity, or anxiety. ABNORMAL MOISTURE: Diaphoresis (excessive sweating) is an abnormal finding in the absence of strenuous activity. This may be a reflection of hyperthermia, extreme anxiety, pain, or shock. Excessively moist skin may often be seen with metabolic conditions such as (hyperthyroidism) MOBILITY AND TUGOR: Skin mobility and turgor are assessed by picking up and slightly pinching the skin on the forearm or under the clavicle. The skin should be elastic and return to place immediately when released. ABNORMAL MOBILITY AND TUGOR: Edema, excessive scarring to the skin, or come connective tissue disorders (such as scleroderma) reduce skin mobility. Poor skin turgor is noted if "tenting" is observed or the skin slowly recedes back into place. Decreased turgor may result from dehydration or may be a finding in an individual who has experienced significant weight loss. THICKNESS: Skin thickness varies based on age and area of the body. Typically skin thickens until adulthood and decreases in thickness age 20. the skin is thickest over the palms of hands and soles of feet and thinnest over the eyelids. ABNORMAL THICKNESS: An increase in skin thickness is seen in patients with Diabetes Mellitus and is through to be caused by abnormal collagen resulting from hyperglycemia. Excessively thin skin may take on a shiny or transparent appearance and is seen in hyperthyroidism, arterial insufficiency, and aging.

PALPATE the rectal wall for surface characteristics:

THIS IS INDICATED WHEN A PATIENT PRESENTS WITH RECTAL PAIN, BLEEDING, OR FULLNESS. Lubricate the first two fingers of a gloved hand. Place your middle finger, palm side up, over the anus. Ask the patient to bear down; while she is doing so, gently insert your middle finger into the rectum. With the index and middle fingers inserted as far as possible, instruct the patient to bear down. This brings more rectal wall into the range of palpation. Gently rotate the finger in the rectum (middle finger) to evaluate the characteristics of the rectal wall. NORMAL FINDINGS: The rectal wall should feel smooth and be without any areas of masses, fistulas, fissures, or tenderness.

Internal Structures of Male Reproductive: Testes

Testes: The testes are paired sex organs located within the scrotum. They are oval shaped, with a smooth surface and rubbery texture. The primary function of the testes is the production of sperm (spermatogenesis). Each testicle contains a series of coiled ducts (seminferous tubules) where spermatogenesis occurs. As sperm produced, they move toward the center of the testis, traveling into the efferent tubules adjacent to the epididymis.

TEST muscle strength in the extremities (upper and lower extremities) and compare sides:

Testing muscle strength may be performed as part of the musculoskeletal or neurologic system examination. TEST MUSCLE STRENGTH RIGHT AND LEFT SIDES SIMULTANEOUSLY NOT ONE AT A TIME. Ask the patient to flex muscle being evaluated and then resist when you apply opposing force against it. Three scales are used to determine the functional level or "measure" of muscles (lovett scale, grade, and percent of normal) and each requires a SUBJECTIVE assessment of muscle strength. FINDINGS: Expected muscle strength to be 5, bilaterally symmetric, with full resistance to opposition. The patients muscle strength is documented as 5/5 (or normal on the Lovett scale), with the patients values in the numerator and the expected value in the denominator. ABNORMAL FINDINGS: Muscle weakness may indicate a muscular or joint disease or atrophy from disuse. A muscle strength of 1/5 means that the patient has slight muscle contraction, with 1 representing the patients values and 5 representing the expected value.

Female Reproductive System:

The anatomy of the female reproductive system can be categorized into external genitalia and internal structures.

Male Reproductive System

The anatomy of the male reproductive system can be categorized into internal structure (testes, ducts, and glands) and external genitalia (penis, scrotum).

INSPECT the ankles and feet for contour, number of toes, alignment, and deformity:

The ankles should be smooth, symmetric, with no deformity. Aligned with the lower leg. The feet are in a straight position aligned with the long axis of the lower leg with 5 toes that are extended and straight on each foot. ABNORMAL FINDINGS: Misalignment for the feet with the ankle or leg or amputation or deformity of toes may require further evaluation. Medial deviation of the toes, hallux valgus, claw toes, hammertoes, and calluses are abnormal.

INSPECT the perianal area and anus for pigmentation and surface characteristics:

The buttocks are spread with both hands to inspect this area. The anus should exhibit increased pigmentation and coarse, intact skin. The anus should be tightly closed. No lesions or inflammation should be present. If a lesion is present, identify the location of the abnormality in terms of the position of a clock, with 12 o'clock position being toward the symphysis pubis and the 6 o'clock position toward the sacrococcygeal area. Ask the patient to bear down while you inspect the anal area. Again no lesions should be observed. ABNORMAL FINDINGS: Note the presence and location of inflammation and lesions. Lesions that may be seen include external hemorrhoids, ulcerations, warty growths (condylomata acuminate) skin tags, inflammation, fissures, and fistulas. While the patient is straining, note the presence of internal hemorrhoids, polyps, tumors, and rectal prolapse.

INSPECT the areolae for color, shape, and surface characteristics:

The color of the areola may vary, depending on the patients skin color. Normal to be darker than the skin. (ranging from pink to black) The areola should be round or oval and appear bilaterally similar. Montgomery glans may appear as slightly raised bumps on the areola tissue. Hairs on the nipple may also be seen. ABNORMAL FINDINGS: Abnormal findings include areolae that are unequal bilaterally, have an irregular shape, or have lesions or changes in color. Areola: - Lesion present - Change in pigmentation

INSPECT and PALPATE the penis for surface characteristics, color, tenderness, and discharge:

The dorsal vein should be apparent on the dorsal surface of the shaft of the penis. The skin is usually dark and hairless, with a wrinkled surface and frequently apparent vascularity. (darker pigmentation than overall flesh color) In circumcised men the prepuce is present and folded over the glans; In circumcised men the amount of prepuce varies. In uncircumcised males (foreskin covers glans of penis tip) gently retract/patient can retract foreskin to examine skin integrity and the position of the urethral meatus. The foreskin should retract easily and completely over the glans. ABNORMAL FINDINGS: Inability to retract the foreskin, discomfort on retraction, or difficulty returning the foreskin to the original position should be considered abnormal. Phimosis = is a very tight foreskin that (cannot be retracted) over the glans. Paraphimosis = is the inability to (return) the foreskin over the glans Balanitis Inspect the glans and under the fold of the prepuce. The glans should be smooth, pink, and bulbous. Note any erythema, lesions, edema, nodules, or presence of discharge. (if discharge or smegma is present, obtain a specimen on a slide for microscopic examination.) The prepuce fold is wrinkled and loosely attached to the underlying glans: it is darker than the glans. Note: circumcised penises have varying lengths of foreskin remaining; some have multiple folds, and others have none. Inspect the urethral meatus. It should be located centrally at the distal tip of the glans and should appear as a slit-like opening. No discharge should be present. Palpate the glans anteroposteriorly to open the distal end of the urethra. The surface should be pink and smooth, and no discharge should be present. ABNORMAL FINDINGS: Note if the meatus is located either on the upper surface of the penis = (epispadias) or on the bottom of the penis = (hypospadias). Note in discharge is present. The discharge may be yellow-green or milky white or have a foul odor. Palpate the entire shaft of the penis between the thumb and first two fingers. The penis shaft should be nontender and smooth with a semifirm consistency. ABNORMAL FINDINGS: Note lesions, tenderness, edema, nodules, or induration (inflammation loss of elasticity/pilability).

External Vagina:

The external female genitalia is collectively referred to as the = vulva. The vulva includes the mons pubis, labia majora, labia minora, clitoris, prepuce, vaginal vestibule, ducts of Skene's and Bartholin's glands, vaginal orifice, urethral meatus, and perineum. The mons pubis is a layer of adipose tissue that lies over the symphysis pubis. After puberty, this surface is covered with coarse hair that extends down over the outer labia to the perineal and anal areas. The labia major are a pair of folds of tissue that extend downward from the mons pubis, surround the vestibule, and come together at the perineum. The outer surfaces are covered with hair, whereas the inner surfaces are hairless and smooth. Lying inside the labia major are two darker, smooth folds called the labia minor. In some women, the labia minora are completely enclosed within the labia major; in others the labia minora protrude between the labia major. Each of the labia minora divides into a medial and later aspect. The medial aspects join superior to the clitoris to form the clitoral hood (prepuce), and the lateral aspects join inferior to the clitoris to form the frenulum. The clitoris is a small, cylindric bud or erectile tissue that is a primary center of sexual stimulation. The fourchette is a tense band or fold of mucous membrane connecting the posterior ends of the labia minora, just behind (posterior to) the vagina.

Internal Structures: Fallopian Tube and Ovaries

The fallopian tubes extend from the fundus laterally 3 to 5 inches (7.5 to 12.5 cm) to the ovaries. The fimbriated ends of the fallopian tubes (uterine tube) partially project around the ovary to capture and draw ova into the tube for fertilization. The ova are transported to the uterus by rhythmic contractions of the tubal musculature and the cilia that line the fallopian tubes. Ovaries: The almond-shaped ovaries are connected to the uterine body by the ovarian ligaments. The primary functions of the ovaries include ovulation and secretion of reproductive hormones. Ovulation is the release of an ovum (egg), which usually occurs monthly as part of the menstrual cycle. The 2 dominant female sex hormones produced by the ovaries are estrogen and progesterone. These hormones have several functions, including triggering sexual maturation at puberty, development of secondary sex characteristics, and regulation of the menstrual cycle.

With the client in supine: INSPECT the knees for symmetry and alignment:

The knees should be lined up with the tibia and ankle and symmetric without medial or lateral deviation. Look for (symmetry) and (alignment) with the tibia (lateral bone) and ankle. ABNORMAL FINDINGS: Knees that appear bowlegged (genu-varum) or knock-kneed (genu-valgum) are abnormal.

INSPECT the inguinal region and the femoral areas for bulges:

The patient should assume a standing position for this part of the examination. While standing in front of and facing the patient, ask him to bear down. While he is straining, inspect the inguinal canal and femoral area (area just above where the femoral artery is palpated) for presence of a bulge. There should be no bulges. ABNORMAL FINDINGS Note any bulges in the area of the external ring or the femoral area. Presence of bulges suggests a hernia.

Assessment of Self-Care Abilities:

The patient's self-care ability related to hygiene needs affects the nursing care plan. If a patent is unable to care for basic needs, the nurse assists the patient during hospitalization and refers the patient to appropriate community resources for assistance after discharge. The patient's self-care abilities are assessed DURING THE HEALTH HISTORY by asking questions about home care and by observing for any odors or signs of poor hygiene. The nurse must observe the patients abilities to complete activities of daily living (ADLS), which include bathing, mouth care, grooming, toileting, dressing, and eating.

EVALUATE speech for articulation and voice quality and conversation for comprehension of verbal communication:

The patients speech is coherent with sufficient volume. His or her responses indicate an understanding of what is said. Speech should be clear. Has inflections (variations) if monotoned = concerning. ABNORMAL FINDINGS: -Errors in choice of words or syllables - Difficulty in articulation, which could involve impaired thought processes or dysfunction of the tongue or lips. - slurred speech (tone sounds slurred) - poorly coordinated or irregular speech. - monotoned or weak voice - nasal tone - rasping - hoarseness - whispering voice - stuttering my require further assessment

External Genitalia: Penis

The penis serves two functions: It is the final excretory organ in urination, and during intercourse, it introduces sperm into the vagina. The glans penis is lighter pink in color than the rest of the penis. It is exposed when the prepuce (the foreskin) is either pulled back or surgically removed (circumcision). The corona is the ridge that separates the glans from the shaft of the penis. The skin covering the penis is thin, hairless, and a little darker than the rest of the body; it adheres loosely to the shaft to allow for expansion with erection. ERECTION IS A NERVOVASCULAR REFLEX THE PSYCHOGENIC ERECTION AN BE INITIATED BY ANY TYPE OF SENSORY INPUT (AUDITORY, VISUAL, TACTILE, OR IMAGINATIVE)

Assessment of Hygiene and Infection:

The presence of skin, scalp, or oral infections may indicate poor hygiene. The nurse observes for signs of infection on the skin by looking for redness, swelling, or drainage. Infections, redness, itching, or sores on the scalp may indicate poor hygiene or exposure to an infestation, as in PEDICULOSIS. Red, swollen gums, or sores in the oral cavity may be signs of poor oral hygiene. The nurse assesses patients for signs of infection due to poor hygiene practices during the initial interview and while giving care. PATIENT EDUCATION MAY BE NEEDED TO CHANGE THE PAITENTS VIEW OF HYGIENE AND ITS RELATION TO HEALTH.

INSPECT and PALPATE the sacrococcygeal areas for surface characteristics and tenderness:

The sacrococcygeal are is located between the sacrum and the coccyx. The skin surface should be smooth, without lesions. There should be no tenderness with palpation. ABNORMAL FINDINGS: A dimple with an inflamed tuft of hair or a tender palpable cyst in the sacrococcygeal area suggests a pilonidal cyst or sinus.

INSPECT and PALPATE the sacrococcygeal area for surface characteristics and tenderness:

The sacrococcygeal area is located between the sacrum and the coccyx. The skin surface should be smooth, without lesions. There should be no tenderness with palpation. ABNORMAL FINDINGS: A dimple with an inflamed tuft of hair or a tender palpable cyst in the sacrococcygeal area suggests s pilonidal cyst or sinus.

INSPECT and PALPATE the scalp and hair for surface characteristics, hair distribution, texture, quantity, and color:

The scalp should be smooth to palpation and show no evidence of flaking, scaling, redness, or open lesions. The hair should be shiny and soft. The texture of the hair may be fine or coarse. Note the quantity and distribution of the hair for balding patterns and isolated areas of hair loss. If there are areas of isolated hair loss, not whether the hair shaft is broken off or absent completely. Men may show a gradual, symmetric hair loss on the scalp caused by genetic disposition and elevated androgen levels (increased testerone levels) ABNORMAL FINDINGS: Dull, coarse, and brittle hair is seen with nutritional deficiencies, hyperthyroidism, and exposure to chemicals in some hair products and bleach. Hyperthyroidism makes the hair texture fine. Parasitic infection with lice is characterized by the presence of nits (eggs) found on the scalp at the base of the hair shaft. Alopecia (hair loss) often occurs as a manifestation of many systemic diseases, including autoimmune disorders, anemic conditions and nutritional deficiencies, or treatment with radiation or antineoplastic agents.

External Genitalia: Scrotum

The scrotum is a pouch covered with thin, darkly pigmented, rugous (wrinkled) skin. A septum divides the scrotum into two pendulous compartments, or sacs. Each sac contains a testis. Because sperm production requires a temperature slightly below body temperature, the testes are suspended outside the body cavity; the temperature of the scrotum is controlled by a layer of muscle under the scrotal skin that contracts or relaxes in response to the outside temperature. When the temperature is cold, the scrotal sac and its contents move close to the body; conversely, when the temperature rises, the scrotal sac relaxes, and the testes drop downward.

INSPECT the skin of the breasts color, surface characteristics, venous patterns:

The skin of the breast should appear smooth, with an even color. The skin color should be similar to skin on the rest of the body. Although it may be lighter in color compared with sun-exposed skin surfaces. The venous patterns (visible veins under the skin) should be bilaterally similar. The venous pattern may be pronounced in obese or pregnant females. ABNORMAL FINDINGS: Note any localized or generalized areas of discoloration. Inflammation (e.g., cellulitis or breast abscess) in the breast tissue may cause surface erythema and heat. A rash on both breasts is likely caused by dermatitis; unilateral breast rash, especially surrounding the areola, could be associated with Pagets disease of the breast (a rare type of breast cancer). Unilateral hyperpigmentation is also considered an abnormal finding. Obese women or women with large breasts may have a red rash with demarcated borders from candidiasis resulting from excessive moisture. Unilateral venous patterns on the breast may occur secondary to dilated superficial veins from an increased blood flow to a malignancy. Roughened, tough, or thickened skin is considered abnormal. Edema may give the skin an orangelike texture and appearance termed peau d' orange Document location and description of any lesions. Changes in sie of breast: - Inflammation - Tumor Rash: - Bilateral = dermatitis - Unilateral = Pagets disease (red, scaly nipple, discharge or crusting) Increased venous pattern on affected side

Subcutaneous Layer:

The subcutaneous tissue (hypodermis) is not actually skin tissue but a support structure for the dermis and epidermis. Literally acting as an anchor for these upper layers. This layer is composed primarily of loose connective tissue interspersed with subcutaneous fat. These fatty cells help to retain heat, provide a protective cushion, and provide calories.

Proper Use of Side Rails:

The top two side rails are often used by the patient for tutoring and positioning. In some circumstances the nurse will raise one of the bottom side rails. When all four side rails are raised, it is considered a form of physical restraint, which requires an order from a primary care provider (PCP). As with any physical restraint, it is critical to weigh the benefits and risks of the use of side rails. Side rails as a restraint should be avoided when possible. Attempting to escape the bed while navigating the side rails can cause injurious falls. The patient may be attempting to get up to do something purposeful, such as go to the bathroom, which is another high-risk situation for falls. A simple measure to promote patient safety and prevent falls is to make patient rounds hourly to attend to basic needs.

External vagina continued:

The vaginal vestibule is the area that lies between the labia minora and contains the urethral (urinary) meatus, the introitus (vaginal opening), hymenal tissue, and Bartholin's and Skene's glands. The urethral meatus is located just below the clitoris and appears as an irregularly shaped slit. The vaginal introitus lies immediately below the urethral meatus and varies in size and shape. The hymen is a fold of mucous membrane at the vaginal opening separating the external genitalia from the vagina and appears as small, fleshy tags of skin (sometimes referred to as hymenal remnants or hymenal tags) The ducts of Skene's glands and Bartholins glands open within the vestibule. The tiny Skenes glands are numerous and are located in the paraurethral area. During sexual intercourse, they secrete a lubricating fluid. The ducts usually are not visible.

Internal Structures of Male Reproductive: Ducts

There are a series of ducts that are collectively responsible for the transportation of sperm. Once formed in the testes, sperm move into the comma-shaped epididymis - a long and elaborately coiled duct that lies on the posterolateral surface of each testis. As sperm move through the epididymis, they receive nutrients and mature. Eventually they exit the epididymis through the vas deferens. The vas deferens (also known as the ductus deferens) transport sperm from the epididymis to the ejaculatory duct. It is enclosed within the spermatic cord (a connective tissue sheath) along with arteries, veins, and nerves as it ascends through the inguinal canal. The cord enters the inguinal canal through the external inguinal ring; this ring is vulnerable to hernias, or protrusion of the abdominal contents. In the abdominal cavity the vas deferens travels up and around to the posterior aspect of the bladder, where it unites with the seminal vesicle. The union of the seminal vesicles with the vas deferens forms the ejaculatory duct just before the entrance into the prostate gland. Within the ejaculatory duct sperm are transported downward through the prostate gland and into the prostatic portion of the urethra. The innermost tube of the penis, the urethra, is usually about 18 to 20 cm from bladder to meatus. It extends out of the base of the bladder, traveling through the prostate gland into the pelvic floor and through the penile shaft. The urethral orifice is a small slit at the tip of the glans. The urethra is the terminal passageway for both urine and sperm. During ejaculation sperm travel from the ejaculatory duct through the urethra and out of the body.

PALPATE the testes, epididymides, and vas deferens for location, consistency, tenderness, and nodules:

This procedure is done to screen for testicular cancer or when the patient reports pain or edema. (secondary prevention) Palpate the testes simultaneously with both hands, using the thumb and the first two fingers. Note that the teste are present in each sac; they should be equal in size, bilaterally sensitive but nontender to moderate compression, smooth, and ovoid, and movable. ABNORMAL FINDINGS: Note if the testes have not descended into the sac or are enlarged (unilaterally or bilaterally), atrophied, markedly tender, nodular or irregular, or fixed. A painless mass with scrotal edema needs further evaluation for testicular cancer. On the posterolateral surface of each testis, palpate the epididymis; it will fee like a tubular, comma-shaped structure that collapses when gently compressed between your fingers and thumb. This area should be smooth and nontender ABNORMAL FINDINGS: If a problem is noted with the epididymis, determine its position in relation to the testes; whether it can be moved with your fingers; and if it disappears when the patient lies down. Report any tenderness, irregular placement, enlargement, induration, or nodules. The vas deferens lies within the spermatic cord. To palpate, grasp both spermatic cords between the thumb and forefinger and palpate, starting at the base of the epididymides, moving upward to the inguinal ring. Because the vas deferens lies within the spermatic cord along with arteries and veins, it is difficult to identify specifically with palpation. The vas deferens feels like a smooth, cordlike, structure. It should be nontender and palpable from the epididymis to the external inguinal ring. ABNORMAL FINDINGS: Report any tenderness, tortuosity (twisting), thickened or beaded area, or induration. Overall note, undescended testicles = not in scrotum enlarged tender nodular, irregular surface = suggestive of cancer tenderness of epididymis

PALPATE the scrotum for surface characteristics and tenderness:

This procedure is performed to screen for scrotal masses or when the patient reports pain or edema (secondary prevention) Use both hands simultaneously, thumb and first 2 fingers. Palpate each half of the scrotum. The surface should feel coarse, with the skin intact and loose over a muscle layer. The thickness of the skin of the scrotum changes with temperature and age. In cold or cool temperatures, the scrotal skin feels thickened. As the individual ages, the skin thins. The scrotum should be nontender. ABNORMAL FINDINGS: Note any marked tenderness or edema.

Internal Structures of Male Reproductive: Glands

Three glands (seminal vesicles, prostate gland, and bulbourethral glands) produce and secrete fluid that makes up most of the fluid in the ejaculate (semen) Two of the three prostate lobes are palpable through the rectum (right and left lateral lobes). These lobes are divided by a slight groove known as the median sulcus. The third lobe (median lobe) is anterior to the urethra and cannot be palpated. Bulbourethral glands, located on either ide of the urethra just below the prostate, also secrete fluid that contributes to the semen, providing a medium for transport of the sperm.

Electrical Energy:

To ensure fire safety, nurses should regularly check for faulty or loose writing or anything unusual, clinical engineers should conduct scheduled checks and routine maintenance of electrical equipment. Patients may be at increased risk for an electric shock because of the multiple electrical devices to which they may be connected for therapeutic purposes.

OBSERVE the ankles and feet for range of motion:

To evaluate the range of motion of both feet and ankles, ask the patient to: Dorsiflex (flexion) = the ankle by pointing the toes toward the face. Plantar flex the ankle = by pointing the toes toward the floor. Evert (eversion) = ankle turns outward (NOTE: you may need to stabilize the heel during these maneuvers) Invert (inversion) = ankle turns inward toward midline. Abduction = foot turning away from midline Adduction = foot turning inward toward midline Flex and extend toes = these should be active movements. All movements should be bilaterally equal and performed without pain. ABNORMAL FINDINGS: Limitations in range of motion, pain, and asymmetry my require further evaluation. Tightening or trauma o the Achilles tendon may cause plantar flexion.

TEST the leg muscles for strength:

To test the quadriceps with the patient SITTING, have the patient extend their legs at the knee while you attempt to flex the knee. To evaluate the hamstrings with the patient sitting, have the patient attempt to bend their knee while you straighten it. EXPECTED FINDINGS: For quadriceps and hamstrings, strength should be bilaterally equal, and you should be unable to flex the knee. For grading muscle strength it should be 5/5 or normal bilaterally. ABNORMAL FINDINGS: An unequal response, weak response, muscular spasm, and pain may be caused by joint or muscle inflammation, trauma, or injuries.

TABLE 14-1 RANGE OF MOTION FOR DIARTHRODIAL JOINTS: - TOES

Toes: - Flexion: curls toes downward. - Extension: Straighten toes. - Abduction: Spread toes apart. - Adduction: Bring toes together.

PALPATE the ankles and feet for contour:

Use the PADS of the thumbs and fingers to palpate the ankle and the heel; use both hands to palpate one foot at a time. These structures should feel firm and smooth. No tenderness. ABNORMAL FINDINGS: Heat, redness, edema, and pain are signs of an inflamed joint due to rheumatoid arthritis, gout, fracture, or tendonitis. A localized pain in one heel may indicate a bone spur. Pain in both feet that is worse on arising may indicate plantar fasciitis.

PALPATE bones for pain/tenderness; joints for pain/tenderness, temperature, and edema; and muscles for pain/tenderness, temperature, edema, and tone:

Using the PADS of the THUMBS and FINGERS of BOTH hands, palpate both of the patients shoulders simultaneously. Compare one side with the other. Move distally and symmetrically, palpating the muscles, the bones, and joints of the arms and hands. Use the dorsum of your hands to detect temperature of muscles and joints. Use the same technique for palpating the legs from the hips to the toes. (palpate distally and symmetrically, palpating the muscles, the bones, and joints of the arms and hands. Then use the dorsum of your hands to detect the temperature of muscles and joints) NORMAL FINDINGS: Bones should be painless/ no tenderness on palpation. Joints should be freely moveable without pain. No pain or edema should be detected on palpation of joints or muscles. The joints and muscles should be at the SAME temperature as the surrounding tissue. (NO-HEAT) Muscle should feel FIRM, not hard or soft. Muscles should have no tenderness. Muscles should have no edema. Muscle tone should be equal bilaterally, well developed. ALWAYS COMPARE BILATERALLY LEFT SIDE TO RIGHT SIDE. ABNORMAL FINDINGS: Pain, edema, and warmth in affected joints are found bilaterally in patients with = rheumatoid arthritis. Pain and enlarged joints with pain on movement are found unilaterally in patients with osteoarthritis. Pain, heat, or edema over bones or muscles may indicate tumor, inflammation or trauma. Muscle atrophy may be evident by a decrease in muscle tone.

Internal Structures: Vagina and Uterus

Vagina: The vagina is a canal composed of smooth muscle and is lined with mucous membrane that extends posteriorly from the vestibule to the uterus. It inclines posteriorly at an angle of approximately 45 degrees to the vertical plane of the body. The canal has transverse ridges of mucous membrane lining the vagina in the reproductive years. The uterine cervix enters posteriorly and anteriorly into the vaginal cavity to form a recess, or fornix, around the cervix. The fornix is divided into anterior, posterior, and lateral fornices. The vagina carries menstrual flow from the uterus and is the receptive organ for the penis during sexual intercourse. During birth the vagina becomes the terminal portion of the birth canal. Uterus: The uterus is a hollow, thick, pear-shaped, muscular organ. It is suspended and stabilized in the pelvic cavity by the dour pairs of ligaments (listed previously) . It is fairly mobile, usually loosely suspended between the bladder and rectum. The cervix is a mucus a producing gland that is the lowest portion of the uterus. The cervical opening, or the os, is visible on the surface of the cervix. It appears as a small, round opening in a nulliparous woman (never having borne a child) or as an irregular slit in parous women. The portion of the uterus above the cervix is known as the corpus. The corpus is composed of three sections: the isthmus (narrowing neck from which the cervix extends into the vagina) the main body of the uterus and the fundus which is the bulbous top portion of the uterus. The fundus maintains its position by the attached round ligaments.

Tiny, flat, reddish-purple, nonblanchable spots in the skin less than 0.5 cm in diameter; appear as tiny red spots pinpoint to pinhead in size. Cause: tiny hemorrhages within the dermal or submucosa - caused by intravascular defects and infection:

Vascular Skin Lesions: Petechiae

PALPATE the nipples for surface characteristics and discharge:

Wear examination gloves if there is a history of nipple discharge or if discharge is observed. Palpate nipples with gloved index finger. With the patient in the supine position, palpate the nipples. They should be soft and pliable with no masses or discharge. If a discharge is present, note the color, consistency, quantity, and odor. Try to determine the origin of the discharge by gently palpating the areola completely around the nipple with your index finger. Observe for the appearance of discharge through on of the ducts openings. ABNORMAL FINDINGS: Thickening of the nipple tissue, a mass, and loss of elasticity are signs consistent with malignancy. Nipple discharge is considered an abnormal finding EXCEPT during pregnancy or lactation. Discharge may occur secondary to fluid retention of the ducts, infection, hormonal flux, or carcinoma. Note any discharge: color consistency quantity odor Normal in lactating female ONLY

Disorders of the Central Nervous System: Cerebrovascular Accident (Stroke)

When cerebral blood vessels become occluded by a thrombus or embolus or when intracranial hemorrhage occurs, the brain tissues become ishemic, resulting in a CVA or stroke. Clinical findings: Assessment of patients with a stroke includes level of consciousness, orientation, ability to follow requests such as "squeeze my hand and let go" movement of all extremities, testing sensation with a pin prick, and evaluating speech by having patient describe a picture. Manifestations are directly related to the area of the brain and the extent of the ischemic area. Example, ischemia to the left frontal lobe may result in paralysis of the right arm or leg.

CLINICAL NOTE:

When examining male genitalia, use a firm, deliberate touch. If an erection occurs, reassure the patient that this is a normal physiological response to touch and that he could not have prevented it. Do not stop the evaluation; stopping focuses further on the erection and reinforces the patients embarrassment.

MOTOR Observe gait for balance and symmetry: - coordination - balance

When the patient walks in the room, notice the gait and whether it is symmetric. The patient should be able to maintain an upright posture. Walk unaided (without assistance) maintain balance use opposing arm swing (arms of patient alternately swing with taking steps while walking) Observing equilibrium is a test of CN VIII (acoustic or vestibulocochlear nerve) ABNORMAL FINDINGS: Disorders of the neurologic system such as rigidity or cerebellar diseases cause symmetric abnormalities in gait. Poor posture, ataxia, unsteady gait, rigid or absent are movements, wide - based gait, trunk and head held tight, lurching or reeling, scissors gait, or parkinsonian gait (stooped posture; flexion at hips, elbows, and knees) may require further evaluation.

With client in sitting position, TEST the trapezius muscles for strength (shoulders and spine continued) :

While client is in sitting position, ask the patient to shrug the shoulders while you attempt to push them down. This also tests function of cranial nerve XI (CN XI: spinal accessory) ABNORMAL FINDINGS: Weakness of the trapezius muscles may indicate compressed spinal nerve root or compression of spinal accessory CN XI.

PERFORM HAND HYGIENE INSPECT the breasts and nipples for symmetry, color, size, shape, rashes, and lesions:

With the patient in a seated position, inspect both breasts. The breasts should be flat, symmetric, and without rashes or lesions. Men who are overweight often have a thicker fatty later of tissue on the chest, giving the appearance of breast enlargement. If this is noted, determine if he has a history of weight gain. If the patient reports that his breasts became full as he gained weight, the condition is most likely within expected limits. The nipple and areolar areas should be intact; smooth; and of equal color, size, and shape bilaterally. ABNORMAL FINDINGS: Note any asymmetry or distinct differences between the two side. Note any ulcerations, masses, or swelling. If the patient reports a sudden bilateral or unilateral breast enlargement with associated tenderness, the nurse should consider the situation abnormal and refer the patient for further evaluation.

Ethical, Legal, and Professional Practice BOX 25.6 Litigation Resulting From Breaches in Patient Safety Standards of Care:

Wrong - side surgeries and amputations. Wrong - patient errors (medications given to the wrong patients, diagnostic procedures or treatments performed on the wrong patients) Medication dosage errors resulting in organ damage or failure or in death (not lowering dosage for children or geriatric patients) Fall-related injuries and death (particularly in older adults) Restraint-related injuries and death

Lesions following a nerve (herpes zoster)

Zosteriform

Inspect the client in the standing position - Lordosis

is an anterior curvature of the spine "swayback" Lordosis Lumbar

Callus:

is an area of excessive thickening of skin that is an EXPECTED VARIATION associated with friction or pressure over a particular surface area. calluses are commonly found on hands or feet.

Type of Breast Examinations:

_ Clinical Breast Exams (CBE) - GOAL IS SCREENING for breast cancer performed by a healthcare provider. ( MOSTLY DONE BY Advanced Practice Nurse or Physician ) - Breast Awareness (formerly Breast Self-Exam) - Monthly exam is done by the patient to know the norms for breasts. (IT IS STILL IMPORTANT FOR WOMEN TO EXAMINE THEIR BREASTS HAVING A ROUTINE SCHEDULE, FOR EXAMPLE, DURING SHOWER AND MONTHLY FOLLOWING THE END OF MENSTRUAL PERIOD) - GOAL IS = TO NOTE ANY CHANGES IN THE WAY YOUR BREAST FEEL

The olfactory nerve (CN I) is frequently not tested; however, if the patient mentions altered taste, this may indicate

a need to test for smell. ABNORMAL FINDINGS: Patient reports an absence of smell or lack of taste of food and drink.

When the patient hears you the acoustic or vestibulocochlear nerve ______ is in tact.

acoustic or vestibulocochlear nerve (CN VIII) ABNORMAL FINDINGS: Indications of hearing loss include the patient asking you to repeat yourself; repeatedly misunderstanding questions asked; learning forward or placing the hands behind his or her ears to screen out environmental noises.

For the elbow and wrist, Hyperextension should always be done purposefully and gently. With body in

anatomical position

A positive guaiac test indicates the presence of:

blood

INSPECT and PALPATE the nails for shape, contour, consistency, color thickness, and cleanliness:

capillary refill Inspect the edges of the nails to determine if they are smooth and rounded. The nail surface should be flat in the center and slightly curved downward at the edges. The nail bed and the area under the nails should be clean. Shape: smooth, rounded edges In light skinned slient = pink examine the thickness of the nail itself. The nail should have a uniform thickness. Finally, palpate the nail to ensure that the nail base feels firm and adheres to the nail bed. The skin adjacent to the nail should be intact, the same color as adjacent skin and without edema. In light-skinned individuals nails are pink and blanch with pressure. Individuals with darker-pigmented skin typically have nails that are yellow or brown, and vertical banded lines may appear. Inspect the nail base angle (the angle of the proximal nail fold and the nail plate) The expected ABNORMAL FINDING: Inflammation characterized by edema and erythema of the folds of the finger tissue may indicate infection. Leukonychia appears as white spots on the nail plate. This usually caused by minor trauma or manipulation of the cuticle. Koilonychia (spoon nail) presents as a thin, depressed nail with the lateral edges turn upward. This is associated with anemia or may be congenital. Clubbing = is present when the angle of the nail base exceeds 180 degrees. It is caused by proliferation of the connective tissue, resulting in an enlargement of the distal fingers. Clubbing is most most commonly associated with chronic respiratory or cardiovascular disease. Beaus line manifest as a groove or transverse depression running across the nail. They result from a stressor such as trauma that temporarily impairs nail formation. The groove first appears at the base of the nail by the cuticles and moves forward as the nail grows out. Nail pitting of the nail is commonly associated with psoriasis. Minor pitting may also be seen in persons with no health care problems. Thinning or brittleness of the nail may be secondary to poor peripheral circulation or inadequate nutrition.

Teeth begin mechanical digestion through mastication, or otherwise known as:

chewing

Female Perineal Care:

cleansing from the front to back of the perineal area. (essential component of good hygiene practice is completed as often as necessary ti keep the patient clean, dry, and odor free.) Privacy Request of same sex/female caregiver must be honored. Documentation after care should include noting any odor or areas of redness, drainage, or swelling.

Diathrodial joints are synovial joints because they are lined with synovial fluid. Synovial fluid lubricates the

joint to facilitate its movement in various directions.

When the patients face is symmetric when talking, the facial nerve _____ is in tact.

facial nerve (CN VII) ABNORMAL FINDINGS: Asymmetry of the patients face is abnormal

Mucous:

fluid secreted by mucous membranes traps particles in the nose

The roots of the teeth are surrounded by:

gingivae (gums), which are composed of connective tissue and epithelial cells. The ability to ingest and chew food depends on the health of all parts of the oral cavity.

When you observe the patients swallowing, the glossopharyngeal nerve _____ and vagus nerve _______ are intact.

glossopharyngeal nerve (CN IX) Vagus nerve (X) ABNORMAL FINDINGS: An ability to swallow saliva may need further evaluation.

Hair follicles arise from the dermis, are made up of epithelial tissue (tissue that lines tubes and cavities and the surface of the skin), and generate:

hair

Special shampoos called pediculicidal shampoos are sometimes used when a patient has:

head lice These shampoos can be toxic and may cause central nervous system side effects such as headache, dizziness, and seizures. CONTRAINDICATED FOR PATIENTS WITH A HISTORY OF SEIZURES, PREGNANT WOMEN, AND YOUNG CHILDREN. The nurse uses personal protective equipment when bathing and providing care for patients with pediculosis to avoid spreading the infestation. Combing the patients hair with a fine-tooth before and after application of the shampoo helps remove the lice and their eggs (nits)

Abstract Thinking:

humorous saying

When the patient enunciates words, the tongue and hypoglossal nerve _______ are intact.

hypoglossal nerve (CNXIII) ABNORMAL FINDINGS: Speech that is not clearly articulated may indicate an abnormality with the tongue.

INSPECT AND PALPATE skin lesions:

in-depth examination not preferred during routinely exams. however when lesions changes (in appearance or becomes painful) or a new one pops up it should be examined. A strong light source to determine the exact color, elevation, and borders and centimeter ruler to measure the size of the lesions are helpful. The lesion is documented based on it characteristics, including location, distribution, color, pattern, edges, depth, size, and other characteristics such as presence of exudate. Lesions are classified as primary, secondary, or vascular.

Inspect the client in the standing position - Kyphosis

is a posterior curvature of the thoracic spine. "hunchback" Elderly patients lose height when they are older.

Observe the patients eye movement during the interview. When his or her eyes move, equally from side to side, up and down, and obliquely, . . . what 3 nerves are intact? 6 cardinal directions

the oculomotor nerve (CNIII) trochlear nerve (CN IV) abducens nerve (CN VI) intact. ABNORMAL FINDINGS: Note a lack of eye movement or eyes moving in opposite directions.

In an event of an immediate threat of harm to self or others, the nurse can apply a physical restraint without an order from:

the primary health care provider, but the physician order must be sought and the patient must be seen within an hour of application of the restraint. The physician must renew the physical restraint orders according to facility policy. The interventions and their corresponding rationales provide guidance for safe restraint application and measures for safe restraint application and measures that can be taken to prevent untoward consequences.

PATIENTS WITH A MASTECTOMY: After inspection, using the finger pads of your examining hand PALPATE

the side with the mastectomy, especially around the area of the scar. Use a small CIRCULAR motion, assessing for thickening, lumps, edema, or tenderness; then use a SWEEPING motion to palpate the entire chest area on the affected side to ensure that no abnormalities have been missed. FINALLY, palpate the axillary and supraclavicular areas for lymph nodes. If the patient has had breast reconstruction or augmentation, perform the breast examination in the usual manner, paying particular attention to scars.

documentation of bathing includes:

the type of procedure performed, the date and time, skin-related issues, incontinence, drainage or odors, catheters or dressings, and the patients self-care abilities and response to the procedure.

Hypertonicity

there is too much muscle tone so that arms or legs, for example, are stiff and difficult to move.

Association:

things that go together we go together like peanut butter and... jelly bat and ball cats and dogs

Cilia:

tiny hairs lining the nasal passages helps move the trapped particles to the throat, where they are swallowed.

The perineal surface is the:

triangular - shaped area between the vaginal opening and the anus. The pelvic floor consists of a group of muscles that form a suspended sling supporting the pelvic contents. These muscles attach to various points on the bony pelvis and form functional sphincters for the vagina, rectum, and urethra.

When the patients eye blink, the ophthalmic branch of the _______ nerve is in tact.

trigeminal nerve (CNV) ABNORMAL FINDINGS: Lack of blinking is abnormal

ABNORMALITIES OF GAIT: Ataxia

uncoordinated muscle movement. can lead to unstable gait requires assistive device to ambulate (walk)

Halitosis:

unpleasant breath odor (may result from poor dental hygiene, fungal or bacterial infections, and complications of medical conditions such as diabetic ketoacidosis or renal failure.

Hearing the patients guttural speech sounds (e.g., k or g) indicates another function of the vagus nerve ______

vagus nerve (CN X) ABNORMAL FINDINGS: An absence of guttural sounds or nasal speech may indicate a vagus nerve abnormality.