Assessment Module 7

Fine motor development

Grasp reflex - from birth to 3 months 5 months - grasp voluntarily 7 months - hand to hand transfer 9 months - pincer grasp 12 months - attempts to build a two block tower

Lacrimal apparatus

Inspect and palpate Palpate just inside lower orbital rim on nasal side No drainage should be noted on palpation

Babinski Reflex

Reflex in which a newborn fans out the toes when the sole of the foot is touched Disappears after 2 years A positive response after 2 years suggests pyramidal tract diseas

Sucking Reflex

Reflex that causes a newborn to make sucking motions when a finger or nipple if placed in the mouth disappears at 10-12 mo A weak or absent sucking reflex may indicate a neurologic disorder, prematurity, or CNS depression caused by maternal drug use or medication during pregnancy.

Olfactory Newborn

Smell is fully developed at birth, and newborns can differentiate the smell of their mother's milk and parents' body odors

Intraductal papilloma

small growth inside a milk duct of the breast, often near the areola. It is harmless and occurs in women ages 35-50 -Causes: pregnancy, include lactation, hypothyroidism, pituitary adenoma, oral contraceptives, antihypertensives, and tranquilizers Nipple DC: bloody (possibly from a papilloma in the duct); greenish (often from a draining breast cyst); or clear (more likely associated with cancer unless from both nipples)

Myopia

(impaired far vision) visual acuity test result is larger than the first (20/40). The higher the second number, the poorer the vision. A client is considered legally blind when vision in the better eye with corrective lenses is 20/200 or less. Refer any client with vision worse than 20/30 for further evaluation.

Presbyopia

(impaired near vision) when the client moves the chart away from the eyes to focus on the print. It is caused by decreased accommodation. -common condition in clients over 45

Eyelids

(palpebrae) two movable flaps of skin which cover and uncover each eyeball.

Jaundice in newborn

during first 24 hours: jaundice is pathological (r/t liver problems) after 24 hours: physiological jaundice r/t inc amount of unconjugated bilirubin in system

Choroid

-vascularity necessary to provide nourishment to the inner aspect of the eye and prevents light from reflecting internally. Anteriorly, it is continuous with the ciliary body and the iris.

Eyelids and eyelashes

-Assess ability of eyelids to close -Width and position of palpebral fissures -Unusual turnings, color, swelling, lesions, discharge of eyelids -Position and alignment of eyeball in socket -Inspect bulbar conjunctiva and sclera ABNORMAL: Ptosis: culomotor nerve damage, myasthenia gravis, weakened muscle or tissue, or a congenital disorder Hyperthyrodism: retracted lid margins, which allow for viewing of the sclera when the eyes are open. Lids to close risk for corneal damage Entropion- inverted lid may cause pain as eyelash brushes against conjunctive and cornea. Ectropion, everted lower eyelid, exposure of drying conjunctiva.

external structures of the eye

-Eyelids -Lateral and medial canthus -Puncta -Caruncle -Palpebral fissure -Eyelashes -Conjunctiva -Lacrimal appartus -Extraocular muscles

Visual Reflexes

-Pupillary light reflexes-causes pupils immediately to constrict when exposed to bright light -Direct-constriction occurs in the eye exposed to the light -Consensual (indirect)-which exposure to light in one eye results in constriction of the pupil in the opposite eye. These protective reflexes, mediated by the oculomotor nerve, prevent damage to the delicate photoreceptors by excessive light. - accommodation:functional reflex allowing the eyes to focus on near objects. through movement of the ciliary muscles, causing an increase in the curvature of the lens

Internal Structures of the Eye

-Sclera -Cornea -Iris -Ciliary body -Choroid -Pupil -lens -Optic disc -retinal vessels: venules & arterioles -Macula

Retinal vessels: venules & arterioles

-viewed w ophthalmoscope -four sets of venules & arterioles - -Venules: are dark red and grow progressively narrower as they extend out to the peripheral areas -Arterioles: carry oxygenated blood and appear brighter red and narrower than the veins. -Fundus or gen. background varies in color.

Vision

-Visual fields (each divided in quadrants) -Upper and lower temporal, nasal upper & lower -Binocular vision-"two sided vison" -Light rays strike retina- visual perception -Upside down image reversed -Optic chiasma- the nerve fibers from the nasal quadrant of each retina (from both temporal visual fields) cross over to the opposite side.

Health HX Eyes:

-Visual impairments: any visual defect that affects ADL ability -Low vision -Functional blindness -Total blindness -Congenital: (occurring in fetal development) -Adventitious:occurring after having normal vision through a hereditary condition or a trauma -Legal blindness: acuity of 20/200 or less -Recent visual difficulty, changes -Spots or floaters- NORMAL myopia or in clients over age 40 -Blind spots: 1.Intermittent: may be associated with vascular spasms (ophthalmic migraines) or pressure on the optic nerve by a tumor or increased intracranial pressure. 2. Scotoma: blind spot, normal or diminished peripheral vision. It MAY be glaucoma. 3. CONSTANT: retinal detachment (referral to opthalmologist) -Halos-narrow-angle glaucoma. Trouble with night vision-associated with optic atrophy, glaucoma, and vitamin A deficiency. -Diplopia- Double vision: may indicate increased intracranial pressure due to injury or a tumor. -Eye pain: Most common eye disorders are not associated with actual pain. Therefore, immediately refer reports of eye pain. 2.-Throbbing, stabbing, or deep, aching pain: foreign body in the eye or changes within the eye 3.tching/burning :allergies or superficial irritation. 4. photophobia: pain w bright light. -Redness or swelling- inflammatory response caused by allergy, foreign body, or bacterial or viral infection. 1.Excessive tearing: (epiphora) exposure to irritants or obstruction of the lacrimal apparatus. 2. Unilateral epiphora- foreign body or obstruction. 3.Bilateral epiphora- exposure to irritants, such as makeup or facial cleansers, or it may be a systemic response. -Eye discharge: bacterial or viral infection

cornea

-external layer -WINDOW OF EYE the transparent layer forming the front of the eye. -permits the entrance of light, which passes through the lens to the retina. It is well supplied with nerve endings, making it responsive to pain and touch.

Lacrimal Apparatus

-glands and ducts that lubricate the eye

Retina

-innermost layer -extends only to the ciliary body anteriorly. -receives visual stimuli and sends it to the brain. -specialized nerve cells are often referred to as "photoreceptors" because they are responsive to light (rods and cones) -Rods:sensitive to light, regulate black-and-white vision, and function in dim light -Cones: bright light and are sensitive to color.

optic disc

-optic nerve enters the eyeball. -round or oval Region at the back of the eye where the optic nerve meets the retina. It is the blind spot of the eye because it contains only nerve fibers, no rods or cones, and is thus insensitive to light.

extraocular muscles

-six muscles attached to the outer surface of each eyeball -four rectus muscles (superior, inferior, lateral, and medial) and two oblique muscles (superior and inferior) that are responsible for moving the eye in the direction controlled by that muscle -allows for parallel movement of the eyes and thus the binocular vision characteristic of humans. -three cranial nerves: the oculomotor (III), trochlear (IV), and abducens (VI).

lacrimal gland

-upper outer corner of the orbital cavity just above the eye, produces tears -lid blinks, tears wash across the eye then drain into the puncta, which are visible on the upper and lower lids at the inner canthus. - Tears empty into the lacrimal canals and are then channeled into the nasolacrimal sac through the nasolacrimal duct. They drain into the nasal meatus

Chest, lungs, breasts, heart

1- With first breaths, the decrease in pulmonary pressure closes the foramen ovale (increasing oxygen tension) and (closing) ductus arteriosus -lungs cont. develop after birth & new alveloli form until about 8yrs. 2-May be supernumerary breasts along milk line 3- Breasts may be temporarily enlarged 4- Systolic murmurs -due to the transition from intrauterine to extrauterine life. -resolves within 24 to 48 hours after birth 5-HR 120 -160, declines to 120's at 6 months and 110's 6 months to 1 year 6- 4th intercostal margin left of MCL (auscultated at )

Fibroadenomas

1-5 cm, round or oval, mobile, firm, solid, elastic, nontender, single or multiple benign masses found in one or both breasts.

4. Perform subsequent follow-up physical assessments of the newborn/ INFANT

1. General appearance 2.Cognitive, language, social, gross & fine motor development 3.Vital signs HR 120-160 (1 month) 110 (6 months to 1 year), respiratory rate 30-60 4. Length, weight, head & chest circumference 5. Skin color, odor, lesions, temperature, texture, moisture, turgor, edema using the correct techniques. 6. Inspect & palpate hair & nails 7. Inspect & palpate head 8. Test head control, posture, ROM 9 Inspect & palpate face, neck 10. Inspect eye, eyelid placement, swelling, discharge, lacrimal duct, sclera, conjunctiva, iris, pupils, eyebrows, eyelashes 11.Test visual acuity (ability to focus on & follow objects) 12. Shine light at cornea while infant looks ahead, assess whether eyes follow position of head 13. Ophthalmoscopic exam 14. Placement, discharges, lesions of ears 15. Otoscopic exam 16. Hearing acuity 17. Inspect mouth & throat, condition of gums, tonsils 18. Inspect nose & sinuses I9. Inspect thorax shape, breathing pattern 20. Percuss & auscultate chest 21.Inspect & palpate breasts 22. Inspect & palpate precordium (4th ICS, slightly left of LMCL)

Internal Anatomy Female Breast

1. Glandular:constitutes the functional part of the breast, allowing for milk production -Gladular tissue arranged in 15 - 20 lobes -Lobules & secreting alveoli -Mammary ducts:conveys milk to the nipple. lactiferous duct-slight enlargement in each duct before it reaches the nipple Lactiferous sinus- Milk storage ***NIPPLE 2. Fibrous tissue:provides support for the glandular tissue largely by way of bands called Cooper ligaments (suspensory ligaments) Fibrous tissue - Cooper ligaments - support 3.-fatty tissue: third component of the breast. The glandular tissue is embedded in the fatty tissue. Determining size and shape of breast. Fatty tissue - provides substance, shape, and bulk !!!Size and shape not related to functionality!! 4. Axillary lymph nodes: anterior: pectoral --drain the anterior chest wall and breasts. posterior: subscapular --posterior chest wall and part of the arms are drained lateral:brachial --drain most of the arms central: mid-axillary --receive drainage from the anterior, posterior, and lateral lymph node Note: small proportion of the lymph also flows into the infraclavicular or supraclavicular lymph nodes or deeper into nodes within the chest or abdomen.

Head & neck Newborn

1. Head circumference greater than chest by 2cm 2. Coronal, lambdoid, sagittal sutures - anterior & posterior fontanelles Posterior Fontanelles: measure 1 to 2 cm at birth and close at 2 mo. Anterior fontanelle: usually measures 4 to 6 cm at birth and closes between 12 and 18 months. 3. Asymmetry of skull- molding in birth process 4.Short neck: (lengthening at about age 3 or 4 years). Lymphoid tissue: develop at birth, reaches adult size by age 6.

EENT

1. Little pigment in iris, small pupils, no macula develops at 4 months and is mature by 8 months. (central vision we need for reading, driving, and seeing fine detail) 2. Lack of central vision, visual acuity about 20/200, pseudostrabismus- false appearance of crossed eyes. -Cannot distingusih colors until 8 mo. -Tearing/ control begin 2/3 mo 3. Startle reflex to (loud sounds) at 90 decibles 4. Pull pinna down and back for otoscope 5. Eustachian tube wider, shorter, more horizontal cause of infection from pharynx. 6.Minimal saliva at birth, tonsils & adenoids hard to see at birth. Pharynx: is seen with crying. 7. Obligatory nose breathers- have significant distress when their nasal passages are obstructed -maxillary and ethmoid sinuses: e0th week and are present at birth. However, they are small and cannot be examined until they further develop

Palpation of Breast what to look for

1. Masses - location, size, shape, mobility, consistency, tenderness, consistency of skin: 2. SKIN: Smooth, firm, elastic tissue **Thickening of tissue indicates underlying malignant tumor 3. TENDERNESS & TEMP: -normal body -nodularity and tenderness may be a normal finding associated with the menstrual cycle or hormonal medications. ** Pain/tender: fibrocystic breasts, especially right before menstruation. **Pain: malignant tumor ** Heat: inflammation 4.MASSES: No masses. Firm inframmamary transverse ridge may be normally palpated at lower base of breast. **hard, immobile, and fixed to surrounding skin and soft tissue, with poorly defined or irregular margins. 5. Nipples - send specimen of discharge 6. Mastectomy/lumpectomy site- Scar is whitish with no redness or swelling. No lesions, lumps, or tenderness noted. ** Redness & Inflammation: infection ** Lesions, lumps, tenderness referral. 7.Axillae: free of rash or infection -no palpable nodes: discrete, nontender, movable nodes in the central area **acanthosis nigricans: Dark, velvety pigmentation of the axillae ** Redness & Inflammed: infection of sweat glands. **enlarged nodes >1 indicate infection, **large nodes hard and fixed to skin indicate underlying malignancy. 8. BSE demo: BOX 20-1 Client may request instructions on how to perform the examination or choose not to learn how to perform the examination. Either choice needs to be accepted by the examiner.

History PREGNANCY/ Newborn & Infant

1. Pregnancy planned, prenatal care, problems with pregnancy 2.Accidents, medications, alcohol, tobacco during pregnancy 3.Delivery, where, anesthesia, interventions, initial APGAR, weight, length, head circumference, problems after birth 4.Past illnesses or injuries, immunizations, allergies, medications 5. Chronic diseases in family 6. 2 generation genogram 7.Communicable diseases in house

Musculoskeletal & neurological

1. Should have full ROM all extremities 2. Check hips for dislocation- Ortolani test and Barlow sign. 3. Single C shaped curve to spinal column 4. Immature neurological system - motor control in spinal cord & medulla -most actions are primitive reflexes 5. Primitive reflexes diminish with time over 1st year -nervous system 5% of adult capacity at birth, 50% by age 1 year, 80% by age 3, and 90% by age 7. 6. Stimuli must be strong, response not localized 7. Motor control develops head to neck, trunk to extremities

Inspection of Breast

1. Size & symmetry: round and pendulous, One larger than other. Abnormal: increase in size = inflammation or abnormal growth. 2.Color & texture: normal to ethnicity smooth, with no edema ABNORMAL: Red: inflammation Pigskin-like or orange peel (peaud'orange): edema, seen in metastatic breast disease. 3. Superficial venous pattern: Veins radiate horizontally towards the axilla transverse) or vertically with a lateral flare (longitudinal). ABNORMAL: -prominent venous pattern: increased circulation due to a malignancy. -asymmetric venous pattern may be due to malignancy. 4. Areolas & nipples: vary dark pink to dark brown. -Round and size vary -Small Montgomery tubercles present ABNORMAL: -PEAU D'ORANGE SKIN: Carcinoma, may be first seen in the areola. -Red, scaly, crusty areas may appear in Paget disease NIPPLES: nearly equal bilaterally in size, same location on ea breast. Everted but may be inverted or flat. -recently etracted nipple that was previously everted suggests malignancy SUPPERNUMERARY NIPPLES: appear in the milk line- no discharge should be presnt 5. Retraction & dimpling (arms overhead, hands to hips, hands together, lean forward from waist): Breast should rise symmetrically Abnormal: Usually caused by maligant tumor that has fiborus strands attached to the breast tissue and the fascia of muscles. Muscles contract it draes the tissue and skin with it causing dimpling or retraction. -Breast should hang freely and symmetrically. Abnormal;: Restricted or retraction of skin or nipple indicates fibrosis and fixation of the underlying tissues. Usually due to underlying malignant tumor.

Peripheral vascular

1. Skin generally pink and well perfused 2. May be acrocyanosis (blue )at times/hands &feet/ normal/ when baby is cold -Cyanosis- bluing skin, lips, nail beds, after crying or eating. Cardiac defects. 3.Peripheral pulses: radial, brachial & femoral **Weak femoral pulse suggests coarctation of the aorta **bounding pulses suggest patent ductus arteriosus

Skin, hair & nails Newborn

1. Skin smooth & thin (see p. 742) 2.Thin layer of fat (subq) - poor insulation. -inability to contract and shiver, results in ineffective temperature regulation 3, Vernix caseosa- thick, cheesy, white substance on the skin and is especially prevalent in skin folds. This is normal and usually absorbs into the skin 4. Milia- -are tiny white bumps that appear across a baby's nose, chin or cheeks -sebaceous glands are active because of high levels of maternal androgen 5. Active eccrine glands- creating palmar sweating, which is helpful when assessing pain Lanugo- fine, downy hairs, newborn's body, shoulders, and/or back at birth, develop in the fetus at 3 months gestation and disappear within the first 2 weeks of life.

Genitalia, anus, rectum, prostate

1. Testes descend about 8th month of gestation. -1 cm wide and 1.5 to 2 cm long 2. Female genitals may be engorged at birth -blood may be present/hormones. -returns to normal small size until puberty. 3.Meconium (first stool) passed during 1st 24 hours 4. Prostate not palpable

Abdomen

1. Umbilical chord - two arteries, one vein 2.May see peristaltic waves: **3 months of age and may be indicative of a disease or disorder such as pyloric stenosis 3. Liver palpable 0.5 to 2.5 cm below right costal margin 4.Bladder between symphysis pubis and umbilicus (higher than adults)

Risk factors for breast cancer

1.Female gender- 100x more likely to develop bc than men (estrogen and progesterone are implicated). 2.Age:especially for invasive breast cancers 3.BRCA1 and BRCA2 genes:5-10% hereditary 4.Race: White- greater risk for dx Black: Greater risk for dying of bc 5. Family history: Even if father or brother has had breast cancer, risk is increased. 6.Personal history of breast ca: three- to fourfold risk of cancer in the same or other breast) 7. Breast consistency:Dense Breast 8. Early menstruation, late menopause: (before 12 years of age) or later menopause (older than 55 years) Radiation to chest 9. Exposure to diethylstilbesterol: 1940s and 1950s), used by women to avoid miscarriage, or in daughters of mothers who took this medication

Modifiable Risk Factors Breast Cancer

1.No children or first child > age 30 2.Recent oral contraceptive use (risk declines to normal after 10yrs wo ) 3. Hormone replacement therapy both estrogen and progesterone; risk is highest in first 2-3 years but long use increases risk; risk reduces to normal risk after 2-3 years without therapy). -Estrogen-only therapy increases risk if used for 10 years or longer. 4. No history of breast feeding-due to reduced lifetime number of menstrual cycles. 5.Alcohol consumption: increased drink 2-5 drinks daily 6.Overweight: increased fatty tissue after menopause & increased estrogen levels 7. Limited physical activity: 1.25 to 2.5 hours of brisk walking at least 5 days. reduces by 18% 8. Dim light at night while sleeping: speed the growth of human breast cancer tumors implanted into rats, and makes the tumors resistant to tamoxifen UNDER FURTHER STUDY Night shift work Second hand smoke Environmental estrogen like chemicals Diet and vitamin intake

Breast Cancer Classification

1.Type and grade (1 - 3) 2. Estrogen or progesterone receptors positive or negative 3. Heu2/neu positive or negative: -(a growth-promoting protein instructed by the Heu2/neu gene to produce too much of the protein, which causes cancers to grow faster) 4.DNA and other gene expressions

Perform subsequent follow-up physical assessments of the newborn/ INFANT Continued

23. Auscultate heart (may here irregularity, split S2, S3, venous hum) 24. Inspect shape of abdomen, umbilicus 25. Auscultate bowel sounds 26.Palpate for masses, tenderness 27. Palpate liver, spleen, kidneys, bladder 28. Inspect & palpate penis, urinary meatus, scrotum, testes, inguinal area 29. Inspect external female genitalia 30. Inspect anus & rectum 31. Assess arms, hands, feet, legs 32. Assess for hip dysplasia - equal gluteal folds, full hip abduction (p. 752) 33. Assess joints & muscles 34. Assess cry, responsiveness, adaptation 35. Deep tendon reflexes & superficial reflexes 36. Motor function 37. Denver Developmental Screening Test pp. 756-757

Cognitive & psychological development Page 726

6 months - attempts to imitate sounds By 1 year infants have a vocabulary of 2-4 words Trust vs Mistrust (Erikson): develop trust or mistrust -learns that life is predictable and that his or her needs will be met -consistent delay: leading to mistrust of caregivers and the environment Oral stage (Freud): crying, tasting, eating, and early vocalization; biting, to gain a sense of having a hold on and having greater control of the environment; and grasping and touching, to explore texture variations in the environment.

Sensory Development

8 months - distinguishes colors Attend to human voice Prefers sounds associated with pleasure Differentiate odors Well developed sense of touch term

Snellen Chart

Client stands 20 feet away Last line the client can read Different versions for children May test with or without glasses Cover one eye

3. Perform an initial physical assessment of the newborn using the correct techniques.

APGAR! 8-10 Score & 100bpm 1. Stroke back or soles- cry 2.Check muscle tone by extending legs & arms: Active ROM 3. Skin color of extremities -Pink, acrocyanosis is common **Cyanotic Pale 4.Axillary temperature- 97.5-99 *Hypothermia: <97.5/ Sepsis *Hypertermia: >99.- infection 5.Auscultate lung sounds 6.Check respiratory rate and apical pulse 7.Weigh 8. Measure length, head & chest circumference 9. Assess gestational age 10. Square window sign (bend wrist forward), arm recoil, popliteal angle, 11. Scarf sign, heel to ear test 12. Skin parchment like 13. Amount of lanugo 14. Creases in plantar aspect of feet 15. Breast bud tissue 16. Ear cartiladge upper pinna 17. Genitals 18. Newborn reflexes (rooting, palmar grasp, sucking, plantar grasp, tonic neck, startle, stepping) pp. 754-755 19. APGAR p. 733

Macular degeneration risk factors

Age- advancing Smoking Family history Female gender Obesity bmi>30 Caucasian race Light eye color Sun exposure Fat, cholesterol & sugar in diet HTN-narrows blood vessels in retina CV disease Inactivity-probably related to vascular oxygen levels

People who are at risk for glaucoma:

Ages 40 to 54, every 1 to 3 years Ages 55 to 64, every 1 to 2 years Ages 65 and older, every 6 to 12 months

Corneal light reflex test

Assesses parallel alignment Penlight 12 inches from face Shine light toward bridge of nose Reflection on corneas should be symmetrical Abnormal:Asymmetric position of the light reflex indicates deviated alignment of the eyes. This may be due to muscle weakness or paralysis

Erythema toxicum neonatorum

Benign neonatal rash characterized by blanching erythematous papules and/or pustules. It resolves spontaneously within 2 weeks of birth

Chapter 16- Assessing the eyes

Chapter 16- Assessing the eyes

Chapter 20 ASSESSING BREASTS AND LYMPHATIC SYSTEM

Chapter 20 ASSESSING BREASTS AND LYMPHATIC SYSTEM

Chapter 30 Newborns and infants

Chapter 30 Newborns and infants

Breast Palpation

Client lying with same side arm up, pillow or roll under breast being palpated Flat pads of three fingers Palpate systematically Be sure to palpate every square inch including nipple & tail of Spence Bimanual technique for large breasts

Visual fields

Confrontation test Cover one eye Position fingers midway between you and client Test all four visual fields

Macular degeneration

Development of blind spots\Blurred discoloration vision Dry (most common) OR wet forms! Can be a mixture! Screening with Amsler chart: recommended for 65 years and older. Regular screening for older adults: 1. American Academy of Ophthalmology: 1 to 2 years 65&up w no risk 2.American Optometric Association Consensus: Annual exams 61 & up 3. American College of Obstetricians and Gynecologists: screening for women 65&up.

Lifestyle and Health Practices PAGE 728

Diet- nurtrion & gastroins function. Sleep Pattern- varies Sleep Position- Supine, side-lying SIDS

Ability of eyelids to close

Entropion - inverted lower lid Ectropion - everted lower lid Turnings, color, swelling, lesions, discharge Redness or crusting on margins - seborrhea, blepharitis, hordeolum (stye), chalazion (infection of meibomian gland)

1. Describe the structures and function of the eyes.

External and Internal Structures

Family HX of Eye Problems

Eye problems or visual loss Glaucoma Refraction errors Allergies Macular degeneration:a major cause of visual impairment.

2. Discuss the risk factors for cataracts and ways to reduce those risk factors.

Fading or cloudy vision Poor night vision Halos Double vision in a single eye RISK FACTORS: Age Diabetes Excessive alcohol Sunlight or radiation exposure Family history Obesity Eye injury, inflammation, surgery Steroids Smoking Corticosteroid: ingested or topical Screening: early detection and treatment of cataracts can greatly reduce the risk of partial or complete blindness and recommends that adults 65 years or more who have no symptoms have their eyes examined every 1 to 2 years.

Types of Benign masses

Fibroadenoma - 1-5 cm, round, nontender, mobile, solid, elastic Milk cysts Lipoma - soft fatty tissue Intraductal papilloma

telangiectatic nevi

Flat, pink or red marks that easily blanch and are found on the back of the neck, nose, upper eyelids, and middle of forehead

1. Describe the structure and functions of the breast and major axillary lymph nodes.

Four quadrants: Upper outer quadrant leads into the tail of Spence- Axillary (Most tumors occur in this quad) Areola:surrounds nipple (generally 1- to 2-cm radius) and contains elevated sebaceous glands (Montgomery glands) that secrete a protective lipid substance during lactation Nipple- milk passage Lymph nodes- male and female Milk line (supernummary nipples):

3. Interview a client for an accurate nursing history of the breast and axillary lymph region.

HISTORY OF PRESENT CONCERN --benign breast conditions (fibrocystic breast disease), fibroadenomas, or malignant tumors -Lumps or swelling/IN axillae: enlarged, appearing as lumps or swelling with inflammation, fibroadenomas, infections, and breast cancer. -related to menstrual cycle?: lumpiness and soreness that subside after the end of the menstrual cycle may indicate benign breast disease (fibrocystic breast changes). -Rash on breast, nipple, axillary area: -Redness, warming=Inflammation -Dimpling of breasts=nipple or fibrous tissue may indicate breast cancer. -Change in size or firmness: indicate inflammation, pregnancy, lactation, or abnormal growth. -Pain in breasts - COLDSPA FURTHER EVAL: -Discharge from nipples: Blood or blood tinged: referred for eval. discharge is spontaneous, unilateral, is bloody or guaiac-positive discharge; if the client is over 40 or a male; or if a mass is also palpable. Clear D/C Stimulation of breast & Medicaitons: (oral contraceptives, phenothiazines, steroids, digitalis, and diuretics)

Cardinal fields test

Have client focus on object 12 inches away Move the object through the six positions in clockwise direction Observe eye movement Assessment of extraocular muscles and cranial nerves III, IV, VI May see nystagmus Normal: Movement smooth and symmetrical. Abnormal: Unsymettrical eye movement- indicates weakness in one or more extra ocular muscle or dysfunction. 1. Nystagmus—an oscillating (shaking) movement of the eye—may be associated with an inner ear disorder, multiple sclerosis, brain lesions, or narcotics use

Lifestyle and health practices: Breast

Hormones, contraceptives, antipsychotic agents: -engorgement in women -increase the risk of breast cancer -Haloperiodol (Haldol) can cause GALACTORRHEA- persistent milk secretion whether or not the woman is breast-feeding) and lactation -Depo-Provera- cause lactation -GALACTORRHEA- medication induces --pituitary tumor --hypothalamic and pituitary stalk lesions, neurogenic stimulation, thyroid disorders, and chronic renal failure Exposure to radiation, benzene, asbestos: increase risk Typical diet: high-fat diet increases Alcohol, caffeine- -exceeding two drinks per day & tobacco use increases -Caffeine can aggravate a fibrocystic breast condition. Exercise & protective equipment: -elasticity loss if vigorous exercise -well fitting bra reduces discomfort Importance of breasts to self concept: Alterations in the breasts may threaten a woman's body image and feelings of self-worth, and men may be embarrassed to have enlarged breasts Breast self examination: breast self-awareness (becoming familiar with the appearance, feel, and shape of one's breasts and nipples) -Regularly after period -more comfy while showering or getting dressed. Breast exams by health care provider- acs recommends against regular exams based off of research finding. HOWEVER, any previous exam findings provide baseline comparative assessment. Choice of the patient. Last mammogram- screening of choice for breast cancer. -Age 40 &up -Every year -50-74/ Biennial screen(Q2 years)

2. Complete a newborn history by interviewing parents about their newborn's prenatal development and by reviewing prenatal/delivery records.

Hx of present concern: What prompted this visit General state of health

Biographical data

Infant's name, nickname, parents' or caregivers names Primary care provider & last well baby appointment Where does infant live Parents in same residence? Composition of family Adopted, foster, natural? Ethnic origin, religion Occupation of parents

Iris and Pupil

Measure dilated and constricted Direct response Consensual response Accommodation

Neonate & Infant

Neonate (newborn): birth to 28 days Infant: 1 mo- 12 mo

Cafe au lait spots

Neurofibromatosis Smooth edged tan-to-brown pigmentations on the skin seen in NF1

Gross motor development

Newborns - unable to turn their heads while on soft surface 3-4 months - almost no head lag, can push up from prone position 5 months - roll from front to back 6-7 months - sit unsupported 9 months - pull to stand 12 months - walk with hand holding

Male Breast

No swelling, nodules, or ulceration should be detected. 1.May be enlarged with obesity 2.Gynecomastia - smooth, firm, movable disc of glandular tissue, (may be seen in puberty) ** hormonal imbalance, drug abuse, cirrhosis, leukemia, thyrotoxicosis. 3. Irregular hard nodules occur in breast cancer

8. Analyze the data from the interview and physical assessment of the breasts and axillary lymph nodes to formulate valid nursing diagnoses, collaborative problems, and/or referrals.

Nursing Diagnosis: Readiness for enhanced knowledge: requests information on BSE Risk for ineffective health maintenance r/t lack of breast self-awareness Fear of breast cancer r/t increased risk factors aeb ... Disturbed body image r/t mastectomy aeb ... Collab/Referrals: R/C mastitis R/C benign breast disease R/C breast cancer

palpebral conjunctiva

Only inspect if client complains of something in eye Avoid pressure to eyeballs Pull down lower lid to expose conjunctiva Evert upper lid while pulling down by lash and with cotton applicator Return to normal position by having client look up and blink

Risk Factors for Glaucoma

Open angle: High eye pressure Fam HX IOP- intraocular pressure Age 40 OR African American Thin cornea Myopia (very severe nearsightedness) Diabetes Eye surgery or injury HTN Corticosteroids (drops, pills, inhalers, creams) CLOSED ANGEL: Age 40 and older Family history Farsightedness (Presbyopia) Eye surgery or injury East Asian, Inuit

Glaucoma

Open angle: Patchy blind spots in your side (peripheral) or central vision, frequently in both eyes Tunnel vision in the advanced stages Closed angle: Slow insidious onset Irreversible vision loss SYMPTOMS: Patchy blind spots (open angle) --Tunnel vision Headache, eye pain (closed angle) --Nausea and vomiting --Halos --Eye redness

Ophthalmoscopic exam

Optic disc - round or oval, sharp defined borders Physiologic cup - slightly depressed and lighter color 4 sets of arterioles and venules A-V ratio 2:3 or 4:5 A-V crossings (vein seen right up to the column of blood on either side of the arteriole) Retinal background - consistent in texture Fovea and macula Anterior chamber (rotate lens to +10 or +12) In case of eye trauma observe for foreign body, blood in anterior chamber, irregularity of pupil

Types of Breast Cancer

PAGE 415 1. Ductal carcinoma in situ (DCIS)- 2.Invasive ductal carcinoma (IDC) 3.Medullary carcinoma 4.Invasive lobular carcinoma (ILC) 5.Triple negative carcinoma (TNC) 6.Tubular carcinoma 7.Mucinous carcinoma 8.Inflammatory breast carcinoma (IBC) 9.Paget disease of the breast

Breast self exam: BSE

PAGE 417 MOST IMPORTANT: report changes to hcp.

Pain in the Breast Coldspa

Pain and tenderness of the breasts are common in fibrocystic breasts, especially just before and during menstruation. This is especially true for clients taking oral contraceptives. Symptoms of fibrocystic breasts may include: -Breast pain or tenderness -Lumps or areas of thickening Fluctuating size of breast lumps -Green or dark brown nonbloody nipple discharge -Changes in both breast ! Breast pain can also be a late sign of breast cancer.

Eyeball and sclera

Position and alignment of eyeball - exophthalmos, sunken appearance Sclera - redness, jaundice, dryness, subconjunctival hemorrhage

Personal History Eyes

Previous problems with eyes or vision Eye surgery-alter the appearance of the eye and the results of future examinations. Past treatments-Client may not be satisfied with past treatments for vision problems. Medications-alpha-1 blockers, some antiarrhythmics, anticholinergics (including antihistamines, antipsychotics, antispasmodics, cyclic antidepressants, and mydriatics), anticoagulants, antimalarials, bisphosphonates, corticosteroids, digoxin, erectile dysfunction medications, fluoroquinolones and some other antibiotics, and many other medications Last eye exam-Risk: Annually Healthy 18-60: Q 2 years 61&Up: Annually Amsler chart for macular degeneration: -wear glasses - bottom portion to view the chart if they wear bifocals -Wall at eye level -12-14 ft. comf. reading distance. -covering one eye -one eye center dot -distored, gray, blurry, or blank spots marked report to hcp. Use of prescription glasses or contacts:Clients who do not wear the prescribed corrective lenses are susceptible to eyestrain. Improper cleaning or prolonged wearing of contact lenses can lead to infection and corneal damage. Previous glaucoma test: Tonometry: measure pressure within the eye. -Normal: 10-21 mmHG ->22 Increase risk for developing glaucoma. -HOWEVER: people w normal eye pressure may develop glaucoma

Personal HX Breast

Prior breast disease, surgery, trauma: -Breast cancer increases the risk for recurrence of cancer. -Surgeries alert appearance -Problems may occur w silicone implants -Trauma from sports, accidents of physical abuse can result in breast tissue changes. Age of menarche, menopause: early menses before age 12) or delayed menopause (after age 52) increases the risk for breast cancer. Children, age of first child: greater for women who have never given birth or for those who had their first child after age 30. First and last day of menstrual cycle: prompts the nurse, optimal time to examine the breasts. Hormone-related swelling, breast tenderness, and generalized lumpiness are reduced right after menstruation. History of breast cancer in family: -increases risk -Hereditary forms of breast cancer consitute only 5-10% cancer cases overall.

Collaborative problems & referrals Eye

R/C increased intraocular pressure R/C corneal ulceration or abrasion R/C eye infection R/C foreign body in eye

Routine and focused screening

ROUTINE: Size, symmetry, color, texture Superficial venous pattern Areolas & nipples Retraction or dimpling Palpate texture & elasticity Palpate tenderness & temperature Demonstration of BSE FOCUSED: Palpate nipples for discharge Palpate breasts for masses Palpate mastectomy or lumpectomy site Inspect & palpate axillae

Nursing DX EYE

Readiness for enhanced knowledge: improved visual integrity Risk for eye injury r/t... Risk for self care deficit r/t vision loss aeb ... Dry eye r/t ... aeb ... Social isolation r/t vision loss aeb ...

Opthalmoscope

Red numbers - negative diopter - myopic client Black numbers - positive diopter - farsighted client Begin 10 - 15 inches from client at 15 degree angle Move closer and rotate lenses to improve focus Do not move; instead ask client to look into light

APGAR- Inital newborn assessment

Score: 8-10 <8 indicate poor transition from intrauterine to extra uterine life. Apical Pulse: >100 bpm <100bpm= bradycardia, absent heartbeat indicates fetal demise.

Cornea and lens

Shine light from side of eye Cornea should be transparent Opacities may indicate cataracts

Objective Data Eye

Snellen chart Hand held vision card Penlight Opaque cards Opthalmoscope

Cover test

Stare straight ahead focusing on an object Cover one eye observing uncovered eye for movement Uncover the eye and observe the previously covered eye for movement Repeat on opposite eye Abnormal: Eye will move to establish focus. indicates a deviation in alignment of the eyes and muscle weakness 1.Phoria is a term used to describe misalignment that occurs only when fusion reflex is blocked. 2.Strabismus is constant malalignment of the eyes. 3.Tropia is a specific type of misalignment: esotropia is an inward turn of the eye, and exotropia is an outward turn of the eye.

Moro (or startle) Reflex

The Moro reflex is a response to sudden stimulation or an abrupt change in position. This reflex can be elicited by using either one of the following two methods: 1. Hold the infant with the head supported and rapidly lower the whole body a few inches. 2. Place the infant in the supine position on a flat, soft surface. Hit the surface with your hand or startle the infant in some way. Disappears at 3 mo cns injury, cerberal edema or intracrainal hemmorage.

lateral (outer) canthus

The outer corner(s) where the upper and lower eyelids meet

Denver Developmental Screening Test (DDST)

To chart normal progress between the ages of 1 mo. to 6 yrs. To identify children who are NOT developing normally

Tactile infants

Touch is well developed at birth, especially the lips and tongue. Touch should be used frequently because infants enjoy rocking, warmth, and cuddling.

Plantar Grasp Reflex

Touch the ball of the newborn's foot. The toes should curl downward tightly. Disappears 8-10 mo prematurity; no response suggests neurologic deficit.

Screening reccomendations

USPSTF Biennial mammography age 50 - 74 Individual decision before and after Value of breast self exam controversial ACS supports earlier & more frequent mammograms

Near vision test

Use this test for middle-aged clients and others who have difficulty with near vision or with reading Hand held card or newspaper 14 inches from client Jaeger test for adults over 40- NEAR VISION: Jaeger test or newspaper print 14 in .from the eye. Clients who have decreased accommodation to view closer print will have to move the card or newspaper further away to see it.

Ballar scale

Used to rate neuromuscular and physical maturity of gestational age.

Lifestyle and Health practices R/T eye

Workplace exposures: protective eyewear or safety measures. Sunglasses- exposure of UV radiation (SUN) risk for cataracts Effect of vision loss on self care/work: SELFCARE: client may be unable to read medication labels or fill insulin syringes. If the vision problem is severe, the client's ability to perform hygiene practices or prepare food may be affected WORK: the job is one that depends on sight, such as a pilot or commercial motor vehicle operator. Use of visual aids: magnifying glasses, audiotapes, CDs, special glasses for viewing television, large-numbered phones, large-print checks, large print books) Typical diet: PAGE 308 A well-balanced diet is essential. -Lutein and zeaxanthin:green leafy vegetables, eggs -Vitamin C -Vitamin E: is a powerful antioxidant which, when taken with antioxidants beta-carotene, vitamin C, and zinc. Smoking: strongly associated with eye diseases, doubling the chance of forming cataracts and causing a three-fold risk of developing AMD

Rooting reflex

a baby's tendency, when touched on the cheek, to turn toward the touch, open the mouth, and search for the nipple -3-4 mo. -absence indicaes serious CNS disease.

Aquenos humor

a clear liquid substance produced by the ciliary body. Aqueous humor helps to cleanse and nourish the cornea and lens as well as maintain intraocular pressure. The aqueous humor filters out of the eye from the posterior to the anterior chamber then into the canal of Schlemm through a filtering site called the trabecular meshwork.

port-wine stain

a large, reddish-purple discoloration of the face or neck

Stepping Reflex

a neonatal reflex in which an infant lifts first one leg and then the other in a coordinated pattern like walking Disappears at 2 mo injury of the leg, CNS damage, or peripheral nerve injury.

Caruncle

a small, fleshy mass that contains sebaceous glands

Strawberry hemangioma

a soft, raised, dark-reddish-purple birthmark

Limpomas

are a collection of fatty tissue that may also appear as a lump

eyelashes

are projections of stiff hair curving outward along the margins of the eyelids that filter dust and dirt from air entering the eye.

Lens

biconvex, transparent, avascular, encapsulated structure located immediately posterior to the iris.

Mongolian spots

bluish purple spots of pigmentation

Pupil

central aperture of the iris

Iris

circular disc of muscle containing pigments that determine eye color. a ring of muscle tissue that forms the colored portion of the eye around the pupil and controls the size of the pupil opening (light entering eye)

ciliary body

consists of muscle tissue that controls the thickness of the lens, which must be adapted to focus on objects near and far away.

Medial (inner) canthus

contains the puncta two small openings that allow drainage of tears into the lacrimal system, and the caruncle, a small, fleshy mass that contains sebaceous glands.

Palmar Grasp Reflex

in response to stroking a baby's palm, the baby's hand will grasp. This reflex lasts a few months Disappears at 3-4 mo prematurity; no response suggests neurologic deficit; asymmetric grasp suggests fracture of the humerus or peripheral nerve damage. If this reflex persists past 4 months, cerebral dysfunction may be present.

palpebral

lines the inside of the eyelids

Anterior and posterior chambers

located between the cornea and iris; the posterior chamber is the area between the iris and the lens.

Viterous humor

located in the area behind the lens to the retina. It is the largest of the chambers and is filled with a vitreous humor that is clear and gelatinous.

Eyeball

located in the eye orbit, a round, bony hollow formed by several different bones of the skull.

Bulbar Conjuctiva covers

most of the anterior eye, merging with the cornea at the limbus.

meibomian glands

oil glands found in the upper and lower edges of the eyelids that help lubricate the eye

Normal tension glaucoma

optic nerve damage despite normal IOP-intraocular pressure CV disease Family history Low IOP-intraocular pressure Japanese ethnicity

limbus

point or border where the cornea and sclera

Macula

round darker area of the ocular fundus that mediates vision only from the central visual field. -The fovea centralis (located adjacent to the optic disc in the temporal section of the fundus) and macular area are highly concentrated with cones and form the area of highest visual resolution and color vision

Milk cysts

sacs filled with milk) and infections (mastitis), may turn into an abscess and occur if breastfeeding or recently given birth. Bruise from injury: blood collection that appears as a lump, which goes away in days or weeks, or the blood may have to be drained by a health care provider.

fibrocystic breast disease

that feels ropy, lumpy, or bumpy in texture is referred to as "nodular" or "glandular" breast tissue. Benign breast disease consists of bilateral, multiple, firm, regular, rubbery, mobile nodules with well-demarcated borders. Pain and fullness occurs just before menses.

Tonic Neck Reflex

the newborn should be supine. Turn the head to one side, with newborn's jaw at the shoulder. The tonic neck reflex is present when the arm and leg on the side to which the head is turned extend and the opposite arm and leg flex. This reflex usually does not appear until 2 months of age. dissapears at 4-6 mo Reflex persist until later infancy, brain damage is usually present

conjunctiva

thin, transparent, continuous membrane that is divided into two portions: a palpebral and a bulbar portion.

Puncta

two small openings that allow drainage of tears into the lacrimal system visible on the upper and lower lids at the inner canthus; where tears drain.

Sclera

white part of the eyeball -external layer -dense, protective, white covering that physically supports the internal structures of the eye

palpebral fissure

white space between open eyelids