Health Assessment Final

Marasmus (protein-calorie malnutrition)

Inadequate intake of protein and calories due to prolonged starvation Anorexia, bowel obstruction, cancer, chronic illness among risk factors Decreased anthropometric measures, wt loss, subcue fat and muscle wasting Starved appearance Wt < 80% standard for ht, TSF <90% of standard MAC < 90% standard Creatinine ht index ,80% standard

Abnormal Findings Specific to Pediatrics

Fetal alcohol syndrome Congenital hypothyroidism Down syndrome

Aging Adult Considerations

Loss of bone occurs more rapidly than bone regeneration Shortening of the vertebral column leads to decreased height Loss of water content and thinning of disks Progressive decrease in height from age 40 in males and 43 in females, but not significant until age 60 Greater decrease in height in 70's and 80's due to osteoporosis Kyphosis, backward head tilt Loss of subcutaneous fat Bony prominences more marked and hollows deeper Loss of muscle mass, producing weakness Physical exercise increases muscle mass

Neurologic Recheck (Glasgow Coma Scale)

Quantitative tool Looks at eye opening, verbal response & motor response Fully alert, normal= 15 7 or less= coma

Abnormal Findings Respiration Patterns

Sigh Tachypnea Bradypnea Hyperventilation Hypoventilation Cheyne-Stokes respiration Biot's respiration Chronic obstructive breathing

Personal Questions

You may provide brief personal information if you feel it is appropriate Be sensitive to the possibility of motive Redirect conversation back to the client

Which of the following percussion findings would be found in a patient with a large amount of ascites? a. Dullness across the abdomen b. Flatness in the right upper quadrant c. Hyperresonance in the left upper quadrant d. Tympanny in the right and left lower quadrants

A

Types of Pain

Acute: short-term; self-limiting; predictable; dissipates after healing Surgery, trauma & kidney stones Warns of actual or potential tissue pain Chronic/persistent: 6 months or longer (may be yrs.) Malignant: cancer related; tissue necrosis or stretching of organ by tumor Nonmalignant: musculoskeletal conditions; arthritis, low back pain, fibromyalgia Abnormal processing of pain fibers (cellular level) Patient self-report (may not be believed) Breakthrough: starts or escalates before next does is due

Functional Assessment Domains

Activities of daily living (ADL), Instrumental activities of daily living (IADL) Mobility Two approaches to functional assessment Individual's self-report about his or her ability to perform tasks Observing his or her ability to perform tasks For persons with memory problems, use of surrogate reporters (proxy reports), such as family members or caregivers may be necessary, keeping in mind that they may either overestimate or underestimate actual abilities

Advanced activities of daily living (AADLs)

Activities older adults perform as family member, member of society and community, including occupational and recreational activities Various AADL instruments commonly include self-care, mobility, work (either paid or volunteer), recreational activities/hobbies, and socialization Occupational therapists often perform assessment of AADLs Older adult sets priorities for these activities so that interventions can be individualized

Nonverbal: Persistent/Chronic Pain Behaviors

Adapts over time (won't see obvious behaviors) May note rubbing, diminished activity, sighing, change in appetite How do you behave when you are in pain?

Subcutaneous Layer

Adipose tissue Made up of lobules of fat cells Stores fat for energy, provides insulation, cushions the body

Cover Test

Detects small deviations of alignment Fixate on object, then cover one eye Remove cover If eye jumps into alignment, sign of weakness Phoria- mild weakness Tropia- severe constant misalignment

Hydrocephalus

Hydrocephalus Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head Increasing pressure also produces dilated scalp veins, frontal bossing, and downcast or "setting sun" eyes (sclera visible above iris) Cranial bones thin, sutures separate, and percussion yields a "cracked pot" sound

Aging Adult

Facial bones and orbits appear more prominent, facial skin sags resulting from decreased elasticity, decreased subcutaneous fat, and decreased moisture in skin Lower face may look smaller if teeth have been lost

Infants

Lanugo Not fully developed the skin is smooth and thin and more permeable so the infant is at greater risk of fluid loss and temperature change Eccrine sweat glands do not secrete in response to heat Skin cannot protect against the cold because it cannot contract and shiver and the subcutaneous layer is inefficient

IADLs: Screening Tools

Lawton Instrumental Activities of Daily Living OARS-IADL , Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire-IADL Direct Assessment of Functional Abilities (DAFA)

Paraphimosis

Foreskin is retracted and fixed. Once retracted behind glans a tight or inflamed foreskin cannot return to its original position Constriction impedes circulation so the glans swells If untreated it may compromise circulation

Gordon's Model (2000)

Framework of 11 functional health patterns Pattern used to signify a sequence of recurring behavior Nurse collects data about dysfunctional as well as functional behavior By using Gordon's framework to organize data, nurses are able to discern emerging patterns

Heart Sound Assessment

Frequency (pitch)-high or low pitched Intensity (loudness) loud or soft Duration-evidence of heart sound throughout the cardiac cycle Timing-systole or diastole

Subjective Data-Pregnant Female

Number of pregnancies Food preferences or avoidance

Hydrocele

Painless swelling, nontender Enlarged, mass does not transilluminate with a pink glow May occur following epididymitis, trauma, hernia, tumor of the testis, or spontaneously

Human Papilloma Virus (HPV)

Painless warty growths, pink, flesh colored, may go unnoticed, occur around the vulva, anus, cervix, introitus Common among sexually active women

Early Testicular Tumor

Painless, found on examination Firm nodule Most occur between 18 and 35 y.o. Nearly all malignant Early detection important in prognosis

Epidermis

Thin but tough. Tightly bound cells that serve as protective barrier. Melanocytes interspersed along the basal cell layer of the epidermis produces melanin. All people have the same number of melanocytes, but the amount of melanin varies depending on genetics, hormones and environmental factors

Cranial nerves IX and X

glossopharyngeal and vagus nerves Motor function Depress tongue with tongue blade, and note pharyngeal movement as person says "ahhh" or yawns; uvula and soft palate should rise in midline, and tonsillar pillars should move medially Touch posterior pharyngeal wall with tongue blade, and note gag reflex; voice should sound smooth, not strained Sensory function Cranial nerve IX does mediate taste on posterior one third of tongue, but technically too difficult to test Both deal with motor pharynx IX- phonation and swallowing X swallowing, larynx, =motor

Carpal Tunnel Syndrome

occurs when the median nerve, which runs from the forearm into the hand, becomes pressed or squeezed at the wrist. The median nerve controls sensations to the palm side of the thumb and fingers (although not the little finger), as well as impulses to some small muscles in the hand that allow the fingers and thumb to move. The carpal tunnel - a narrow, rigid passageway of ligament and bones at the base of the hand ¾ houses the median nerve and tendons. Sometimes, thickening from irritated tendons or other swelling narrows the tunnel and causes the median nerve to be compressed. The result may be pain, weakness, or numbness in the hand and wrist, radiating up the arm. carpal tunnel syndrome is the most common and widely known of the entrapment neuropathies in which the body's peripheral nerves are compressed or traumatized. Symptoms usually gradual frequent burning, tingling, or itching numbness in the palm of the hand and the fingers, especially the thumb and the index and middle fingers. often first appear in one or both hands during the night, since many people sleep with flexed wrists. may wake up feeling the need to "shake out" the hand or wrist. As symptoms worsen, people might feel tingling during the day. Decreased grip strength may make it difficult to form a fist, grasp small objects, or perform other manual tasks. In chronic and/or untreated cases, the muscles at the base of the thumb may waste away. Some people are unable to tell between hot and cold by touch. causes often the result of a combination of factors that increase pressure on the median nerve and tendons in the carpal tunnel, rather than a problem with the nerve itself. Most likely the disorder is due to a congenital predisposition - the carpal tunnel is simply smaller in some people than in others. Other contributing factors include trauma or injury to the wrist that cause swelling, such as sprain or fracture; overactivity of the pituitary gland; hypothyroidism; rheumatoid arthritis; mechanical problems in the wrist joint; work stress; repeated use of vibrating hand tools; fluid retention during pregnancy or menopause; or the development of a cyst or tumor in the canal. In some cases no cause can be identified. There is little clinical data to prove whether repetitive and forceful movements of the hand and wrist during work or leisure activities can cause carpal tunnel syndrome. Repeated motions performed in the course of normal work or other daily activities can result in repetitive motion disorders such as bursitis and tendonitis. Writer's cramp - a condition in which a lack of fine motor skill coordination and ache and pressure in the fingers, wrist, or forearm is brought on by repetitive activity - is not a symptom of carpal tunnel syndrome Women are three times more likely than men to develop carpal tunnel syndrome, The dominant hand is usually affected first and produces the most severe pain. usually occurs only in adults. risk not confined to people in a single industry or job, but is especially common in those performing assembly line work - manufacturing, sewing, finishing, cleaning, and meat, poultry, or fish packing. In fact, carpal tunnel syndrome is three times more common among assemblers than among data-entry personnel diagnosis Early diagnosis and treatment are important to avoid permanent damage to the median nerve. Each finger should be tested for sensation, and the muscles at the base of the hand should be examined for strength and signs of atrophy. Routine laboratory tests and X-rays can reveal diabetes, arthritis, and fractures. Phalen test having the patient hold his or her forearms upright by pointing the fingers down and pressing the backs of the hands together. The presence of carpal tunnel syndrome is suggested if one or more symptoms, such as tingling or increasing numbness, is felt in the fingers within 1 minute. Tinel test tap on the median nerve in the patient's wrist. The test is positive when tingling in the fingers or a resultant shock-like sensation occurs. confirm the diagnosis by use of electrodiagnostic tests a nerve conduction study; electrodes are placed on the hand and wrist. Small electric shocks are applied and the speed with which nerves transmit impulses is measured electromyography, a fine needle is inserted into a muscle; electrical activity viewed on a screen can determine the severity of damage to the median nerve. Ultrasound imaging can show impaired movement of the median nerve. Magnetic resonance imaging (MRI) can show the anatomy of the wrist but to date has not been especially useful in diagnosing carpal tunnel syndrome. Initial treatment generally involves resting the affected hand and wrist for at least 2 weeks, avoiding activities that may worsen symptoms, and immobilizing the wrist in a splint to avoid further damage from twisting or bending. If there is inflammation, applying cool packs can help reduce swelling. Nonsteroidal anti-inflammatory drugs, Orally administered diuretics can decrease swelling. Corticosteroids can be injected directly into the wrist or taken by mouth to relieve pressure on the median nerve and provide immediate, temporary relief to persons with mild or intermittent symptoms. Exercise - Stretching and strengthening exercises can be helpful in people whose symptoms have abated. Alternative therapies - Acupuncture and chiropractic care have benefited some patients but their effectiveness remains unproved. An exception is yoga, which has been shown to reduce pain and improve grip strength among patients with carpal tunnel syndrome. Surgery Carpal tunnel release is one of the most common surgical procedures in the United States. Generally recommended if symptoms last for 6 months, surgery involves severing the band of tissue around the wrist to reduce pressure on the median nerve. Surgery is done under local anesthesia and does not require an overnight hospital stay. Many patients require surgery on both hands. Open release surgery, the traditional procedure used to correct carpal tunnel syndrome, consists of making an incision up to 2 inches in the wrist and then cutting the carpal ligament to enlarge the carpal tunnel. The procedure is generally done under local anesthesia on an outpatient basis, unless there are unusual medical considerations. Endoscopic surgery may allow faster functional recovery and less postoperative discomfort than traditional open release surgery. prevention on-the-job conditioning, perform stretching exercises, take frequent rest breaks, wear splints to keep wrists straight, and use correct posture and wrist position. Wearing fingerless gloves can help keep hands warm and flexible. Workstations, tools and tool handles, and tasks can be redesigned to enable the worker's wrist to maintain a natural position during work. Jobs can be rotated among workers.

Eccrine Sweat Glands

open directly onto the skin surface and produce a dilute saline solution called sweat; mature in a 2 month old infant

Apocrine Sweat Glands

produce a thick milky secretion and open into the hair follicles. Located in axillae, anogenital area, nipples, and naval; vestigial in human; active during puberty and combine with eccrine to produce musty body odor; decrease with aging

Torn Rotator Cuff

tendons become inflamed from frequent use, aging or injury. Treatment depends on age, health, sesverity, how long the person has had the torn rotator cuff. Rest Heat or cold to the sore area Medication to reduce pain and swelling Electrical stimulation of muscles and nerves Ultrasound Cortisone injection Exercise to improve range-of-motion, strength, and function Surgery if the tear does not improve with other treatments.

Which of the following factors may contribute to sensorineural hearing loss? aImpacted cerumen bOtosclerosis cDrugs affecting the cochlea dVertigo

Correct Answer: C. Anything that impedes sound transmission, such as impacted cerumen, foreign bodies, or otosclerosis, can cause conductive hearing loss. Pathology of the inner ear caused by gradual nerve degeneration or ototoxic drugs may cause sensorineural hearing loss. Vertigo is a symptom of a disturbance in equilibrium.

Documentation

Detailed nonbiased notes Use of injury maps Photographic documentation

Ten traps of interviewing

1.Providing false assurance or reassurance 2. Giving unwanted advice 3. Using authority 4. Using avoidance language 5. Engaging in distancing 6. Using professional jargon 7. Using leading or biased questions 8. Talking too much 9. Interrupting 10. Using "why" questions

Abnormalities of the Ankle and Foot

Achilles tenosynovitis Chronic/acute gout Hallux vagus with bunion and hammer toes Callus Plantar wart Ingrown toenail

Developmental considerations-Pre-Schooler

2-6 is ego centric Communication is direct, concrete and literal Avoid expressions that are easily misinterpreted " climbing the walls" Short sentences; appropriate language Animistic thinking

Cranial nerve V

: trigeminal nerve Sensory function: with person's eyes closed, test light touch sensation by touching a cotton wisp to designated areas on person's face: forehead, cheeks, and chin Motor function: assess muscles of mastication by palpating temporal and masseter muscles as person clenches teeth Muscles should feel equally strong on both sides; try to separate jaws by pushing down on chin; normally you cannot Tests all three divisions of CN V: ophthalmic, maxillary, and mandibular Corneal reflex: omit test, unless person has abnormal facial sensation or abnormalities of facial movement Remove any contact lenses; with person looking forward, bring wisp of cotton in from side (to minimize defensive blinking) and lightly touch cornea, not conjunctiva Normally, person will blink bilaterally Corneal reflex may be decreased or absent in those who have worn contact lenses This procedure tests sensory afferent in cranial nerve V and motor efferent in cranial nerve VII (muscles that close eye)Sensation lost on opposite side of lesion

Cranial Nerves III, IV, and VI

: oculomotor, trochlear, and abducens nerves Palpebral fissures usually equal in width Check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation (3) Assess extraocular movements by cardinal positions of gaze (3,4,6) Abnormal: Nystagmus is back-and-forth oscillation of eyes Palpebral fissures usually equal in width Check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation (3) Assess extraocular movements by cardinal positions of gaze (3,4,6) Abnormal: Nystagmus is back-and-forth oscillation of eyes

Heart Murmurs

A murmur is a gentle, blowing, swishing sound that can be heard on the chest wall. Causes: Increased flow rates through normal or abnormal valves Forward flow through constricted or irregular valve or dilated vessel Backward flow through an incompetent valve, septal defect or patent ductus arteriosus Decreased blood viscosity-increased flow turbulence Characteristics of Sound Frequency (pitch)-heart sounds are described as high or low pitched Intensity (loudness)-loud or soft Duration-very short for heart sounds; silent periods are longer Timing-systole or diastole

Carcinoma of Endometrium

Abnormal or intermenstrual bleeding Any postmenopausal bleeding, pain, weight loss Enlarged uterus Risk Factors: early menarche, late menopause, hx infertility, obesity, tamoxifen

Cryptorchidism

Absent testis

AUDIT questionnaire (Jarvis p. 97)

A quantitative form that has the advantage of letting the examiner document a number for a response so it is not open to individual interpretation The AUDIT will help detect less severe alcohol problems (hazardous and harmful drinking) as well as alcohol abuse and dependence disorders AUDIT questionnaire Helpful with emergency department (ED) and trauma patients because it is sensitive to current, as opposed to past alcohol problems Useful in primary care with adolescents and older adults Relatively free of gender and cultural bias Note that AUDIT covers three domains Alcohol consumption Drinking behavior or dependence Adverse consequences from alcohol The AUDIT-C is shorter form helpful for acute and critical care units

Individuals at Risk to Become Abuser

Abuses alcohol or drugs Witnessed abuse as a child Was a victim of abuse as a child Abused former partners Unemployed or underemployed Abuses pets

Family History

Accurate to note familial disease trends Pedigree or genogram- uses symbols to depict gender, relationship, age of immediate blood relatives, parents, grandparents and siblings; health of spouse

Stomach ulcer

A stomach ulcer (also called a peptic ulcer) is a small erosion (hole) in the gastrointestinal tract. The most common type, duodenal, occurs in the first 12 inches of small intestine beyond the stomach. Ulcers that form in the stomach are called gastric ulcers. An ulcer is not contagious or cancerous. Duodenal ulcers are almost always benign, while stomach ulcers may become malignant. Infection with the bacterium Helicobacter pylori is thought to play an important role in causing both gastric and duodenal ulcers. Helicobacter pylori may be transmitted from person to person through contaminated food and water. Another major cause of ulcers is the chronic use of anti-inflammatory medications, such as aspirin. Cigarette smoking is also an important cause of ulcer formation and ulcer treatment failure The major symptom of an ulcer is a burning or gnawing feeling in the stomach area that lasts between 30 minutes and 3 hours. This pain is often interpreted as heartburn, indigestion or hunger. The pain usually occurs in the upper abdomen, but sometimes it may occur below the breastbone. In some individuals the pain occurs immediately after eating. In other individuals, the pain may not occur until hours after eating. The pain frequently awakens the person at night. Weeks of pain may be followed by weeks of not having pain. Pain can be relieved by drinking milk, eating, resting, or taking antacids.

Calculating Pack Years *HESI

A way to measure the amount a person has smoked over a long period of time. It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked. For example, 1 pack year is equal to smoking 1 pack per day for 1 year, or 2 packs per day for half a year, and so on. (National Cancer Institute, 2015) 15 cigarettes a day for 1 year = ¾ pack year 20 cigarettes a day for 1 year = 1 pack year 40 cigarettes a day for 1 year = 2 pack years # cigarettes a day/20 x # of years smoked

Which of the following is the cause of ascites? a. Fluid b. Feces c. Flatus d. Fibroid tumors

A- In medicine (gastroenterology), ascites (also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy) is an accumulation of fluid in the peritoneal cavity. Although most commonly due to cirrhosis and severe liver disease, its presence can portend other significant medical problems. Diagnosis of the cause is usually with blood tests, an ultrasound scan of the abdomen, and direct removal of the fluid by needle or paracentesis (which may also be therapeutic). Treatment may be with medication (diuretics), paracentesis, or other treatments directed at the cause

Activities of daily living (ADLs)

ADLs measure tasks necessary for self-care Eating Bathing Grooming (washing, combing hair, shaving, cleaning teeth, dressing) Toileting Walking, including propelling a wheelchair, using stairs Transferring, such as bed to chair ADL instruments are designed as either self-report, observation of tasks, or proxy/surrogate report

Intervention

Advise and Assist: Consequences of substance abuse are so debilitating and destructive to patients and their families that a short statement of assistance and concern is what should be presented -- it is not your role nor with in your scope of practice to present a treatment plan If you determine the person has an alcohol use disorder, state your conclusion and recommendation clearly: "I believe that you have an alcohol use disorder." "I strongly recommend that you quit drinking, and I'm willing to help." Relate this to the person's concerns and medical findings (If present).

Breast Development: Aging Women

After menopause, ovarian secretion of estrogen and progesterone decreases, causing breast glandular tissue to atrophy This is replaced with fibrous connective tissue; fat envelope atrophies also, beginning in middle years and becoming marked in eighth and ninth decades These changes decrease breast size and elasticity so breasts droop and sag, looking flattened and flabby Drooping accentuated by kyphosis in some older women Decreased breast size makes inner structures more prominent A breast lump may have been present for years but is suddenly palpable Around nipple the lactiferous ducts are more palpable and feel firm and stringy because of fibrosis and calcification Axillary hair decreases

Abnormal Findings Levels of Consciousness

Alert Lethargic (somnolent) Obtunded Stupor or semicoma Coma Acute confusional state (delirium)

Assessing those in pain

Alleviating pain should be priority over other aspects assessment Providing comfort can help maximize information gathered It may be necessary to administer premedication Paramount to remember older adults with cognitive impairment do not experience less pain This population suffers from conditions typically associated with pain, such as arthritis, osteoporosis, cancer, and shingles Alleviating pain should be priority over other aspects assessment (cont.) A variety of pain assessment scales are available to use in cognitively impaired older adult population The "gold standard" continues to be person's self-report

Non-directive interview-

Also called rapport building, nurse allows patient to control the purpose, subject matter and pacing Rapport is an understanding between two people Used when ample time and when goal is to establish rapport

Altered Cognition?

Altered cognition in older adults is commonly attributed to three disorders Dementia Delirium Depression

Ectopic Pregnancy

Amenorrhea or irregular vaginal bleeding, pelvic pain Softening of the cervix, movement of uterus causes pain Palpable tender pelvic mass, solid and unilateral Medical emergency

Developmental Competence-Pregnant Women

Among pregnant women 15 to 44 About 10.6% report current alcohol use 4.5% reporting binge drinking and 0.8% reporting heavy drinking No amount of alcohol has been determined safe for pregnant women Potential adverse consequences of alcohol use to fetus are well known All women who are contemplating pregnancy or who are pregnant should be screened for alcohol use, and abstinence should be recommended

Bundle of His

Continuation of conduction to the ventricles

Tuberculosis

An infectious disease that usually attacks the lungs but can attack almost any part of the body Airborne Active disease or latent High risk: HIV/AIDS Close contact of pt with TB Chronic disease or immunocompromised Pts from countries with high TB rates Some racial or ethnic minorities People who work in or are residents of long-term care facilities (nursing homes, prisons, some hospitals) Health care workers and others such as prison guards Malnourished Alcoholics, IV drug users and homeless A person with TB infection will have no symptoms. A person with TB disease may have any, all or none of the following symptom Persistent cough Feeling tired all the time Weight loss Loss of appetite Fever Coughing up blood Night sweats A person with TB disease may feel perfectly healthy or may only have a cough from time to time; important to screen high risk groups with skin test (PPD) Treatment: Depends on whether a person has active TB disease or only TB infection. Infected with TB, but no active TB disease may be given preventive therapy to kill germs that are not doing any damage right now, but could so do. daily dose of isoniazid (also called "INH"); an inexpensive TB medicine. The person takes INH for nine months (up to a year for some patients), with periodic checkups to make sure the medicine is being taken as prescribed. Treatment for active TB (months of drug therapy) first-line anti-TB agents isoniazid (INH) rifampin (RIF) ethambutol (EMB) pyrazinamide (PZA)

What is Domestic Violence?

An intimate relationship between two adults in which one partner uses a pattern of assault and intimidating acts to assert power and control over the other partner Includes various violent relationships; child abuse, elder abuse Not limited to physical acts of violence; includes psychological, economic, and sexual abuse as well as attempts to isolate the partner. More same-sex partners and male victims of violence perpetrated by women are reporting their victimization.

Eating Disorders

Anorexia Nervosa Bulimia Nervosa

Objective Data: Anterior Chest

Anterior Chest—Inspect Shape and configuration of chest wall Facial expression Level of consciousness Skin color and condition Quality of respirations Rib interspaces Accessory muscles Anterior Chest—Palpate Symmetric chest expansion Tactile fremitus Palpate the anterior chest wall Anterior Chest—Percuss Predominant note over lung fields Borders of cardiac dullness Anterior Chest—Auscultate Breath sounds Abnormal breath sounds Adventitious sounds Measurement of pulmonary function status Forced expiratory time; 4 sec or less norm. Pulse oximeter 12-minute distance (12MD) walk Peak Flow

Who is at risk for Colon Cancer?

Anyone can get colorectal cancer. But some people seem to be at a higher risk of this disease. You may be at risk of getting colorectal cancer... > if you have a condition called Crohn's disease > if you are over 50 > if a member of your family has had colon cancer > if you have had cancer of the breast, ovary, or uterus > if you smoke > if you are overweight > if you eat a diet that is high in fat and low in fiber Crohn's disease is an inflammatory bowel disease (IBD). It causes inflammation of the lining of your digestive tract, which can lead to abdominal pain, severe diarrhea and even malnutrition 148,300 annual cases = 107,300 annual cases of colon cancer and 41,000 annual cases of rectum cancer and 50,000 deaths 1 in 26 women and 1 in 17 men will develop colorectal cancer during their lifetime

S2 Sound

Aortic and pulmonic valve closure Beginning of ventricular diastole, S2 follows arterial pulsation A2=aortic valve closure, P2=pulmonic valve closure. (AV produces most of the sound) Diaphragm of stethoscope, Aortic area-2nd ICS/left sternal border "Dub" of the "lub-dub"

Abnormalities of the Buccal Mucosa

Aphthous ulcers Koplik's spots Leukoplakia Candidiasis or monilial infection

Developmental Considerations- Preschool

Appetite sporadic Likes to eat one food at a time Usually dislikes strong tasting foods

Veins

Are they usually seen when examining the abdomen? Prominent dilated veins occur with what disease entities? Hypertension, portal hypertension, cirrhosis, ascites, vena cava obstruction, malnutrition

Precordium

Area of the anterior chest which overlaying the heart and great vessels

Abnormalities in the retinal vessels

Arteriovenous crossing Narrowed arteries Vessel nicking Silver wire arteries Copper wire arteries

Children

As the child grows the epidermis thickens, toughens and darkens and becomes better lubricated At puberty secretion from apocrine sweat glands increases and become more active

Hearing Impaired

Ask as to preferred way to communicate Interpreter may be needed (sign language) Talk normally if lip reader May use written communication

Culture & Genetics

Ask how behaves when in pain Black & Hispanic patients: prescribed and given less analgesics

Developmental Competence: Preschool and school age children

Assess the child's general behavior during play activities, reaction to parent, and cooperation with parent and with you Much of motor assessment can be derived from watching child undress and dress and manipulate buttons; indicates muscle strength, symmetry, joint range of motion, and fine motor skills Use Denver II to screen gross and fine motor skills appropriate for child's age Note child's gait both walking and running; allow for normal wide-based gate of toddler and normal knock-kneed walk of preschooler Normally, child can balance on one foot for about 5 seconds by 4 years, for 8 to 10 seconds at 5 years, and can hop at 4 years Fine coordination not fully developed until child is 4 to 6 years; consider it normal if younger child can bring finger to within 2 to 5 cm of nose When you need to test DTRs in young child, use your finger to percuss tendon Use reflex hammer only with an older child; coax child to relax, or distract and percuss discreetly when child not paying attention Knee jerk present at birth; then ankle jerk and brachial reflex appear; and triceps reflex present by 6 months

Corneal Light Reflex

Assesses alignment Normal Light shines in same spot in each eye Abnormal Asymmetry of light reflection Indicates misalignment of eyes due to muscle weakness or paralysis If noted perform cover test

Assess Sensory System

Ask person to identify various sensory stimuli in order to test intactness of peripheral nerve fibers, sensory tracts, and higher cortical discrimination Routine screening procedures include testing superficial pain, light touch, and vibration in few distal locations, and testing stereognosis Complete testing of sensory system warranted in those with neurologic symptoms (e.g., localized pain, numbness, and tingling) or if you discover abnormalitiesCompare sensations on symmetric parts of body When you find definite decrease in sensation, map it by systematic testing in that area Proceed from point of decreased sensation toward sensitive area; ask person to tell you where sensation changes; you can map exact borders of deficient area; draw results on diagram Person's eyes should be closed during tests Take time to explain what will be happening and exactly how you expect person to respond Spinothalamic tract Pain: tested by person's ability to perceive pinprick Temperature: test temperature sensation only when pain sensation is abnormal; otherwise, you may omit it because the fiber tracts are much the same. Light touch: apply wisp of cotton to skin in random order of sites and at irregular intervals; include arms, forearms, hands, chest, thighs, and legs; ask person to say "now" or "yes" when touch is felt Compare symmetric points Posterior column tract Vibration: test person's ability to feel vibrations of tuning fork over bony prominences Compare right side with left side; if you find a deficit, note whether gradual or abrupt Position (kinesthesia): test person's ability to perceive passive movements of extremities Not done in our physical exam Tactile discrimination (fine touch): tests also measure discrimination ability of sensory cortex Stereognosis. test person's ability to recognize objects by feeling their forms, sizes, and weights Graphesthesia: ability to "read" a number by having it traced on skin Two-point discrimination: test ability to distinguish separation of two simultaneous pin points on skin Extinction: simultaneously touch both sides of body at same point; normally, both sensations are felt Point location: touch skin and withdraw stimulus promptly; ask person to put finger where you touched

Abnormal Findings Common Respiratory Conditions

Atelectasis Pneumonia Bronchitis Emphysema Asthma (reactive airway disease) Pleural effusion thickening Congestive heart failure Pneumothorax Pneumocystis carinii pneumonia Tuberculosis Pulmonary embolism Acute respiratory distress syndrome (ARDS)

Valves

Atrioventricular Between atria and ventricles Tricuspid (three leaflets) Mitral (bicuspid valve) First heart sound (S1) is produced as the mitral and tricuspid valves close Semilunar Between ventricles and arteries Each valve has three-cusps, looking like a half moon Pulmonic Aortic Second heart sound (S2) is produced when the aortic and pulmonic valve close

Hearing

Auditory system has three levels Peripheral; ear transmits sound and converts sound in to electrical impulses Brainstem; sensitive to timing and intensity of sound heard from both ears, can determine which direction sound is coming from and identify sound Cerebral cortex; interprets meaning of sound and begin appropriate response Pathways of hearing Air conduction Bone conduction

A patient is having difficult swallowing her medications and her food. In your charting, you would say that she is experiencing: a. Aphasia b. Dysphagia c. Dysphasia d. Myophagia

B

Which of the following is a cause of hypoactive bowel sounds? a. Diarrhea b. Peritonitis c. Laxative use d. Gastroenteritis

B

Which of the following is a normal finding in the abdominal assessment? a. The presence of a bruit in the femoral area b. A tympanic percussion note in the umbilical region c. A palpable spleen between the 9th and 11th ribs in the left mid axillary line d. A dull percussion note in the left upper quadrant at the midclavicular line

B (tympany predominates air rises)

The test utilized to assess for inflammation of the GB or cholecystitis is: a. Obturator test b. Murphy's test c. Rebound tenderness d. Iliopsoas muscle test

B Classically Murphy's sign is tested for during an abdominal examination; it is performed by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to inspire (breathe in). Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm moves down (and lungs expand). If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner's fingers), the test is considered positive. A positive test also requires no pain on performing the maneuver on the patient's left hand side. Ultrasound imaging can be used to ensure the hand is properly

Typical Sequence

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

If patient is new immigrant...

Biographical data Spiritual resources Past health- immunizations Health perception Nutrition

Abnormalities of the Teeth and Gums

Baby bottle tooth decay Malocclusion Dental caries Epulis Gingival hyperplasia Gingivitis

Abnormal Findings Configurations of the Thorax

Barrel chest Pectus excavatum Pectus carinatum Scoliosis Kyphosis

Developmental Considerations- Older Adult

Be alert for hopelessness and despair Address by "Mr., Miss, Mrs." Long story to tell; may need to conduct in sessions Adjust pace of interview Consider physical limitations Touch may be valuable nonverbal skill

Drugs or Alcohol

Be aware of poly-substance abuse Be aware of dual diagnosis Ask simple and direct questions Behavior result of the effects of the substance, not because of you Avoid confrontation "How much, What substance, When"...be as specific as possible

Costovertebral Angle

Bean shaped kidneys are retroperitoneal (posterior) to the abdominal contents Protected by posterior ribs and muscles 12th rib forms an angle with vertebral column called costovertebral angle Kidneys lie at 11th and 12th rib Because of liver, R kidney 1-2cm lower than L kidney

Preparation for MMSE

Before administering MMSE: Examine medical and psychiatric patient history Examine patient's occupation, level of education, right vs. left handedness

When To Perform a Mental Status Exam**

Behavior changes Brain lesions (trauma, tumor, brain attack) Aphasia (caused by brain damage) Symptoms of psychiatric mental illness

Direct Hernia

Behind and through external inguinal ring Rarely enters scrotum Painless, round swelling close to the pubis in the area of internal inguinal ring Easily reduces when supine Caused by heavy lifting, muscle atrophy, obesity, cough, ascites

BPH

Benign Prostatic Hypertrophy Tissue enlarges starting at 40 y.o. Symmetric Nontender Median sulcus obliterated

Abnormal Findings: Breast Lump

Benign breast disease (formerly fibrocystic breast disease) Cancer Fibroadenoma

Lesions on the Eyelids

Blepharitis (inflammation of the eyelids) Chalazion- nodule or cyst, non tender, points inside and not on lid margin like a stye Hordeolum (stye)- painful, red , swollen at lid margin Dacryocystitis (inflammation of the lacrimal sac) Dacryoadenitis (inflammation of the lacrimal gland) Basal cell carcinoma- rare but occur on lower lid and medial canthus

BMI

Body Mass Index Marker of optimal wt for ht Indicator for obesity or malnutrition BMI= Wt (Kg) / Ht (M) or BMI= Wt (lbs) / Ht (in) X703 BMI (adults) <18.5 Underweight 18.5-24.9 Normal wt 25.0-29.9 Overweight 30.0-39.9 Obesity > 40 Extreme obesity BMI (children 2-20) 85-95th percentile= risk for overweight using growth chart

Developmental Care: Infants & Children

Bones of neonatal skull are separated by sutures and fontanels, spaces where the sutures intersect These membrane-covered "soft spots" allow growth of brain during 1st year; gradually ossify Triangle-shaped posterior fontanel closes by 1 to 2 months, and diamond-shaped anterior fontanel closes between 9 months and 2 years During fetal period, head growth predominates; head size is greater than chest circumference at birth and reaches 90% of final size at 6 years old

Breast Development: Pregnancy

Breast changes start during the second month of pregnancy and are an early sign for most women Pregnancy stimulates expansion of ductal system and supporting fatty tissue as well as development of true secretory alveoli Thus breasts enlarge and feel more nodular; nipples are larger, darker, and more erectile Areolae become larger and grow darker brown as pregnancy progresses, and tubercles become more prominent Venous pattern prominent over skin surface Colostrum may be expressed after fourth month This thick yellow fluid is precursor for milk, containing same amount of protein and lactose, but practically no fat Breasts produce colostrum for first few days after delivery It is rich with antibodies that protect newborn against infection, so breastfeeding is important Lactation, milk production, begins 1 to 3 days post partum; whitish color is from emulsified fat and calcium caseinate

Objective Data: Adolescent Girl

Breast development usually begins on an average between 8 and 10 years Expect some asymmetry during growth; record stage of development using Tanner's staging Use chart to teach adolescent normal developmental stages and to assure her of her own normal progress With maturing adolescents, palpate breasts as you would with adult; note any mass Teach BSE now, so that technique will become a natural, comfortable habit by time girl becomes an adult

BREAST

Breast mass Retraction Edema Axillary mass Scaly nipple Tender breast

Objective Data: Aging Woman

Breasts look pendulous, flat, and sagging Nipples may be retracted but can be pulled outward On palpation, breasts feel more granular; terminal ducts around nipple feel more prominent and stringy Thickening of inframammary ridge at lower breast is normal, and feels more prominent with age Reinforce value of BSE Women over 50 years old have increased risk of breast cancer Older women may have problems with arthritis, limited range of motion, or decreased vision that may inhibit self-care Suggest aids to self-examination; for example, talcum powder helps fingers glide over skin

Reason for Seeking Care

Brief statement in patient's own words Used to be called chief complaint Can use quotations "Sore throat for 3 days that is getting worse. "Yearly physical for preventing illness."

Nails

Brittle nails signify possible iron deficiency and thyroid problems, impaired kidney function, and circulatory problems. Yellow nails can indicate internal disorders long before other symptoms appear. Problems with the lymphatic system, respiratory disorders, diabetes, and liver disorders may create this appearance Nails that chip, peel, crack or break easily indicate a nutritional deficiency, protein and minerals Brittle, soft, shiny nails without a moon may indicate an overactive thyroid White lines across the nail may indicate liver disease White lines lengthwise may indicate heart disease, fever, or arsenic poisoning Nails raised at the base ("clubbing") with small white ends show a respiratory disorder such as emphysema or chronic bronchitis. ("Clubbing" with lung disorders is one condition of the nails that is recognized by Standard Medicine. ) Downward curved nail ends may denote heart, liver, or respiratory problems. Ridges running up and down the nails indicate a tendency to develop arthritis. Lack of vitamin A and calcium causes dryness and brittleness. Vitamin B deficiency causes fragility, with horizontal and vertical ridges. Insufficient intake of vitamin B 12 leads to excessive dryness, very rounded and curved nail ends, and darkened nails. White bands can indicate protein deficiency.

Interviewing the Parent (Developmental considerations)

Build rapport with parent and child < 6 years, focus on parent Explore sensitive issues with parent alone Avoid being judgmental Do not ignore child all together as you will eventually need to examine child Nonverbal communication important to children

Abnormalities in cranial nerves

CN I, olfactory nerve Anosmia CN II, optic nerve Defect or absent central vision Defect in peripheral vision, hemianopsia Absent light reflex Papilledema Optic atrophy Retinal lesions CN III, oculomotor nerve Dilated pupil, ptosis, eye turns out and slightly down Failure to move eye up, in, down Absent light reflex CN IV, trochlear nerve Failure to turn eye down or out CN V, trigeminal nerve Absent touch and pain, paresthesias No blink Weakness of masseter or temporalis muscles CN X, vagus nerve Uvula deviates to side No gag reflex Voice quality: Hoarse or brassy Nasal twang Husky Dysphagia, fluids regurgitate through nose CN XI, spinal accessory nerve Absent movement of sternomastoid or trapezius muscles

Costovertebral Angle Tenderness

CVA tenderness is often associated with renal disease. Use the heel of your closed fist to strike the patient firmly over the costovertebral angles.

Physical Exam: Neck Vessels

Carotid Palpate the carotid artery, avoiding higher in the neck as excessive pressure can stimulate the vagus nerve. Palpate one carotid at a time so not to compromise arterial blood flow to the brain The amplitude of the pulse should be +2 with a rapid upstroke and slow down stroke, this should be consistent bilaterally. Ausculate along each artery, noting any bruits or radiation of a cardiac murmur. Bruits indicate turbulent blood flow consistent with atherosclerosis. Jugular Venous Pulse Can assess central venous pressure and heart efficiency as a pump. External Jugular more readily visible Place patient at a 30-45 degree angle, where the pulse is most visible. Turn the patients neck away from the examining side Full distended jugular veins is indicative of heart failure

Neck Vessel Assessment: Carotid Artery

Carotid Artery Located in the grove between the trachea and the sternomastoid muscle, medial to and alongside the muscle. Central artery close to the heart that coincides with ventricular systole Carotid assessment: narrowing of the vessels, abnormality in blood flow to the brain, radiation of murmurs.

Pregnancy

Change in hormone levels results in increased pigmentation in the areolae and nipples Linea Nigra- dark pigmentation in the midline of the abdomen Chloasma- darkened pigmentation of the face Striae gravidarum- abdomen, breasts and thighs Fat deposits are laid down in the buttocks and hips as reserves for nursing the baby

Ear Assessment Summary

Chapter 15: Ear Examination 1. Inspect external ear Size and shape of auricle Position and alignment on head Note skin condition—color, lumps, lesions Check movement of auricle and tragus for tenderness Evaluate external auditory meatus—note size, swelling, redness, discharge, cerumen, lesions, foreign bodies 2. Otoscopic examination External canal Cerumen, discharge, foreign bodies, lesions Redness or swelling of canal wall 3. Inspect tympanic membrane Color and characteristics Note position (flat, bulging, retracted) Integrity of membrane 4. Test hearing acuity Note behavioral response to conversational speech Voice test Tuning fork tests—Weber and Rinne

Abnormalities of the Lips

Cleft lip Herpes simplex I Angular cheilitis (stomatitis, perleche) Carcinoma Retention "cyst" (mucocele)

Abnormalities of the Oropharynx

Cleft palate Bifid uvula Oral Kaposi's sarcoma Acute tonsillitis and pharyngitis

Developmental Considerations: Older Adult

Cognitive impairment is no longer considered normal or an expected change of aging. Older adults are at higher risk than the rest of the population, changes in cognitive function often call for prompt assessment In older patients, cognitive functioning is especially likely to decline during illness or injury. The nurses' assessment of an older adult's cognitive status is instrumental in identifying early changes in physiological status, ability to learn, and evaluating responses to treatment.

Purpose of Health History

Collect subjective data Complete picture- past & present health Well person- what is the person doing right? Exercise, diet, risk reduction, health promotion Ill person- chronologic record of problem

Objective Data: Physical Examination (cont.)

Complete Physical Examination Skin assessment integrated throughout examination Scrutinize the outer skin surface first before you concentrate on underlying structures Separate intertriginous areas (areas with skinfolds) such as under large breasts, obese abdomen, and groin and inspect them thoroughly These areas are dark, warm, and moist and provide perfect conditions for irritation or infection Always inspect feet, toenails, and between toes Inspection Observe skin color, tone, bleeding, ecchymosis, vascularity, texture, turgor, edema Facing the patient face, eyes, ears, nose, lips, mucous membranes Head and neck Arms and hands Chest Abdomen Back Lower extremities Genitalia, perianal, anus Common pigmentations or findings: Freckles (ephelides) Birthmarks- strawberry hemangioma, port-wine stain Scars Keloids- excessive collagen formation

Physical Exam

Complete head-to-toe exam checking for: Bruise/contusion Laceration/avulsion Ecchymosis/purpura Petechiae Rug burn/friction abrasion Incision/cut Cut/sharp injury Stab wounds Hematoma

Hearing loss

Conductive Mechanical dysfunction of external or middle ear Partial loss; able to hear if amplitude is increased May be caused by impacted cerumen, foreign bodies, perforated TM, pus or serum in meddle ear and otosclerosis decrease in mobility of ossicles) Sensorineural (perceptive) Loss signifies pathology of inner ear, cranial nerve VIII, or auditory areas of cerebral cortex Increase in amplitude may not enable pt to understand words May be caused by presbycusis (gradual nerve degeneration ocuring with ageing) or by ototoxic drugs Equilibrium Labyrinth inflamed; feeds wrong info to brain regarding position in space Creates staggering gait and strong vertigo

Tuning Fork Tests

Conductive hearing loss Results with Weber test Results with Rinne test Sensorineural hearing loss Results with Weber test Results with Rinne test

Pilonidal Cyst

Congenital disorder Inflamed or abscess

A change that may occur in the GI system of an elderly patient is: a. Increased salivation b. Decreased peristalsis c. Increased esophageal emptying d. Decreased gastric acid secretion

D

Evidence-Based Assessment

Depends on: patient preferences & values, research evidence, physical exam, clinical expertise Past barriers: nurses lack research skills (?), lack of time, inadequate libraries

Neuropathic Pain: Abnormal Processing of Pain Message

Damage to nerve fibers Difficult to assess and treat Is present long after injury heals Can start 2-3 years after initial injury Nociceptive can change into Neuropathic over time Due to constant irritation of nerve cells -makes hypersensitive Conditions that may cause: DM, herpes zoster, HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, and more...

Lumps and Lesions on the External Ear

Darwin's tubercle- small painless nodules at helix. Non-pathological Sebaceous cyst-behind the ear, can be large an painful. Need to be drained Tophi- non tender white-yellow non-tender nodules in or near the helix. Contain uric acid and are a sign of gout Keloid- massive scar tissue. More common in dark skinned people and can be seen at site of ear piercing Carcinoma- ulcerated crusted nodule

Abnormal postures

Decorticate rigidity Upper extremities Flexion of arm, wrist, and fingers Adduction of arm: tight against thorax Lower extremities Extension, internal rotation, plantar flexion; indicates hemispheric lesion of cerebral cortex Opisthotonos Prolonged arching of back, with head and heels bent backward; indicates meningeal irritation

Peripheral cyanosis

Decreased blood flow, peripheral vasoconstriction, anxiety, heart failure

Fecal impaction

Decreased bowel motility Constipation with diarrhea around the impaction

Developmental care: eyes

Developmental care Infants and children- function limited at birth but quickly matures. Peripheral vision intact at birth. Eye site good by 8 months. Eyeball reaches adult size by age 8 Aging adult- pupil size decreases; arcus senilus; presbyopia (decreased ability of the lens to change shape to accommodate for close vision); floaters Cataracts- age 70; transparent fibers of the lens begin to thicken and yellow Glaucoma- increased occular pressure; chronic angle glaucoma is most common and leads to loss of peripheral vision Macular degeneration- loss of central vision and most common cause of blindness. Unable to do fine motor tasks or see facial features Cross-cultural care- review these in your textbook Racial variations Arcus senilis- infiltration of liquid material around the limbus Additional history for infants and children Vaginal infection during delivery Developmental milestones Routine vision testing Safety measures Additional history for aging adult Visual difficulty Glaucoma test Cataracts Eye dryness (decreased tear production with aging) Decreased activities (reading, sewing)

Abnormalities in the General Background

Diabetic retinopathy Microaneurysms Dot-shaped hemorrhages Flame-shaped hemorrhages Soft exudates Hard exudates

Diastasis Recti

Diastasis recti is a separation between the left and right side of the rectus abdominis muscle, which covers the front surface of the belly area. Symptoms A diastasis recti looks like a ridge, which runs down the middle of the belly area. It stretches from the bottom of the breastbone to the belly button, and increases with muscle straining. In infants, the condition is most easily seen when the baby tries to sit up. It may not be seen when the child lies on the back and is relaxed. When the infant is relaxed, you can often feel the edges of the rectus muscles. Diastasis recti is commonly seen in women who have multiple pregnancies, because the muscles have been stretched many times. Extra skin and soft tissue in the front of the abdominal wall may be the only signs of this condition in early pregnancy. In the later part of pregnancy, the top of the pregnant uterus is often seen bulging out of the abdominal wall. An outline of parts of the unborn baby may be seen in some severe cases. Separation of the abdominal rectus muscleTwo out of three women experience a separation of the rectus abdominis muscle, the long muscle located in the middle of the abdomen, during their pregnancy.

Kwashiorkor (protein malnutrition)

Diet mainly carbs may be high in calories Little or no protein Depressed immune system Have adequate anthropometric measurements Well nourished appearance may be edematous Wt > 100% standard for ht TSF > 100% standard Serum albumin ,3.5 g/dl Serum transferrin <150mg/dl Lymphocytes <1500mm3

Components of a Nutritional Assessment

Dietary Data Medical Data Anthropometric Data Physical Data Laboratory Data

Breast Development: Embryonic to Birth

During embryonic life, ventral epidermal ridges, or "milk lines," are present and curve down from axilla to groin bilaterally Breast develops along ridge over thorax, and rest of the ridge usually atrophies Occasionally a supernumerary nipple (i.e., an extra nipple) persists and is visible along track of mammary ridge At birth, the only breast structures present are lactiferous ducts within nipple; no alveoli have developed; little change occurs until puberty

Pregnant Female

During second trimester, chloasma may show on face; a blotchy, hyperpigmented area over cheeks and forehead that fades after delivery Thyroid gland may be palpable normally during pregnancy

Reducing Risk Factors of colon cancer

Eat a variety of fruits and vegetables and whole grains each day Cut back on foods that have a lot of fat (processed foods, fried foods, whole-milk dairy products, and snacks) Quit smoking Exercise every day by walking, swimming, bike riding, or other activity Have regular checkups with your doctor * Keep all of your doctor's appointments * Colonoscopy at age 50 or earlier if family history Studies suggest that the average duration of symptoms (from onset to diagnosis) is 14 weeks

Cardiovascular Assessment:Edema

Edema: Any swelling of your feet or legs? Onset: When did you first notice the swelling? Time of day the swelling occurs? Does the swelling go away w/ rest, elevation, after a night's rest? Associated symptoms? SOB? Rationale: Edema is dependent w/HF. Cardiac edema is worse in the evening. Does our patient have any evidence of edema?

Xanthelasma (yellowish, raised plaques along nasal portion of one or both eyelids)

Elevated cholesterol levels

Emphysema

Emphysema Destruction of air sacs (alveoli) in the lungs where oxygen from the air is exchanged for carbon dioxide in the blood Walls of the air sacs are thin and fragile and damage to the air sacs is irreversible and results in permanent "holes" in the tissues of the lower lungs As air sacs are destroyed, the lungs are able to transfer less and less oxygen to the bloodstream, causing shortness of breath. Lungs lose their elasticity pt has difficulty exhaling Insidious onset, most often due to smoking Symptoms cough, shortness of breath and a limited exercise tolerance diagnosis pulmonary function tests, along with the patient's history, examination and other tests.

External factors

Ensure privacy Refuse interruptions Physical environment Dress Note-taking Tape and video recording

Environmental Assessment

Environmental modifications can promote mobility and reduce risks Concerns: falls, older-adult drivers, sleep changes Common environmental risks include: Lighting Rugs Hallways Cords Toilet seats Neighborhood safety Transportation access

Hernia types

Epigastric Umbilical inguinal femoral

Infants and Children Considerations

Epyphyseal plates End of long bones where growth occurs Injury to area may impede growth Last closure occurs around age 20

Thining of the skin around pacers

Erosion of the device

Skin fold thickness

Estimate of body fat stores Triceps most common site Pt stands with arms hanging freely gently grasp skin fold on posterior aspect of L upper arm midway b/t acromion process of scapula and tip of elbow 10% below or above suggest under or over nutrition

Intimate Partner Violence

Evidence or threat of physical/sexual violence Psychological/emotional abuse and/or coercive tactics after physical violence Between spouses, non-marital partners, or former spouses or partners (CDC)

Eye Assessment Summary

Examination Summary Checklists Eye Examination 1. Test visual acuity Snellen eye chart Near vision (those older than 40 years or those having difficulty reading) 2. Test visual fields—confrontation test 3. Inspect extraocular muscle function Corneal light reflex (Hirschberg test) Cover test Diagnostic positions test 4. Inspect external eye structures General Eyebrows Eyelids and eyelashes Eyeball alignment Conjunctiva and sclera Lacrimal apparatus 5. Inspect anterior eyeball structures Cornea and lens Iris and pupil Size, shape, and equality Pupillary light reflex Accommodation 6. Inspect the ocular fundus (you won't be doing) Optic disc (color, shape, margins, cup-disc ratio) Retinal vessels (number, color, artery-vein [AV] ratio, caliber, arteriovenous crossings, tortuosity, pulsations) General background (color, integrity) Macula

Objective Data: Male Breast

Examination of male breast can be abbreviated, but do not omit it Combine breast exam with that of anterior thorax Inspect chest wall, noting skin surface and any lumps or swelling Palpate nipple area for any lump or tissue enlargement; it should feel even, with no nodules Palpate axillary lymph nodes

Acromegaly

Excessive secretion of growth hormone from pituitary after puberty creates an enlarged skull and thickened cranial bones Note elongated head, massive face, prominent nose and lower jaw, heavy eyebrow ridge, and coarse facial features

Review of Systems (ROS)

Evaluate past and present health state of body system Double-check for omitted data Evaluate health promotion!!! Record presence or absence of all symptoms; not just "negative" Not for objective data; limited to subjective General overall state of health: weight loss/gain; fatigue; weakness; fever, chills, sweats Skin: skin disease; mole changes; dry/moist; pruritus; bruising; rash or lesion Hair: loss; change in texture; Nails: shape, color, brittle Head: headaches; head injury; dizziness Eyes: vision issues; eye pain; diplopia; redness or swelling; watering or discharge; glaucoma or cataracts Ears: earaches; infections; tinnitus; vertigo Nose & sinuses: discharge; severe colds; sinus pain; obstruction; bleeds; allergies; change in smell Mouth & throat: pain; sore throat; bleeding gums; toothaches; lesions; dysphagia; hoarseness Neck: pain; limited ROM; lumps; enlarged nodes; goiter Breast: pain; lump; discharge; rash; disease; surgery Axilla: tenderness; lump; swelling Respiratory: diseases; chest pain with breathing; wheezing; shortness of breath; sputum Cardiovascular: pain; palpitation; cyanosis, DOE; murmur, htn, CAD Peripheral vascular: coldness; numbness/tingling; swelling; discoloration; varicose veins Gastrointestinal: appetite; food intolerance; heartburn; pain; N/V; disease; BMs- any changes Urinary system: frequency; urgency; nocturia; dysuria; polyuria; incontinence; disease Male genital system: pain or sores; discharge; lumps; hernias Female genital system: menstrual history; vaginal itch; discharge; menopause Sexual health: relationship; condoms/contraceptives; risk for STI Musculoskeletal system: history arthritis or gout; joint or back pain or issues (see book for details) Neurologic system: seizures; strokes; fainting; motor or sensory function concerns (see book for details) Hematologic system: bleeding; bruising; node swelling; exposures Endocrine system: diabetes or symptoms; thyroid; heat/cold issues; nervousness

Eyes: Structure and Function

External Anatomy Palpebral fissure-space between eyelids Limbus-dark circle surrounding iris Tarsal plates-thick connective tissue of the eyelids Meibomian glands-near eye brow produces oil for lubrication Conjunctiva Lacrimal apparatus-upper and outer eyelid Extraocular muscles The exposed part of the eye is the conjunctiva. Lacrimal apparatus provides constant irrigation to keep the conjunctiva moist. The lacrimal gland secretes tears. Tears drain into the puncta and then into the nasolacrimal duct and then empty into the inferior meatus in the nose. A tiny fold of mucous membrane prevents air form being forced up into the lacrimal duct when you blow your nose. Extraocular muscles Superior rectus Inferior rectus Lateral rectus Medial rectus Superior oblique Inferior oblique Six muscles that attach the eyeball to the orbit. Each muscle is coordinated with the one in the other eye so that their movement is always parallel. This is called conjugated movement. This is very importamt because the human brain can tolerate only seeing one image at a time. Movement of the extraoccular muscles is stimulated by three cranial nerves: VI, IV and III Internal anatomy Outer layer—sclera Middle layer—choroid Ciliary body and iris Pupil Lens Anterior chamber Inner layer—retina Optic disc Retinal vessels Macula Sclera is a tough protective covering that is white. It is continuous with the smooth transparent cornea. The cornea is very sensitive to touch. Contact with a wisp of cotton = corneal reflex. Choriod layer is very vascularized to deliver blood to the retina. The pupil is round and regular. Its size is determined by the parasympathetic and sympathetic chains of the autonomic nervous system. Cranial nerve III causes pupillary constriction. Lens is the disc that keeps a viewed object in continuous focus on the retina. It bulges for near objects and flattens for far objects. Anterior chamber contains aqueous humor that determines intraoccular pressure Inner layer- retina, optic disc and macula Visual pathways and visual fields Refraction of light rays Crossing of fibers at optic chiasm Visual reflexes Pupillary light reflex Direct light reflex Consensual light reflex Fixation Accommodation Pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. When one eye is exposed to bright light, light reflex occurs (pupil constricts). At the same time, the other pupil constricts and this is called consensual reflex. Fixation is the ability of the eye to fixate on an object. The ocular movements are affected by drugs, alcohol, fatigue and inattention Accommodation adaptation of the eye for near vision. Although we cannot see the lens when we do this test, we can see movement of the eyeball and pupillary constriction

Behavior

Facial expression: person maintains eye contact (unless a cultural taboo exists), expressions appropriate to situation, e.g., thoughtful, serious, or smiling Note expressions both while face is at rest and while person is talking Mood and affect: person comfortable and cooperative with examiner and interacts pleasantly Speech: articulation (ability to form words) clear and understandable Stream of talking is fluent, with an even pace Conveys ideas clearly Word choice appropriate to culture and education Person communicates in prevailing language easily by himself or herself or with interpreter Dress: appropriate to climate, looks clean and fits body, and is appropriate to person's culture and age group; for example, normally: Amish women wear clothing from nineteenth century Indian women may wear saris Culturally-determined dress should not be labeled as bizarre by Western standards or by adult expectations Personal hygiene: person appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group

Techniques of Communication-responses

Facilitation Silence Reflection Empathy Clarification Confrontation Interpretation Explanation Summary

Adnexal Enlargement

Fallopian tube mass—acute salpingitis (pelvic inflammatory disease or PID) Fallopian tube mass—ectopic pregnancy Fluctuant ovarian mass—ovarian cyst Solid ovarian mass—ovarian cancer

CV History: Family History

Family Cardiac History Any family history of HTN Obesity DM CAD Sudden death CVA

Family History

Family tree: siblings, parents and grandparents Child's father vs. husband Note: heart disease, HTN, DM, blood disorders, cancer, sickle-cell, arthritis, allergens, CF, alcoholism, mental illness, learning disabilities, birth defects, SIDS

Rectocele

Feeling of pressure in the vagina With straining or standing Part of the rectum prolapses into the vagina Surgery

Abnormal Findings of Mood and Affect

Flat affect (blunted affect) Depression Depersonalization (lack of ego boundaries) Elation Euphoria Anxiety Fear Irritation Rage Ambivalence Lability Inappropriate affect

OBTURATOR SIGN

Flex hip and adduct across the abdomen. If pain is present it is a peritoneal sign. This is due to inflammation to the obturator muscle lying underneath the peritoneal cavity

Infants

Focus on procedural pain; little understanding of chronic pain Look for changes in facial activities and body movements May see physiologic changes (CRIES score): sweating, increases in BP and HR, N/V, changes on O2 sat (NOT EXCLUSIVE TO PAIN) If a procedure/disease process is known to be painful, it will be painful!

Functional Ability: Social Domain

Focuses on relationships within family, social groups, and community Comprises multiple dimensions including sources of formal and informal assistance available from those relationships Comprehensive social assessment is typically spread over several evaluation periods

Developmental Considerations- Toddlers

Food jags; stuck on one food Food strikes; refusal to eat meals Related to autonomy; want sense of control

Developmental Considerations- School age

Food practices well established Play takes priority

Blood Pressure

Force of blood pushing against vessel wall Systolic: max pressure felt on artery during left ventricular contraction & diastolic: elastic recoil pressure that blood exerts between each contraction Pulse pressure: difference between systolic & diastolic= stroke volume Mean arterial pressure (MAP): pressure forcing blood into tissues, averaged over cardiac cycle

Afterload

Force the heart must pump against to push blood out of the left ventricle. As afterload increases, stroke volume decreases.

Preload

Force used to stretch the muscle fibers at the end of diastole, the heart's maximum fill point. Preload is determined by venous return (volume) and fiber length and the ability to stretch.

Mobility

Gait: normally, base is as wide as shoulder width Foot placement: accurate; walk smooth, even, and well-balanced; and associated movements, such as symmetric arm swing, are present Range of motion: note full mobility for each joint, and that movement is deliberate, accurate, smooth, and coordinated No involuntary movement

Objective Data to Assess Nutrition

General Observations Anthropometric Measurements Diet History/Calorie Count Mouth Inspection Swallowing Evaluation Lab Values

Past Health

General health: past 5 years Accidents or injuries, serious or chronic illnesses, hospitalizations, operations: can be filled out at home; may take time; may not be in order Last examination: mammogram; colonoscopy; tonometry Obstetric status: details not needed past menopause; record # of pregnancies & health of newborn Current medications: name, purpose and schedule System to remember Consider: Large number of drugs with different prescribers Bring in meds to identify name/purpose Cost Does patient travel to pharmacy OTC meds Sharing of meds

Subjective Data-Infants and children

Gestational nutrition Maternal hx of ETOH or drugs Diet related complications during pregnancy Infant BW Evidence of delayed growth or development Breast or bottle fed Willingness to eat / appetite

Gouty Arthritis

Gout causes sudden, severe attacks of pain and tenderness, redness, warmth, and swelling in some joints. Usually affects one joint at a time -- often the big toe. Symptoms Quick onset first episode often occurs at night. Causes Drinking too much alcohol Eating too much of certain foods Surgery Sudden, severe illness Crash diets Joint injury Chemotherapy results from a build-up in the body uric acid, which forms crystals that deposit in joints and cause inflammation. Risk Mostly men over age 40, but it can affect anyone of any age. Women with gout usually develop it after menopause. Diagnosis Physical exam and medical history. Blood tests to measure uric acid. Joint fluid test to check for presence of uric acid crystals. Treatment Options Diet Medications: Colchicine, corticosteroids, NSAIDs, Probenecid, Sulfinpyrazone Surgery (rare)

Gout

Gout can cause: Pain Swelling Redness Heat Stiffness in joints. In addition to the big toe, gout can affect the: Insteps Ankles Heels Knees Wrists Fingers Elbows. Arthritis develops in 1 day, producing a swollen, red, and warm joint Attack of arthritis in only one joint, usually the toe, ankle, or knee.

Developmental Considerations- Adulthood

Growth and nutrients needs stabilize Unhealthy habits; smoking, stress, lack of exercise, ETOH, high fat, salt cholesterol, sugar, low fiber Leads to increase risk for chronic illness DM, HTN, overwt, arthrosclerosis, cancer, osteoporosis

Developmental History

Growth: height & weight at birth and ages 1,2,5 and 10; rapid gain or less; dentition Milestones: age= head erect, rolled over, sat alone, walked alone, first tooth, first words, spoke sentences, toilet trained, tied shoes, dressed self; normal? Current development (1 month thru preschool): gross motor (rolls over, sits, walks, skips) ; fine motor (hands to mouth, pincer, stacks blocks, feeds self); language-skills (first words, sentences, speech issues); personal-social skills (smiles, turns head); method for toilet training School-age child: gross motor (runs, jumps, climbs); fine motor (tie shoelaces, use scissors, writes names); language (time telling, reading level)

Abnormal Findings: Male Breast

Gynecomastia Male breast cancer

Signs of Poor Nutrition & Possible Nutritional Deficiency

Hair *see table 11-5 p 186 text Skin Wound Healing Gums Muscles Lack of Growth Posture Mental Status General Appearance & Vitality Weight Nails Lips Tongue GI System Nervous System

Hallux vagus with bunion and hammer toes

Hallux valgus Common deformity from RA Lateral outward deviation of great toe with medial prominence of head of first metatarsal Bunion Inflammed bursa of the great toe Hammer Toes Deformities in the second, third, and fourth toes Hyperextension of the metatarsophalangeal joint and flexion of the proximal interphalangeal joint

Nails

Hard plates of keratin on dorsal edges of fingers and toes Nail plate is clear with fine longitudinal ridges that become prominent with aging Nails pink due to highly vascular epithelial cells of the nail bed Lunula is white opaque semilunar area at the proximal end of the nail The nail is a complex structure involving 3 different layers. The nail bed (or matrix or plate) is underneath the nail and is responsible for nail growth and support. The nail itself is the hard substance on the back of the finger or toe. The eponychium (cuticle) and lateral nail folds (raised skin on the sides of the nail) are also part of the nail.

Interviewing People With Special Needs

Hearing-impaired people Acutely ill people People under the influence of street drugs or alcohol Personal questions asked of the clinician Sexually aggressive people People who are crying Angry people People who threaten violence Anxious people

What diseases present with Ascites?

Heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, cancer

Screening for Partner Violence

How to screen Open with "Because domestic violence is so common in our society, we are asking all of our female patients the questions that follow" Assessment History Physical examination Documentation

Important Tests

Heel Tap Obturator sign Murphy's sign Guarding Rebound tenderness Iliopsoas muscle test

Torticollis (Wryneck)

Hematoma in one sternomastoid muscle, probably injured by intrauterine malposition, results in head tilt to one side and limited neck ROM to opposite side

Spiritual Assessment

Highly individual May be delayed until nurse-patient relationship has been developed Open-ended questions beneficial Sample question posed during initial assessment may be "Do you consider yourself to be a spiritual person?" Involving chaplains or clergy members, when possible and appropriate, can provide older adult with support and can serve as resource to clinician

Directive Interview-

Highly structured to elicit specific information; controlled by the nurse; client has limited opportunity to respond to or to ask questions; effective when time is short and information critical

Epispadias

Hole on dorsal side of shaft Congenital

Subjective Data-Aging Adult

How does diet differ from younger yrs. ? Socioeconomic, social factors

Callus

Hypertrophy of the epithelium Caused by prolonged exposure to pressure Commonly on plantar surface of the metatarsal head Not painful

Heart Murmur Grades

I- Very faint, distant; not usually heard within first few minutes of listening II-Faint, but heard immediately III-Immediate intensity IV-Louder than III with a palpable thrill V-Very loud with stethoscope lightly on the chest; thrill present VI-Very loud with stethoscope above the chest surface; thrill present; may be heard w/ear on chest

Purpose of Nutritional Assessment

Identify malnourished or risk of developing malnutrition Provide data for designing a nutrition plan of care Establish baseline data for evaluating efficacy of nutrition

Objective Assessment: If Nonverbal...

Identify pain using behavioral cues May vary according to age, culture, gender and acute vs. chronic pain

Shifting Dullness

If dullness on percussion shifts when the patient is rolled on the side, peritoneal fluid (ascites) may be present.

Present Health or History of Present Illness (HPI)

If well, statement of general health If ill, time the symptom started until now Collect data before jumping to conclusions Eight critical characteristics

Challenges of Note-taking

Impedes eye contact Attention-shifting Interruption of patient's narrative flow Impedes observation of nonverbal behavior Can be threatening

Indicates hearing loss in child

Inattentive to conversation Reacts more to movement and facial expression than sound Facial expression is strained or puzzled Frequently asks for things to be repeated Confuses words that sound alike Speech problem Shy and withdrawn; lives in world of their own Frequently c/o ear pain Hears better in quiet environment

Functional Ability: Social Domain: Formal Supports

Include programs such as social welfare and other social service and health care delivery agencies such as home health care Several studies conclude that presence of a caregiver is most important factor in discharge plan of older adults from an acute care hospital Knowing who would be available to help person if he or she becomes ill is important to document even for healthy elders Several standardized assessment instruments are available to provide structured assessment

Functional Ability: Social Domain: Informal Supports

Includes family and close long-time friends, and is usually provided free of charge Total economic value of informal caregiving in U.S. estimated to be more than twice amount paid for nursing home care Services provided include tasks such as shopping, bathing, feeding, and paying bills

Adolescents

Increase in sebaceous gland activity creates increases oiliness and acne Most common skin problem of adolescence Milder form = blackheads Severe includes papules, pustules, nodules Face, chest, back and shoulders Young as 7 years old

Abnormal Findings Abnormal Tactile Fremitus

Increased tactile fremitus Decreased tactile fremitus Rhonchial fremitus Pleural friction fremitus

Abnormal fremitus

Increased tactile fremitus Occurs with conditions that increase the density of lung tissue, thereby making a better conducting medium for vibrations compression or consolidation, pneumonia. decreased tactile fremitus Occurs when anything obstructs transmission of vibrations obstructed bronchus, pleural effusion or thickening, pneumothorax, emphysema. Rhonchal fremitus vibration felt when inhaled air passes through thick secretions in the larger bronchi; may decrease somewhat by coughing Pleural friction fremitus Produced when the inflammation of the parietal or visceral pleura causes a decrease in the normal lubricating fluid. Opposing surfaces make a coarse grating sound when rubbed together during respirations.Best detected by auscultation. "Palpable friction rub".

Developmental competence: Infants and children

Infants and children Transient acrocyanosis and skin mottling at birth Pulse force should be normal and symmetric; pulse force also should be same in upper and lower extremities Palpable lymph nodes occur often in healthy infants and children; they are small, firm (shotty), mobile, and nontender Vaccinations can produce local lymphadenopathy; note characteristics of palpable nodes, local or generalized

Developmental Considerations:nose, mouth, throat

Infants and children: Sinuses Only maxillary and ethmoid present at birth, frontal develop by age 7-8, all full size by puberty. Sphenoid minute at birth. Nose Develops during adolescence age 12 or 13 to age 16-18 Mouth Salivation starts at 3 mos Drools before learns to swallow Teeth develop in utero 20 deciduous (baby teeth) Erupt 6-24mos All 20 by 2 ½ yo Lost age 6-12 Pregnant Female: Nasal stiffness and epistaxis r/t increased vascularity of respiratory tract Gums hyperemic and soft and may bleed easily Aging Adult: Nose Gradual loss of subcue fat makes nose look more prominent Nasal hairs coarser and stiffer, may not filter air as well Sense of smell diminished r/t decrease in number of olfactory nerve fibers, starts age 60 and progresses Mouth Oral cavity soft tissues atrophy and epithelium thins; loss of taste buds with 80% reduction in taste functioning Decrease in salivary production Dental changes Gums recede; teeth erode at gumline; sensitivity, tooth loss Remaining teeth may drift; malocclusion

Anthropomorphic Measures- Developmental Considerations

Infants, children and adolescents Wt=ht and wt at regular intervals use grwth chart Skinfold thickness may be useful for child or teen over nutrition Pregnant female- Wt Monthly up to 30 wks gestation, then every 2 wks until last month, then wkly Aging Adult- Ht loss starting early 30's 2.9cm in men 4.9 cm in women Arm span may be easier MAC and TSF may in inaccurate due to sagging skin and changes in fat distribution and declining muscle mass BMI and waist to hip more accurate to indicate obesity

Cervical Spine Assessment

Inspect alignment of head and neck Palpate spinous processes and muscles Motion and expected range Chin to chest Lift chin Each ear to shoulder Turn chin to each shoulder

Hair Inspection

Inspect and Palpate Texture Distribution Lesions

Nail Assessment

Inspect and Palpate the Nails Shape and contour (profile sign; normal 160 degrees; clubbing 180 degrees) Consistency (not brittle or splitting) Color- translucent Capillary refill- blanch and release; color should return 1-2 seconds

Objective Data: Physical Examination

Inspect and palpate skull Note general size and shape Assess shape: place fingers in person's hair and palpate scalp Skull normally feels symmetric and smooth Cranial bones that have normal protrusions are: forehead, lateral edge of parietal bones, occipital bone, and mastoid process behind each ear There is no tenderness to palpation

Spine Assessment

Inspect while person stands Palpate spinous processes Motion and expected range Bend sideways, backward Twist shoulders to each side Straight leg raising Measure leg length discrepancy

Ankle and Foot Assessment

Inspect with person sitting, standing, and walking Palpate joints Motion and expected range Point toes down, up Turn soles out, in Flex and straighten toes

Objective Data: Physical Examination

Inspect and palpate skull Note general size and shape Assess shape: place fingers in person's hair and palpate scalp Skull normally feels symmetric and smooth Cranial bones that have normal protrusions are: forehead, lateral edge of parietal bones, occipital bone, and mastoid process behind each ear There is no tenderness to palpation Palpate temporal artery above zygomatic (cheek) bone between eye and top of ear Palpate temporomandibular joint as the person opens the mouth, and note normally smooth movement with no limitation or tenderness Inspect face Note facial expression and appropriateness to behavior or reported mood Facial structures always should be symmetric Note symmetry of eyebrows, palpebral fissures, nasolabial folds, and sides of mouth Note any abnormal facial structures (coarse facial features, exophthalmos, changes in skin color or pigmentation), or abnormal swellings Note any involuntary movements (tics) in facial muscles; normally none occur Inspect and palpate neck Symmetry Range of motion Lymph nodes Trachea Thyroid gland Posterior approach Anterior approach Auscultate thyroid for bruit, if enlarged Symmetry Head position is centered in midline, and accessory neck muscles should be symmetrical Head should be held erect and still Range of Motion (ROM) Note any limitation of movement during active motion When neck is supple, motion is smooth and controlled Test muscle strength and status of cranial nerve XI by trying to resist person's movements with your hands as person shrugs shoulders and turns head to each side ROM (cont.) Look for swelling below angle of jaw; note thyroid gland enlargement though normally none is present Note any obvious pulsations; carotid artery creates brisk localized pulsation just below angle of the jaw Normally, there are no other pulsations while person is in sitting position Lymph nodes Normal nodes feel movable, discrete, soft, and nontender If any nodes are palpable, note location, size, shape, delimitation (discrete or matted together), mobility, consistency, and tenderness If nodes enlarged or tender, check area they drain for source of the problem; they often relate to inflammation or neoplasm in head and neck Follow up on or refer your findings; an enlarged lymph node, particularly when you cannot find the source of problem, deserves prompt attention Using a gentle circular motion of fingerpads, palpate lymph nodes Beginning with preauricular lymph nodes in front of ear, palpate the 10 groups of lymph nodes in routine order Many nodes are closely packed, so you must be systematic and thorough in your examination Do not vary sequence or you may miss some small nodes Trachea Normally, trachea is midline; palpate for any tracheal shift Space should be symmetric on both sides Note any deviation from midline Thyroid gland Difficult to palpate; check for enlargement, consistency, symmetry, and presence of nodules If enlarged, auscultate thyroid for presence of bruit, which occurs with accelerated or turbulent blood flow, indicating hyperplasia of thyroid (e.g., hyperthyroidism)

Candidiasis

Intense pruritus, thick whitish discharge Vulva and vagina are erythematous and edematous Predisposing factors: oral contraceptives, antibiotics, pregnancy and diabetes

Acutely Ill People

Interview and examine at the same time Directive interview with closed questions Abbreviate your questions "cut to the chase" Comfort the patient; then determine the priority Subjective assessment critical Cannot always postpone

Clinical Signs and Symptoms of Substance Abuse

Intoxication - maladaptive behavior (CNS) Abuse - inability to stop, impaired life functioning Dependence - physiologic dependence Tolerance - need more for same result Withdrawal - cessation produces syndrome of physiologic symptoms

Transferrin

Iron transport protein, measures total iron binding capacity, indicator of protein status Norm 170-250 mg/dl

Neck Vessel Assessment: Jugular Vein

Jugular veins empty unoxygenated blood directly into the superior vena cava Correlates with function of the right atrium Jugular vein- present in each side of neck Internal- larger, usually not visible External- more superficial Jugular pulse results from a "backwash," a waveform moving backward caused by events upstream

Aorta

Just left to the midline in the upper part of the abdomen 2 cm below umbilicus, it bifurcates into the right and left common renal arteries which become the iliac arteries Right and left iliac arteries become the femoral arteries in the groin area Aorta and femoral arteries can be palpated

ADLs: Screening Tools

Katz Index of Independence in ADL Barthel Index Functional Independence Measure (FIM) Rapid Disability Rating Scale-2 (RDS-2)

Medical Complications from Laxative Abuse

Laxative abuse is very taxing on the body and as such, it can result in a number of health complications. The severity of the following medical conditions is dependant on a number of criteria, specifically, the types and amounts of laxatives used as well as the length of time they were being used. The most common health conditions that arise from laxative abuse include: Severe dehydration and electrolyte imbalances Severe constipation or chronic diarrhea Edema (swelling) Blood in the stools which may cause anemia Laxative dependency Laxative abuse may result in an increased risk of colon cancer

Ventricles (Left)

Left: "Main Pump" of the heart Conical in shape Thick walled 8-15mm thick, high pressure system Squeezes and ejects blood into the systemic circulation via the aorta during ventricular systole Mitral and Aortic Valves

Aging Adult:throax

Less mobile thorax Respiratory muscle strength decreases after age 50 and continues through age 70 Decrease in elastic properties making lungs more rigid and more difficult to inflate

Internal factors

Liking others Empathy Ability to listen

Practice Guidelines

Listen; use all senses, speak slowly Use language patient understands Plan questions to follow logical sequence Ask only one question at a time Do not impose own values on the patient Avoid personal examples ("If I were you......") Nonverbally convey respect Use and accept silence Use eye contact, be unhurried

Herpes

Local pain, dysuria, fever Clusters of small vesicles surrounding erythema erupt on genital areas and inner thigh Once vesicles rupture leave painful ulcers Virus remains dormant indefinitely

Paget's Disease of Bone (Osteitis Deformans

Localized bone disease of unknown etiology that softens, thickens, and deforms bone Affects 3% of adults over age 40 years and 10% over age 80 years and occurs more often in males

Abscess

Localized cavity of pus from an infection Throbbing rectal pain May be superficial or deep

Location of the Heart

Location of the Heart Base of the Heart: 2nd intercostal space @ R/L sternal borders Apex of the heart: 5th intercostal space @ mid-clavicular line Most posterior aspect: Left Atrium Most anterior aspect: Right Ventricle Heart is upside down triangle: top of the heart is the broader BASE; and the bottom is the APEX that points down and to the left During contraction, the apex beats against the chest wall producing the APICAL pulse

Ventricles (Right)

Major "pumps" of the heart Right: most anterior of the 4 chambers Crescent shaped Thin walled 4-5mm thick, low pressure system Contracts and propels deoxygenated blood into the pulmonary circulation via the pulmonary artery. Tricuspid and pulmonic valves

Condylomata acuminata

Male genital lesions: (genital warts).

Carcinoma

Malignant neoplasm in the rectum, Asymptomatic Early lesion may be single firm lesion Rectal palpation may identify

Abnormal Findings: Abnormal Nipple Discharge

Mammary duct ectasia Carcinoma Intraductal papilloma Paget's disease (intraductal carcinoma)

Infants & Children

May be preverbal or incapable of self-report (need objective data) Children > 2 yrs. can report pain and point to location How does child usually describe pain (i.e.- boo boo); may be fearful of getting a shot Rating scales at 4 to 5 yrs. (Faces or Oucher scale- uses photographs)

Nonverbal: Acute Pain Behaviors

May exhibit: guarding, grimacing, vocalizations (moaning), agitation, restlessness, stillness, diaphoresis or change in vital signs May be other reasons why patient is displaying these behaviors

Albumin

Measures protein status Norm 6mos to adult 3.5-5.5 g/dl

Thoracic Cavity

Mediastinum Middle section of the thoracic cavity Contains esophagus, trachea, heart, and great vessels Right and left pleural cavities on either side contain lungs Lobes of the lungs Lobes separated by fissures Not symmetrical Left 2 lobes narrower r/t heart bulges to L. Right shorter r/t liver 3 lobes Anterior Apex 3-4cm above inner 1/3 of clavicle Base lies on diaghram at 6th rib in midclavicular line Posterior C-7 marks the apex and T-10 marks the base Lateral Lies from apex of axilla to 7th rib Pleurae Thin slippery envelope between the lung and the chest wall Visceral pleura lines outside of lungs dipping down in to the fissures and is continuous with the parietal pleura lining the inside of the chest wall and diaphragm Tiny space between visceral and parietal pleura (few mm) filled with fluid at base of lungs pleurae extend 3cm further than lungs forming costodiaghramic recess normally empty space Trachea and bronchial tree Location of trachea and bronchi Dead space Space filled with air but not available for gaseous exchange Function of acinus

Gender Differences

Men raised to be more stoic Women- emotional displays Migraines, premenstrual period, fibromyalgia Pain gene: Human Genome Project

Mental Status

Mental status is inferred through individual's behaviors Consciousness Language Mood and affect Orientation Attention Memory Abstract reasoning Thought process Thought content Perceptions

Defining Mental Status

Mental status—emotional and cognitive functioning Mental disorder Organic disorder Psychiatric mental illness

Abnormalities of the Knee

Mild synovitis Prepatellar bursitis Swelling of menisci Osgood-Schlatter disease Chondromalacia patellae

Common Cognitive Assessment Instruments

Mini Mental State Examination Short Partable Mental Status Questionnaire Mini-cog Blessed Orientation-memory-concentration Geriatric Depression scale, short form Confusion assessment method Neecham Confusion Scale

Supplemental Mental Status Examination

MiniMental State Orientation Registration Attention and calculation Recall Language

Skin Examination

Mole (nevus) Danger Signs ABCDE asymmetry border irregularity color variation diameter> 6mm elevation, enlargement Any of these signs raise suspicion of malignant melanoma and warrant referral In dark skinned people, the amount of normal pigment may mask color changes Under the tongue, the buccal mucosa, conjunctiva and sclera are more appropriate sites to observe changes in skin color Colors: cyanosis, pallor, erythema, and jaundice

Caregiver Assessment

Most elders with functional impairment live with help of informal support Spouse, child, or other family member High levels of functional dependency place a burden on caregiver and may result in caregiver: Burnout Sleep disturbances Depression Morbidity Increased mortality Primary caregivers Increased stress, burden, and impaired physical health for caregiver Especially spouse and adult children often face High levels of demand Limitations on personal freedom Older person's need for institutionalization often better predicted from assessment of caregiver than from severity of patient's illness Health and well-being of patient and caregiver are closely linked Part of caring for a frail elder involves paying attention to the well-being of caregiver Social worker may help identify programs such as caregiver support groups, respite programs, adult day care, or hired home health aides Assessment of caregiver burden All caregivers should be screened for caregiver burden Caregiver burden is perceived strain by person who cares for an elderly, chronically ill, or disabled person Caregiver burden is linked to caregiver's ability to cope and handle stress Level of care older adult requires may exceed caregiver ability Signs of possible caregiver burnout include multiple somatic complaints, increased stress and anxiety, social isolation, depression, and weight loss

Developmental considerations-infant

Most of interaction with parents Speak softly Handle infant in secure manner More cooperative when parent in view

Developmental Considerations- Newborn & Infancy

Most rapid period of growth Regain birth weight within 7-10 days after birth. Double birth by 6 months, triple by one year. Increase their length by 50% by end of first year. Breastfeeding recommended Contraindicated in HIV

Assessment Summary: Mouth, nose, throat

Nose, Mouth, and Throat Examination Nose 1. Inspect external nose for symmetry, any deformity, or lesions 2. Palpation—Test patency of each nostril 3. Inspect using nasal speculum Color and integrity of nasal mucosa Septum—Note any deviation, perforation, or bleeding Turbinates—Note color, any exudate, swelling, or polyps Palpate the sinus areas—Note any tenderness Mouth and Throat 1. Inspect using penlight Lips, teeth and gums, tongue, buccal mucosa—Note color; if structures are intact, any lesions Palate and uvula—Note integrity and mobility as person phonates Grade tonsils Pharyngeal wall—Note color, any exudate, or lesions 2. Palpation When indicated in adults, bimanual palpation of mouth With the neonate, palpate for integrity of palate and to assess sucking reflex

Rectal Prolapse

Mucous membrane protrudes through the anus Moist red doughnut May include anal sphincters Occurs during exercise, straining, valsalva maneuver

Thyroid/Multiple Nodules

Multiple nodules usually indicate inflammation or multinodular goiter rather than a neoplasm; however, suspect any rapidly enlarging or firm nodule Most solitary nodules are benign; solitary nodule poses a greater risk of malignancy Suspect any painless, rapidly growing nodule, especially the appearance of a single nodule in a young person Cancerous nodules tend to be hard and are fixed to surrounding structures

Nail Growth in Elderly

Nail growth rate decreases May have longitudinal ridges Surface may be brittle, peeling and yellow Toenails are also thickened and may grow mis-shapen or even grotesque Fungal infections are common Overall process or thickening due to aging and/or chronic PVD

Developmental Considerations- Pregnancy & Lactation

Need more calories, protein, vitamins and minerals to support maternal and fetal tissues 25-35lbs wt gain for normal wt. 28-40 for underwt. 15-25 for overwt.

Nociceptors

Nerve endings- detect painful sensations from periphery and transmits to CNS Within skin, connective tissue, muscle & thoracic, abdominal, and pelvic viscera Stimulated by trauma or injury or secondarily by chemical mediators (site of tissue damage) A fibers- transmit pain signal rapidly (myelinated & large) C fibers- slower (unmyelinated & small) Develops when nerve fibers in periphery and CNS are functioning and intact Pain starts outside the nervous system 4 phases Transduction Transmission Perception Modulation

Abnormalities in the optic disc

Optic atrophy (disc pallor) Papilledema (choked disc) Excessive cup:disc ratio

MMSE—functional areas

Orientation—what is the year, season, date, day, month? Registration—name 3 objects, then repeat them Attention/calculation—spell "world" backwards, do serial 7s Recall—name previous 3 objects Language—point and name to a pencil, follow simple instructions, repetition, writing, drawing

General Manifestations of Altered Nutrition

Overweight Obesity Morbid Obesity Underweight Altered Bowel Status Altered skin, hair, & mucous membranes

Abdominal palpation findings

Palpate Liver, spleen, gallbladder, kidney Enlarged ? Describe ? Enlarged nodular liver- late portal cirrhosis, metastic CA, tertiary syphilis Enlarged gall bladder- difficult to assess d/t pain and involuntary guarding, positive Murphy's sign Enlarged spleen- stopped by diaphragm so enlarges downward, Acute infection such as mono= enlarged and soft; with chronic problems= hard and enlarged; usually not tender to palpate unless peritoneum is inflamed Enlarged kidney- hydronephrosis, cyst, neoplasm. Aortic aneurysm- 80% palpable during PE. Hear bruit. Femoral pulsed present but decreased

Rebound Tenderness

Palpate deeply and then quickly release pressure. If it hurts more when you release, the patient has rebound tenderness. Rebound tenderness is a clinical sign that a doctor may detect in physical examination of a patient's abdomen. It refers to pain upon removal of pressure rather than application of pressure to the abdomen. (The latter is referred to simply as abdominal tenderness.) It represents aggravation of the parietal layer of peritoneum by stretching or moving. Rebound is regarded as one of the classic local signs of peritonitis which can occur in diseases like appendicitis, and may occur in ulcerative colitis with rebound tenderness in the right lower quadrant. The others are tenderness and abdominal guarding. However, in recent years the value of rebound tenderness has been questioned, since it may not add any diagnostic value beyond the observation that the patient has severe tenderness Blumberg's sign; positive determines peritoneal inflammation

MURPHY'S SIGN

Palpate deeply in the RUQ while patient inhales deeply. Tenderness can indicate Gallbladder disease.

AADL instruments

Physical Performance Test (PPT) Performance Activities of Daily Living (PADL) Up and Go Test

Elder Abuse and Neglect

Physical abuse—violence Physical neglect—failure to provide basic services Psychological abuse—mental anguish Psychological neglect—failure to provide stimulation Financial abuse—intentional misuse of resources Financial neglect—failure to use assets

Nonverbal techniques of interview

Physical appearance Posture Gestures Facial expression Eye contact Voice Touch

Factors Affecting Nutrition

Physiologic Ability to acquire & prepare food Environmental Economical Functional Lack of Knowledge Discomfort Psychosocial

Individuals at Risk of Being Abused

Planning to leave or has recently left an abusive relationship Previously in an abusive relationship Poverty or poor living situations Unemployed Physical or mental disability Recently separated or divorced Isolated socially from family and friends Abused as a child Witnessed domestic violence as a child Pregnancy, especially if unplanned Younger than 30 years Stalked by a partner

Ecchymosis

Platelet inhibitors

Abnormal Findings: Disorders During Lactation

Plugged duct Breast abscess Mastitis

Posterior Thoracic Landmarks**

Posterior thoracic landmarks Vertebra prominens; C-7 Spinous processes; knobs T-1 down to T-4 align with same numbered ribs after T-4 spinous processes angle downward Inferior border of scapula Lower tip of scapula is at the 7th or 8th rib Twelfth rib Palpate midway between spine and person's side to feel its free tip

Heart Assessment: Precordium

Precordium Inspect the anterior chest Apical pulse Location Size Amplitude Duration Palpate across the precordium Thrill: palpable vibration signifying turbulent blood flow and accompanies loud murmurs.

Developmental Competence: Pregnancy

Pregnant woman Expect diffuse bilateral pitting edema in lower extremities, especially at end of day and into third trimester Varicose veins in legs common in third trimester

Development: Pregnancy

Pregnant woman Hormonal changes cause vasodilatation and a resulting drop in blood pressure Growing uterus obstructs drainage of iliac veins and inferior vena cava This condition causes low blood flow and increases venous pressure This, in turn, causes dependent edema, varicosities in legs and vulva, and hemorrhoids

Past Health

Prenatal status: (see book for details); start open-ended "Tell me about your pregnancy?" Labor and delivery: duration of pregnancy; anesthesia; type of delivery; birth weight; Apgar; use of equipment Postnatal status: length of hospital stay; breast/bottle; weight gain; feeding problem; crying/sleeping; mother's reaction Childhood illnesses: age/complications Serious accidents/injuries: age; extent of injury; treatment; complications Serious or chronic illnesses: age; treatment; complications Operations or hospitalizations: reason; age; surgeon or PCP; hospital; duration of stay; complications Immunizations: age; date; reactions; suggested scheduled per CDC and American Academy of Pediatrics Allergies: drugs; foods; agents; what is reaction; note allergic rhinitis, insect hypersensitivity, eczema, urticaria Medications: prescription and OTC; dose, daily schedule, purpose, problems

Objective Data

Preparation Position Equipment needed Penlight Lubricating jelly Glove Guaiac test container Inspection of the Perianal Area Skin- inflammation, lesions, scars Anal opening- lesions, hemorrhoids, fissures Sacrococcygeal area- break in skin integrity, should be smooth and even Valsalva maneuver- no break in skin integrity or protrusion through the anal opening Palpation of the Anus and Rectum Palpation technique- press gently, never at a right angle, feel the sphincter tighten then relax Canal wall- smooth and even Perianal tissue- bidigital palpation for swelling or tenderness Rectal wall- smooth and no nodularity Prostate gland Size- 2.5 cm X 4 cm Shape- heart shaped, central groove Surface- smooth Consistency- elastic, rubbery Mobility- slightly movable Sensitivity- nontender Examination of stool for occult blood

Palmar Grasp

Present at birth Strongest at 1-2 months Disappears by 3-4 months

REBOUND

Press on the abdomen and then release suddenly. If pain is worse during the release this is a positive peritoneal sign.

Objective Data:inspection

Preparation Woman sitting up facing examiner An alternative draping method is to use a short gown, open at back, and lift it up to woman's shoulders during inspection During palpation when woman is supine, cover one breast with gown while examining other Be aware that many women are embarrassed to have their breasts examined; use a sensitive but matter-of-fact approach After examination, be prepared to teach woman breast self-examination Inspect the breast General appearance Note symmetry of size and shape; common to have a slight asymmetry in size; often left breast is slightly larger than right Skin Normally is smooth and of even color Note any localized areas of redness, bulging, or dimpling; also any skin lesions or focal vascular pattern Fine blue vascular network visible during pregnancy; pale linear striae, or stretch marks, follow pregnancy Normally no edema is present Lymphatic drainage areas Observe axillary and supraclavicular regions; note any bulging, discoloration, or edema Nipple Should be symmetrical on same plane on both breasts Nipples usually protrude, although some are flat and some are inverted Normal nipple inversion may be unilateral or bilateral and usually can be pulled out Note any dry scaling, any fissure or ulceration, and bleeding or other discharge Supernumerary nipple is normal variation An extra nipple along embryonic "milk line" on thorax or abdomen is congenital finding Usually, below breast near midline and has no associated glandular tissue; looks like a mole, although a close look reveals a tiny nipple and areola Maneuvers to screen for retraction Direct woman to change position to check breasts for skin retraction signs; first ask her to lift arms slowly over head; both breasts should move up symmetrically Next ask her to push her hands onto her hips and then to push her two palms together; these maneuvers contract pectoralis major muscle; slight lifting of both breasts will occur Ask woman with large pendulous breasts to lean forward while you support her forearms; note symmetric free-forward movement of both breasts Inspect and palpate the axillae Examine axillae while woman is sitting Inspect skin, noting any rash or infection; lift woman's arm and support it, so that her muscles are loose and relaxed; use right hand to palpate left axilla Reach fingers high into axilla; move them firmly down in four directions Move woman's arm through range-of-motion to increase surface area you can reach Usually nodes are not palpable, although you may feel a small, soft, nontender node in central group Note any enlarged and tender lymph nodes Concerns: Sudden increase in size Retraction of breast or nipple: growing neoplasm Fixation to chest wall Nipple discharge (abnormal unless pregnant or lactating) Lag in movement of one breast Edema, hyperpigmentation, inflammation

Sebaceous Glands

Produce protective liquid substance called sebum that is secreted through the hair follicles Sebum lubricates skin and hair and prevents water loss Sebaceous glands are everywhere except palms and soles Abundant on forehead, scalp, face and chin

Developmental Considerations- Elders

Prone to under nutrition or over nutrition Poor physical or mental health, social isolation, alcoholism, limited functional ability, poverty, polypharmacy Normal physiologic changes Poor dentition, decreased visual acuity, decreased saliva production, slower gastric motility, decreased absorption, diminished olfactory and taste, socioeconomic issues, Decrease in energy requirements due to loss of lean body mass and increase in fat By age 51-75 energy needs decrease by 200kcal/day, after age 75 decrease by 500kcal for men and 400kcal for women Protein needs are 0.8g/kg/day, same as younger adult

Function of the Nails

Protection to distal surfaces of digits Self protection Qualifier of social and economic status in many cultures

Rectal Polyp

Protruding growth from rectal mucous membrane Biopsy to screen for malignant growth

PQRSTU

Provocative or palliative Quality or quantity Region or radiation Severity Timing Understand patient's perception

Trichomoniasis

Pruritus, watery malodorous discharge Urinary frequency, dysuria Vulva may be erythematous, vagina diffusely red and granular STD

The Adolescent-

Psychosocial review of symptoms Color-coded (green= essential; blue= if time; red=optional) HEEADSSS Home environment Education & employment Eating Peer-related activities Drugs Sexuality Suicide/depression Safety from injury/violence

Mid-Upper Arm Circumference

Pt stands with arms hanging at side measure midpoint b/t acromion process and elbow Record in cm compare with norms (chart) Measurements below 10th percentile or >90th percentile warrant further eval Also can be used with TSF muscle circumference

Abnormalities of the cornea and iris

Pterygium Corneal abrasion Hyphema Hypopyon

CHF

Pump failure with increasing cardiac overload causes pulmonary congestion or increases amount of blood present in pulmonary capillaries Pulmonary capillaries engorged and dependent air sacs deflate Bronchial mucosa swollen Symptoms;Increased RR, SOB on exertion, orthopnea, paroxysmal nocturnal dypsnea, nocturia, ankle edema, pallor Crackles at bases

Carcinoma

Raised ulcer Watery discharge May necrose and slough off Painless Found on glans or lip of foreskin

Developmental Considerations- Adolescence

Rapid growth Endocrine and hormonal changes Increased protein and calories needed to support growth and muscle development Calcium needed for bone growth Iron important for female menses Needs usually not met with 3 meals, need snacks Boys generally grow taller and have less body fat; 12%, girls 25% Girls double body weight age 8-14 Boys double weight age 10-17

Parotid Gland Enlargement

Rapid painful inflammation of parotid occurs with mumps Parotid swelling also occurs with blockage of duct, abscess, or tumor; note swelling anterior to lower ear lobe Stensen duct obstruction can occur in aging adults dehydrated from diuretics or anticholinergic

Heart Assessment: Auscultation

Rate and rhythm Identify S1 and S2 Listen for extra heart sounds and murmurs Listen across the precordium Precordium Pulsations: point of maximal intensity (PMI) Normal location : 5th left ICS @midclavicular line Lateral displacement LV dilation Upward diaphragm displacement Right to left mediastinal shift Medial displacement Downward diaphragm displacement Left to right mediastinal shift

Pruritis Ani

Red, raised, excoriated skin around the anus Pinworms or fungal infection

AV node

Regulates impulse transmission to the ventricles Delays the impulse slightly to allow for atrial contraction Protects the ventricles from rapid atrial impulses (afib/aflutter)

Under nutrition

Reserves depleted Inadequate nutrients to carry out daily activities Vulnerable groups; infants, children, low income, hospitalized, aging adults, Risk for impaired growth and development Lowered resistance to illnesses Delayed would healing Longer hospital stays Higher healthcare costs

Abnormalities of the Tympanic Membrane

Retracted drum Serous otitis media Acute purulent otitis media Perforation Insertion of tympanostomy tubes Cholesteatoma Scarred drum Blue drum (hemotympanum) Bullous myringitis Fungal infection (otomycosis)

Bundle branches

Right and left, directs impulses to the ventricles

Rooting Reflex

Rooting reflex: brush the infant's cheek near mouth; note whether infant turns head toward that side and opens mouth Appears at birth; disappears at 3 to 4 months

Developmental Considerations: Infants

Same capacity for pain as adults 20 wks. gestation- fetus capable of feeling pain (inhibitory neurotransmitters insufficient until birth at full term; preemies= more sensitive to painful stim) Poorly controlled can result in lifelong issues (poo weight gain, learning disabilities, alcoholism, psych issues)

Characteristic Injuries

Rope burns Cigarette burns Bruises Bite marks Welts with the outline of a recognizable weapon (such as a belt buckle) Bilateral injuries usually the arms and legs Defensive posture injuries: These injuries are to the parts of the body used by the woman to fend off an attack. The small finger side of the forearm or the palms when used to block blows to the head and chest The bottoms of the feet when used to kick away an assailant The back, legs, buttocks, and back of the head when the woman is crouched on the floor Injuries inconsistent with the explanation given: The injury type or severity does not fit with the reported cause. The mechanism of injury reported would not produce the signs of injury found on physical examination. injuries in various stages of healing: Signs of both recent and old injuries may represent a history of ongoing abuse. Delay in seeking medical attention for injuries may indicate either the victim's reluctance to involve doctors or his or her inability to leave home to seek needed care. Often goes to the ER or clinic on multiple occasions with no physical exam findings to account for his or her symptoms some typical medical complaints: Headache Neck pain Chest pain Heart beating too fast Choking sensations Numbness and tingling Painful sexual intercourse Pelvic pain Urinary tract infection Vaginal pain

ACS- Summary

Routine risk: Start mammography age 45; yearly until age 55; then every other year Continue screening as long as overall health is good & life expectancy 10 yrs of longer Clinical breast exam not recommended among average risk women at any age Summary of recent studies and other recommendations

Indirect Hernia

Sac herniates through internal inguinal ring Can remain in canal or scrotum Pain with straining, may decrease when lying down Most common of all hernias Congenital or acquired

Functional Assessment

Self-care ability ADLS (bathing, dressing...) Instrumental activities of daily living (IADLs) Self-esteem, self-concept: education, finances, values Activity/exercise: typical day Sleep/rest: patterns, naps, sleep aids Nutrition/elimination: food recall, habits, prep, caffeine; bowel/bladder patterns/problems Interpersonal relationships/resources: social roles, support systems Spiritual resources: F (faith) I (influence) C (community) A (address) Coping & stress management: stressors in past year; ways to relieve stress Personal habits: tobacco (PPD x yrs.) & cessation, alcohol, street drugs Alcohol: amount & frequency; CAGE Illicit or street drugs: i.e.- marijuana, cocaine; pain killers, heroin, OxyContin (frequency & impact) Environment/hazards: housing & neighborhood; safety; heat & utilities; transportation; community services Intimate partner violence: begin open-ended "Do you feel safe"? (help to recognize abusive situation & admit it) If patient admits it ask closed-ended "Have you been emotionally or physically abuse by someone important to you? APGAR FAMILY ASSESSMENT- see health history form Occupational health: describe job; any health hazards; is seeking care related to exposures Perception of health: "How do you define health? "What are your concerns or goals?

Process of Communication

Sending Receiving Internal/external factors

Opacities in the Lens

Senile cataracts Central gray opacity—nuclear cataract Star-shaped opacity—cortical cataract

Older Person

Senile lentigines (liver spots) small flat brown macules > Follow excessive sun exposure Seborrheic keratosis- thick, dark, greasy, "stuck on" raised and rough > Trunk, face, hands; sun or no sun; do not become cancerous Actinic keratosis (senile or solar) less common. Red, tan scaly plaques that increase over the years to become raised and rough Directly related to sun exposure Dry skin (xerosis) common in aging (decline in sweat and sebaceous glands) Acrochordons (skin tags) eyelids, cheeks, neck, axillae and trunk Turgor decreases; tenting recedes slowly

Central cyanosis

Serious cardiac disorders (pulm. Edema and congenital HD) in which blood is not reoxygenated by the pulmonary vasculature

DANGER ASSESSMENT

Several risk factors have been associated with homicides (murders) of both batterers and battered women in research conducted after the murders have taken place. We cannot predict what will happen in your case, but we would like you to be aware of the danger of homicide in situations of severe battering and for you to see how many of the risk factors apply to your situation. Using the calendar, please mark the approximate dates during the past year when you were beaten by your husband or partner. Write on that date how bad the incident was according to the following scale: 1. Slapping, pushing; no injuries and/or lasting pain 2. Punching, kicking; bruises, cuts, and/or continuing pain 3. "Beating up"; severe contusions, burns, broken bones 4. Threat to use weapon; head injury, internal injury, permanent injury 5. Use of weapon; wounds from weapon

Pediculosis Pubis (Crab Lice)

Severe itching Excoriations and erythematous areas May see little dark spots- lice and nits Treatment is localized

Hollow Viscera

Shape depends on the contents Stomach Gall Bladder Small intestine Colon Bladder

Cool/cold and moist skin

Shock

Organs in left lower quadrant

Sigmoid colon Left ovary and fallopian tube Left ureter and lower kidney pole Left spermatic cord

Objective Data: Muscles

Size: inspect all muscle groups for size Compare right side with left; muscle groups should be within normal size limits for age and should be symmetric bilaterally If muscles in extremities are asymmetric, measure in centimeters and record difference; difference of 1 cm or less is not significant Note that it is difficult to assess muscle mass in very obese people Strength: test muscle groups of extremities, neck, and trunk Tone: normal tension in relaxed muscles Persuade person to relax completely, and move each extremity smoothly through a full range of motion; normally, note mild, even resistance to movement Involuntary movements Normally none occur; if present, note location, frequency, rate, and amplitude; note if movements can be controlled at will

CV Inspection

Skin and mucous membranes Color Temperature Moisture Turgor Edema Pitting Non-pitting Nail beds Bruises/hematomas Petechiae Thorax Shape and contour Symmetry Breathing Pattern

Aging Adult

Skin is a mirror..expect changes Underlying dermis thins and flattens Loses it's elasticity, folds and sags because of the loss of elastin, collagen, and subcutaneous fat and reduced muscle tone. Sun exposure and cigarette smoke accentuate aging of the skin Melanocytes decrease= graying of the hair Testosterone is unopposed due to decreases in estrogen and so facial hair may appear Risk for skin breakdown increases, loss of protective subcutaneous layer Cell replacement is slower and wound healing is delayed Nails grow slower and are lusterless

Pilar Cyst (Wen)

Smooth, firm, fluctuant swelling on scalp; pressure of contents causes overlying skin to be shiny and taut Benign growth

Components of Social Assessment

Social network (formal, semiformal, informal) Caregiver assessment Elder mistreatment Environment Spiritual

Patient Teaching: Testicular self exam

Teach testicular self-examination T = Timing S = Shower E = Examination points Every male from 13y.o. to adulthood Every month Warm hands- avoid cremasteric reflex

Ingrown toenail

Soft tissue grows over nail; nail does not grow into soft tissue Usually great toe medial or lateral side Due to trimming nail too short or toe crowding in shoes Area may become infected when nail grows and the corner penetrates soft tissue

Sexually Aggressive People

Some people experience serious or chronic illness as a threat to their self esteem and sexual adequacy May act out in sexually aggressive ways Set appropriate verbal boundaries

Pneumothorax

Spontaneous pneumothorax sudden collection of air or gas in the chest that causes the lung to collapse in the absence of a traumatic injury to the chest or lung occurs in pts with no known lung disease. affects close to 9,000 persons in the United States each year- most often among tall, thin men between 20 and 40 years old. cause of this type of pneumothorax is the rupture of a bleb or cyst in the lung Symptoms Chest pain on affected side Dyspnea (shortness of breath) Cough Abnormal breathing movement Rapid respiratory rate Spontaneous pneumothorax is diagnosed by chest radiographs. Treatment: objective is to remove the air from the pleural space, allowing the lung to re-expand. small pneumothorax will resolve on its own in 1 to 2 weeks Larger require needle aspiration or a chest tube reexpansion of the lung may take several days with the chest tube left in place Surgery may be performed for a repeated episode to prevent recurrence SECONDARY PNEUMOTHORAX Occurs in pts with known lung disease, most often chronic obstructive pulmonary disease (COPD) commonly causes include tuberculosis, pneumonia, asthma, cystic fibrosis, lung cancer, and certain forms of interstitial lung disease generally severe and often life threatening Symptoms identical to primary spontaneous pneumothorax Treatment same as those for primary spontaneous pneumothorax, but the circumstances are much more urgent. small pneumothorax can be life threatening and virtually all patients are treated with chest tubes Sudden death may occur before chest tubes can be place and respiratory failure can occur within hours after the tubes are inserted mortality rate associated with secondary pneumothorax is high (15%).

Vital Signs: Temperature

Stable core- 37.2 C or 99F Balance of heat production with heat loss Normal oral is 37 C or 98.6 F Rectal is 0.4 to 0.5 C (0.7 to 1 degree F) higher Diurnal temperature cycle: trough early AM, peak late afternoon/early evening Menstrual cycle: progesterone secretion w/ovulation midcycle= 0.5f to 1.0f rise until menses Exercise (increases) Age- older adult temp is lower; less effective heat control in infant & young child

Body Structure

Stature: height appears within normal range for age, genetic heritage Nutrition: weight appears within normal range for height and body build; body fat distribution even Symmetry: body parts look equal bilaterally and are in relative proportion Posture: person stands comfortably erect as appropriate for age Note normal "plumb line" through anterior ear, shoulder, hip, patella, ankle Exceptions Standing toddler who has a normally protuberant abdomen (toddler lordosis) Aging person who may be stooped with kyphosis Position: person sits comfortably in chair or on bed or examining table, arms relaxed at sides, head turned to examiner Body build, contour: proportions are correct Arm span (fingertip to fingertip) equals height Body length from crown to pubis roughly equal to length from pubis to sole Obvious physical deformities: note any congenital or acquired defects

Organs in Left upper quadrant

Stomach Spleen Left kidney and adrenal gland Splenic fissure of the colon Body of pancreas

Pulse

Stroke volume: heart pumps: about 70 ml; force generates a pressure wave (pulse) Use finger pads Rate If regular= count for 30 and multiply x 2 Irregular= full minute Resting rate= 50 to 90 bpm (<50= bradycardia; > 90= tachycardia) More rapid infancy & childhood Rhythm Sinus arrhythmia: varies with respiratory cycle (speeds up inspiration & slows expiration) Force Reflects stroke volume 3+ Full, bounding 2+ Normal 1+ Weak, thread 0 Absent

Acute Salpingitis- PID

Sudden fever, suprapubic pain and tenderness Acute, rigid boardlike lower abdominal musculature Movement of uterus and cervix causes intense pain, Pain in adenxa PID caused by gonorrhea and Chlamydia

Optimal nutritional status

Sufficient nutrients are consumed to support daily activities More active Fewer illnesses Live longer

Anterior Thoracic Landmarks**

Suprasternal notch U-shaped depression just above sternum Sternum Breastbone; manubrium, body, Xyphiod process Manubriosternal angle Bony ridge few centimeters down on manubrium Also called angle of Louis Useful for starting to count ribs, fused with 2nd rib Costal angle Where right and left costal margins meet at the xyphoid process; normal is 90 degree angle, can be wider in chronic hyperinflation i.e emphysema

TMJ

Symptoms Pain in the TMJ Tender or painful jaw muscles Clicking, popping or grating sounds in the joint Difficulty or pain upon opening and/or closing of the mouth Frequent headaches or neck aches Ringing or buzzing sounds in the ears Dizziness or lightheadedness Decreased jaw opening Causes Stress on the surrounding muscles; Teeth clenching or grinding Stress, poor posture or body alignment can cause the muscles surrounding the joint to tighten Abnormal jaw growth Missing teeth Diseases such as arthritis Injury to the TMJ Treatment conservative measures; Physiotherapy Stress management counsellng Muscle relaxant and anti-inflammatory medication Splint therapy Surgical interventions Arthroscopy Arthrocentesis (washing out of the joint) Arthrotomy (open joint surgery) Surgery is only indicated if conservative non-surgical treatment is unsuccessful or if there is clear joint damage. TMJ can make talking, eating and yawning painful. TMJ disorders can be relatively minor or extremely incapacitating.

HEEL TAP

Tap the heel hard. Motion is transferred up to the muscles beneath the peritoneal cavity. If pain is present this is a peritoneal sign.

Contractility

The ability of cardiac muscle cells to contract or shorten after being stretched.

Health Promotion

The assessment of the skin, hair, and nails is an ideal time to share information about skin self-examination and what to do if any suspicious lesions are discovered Information about exposure to ultraviolet light should be discussed. Skin Cancer Risk Factors Ultraviolet light exposure that is repeated and unprotected Family history Second degree burns before the age of 18 Acute sun burns Lack of sun protection- sunscreen with SPF, hats, visors, protective clothing Tanning beds

Mediastinum

The heart and great vessels are located between the lungs in the middle third of the thoracic cavity.

The interview contract

The interview as a contract between patient and examiner Time and place Introduction and explanation Purpose Length Expectations Presence of others Confidentiality Costs

Approach and Avoidance.

The mix of pros (love and economic support) and cons (fear and humiliation) present in the battering relationship leads to ambivalence on the part of the victim. The victim is likely to want to approach the positives in the relationship but avoid the abuse. This struggle between wanting to keep the relationship and wanting to remain safe makes it difficult to decide whether to leave or stay in the relationship. On average, women leave and return to an abusive relationship five times before permanently leaving

Femoral Hernia

Through the femoral ring and canal, below inguinal ligament, more often on right side Pain may be severe, may become strangulated Acquired due to increased abdominal pressure or frequent stooping

Pregnant Female

Thyroid gland enlarges slightly during pregnancy as a result of hyperplasia of tissue and increased vascularity

Palpation

Touch to assess texture, temperature, moisture, organ location & size, swelling, vibration/pulsation, rigidity/spasticity, crepitation, lumps/masses, tenderness/pain Fingertips- tactile- skin texture, swelling, pulsation, lumps Grasping of fingers & thumbs- position, shape & consistency or organ or mass Dorsa (backs) of hands & fingers- temperature Base of fingers (metacarpophalangeal joints) or ulnar surface of hands- vibration Slow & symmetric Calm & gentle Warm hands Identify tender areas last Start light, then deeper Relaxation techniques Intermittent pressure Bimanual Both hands to capture certain body parts two handed; duck bill; hooking

Interatrial pathways

Transmit impulses between both atria

Internodal pathways

Transmit impulses between the SA node and AV node

Tonic Neck Reflex

Turn head to one side See ipsilateral extension of the arm and leg, and flexion of opposite Appears by 2-3 months Decreases 3-4 months Disappears 4-6 months

Pulmonary Embolism

Undissolved material (thrombus or air bubbles or fat globules) originating in legs or pelvis detach and travel through venous system returning blood to right heart, and lodge to occlude pulmonary vessels. Over 95% r/t DVT in lower legs Results in ischemia, increased pulmonary artery pressure, decreased cardiac output, and hypoxia Chest pain worse on inspiration Restless, anxiety, MS changes, cyanosis, cough <80 Pox, diaphoresis, hypotension, Crackles and wheezes

Abnormalities in the Pupil

Unequal pupil size—anisocoria Monocular blindness Constricted and fixed pupils—miosis Dilated and fixed pupils—mydriasis Argyll Robertson pupil Tonic pupil (Adie's pupil) Cranial nerve III damage Horner's syndrome PERRLA

Organs in Midline

Urinary Bladder urethra (female)

Ankle-brachial index (ABI)

Use Doppler stethoscope Highly specific, noninvasive, and readily available way to determine extent of peripheral vascular disease Apply a regular arm blood pressure cuff above ankle and determine systolic pressure in either posterior tibial or dorsalis pedis artery Divide that figure by systolic pressure of brachial artery Normal ankle pressure slightly greater than or equal to brachial pressure; normal ABI is usually 1.0 to 1.2 In people with diabetes mellitus, ABI may be less reliable because of calcification (which makes their arteries noncompressible) and may give falsely high measure ABI is the ratio of the systolic pressure in the ankle to the systolic pressure of the brachial Objective indicator of peripheral vascular disease, quantify the degree of stenosis; with increasing degrees of arterial narrowing, there is a progressive decrease in systolic pressure distal to the involved sites. Check if decreased pulses; 50 yrs. or older; diabetic or smoker No tobacco or caffeine 2 hrs. before checking Normal ABI= about 1.0 Calculating ABI: Highest ankle systolic pressure for each foot divided by the higher of the two brachial systolic pressures: Right brachial: 160 mm Hg Left brachial: 120 mm Hg Right posterior tibial: 80 mm Hg Right dorsalis pedis: 60 mm Hg Left posterior tibial: 100 mm Hg Left dorsalis pedis: 120 mm Hg Right 80/160 mm Hg= 0.50 ABI Left 120/160 mm Hg= 0.75 ABI

Plantar wart

Vascular papillomatous growth due to virus Occurs on the sole of the foot; commonly the ball Extremely painful

Measurement: Weight

Use a standardized balance or electronic standing scale Instruct person to remove his or her shoes and heavy outer clothing before standing on scale When sequence of repeated weights is necessary, aim for approximately same time of day and same type of clothing worn each time Record weight in kilograms and pounds Show person how his or her weight matches up to recommended range for height (BMI) Compare to previous visits Body mass index Body mass index is practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition Concerns: < 19 or > 25 Waist-to-hip ratio Assesses body fat distribution as indicator of health risk Concern for risk of certain diseases with excess abdominal fat

SMAST-G

Use the SMAST-G questionnaire for older adults who report social or regular drinking of any amount of alcohol Older adults have specific emotional responses and physical reactions to alcohol and the 10 questions with yes/no responses address these factors 1 yes = low risk. >2 = an alcohol problem and need for more in-depth assessment

Doppler-ultrasonic stethoscope

Use this device to detect a weak peripheral pulse, to measure low blood pressure or blood pressure in lower extremity Doppler stethoscope magnifies pulsatile sounds from heart and blood vessels Position person supine, with legs externally rotated so you can reach medial ankles easily Place drop of coupling gel on end of handheld transducer Place transducer over pulse site, swiveled at a 45-degree angle; apply very light pressure; locate pulse site by the swishing, whooshing sound

Sources of Pain

Visceral: from larger interior organs; from direct injury to organ or stretching of the organ from tumor, ischemia, distention, or severe contraction Ureteral colic, acute, appy, ulcer pain, cholecystitis Deep somatic: blood vessels, joints, tendons, muscles, bone (injury from pressure, trauma or ischemia Cutaneous: skin surface and subcut tissues (injury superficial with sharp, burning sensation) Referred: felt one place & originates at another (innervated by same spinal nerve) Visceral or somatic structures

Dislocated Shoulder

Visibly deformed or out of place Swollen or discolored (bruised) Intensely painful Immovable may also cause numbness, weakness or tingling near the injury in neck or down arm. muscles may spasm often increasing the intensity of your pain. most frequently dislocated joint of the body because it can move in many directions can dislocate forward, backward or downward, completely or partially. ligaments can be stretched or torn, often complicating the dislocation. a strong force, such as a sudden blow to your shoulder, pulls the bones out of place (dislocation). Extreme rotation of the shoulder joint, such as during a throwing movement, can pop the ball of humerus out of the scapula Complete or partial dislocation (subluxation) may occur. Causes Sports injuries. contact sports, such as football and hockey, and in sports that may involve falls, such as downhill skiing, gymnastics and volleyball. Trauma not related to sports. Falls Treatment Realignment; manual or surgical sling or device to keep the shoulder in place Rest Ice three or four times a day Exercise to improve range of motion, strengthen muscles, and prevent injury. may happen again; common in young, active people. If the dislocation injures tissues or nerves around the shoulder, surgery may be needed.

Developmental considerations-Adolescent

Want to be adults, but lack cognitive ability May regress with stress Value their peers Respect the adolescent Communicate in an honest manner Use icebreakers Short and simple Promise confidentiality

Inspection

Watching Begins immediately- general, then more specific Start each body system with inspection (hold hands behind back as needed) Compare side to side (symmetry) Need good light, adequate exposure, instruments prn

STRIAE

What are these? How do they occur? Recent striae are what color? Older striae are what color? Stretch marks or striae (singular stria), as they are called in dermatology, are a form of scarring on the skin with an off-color hue. They are caused by tearing of the dermis, and over time can diminish but not disappear completely. Stretch marks are often the result of the rapid stretching of the skin associated with rapid growth (common in puberty) or weight gain (e.g. pregnancy or muscle building) or in some cases, severe pulling force on skin that overcomes the dermis's elasticity.[citation needed] Stretch marks may also be influenced by hormonal changes associated with puberty, pregnancy, muscle building etc.

NEED TO KNOW landmarks

Where the landmarks of the lungs lie in relation to bony processes c7-apex of lung begins posteriorly t10- lungs posteriorly end (sometimes up to t12 when inflated) lower tip scapula= rib7-8

Source of History

Who provides the information? Usually the...? How reliable does the information seem? Any special circumstances (i.e.- interpreter) Information provided by the patient, who seems reliable

General Survey

Whole person- general health status & obvious physical characteristics Overall impression First impressions Concentrate on NORMALS Physical appearance, body structure, mobility & behavior

Uterine Prolapse

With straining or standing the uterus protrudes into the vagina Graded- first, second and third degree Surgical repair Pessary

Cranial nerve VIII

acoustic nerve (Vestibulocochlear) Test hearing acuity by ability to hear normal conversation and by whispered voice test

Rheumatoid Arthritis

about 2.1 million people, or between 0.5 and 1 percent of the U.S. adult population, have rheumatoid arthritis. often begins in middle age Daily joint pain and most patients also experience some degree of depression, anxiety, and feelings of helplessness most debilitating of all forms, causing joints to ache and throb and eventually become deformed exact cause unknown, but believed to be the body's immune system attacking the tissue that lines your joints (synovium). two to three times more common in women no cure Rheumatoid arthritis autoimmune inflammatory disease that usually involves various joints in the fingers, thumbs, wrists, elbows, shoulders, knees, feet, and ankles enzymes destroy the linings of joints causes pain, swelling, stiffness, malformation, and reduced movement and function. may have systemic symptoms, such as fatigue, fever, weight loss, eye inflammation, anemia, subcutaneous nodules (bumps under the skin), or pleurisy (lung inflammation). Occurs in several joints at the same time Early in rheumatoid arthritis joints in wrists, hands, feet and knees most often affected As the disease progresses; shoulders, elbows, hips, jaw and neck can become involved affects both sides of the body at the same time rheumatoid nodules may form under the skin at pressure points and can occur at elbows, hands, feet and Achilles tendons; may also occur in the back of the scalp, over the knee or in the lungs nodules can range in size — from as small as a pea to as large as a walnut. Usually aren't painful. can cause inflammation of tear glands, salivary glands, pericardium and viscera, lungs, and in rare cases blood vessels. Symptoms vary in severity and may come and go. WBC move from the bloodstream into synovium causing inflammation inflammation results in the release of proteins that, over months or years, cause thickening of the synovium. proteins can also damage cartilage, bone, tendons and ligaments. Gradually, the joint loses its shape and alignment. Eventually, it may be destroyed. Factors that may increase risk: Age; incidence increases with age. However, incidence begins to decline in women over the age of 80. female Being exposed to an infection, possibly a virus or bacterium, that may trigger rheumatoid arthritis in those with an inherited susceptibility Inheritence of susceptability Smoking Signs and Symptoms Tender, warm, swollen joints Symmetrical pattern of affected joints Joint inflammation often affecting the wrist and finger joints closest to the hand Joint inflammation sometimes affecting other joints, including the neck, shoulders, elbows, hips, knees, ankles, and feet Fatigue, occasional fevers, a general sense of not feeling well Pain and stiffness lasting for more than 30 minutes in the morning or after a long rest Symptoms that last for many years Variability of symptoms among people with the disease Goals of Treatment Relieve pain Reduce inflammation Slow down or stop joint damage Improve a person's sense of well-being and ability to function Current Treatment Approaches Lifestyle Medications Surgery Routine monitoring and ongoing care

Leading-

are closed questions used in directive interviews Leading questions direct patient response "You are frightened aren't you?"

Abnormal Findings:

common Variations in Arterial Pulse: Weak, "thready" pulse, 1+ Full, bounding pulse, 3+ Peripheral Vascular Disease: Arms Raynaud phenomenon Lymphedema Legs Arterial-ischemic ulcer Venous (stasis) ulcer Refer to chart posted in Bb Superficial varicose veins Deep vein thrombophlebitis

Cranial nerve VII

facial nerve Motor function: Note mobility and facial symmetry as person responds to requests to smile, frown, close eyes tightly (against your attempt to open them), lift eyebrows, show teeth Have person puff cheeks, then press puffed cheeks in, to see that air escapes equally from both sides Sensory function: (not tested routinely) Test only when you suspect facial nerve injury When indicated, test sense of taste by applying cotton applicator covered with solution of sugar, salt, or lemon juice to tongue and ask person to identify taste

Lanugo

fine, downy hair present at birth for a few months then is replaced by vellus hair, terminal hair is present on the scalp

Edema

fluid in intercellular spaces; not normally present 1+ mild pitting, slight indentation, no perceptible swelling 2+ moderate pitting; indentation subsides rapidly 3+ deep pitting, indentation remains for short time, legs look swollen 4+ very deep pitting, indentation lasts a long time, leg very swollen

Cranial nerve XII

hypoglossal nerve Inspect tongue; no wasting or tremors should be present Note forward thrust in midline as person protrudes tongue Ask person to say "light, tight, dynamite," and note that lingual speech (sounds of letters l, t, d, n) is clear and distinct If problem, tongue will lean toward side of the lesion

Signs of colon cancer

if you have more diarrhea or constipation than usual if you see blood in your stool (the blood can be bright red or very dark to black in color) if you see blood on your toilet paper after you have a bowel movement if you always seem to feel full or bloated if you always seem to have cramps or an upset stomach if you have gas pains more often than usual if you are losing weight without dieting if you feel more tired than usual if you notice any other changes in the way you feel

Dermis

inner supportive layer containing connective tissue (collagen). Enables the skin to resist tearing. Can stretch. Nerves, sensory receptors, blood vessels and lymphatics lie in the dermis. Hair follicles, sebaceous glands and sweat glands embedded in the dermis

Neutral-

non-threatening that patient can answer without direction Used in non-directive interviews and is open ended

Cranial nerve II:

optic nerve Test visual acuity and visual fields by confrontation

Cranial nerve XI

spinal accessory nerve Examine sternomastoid and trapezius muscles for equal size Check equal strength by asking person to rotate head against resistance applied to side of chin Ask person to shrug shoulders against resistance These movements should feel equally strong on both sides

Teaching Breast Self- Exam (BSE)

Help each woman establish regular schedule of self-care The best time to conduct BSE is right after menstrual period, when breasts are smallest and least congested Advise pregnant or menopausal woman not having menstrual periods to select a familiar date to examine her breasts each month Stress that self-examination will familiarize woman with her own breasts and their normal variation; emphasize absence of lumps (not the presence of them) Encourage her to report any unusual finding promptly Focus on positive aspects of BSE Avoid citing frightening mortality statistics about breast cancer and generating excessive fear and denial that actually obstructs a woman's self-care action Majority of women will never get breast cancer Great majority of breast lumps are benign Early detection of breast cancer is important; if cancer is not invasive, survival rate close to 98% Keep teaching simple (more likely to comply) Describe correct technique and rationale and expected findings to note as woman inspects her own breasts Teach woman to do this in front of a mirror while she is disrobed to waist At home, she can start palpation in shower, where soap and water assist palpation Then palpation should be performed while lying supine Encourage woman to palpate her own breasts while you monitor her technique Highlights: Lie down 3 different levels of pressure Feel up to collarbone, out to armpit, in to middle of chest & down to bottle of rib cage Sit or stand to check under "relaxed" axilla

Objective Data: Palpation

Help woman to a supine position Tuck a small pad under side to be palpated and raise her arm over her head to flatten breast tissue and displace it medially; any significant lumps will then feel more distinct Use pads of your first three fingers and make a gentle rotary motion on breast; vary pressure palpating light, medium, and deep tissue in each location Vertical strip pattern currently recommended to detect a breast mass, but two other patterns are in common use: From the nipple palpating out to periphery as if following spokes on a wheel Palpating in concentric circles out to periphery In nulliparous women, normal breast tissue feels firm, smooth, and elastic After pregnancy, tissue feels softer and looser Premenstrual engorgement is normal from increasing progesterone Consists of slight enlargement, tenderness to palpation, and generalized nodularity; lobes feel prominent and their margins more distinct Normally you may feel a firm transverse ridge of compressed tissue in lower quadrants Inframammary ridge, and it is especially noticeable in large breasts; do not confuse it with an abnormal lump After palpating over four breast quadrants, palpate nipple; note any induration or subareolar mass With your thumb and forefinger, gently depress nipple tissue into well behind areola; tissue should move inward easily If you feel a lump or mass, note characteristics Location: as with clock face, describe distance in centimeters from nipple; or diagram breast in woman's record and mark in location of lump Size: judge in centimeters in three dimensions: width, length, and thickness Shape: state whether lump is oval, round, lobulated, or indistinct Consistency: state whether lump is soft, firm, or hard Movable: is lump freely movable or fixed when you try to slide it over chest wall? Distinctness: is lump solitary or multiple? Nipple: is it displaced or retracted? Note skin over lump: is it erythematous, dimpled, or retracted? Tenderness: is lump tender to palpation? Lymphadenopathy: are any regional lymph nodes palpable? Premenopausal women midcycle have tissue edema and mastalgia (pain) that make it hard to detect lesions If your findings are in question...consider asking woman to return for follow up examination first week after menses when hormone levels are lower and edema not present

Waist to Hip Ratio

Assesses body fat distribution as an indicator of health risk Greater proportion of body fat in upper body especially abd. Have android obesity, those with greater proportion in hips and thighs have gynoid obesity Waist to Hip ratio Waist measured in inches at smallest circumference below rib cage and above umbilicus Hip measured in inches at largest circumference of buttocks Waist to hip ratio= waist circumference / hip circumference 1.0 or > in men or 0.8 or > in women is indicative of android obesity and increased risk for obesity-related diseases and early mortality

Diagnostics Positions Test

Assesses muscles 6 cardinal gazes Examiner holds finger or penlight 12inches away Watch for misalignment, nystagmus, lid lag

Functional Ability: Assessment of Cognition

Assessment of cognitive status in older adults is an important part of the functional assessment Domains of cognition included in most mental status assessments Attention Memory Orientation Language Visuospatial skills Higher cognitive functions

Olecranon Bursitis

causes fluid to collect in a sac that lies behind the elbow, called the olecranon bursa When a bursa becomes inflamed, the sac fills with fluid causes pain and a noticeable swelling behind the elbow may follow trauma or may seemingly pop up out of nowhere. People who rest their elbows on hard surfaces may aggravate the condition Symptoms: Pain around the back of the elbow Swelling directly over the bony prominence of the tip of the elbow Slightly limited motion of the elbow Occasionally, the swelling and inflammation can be the result of an infection within the bursa, this is called infected elbow bursitis. Patients with systemic inflammatory conditions, such as gout and rheumatoid arthritis, are also at increased risk of developing infected elbow bursitis. Signs of infected elbow bursitis Fever Chills or sweats Significant redness around the back of the elbow Breaks in the skin (scrapes/cuts) around the swollen area Treatment Needle aspiration fluid can re-accumulate, and therefore an injection of cortisone is also often performed; Cortisone will suppress the inflammatory response to increase the chance of a lasting solution. rest Usually no special protection or bracing is needed avoiding strenuous activity, lifting, and pressure on the elbow will allow the inflammation to subside. immobilization may be helpful in some patients; a frozen (stiff) elbow joint can easily develop,immobilization beyond a few days should be avoided Anti-inflammatories gentle ROM should be encouraged.

Role of Healthcare Provider

Only 25-30% of battered women say they actually sought health care for one of their injuries 80% say they have been in the health care setting for some reason Many are not ready to seek help from shelters or legal assistance Healthcare providers provide support and play an extremely important role in identifying the early signs of abuse Mandated Reporting; Elderly, Mentally Challenged, Children

OLDCARTS- Bates

Onset Location Duration Characteristics Aggravating factors Relieving factors Timing Severity Prior

Testicular Torsion

Pain, sudden onset, red, swollen scrotum Occurs in late childhood and adolescence Faulty anchoring of testis on the wall of the scrotum allows testis to rotate Blood supply is cut off, ischemia and engorgement Emergency surgery

Fissure

Painful tear in superficial mucosa at the anal margin

Health promotion r/t alcohol

Part of routine assessment To promote a Healthy Lifestyle: Alcohol use can result in reduced personal safety as well as disease Alcohol can interact with most medications Alcohol can make some diseases worse

Cardiovascular History: Modifiable risk factors

Past Cardiac History Modifiable Risk Factors Smoking HTN Hyperlipidemia DM Sedentary lifestyle High stress lifestyle

Epicondylitis

"Tennis elbow" most common injury associated with elbow pain. cause unknown, but it is thought to be due to small tears of the tendons that attach the muscles of the forearm to the arm bone at the elbow joint. symptoms pain on the outside of the elbow that is worsened by grasping objects and cocking back the wrist. The most common symptoms of tennis elbow are: Pain over the outside of the elbow Pain when lifting objects Pain radiating down the forearm usually has a gradual onset, but may also come on suddenly. Most patients with tennis elbow are between the ages of 35-65 years old, and it affects about an equal number of men and women. Tennis elbow occurs in the dominant arm in about 75% of patients. Anyone can be affected, but tennis elbow is most commonly seen in Manual Laborers and athletes tennis elbow is not simply an "inflammation" of the tendons around the joint. problem is thought to be more of a degenerative process either the result of aging, or repetitive use. symptoms may be the result of an incomplete healing response in an area that does not have good blood flow, and therefore difficulty accessing nutrition and oxygen necessary for healing. This leads to degeneration of the tendon causing small tears. Treatment Nonoperative treatment is successful in over 90% of patients. Lifestyle Modification important if tennis elbow does not resolve or if it recurs. With athletes, often an improvement in technique can resolve the problem. Changing Stroke Mechanics & Racquet Tennis racquets should be sized properly, including grip size. Higher stringing tensions may contribute to tennis elbow. Playing on harder surfaces also increases the risk of developing tennis elbow. Stroke mechanics should be evaluated to ensure patients are hitting the ball in the center of the racquet and players should not lead the racquet with a flexed elbow. Anti inflammatories Cortisone injections elbow orthosis, called an elbow clasp, can be worn. The theory behind using this elbow clasp is that the brace will redirect the pull of malaligned muscles. Patients often find relief of pain when using the clasp during activities. Simple exercises; by strengthening the muscles and tendons involved with tennis elbow, you can help prevent the problem from returning. Surgery is usually successful, but rarely needed; about 95% of patients with tennis elbow can be treated without surgery

Osteoporosis

"porous bones," causes bones to become weak and brittle — low levels of calcium, phosphorus and other minerals in your bones Osteoporosis can also accompany endocrine disorders or result from excessive use of drugs such as corticosteroids fractures — spine, hip or wrist more common in females; menopause= estrogen levels drop, bone loss in women increases dramatically. The leading cause in women is decreased estrogen production during menopause early stages of bone loss, usually no pain or symptoms. once bones have been weakened by osteoporosis, may have signs and symptoms that include: Back pain Loss of height over time, with an accompanying stooped posture Fracture of the vertebrae, wrists, hips or other bones Risks depends on how much bone mass you attained between ages 25 and 35 (peak bone mass) and how rapidly you lose it later. higher your peak bone mass, the more bone you have "in the bank" and the less likely you are to develop osteoporosis as you age Not getting enough vitamin D and calcium in the diet may lead to a lower peak bone mass and accelerated bone loss later. Gender Fractures are about twice as common in women as they are in men because women start out with lower bone mass and tend to live longer. They also experience a sudden drop in estrogen at menopause that accelerates bone loss. Slender, small-framed women are particularly at risk. Men who have low levels of testosterone also are at increased risk. From age 75 on, osteoporosis is as common in men as it is in women. Age. The older you get, the higher your risk of osteoporosis. Your bones become weaker as you age. Race. You're at greatest risk of osteoporosis if you're white or of Southeast Asian descent. Black and Hispanic men and women have a lower but still significant risk. Family history. puts you at greater risk, especially if you also have a family history of fractures. Frame size. Men and women who are exceptionally thin or have small body frames tend to have higher risk because they may have less bone mass to draw from as they age. Other medications. Long-term use of the blood-thinning medication heparin, the drug methotrexate, some anti-seizure medications and aluminum-containing antacids also can cause bone loss. Breast cancer. Postmenopausal women who have had breast cancer are at increased risk of osteoporosis, especially if they were treated with chemotherapy or aromatase inhibitors which suppress estrogen. This isn't true for women treated with tamoxifen, which may reduce the risk of fractures. Low calcium intake. A lifelong lack of calcium plays a major role in the development of osteoporosis. What keeps bones healthy Regular exercise Adequate amounts of calcium Adequate amounts of vitamin D, which is essential for absorbing calcium Tobacco use. tobacco use contributes to weak bones. Lifetime exposure to estrogen. The greater a woman's lifetime exposure to estrogen, the lower her risk of osteoporosis. For example, you have a lower risk if you have a late menopause or you began menstruating at an earlier than average age. But if you have a history of abnormal menstrual periods, experience menopause earlier than your late 40s or have your ovaries surgically removed before age 45 without receiving hormone therapy, your risk is increased. Eating disorders. Women and men with anorexia nervosa or bulimia are at higher risk of lower bone density in their lower backs and hips. Corticosteroid medications. Long-term use of corticosteroid medications is damaging to bone. Thyroid hormone. Too much thyroid hormone also can cause bone loss Some diuretics.diuretics cause the kidneys to excrete more calcium, leading to thinning bones. Medical conditions and procedures that decrease calcium absorption. Stomach surgery (gastrectomy) can affect your body's ability to absorb calcium. So can conditions such as Crohn's disease, hyperparathyroidism, anorexia nervosa and Cushing's disease Sedentary lifestyle. Any weight-bearing exercise is beneficial. You can increase your bone density at any age. Excess soda consumption. The link between osteoporosis and caffeinated sodas isn't clear, but caffeine may interfere with calcium absorption and its diuretic effect may increase mineral loss. In addition, the phosphoric acid in soda may contribute to bone loss by changing the acid balance in the blood. Chronic alcoholism. For men, alcoholism is one of the leading risk factors for osteoporosis. Excess consumption of alcohol reduces bone formation and interferes with the body's ability to absorb calcium. Depression. People who experience serious depression have increased rates of bone loss.

Biographic Data

(Name, address, phone number)- may not be used due to HIPAA, age & birth place, marital status, race, ethnic origin & occupation The Joint Commission: note primary language (communication needs); promote health literacy

Abnormalities in the Ear Canal

**Advanced practice Excessive cerumen Otitis externa- lumen narrowed due to swelling Foreign body- children, trpped insect, cotton Furuncle- painful heir follicle on tragus or on ear cartilage

Pallor (skin, fingernails, lips, oral mucosa)

Caused by lack of oxyhemoglobin due to anemia or arterial perfusion

Organs in right lower quadrant

Cecum Appendix Right ovary and fallopian tube right ureter and lower kidney pole Right spermatic cord

Nutritional History

Age dependent- younger= more details Breast: frequency & duration; supplements; method of weaning Bottle: type of formula; frequency & amounts; problems; supplements Introduction of solids: home or commercial-made; amounts; reactions Pre-school, school-age & adolescents: appetite; 24-hour recall; junk food; likes/dislikes

Ano-Rectal Fistula

Chronic inflamed GI tract creates an abnormal passage from the inner anus to the skin surface Red, raised tract may drain serous sanguineous or purulent matter

CV history: Non-modifiable Risk Factors

Age Gender Family History Other Heart murmur Congenital Heart Disease Rheumatic Fever Other admissions for heart disease Post menopausal-HRT Illicit drug use Abnormal EKG/Stress Test/Cardiac Catheterization

Physical Appearance

Age: person appears his or her stated age Sex: sexual development appropriate for gender and age Level of consciousness: person alert and oriented, attends to your questions and responds appropriately Skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesions Facial features: symmetric with movement No signs of acute distress present

Developmental Competence: Aging Adult

Aging adult Dorsalis pedis and posterior tibial pulse may become more difficult to find Trophic changes associated with arterial insufficiency; thin, shiny skin; thick-ridged nails; and loss of hair on lower legs also occur normally with aging

Development Aging Adult

Aging adult Peripheral blood vessels grow more rigid with age, resulting in a condition called arteriosclerosis Produces rise in systolic blood pressure Do not confuse this process with another one, atherosclerosis, or deposition of fatty plaques on intima of arteries Aging produces a progressive enlargement of the intramuscular calf veins Prolonged bed rest, prolonged sitting, and heart failure increase risk of deep venous thrombosis and subsequent pulmonary embolism

Solid Viscera

All abdominal organs are referred to as viscera Solid viscera maintain characteristic shape Liver Pancreas Spleen Adrenal Glands Kidneys Ovaries and uterus

Abnormalities of the Tongue

Ankyloglossia Fissured or scrotal tongue Geographic tongue (migratory glossitis) Smooth, glossy tongue (atrophic glossitis) Black hairy tongue Enlarged tongue (macroglossia) Carcinoma

Open-ended Questions

Associated with non-directive interview Invite patients to discover, explore, elaborate, clarify or illustrate a thought or feeling Begin with "What" or "How"

Breast Development: Adolescent

At puberty estrogen stimulates breast changes Breasts enlarge, mostly as a result of extensive fat de-position; duct system also grows and branches, and masses of small, solid cells develop at duct endings; these are potential alveoli A 1997 study of 17,077 girls in the United States aged 3 through 12 years indicates puberty is occurring earlier Onset of breast development occurred at an average (mean) age between 8 and 9 years for black girls and by 10 years for white girls; earlier studies cited breast development beginning at an average age of 10 to 11 Occasionally, one breast may grow faster than other, producing a temporary asymmetry May cause some distress; reassurance is necessary Tenderness common also; age of onset varies widely, the five stages of breast development follow this classic description of sexual maturity rating, or Tanner staging Full development from stage 2 to stage 5 takes an average of 3 years During this time, pubic hair develops, and axillary hair appears 2 years after onset of pubic hair Beginning of breast development precedes menarche by about 2 years Menarche occurs in breast development stage 3 or 4, usually just after peak of adolescent growth spurt around age 12 Breasts of nonpregnant woman change with ebb and flow of hormones during monthly menstrual cycle Nodularity increases from midcycle up to menstruation During the 3 to 4 days before menstruation, breasts feel full, tight, heavy, and occasionally sore; breast volume is smallest on days 4 to 7 of menstrual cycle

Developmental COnsiderations: Aging Adults

Atrophy with steady loss of neuron structure in brain and spinal cord People over 65 show signs that, in younger adult, would be considered abnormal such as general loss of muscle bulk, loss of muscle tone in face, neck, and around spine, decreased muscle strength, impaired fine coordination and agility, loss of vibratory sense at ankle, decreased or absent Achilles reflex, pupillary miosis, irregular pupil shape, and decreased pupillary reflexes Causes loss of weight and volume with thinning of cerebral cortex, reduced subcortical brain structures, and expansion of the ventriclesAtrophy with steady loss of neurons in brain and spinal cord (cont.) Velocity of nerve conduction decreases making reaction time slower in some older persons Increased delay at synapse results in diminished sensation of touch, pain, taste, and smell Motor system may show general slowing down of movement; muscle strength and agility decrease Progressive decrease in cerebral blood flow and oxygen consumption may cause dizziness and loss of balance

Developmental Milestones

B-2wks; refusal to open eyes after exposure to bright light, may fixate on object 2-4wks; fixate 1mo; fixate and track to midline By 3-4mos; fixate, follow and reach By 6-10mos; fixate and follow in all directions NEED TO KNOW-check info in book* 20/40 age 3 20/30 age Age 5-6 20/20 Pocket snellen for over 40yo or difficulty reading Presbyopia; decrease in power of accommodation with aging Older adult Eyebrows; loss of outer 1/3-1/2, coarse Atrophy of tissue around eyes and lids Decrease in tear production Cornea may look cloudy

Objective Data: Pregnancy

Breasts increase in size, as do nipples Delicate blue vascular pattern is visible over the breasts Jagged linear stretch marks, or striae, may develop if breasts have large increase Nipples become darker and more erectile Areolae widen; grow darker; and contain small, scattered, elevated Montgomery's glands On palpation, breasts feel more nodular, and thick yellow colostrum can be expressed after first trimester

Child: thorax

By age 6 thorax reached adult ratio of 1:2 anteroposterior to transverse diameter Barrel shape after age 6 could indicate asthma or CF

While examining a patient, you observe abdominal pulsations between the xiphoid and umbilicus. You would say that this is: a. Pulsations of the renal arteries b. Pulsations of the inferior vena cava c. Normal abdominal aortic pulsations d. Increased peristalsis due to a bowel obstruction

C

Objective Data: Cerebellar function

Cerebellar function Balance Tests Gait: smooth, rhythmic, and effortless; opposing arm swing is coordinated; person turns smooth Ask person to walk straight line in heel-to-toe fashion; this decreases base of support and accentuates any problem with coordination; normally person can walk straight and stay balanced You may also test for balance by asking person to walk on toes, then on heels for a few steps observe as person walks 10 to 20 feet, turns, and returns to starting point; normally person moves with a sense of freedom; gait is step length about 15 inches from heel to heel Romberg test: Ask person to stand up with feet together and arms at sides; when in stable position, ask person to close eyes and to hold position for about 20 seconds Normally, person can maintain posture and balance even with visual orienting information blocked Ask person to perform shallow knee bend or hop in place, first on one leg, then other Demonstrates normal position sense, muscle strength, and cerebellar function Some individuals cannot hop because of aging or obesity

Past Health

Childhood illnesses: measles, mumps, chickenpox, pertussis, strep throat; What consequences do these have now? Accidents or injuries: auto, fractures, penetrating, head injuries, burns Serious or chronic illnesses: asthma, depression, diabetes, many more... Hospitalizations: Cause, name, treatment, physician Operations: type, date, surgeon, hospital, recovery Obstetric history: Number (gravidity), deliveries full-term (term), preterm pregnancies (preterm), incomplete (abortions), children living (living) Course of pregnancy, labor & delivery; gender, weight, condition of infant; post-partum Spontaneous (S) or induced (I) abortion i.e.- Grav 3, Term 2, Preterm 1, Ab 0, Living 3 Immunizations: measles-mumps-rubella (MMR), polio, diphtheria-pertussis-tetanus (DPT), hep A and B, meningococcal, human papilloma virus (HPV), Haemophilus influenzae type b (HIB), pneumococcal, influenza Last examination date- physical, dental, vision, hearing, EKG, CXR, mammogram, pap, stool occult blood, cholesterol Allergies- allergen & reaction (true med reaction?) Current medications- prescription and OTC Vitamins, birth control, aspirin, antacids Herbal or home therapies Substance use (can ask in social history

Abnormalities of the Nose

Choanal atresia Epistaxis Foreign body Perforated septum Furuncle Acute rhinitis Allergic rhinitis Sinusitis Nasal polyps Carcinoma

Pregnant Female Considerations

Circulating hormones increase mobility in joints May contribute to change in posture to progressive lordosis Lordosis compensates for the growing fetus Creates strain on lower back muscles Shift in posture creates anterior flexion of the neck and slumping of the shoulder putting pressure on the ulnar and median nerves May cause weakness and numbness in the upper extremities

Objective Data-substance abuse

Clinical laboratory findings give objective evidence of problem drinking. These are less sensitive and specific than self-report questionnaires Useful data to corroborate subjective data Serum protein, gamma glutamyl transferase (GGT) is most commonly used biochemical marker of alcohol drinking (Chronic alcohol drinking of >4 drinks/day for 4-8wks significantly raises the GGT) Occasional alcohol drinking will not raise this measure, but chronic heavy drinking will Be aware that nonalcoholic liver disease also can increase GGT levels in the absence of alcohol Clinical laboratory findings give objective evidence of problem drinking cont'd From complete blood count, the mean corpuscular volume (MCV) is an index of red blood cell size MCV is not sensitive enough to use as only biomarker Can detect earlier drinking after long period of abstinence Breath alcohol analysis detects any amount of alcohol in end of exhaled air following a deep inhalation until all ingested alcohol is metabolized This measure can be correlated with blood alcohol concentration (BAC) and is basis for legal interpretation of drinking

Assessing elders with altered cognition

Cognitive impairment may severely restrict ability expression Gathering information from elder firsthand always best but not always feasible To ensure collection of reliable information one strategy is to interview caregiver or family Never assume that he or she cannot respond to questions even with cognitive impairment Using yes or no questions may prevent frustration If a family member or caregiver does need to provide collateral information, avoid doing this in front of client

Pleural Effusion

Collection of fluid in the intrapleural space (b/t visceral and parietal pleurae) with compression of overlying lung tissue Fluid may be blood, purulent matter, exudate, or lymphatic fluid Breath sounds and voice sounds decreased or absent Symptoms; chest pain, dyspnea. Many cause no symptoms but are discovered during the physical examination or seen on a chest x-ray. Causes; heart failure, renal failure hypoalbuminemia infections (TB, bacterial, fungal, viral), pulmonary embolism, and malignancies, 20% cause unknown

Colorectal Cancer

Colorectal cancer is the second leading cancer killer in the United States. Health promotion should include informing adults aged 50 years and older to have regular colorectal screening tests. Early detection of colorectal cancer helps to identify precancerous polyps so that they can be removed before they become cancerous; also, screening helps to find colorectal cancer early, when treatment is most effective

Objective Data: Lactation

Colostrum changes to milk production around the 3rd postpartum day Breasts may become engorged, appearing enlarged, reddened, and shiny and feeling warm and hard Frequent nursing helps drain ducts and sinuses and stimulate milk production Nipple soreness normal, appearing around 20th nursing, lasting 24 to 48 hours, then disappearing Nipples may look red and irritated; may even crack but will heal rapidly if kept dry and exposed to air; frequent nursings best treatment for nipple soreness

Ambiguous Genitalia

Congenital anomaly resulting from hyperplasia of the adrenal glands which exposes the fetus to excess amounts of androgen Diagnostic and genetic evaluations necessary

Vascular disorders of the external eye

Conjunctivitis Subconjunctival hemorrhage Iritis (circumcorneal redness) Acute glaucoma

Things to Remember

Consider inguinal/rectal examination in males. Consider pelvic/rectal examination in females. Disorders in the chest will often manifest with abdominal symptoms. It is always wise to examine the chest when evaluating an abdominal complaint.

Over nutrition

Consumption of nutrients in excess of needs Leads to obesity and diseases Overweight as child increases risk for overweight as an adult

Objective Data: Coordintion adn skilled movements

Coordination and skilled movements Rapid Alternating Movements (RAM) Ask person to pat knees with both hands, lift up, turn hands over, and pat knees with backs of hands; then ask person to do this faster Normally done with equal turning and quick rhythmic pace Alternatively, ask person to touch thumb to each finger on same hand, starting with the index finger, then reverse direction Normally done quickly and accurately Finger-to-finger test: with eyes open, ask person to use index finger to touch your finger, then their own nose; then move your finger to continue test Person's movement should be smooth and accurate Finger-to-nose test: ask person to close eyes and stretch out arms and touch tip of their nose with each index finger, alternating hands and increasing speed Normally this is done with accurate and smooth movement Heel-to-shin test: ask person in supine position to place heel on opposite knee and run it down shin to ankle Normally, person moves heel in straight line down shin

Which is an expected finding in darkly pigmented people? A.Circumoral pallor B.Dappled brown patches on the buccal mucosa C.Bluish lips D.A chalky white raised patch on the mucosa of the tongue

Correct Answer: C. Black persons normally may have bluish lips. Circumoral pallor occurs with shock and anemia in light-skinned people. Dappled brown patches and a chalky white raised patch are abnormal findings. Note to faculty: This is a discussion question. Ask students how mouth examination findings vary among darkly pigmented people.

Which of the following is likely to elicit the most information? A How often do you brush your teeth? B Has your sense of taste changed? C Tell me about your daily dental care. D Do you have any problems with your dentures?

Correct Answer: C. This open-ended question invites the patient to tell the examiner about any and all aspects of self-care—and dental problems. The patient's response will likely prompt follow-up questions from the examiner. Although the three close-ended questions will probably receive short answers, they too may elicit a descriptive answer, depending on the patient.

Which of the following would not contribute to the development of otitis media? aPrematurity bPositioning during bottle feeding cEthnicity dTinnitus

Correct Answer: D. Otitis media is one of the most common illnesses of childhood. Native Americans, Alaskan and Canadian Inuits, and Hispanics have a higher incidence of this infection, as do premature infants and those with Down syndrome. Babies who are bottle fed while in the supine position develop otitis media because the forces of gravity and sucking draw nasopharyngeal contents into the middle ear. Teach parents to hold babies partially upright during feedings.

Cranial Nerve I

Cranial nerve I: olfactory nerve With person's eyes closed, occlude one nostril and present familiar aromatic substance Normally, person can identify an odor on each side of nose; normally decreased with aging; any asymmetry in sense of smell is important (not tested routinely) Test sense of smell in those who report loss of smell, head trauma, and abnormal mental status, and when presence of intracranial lesion suspected

Additional Documentation

Cullen's Sign- bluish discoloration around the umbilicus. Often seen in cases of acute pancreatitis Grey Turner's Sign- bluish discoloration of left flank area. Often seen in cases of acute pancreatitis

Special Considerations

Cultural considerations Culture influences all parts of person's life He or she may want to try traditional/alternative practices to prevent or treat certain conditions Learn how person's culture fits together with suggested interventions Culture also influences whether older adult relies on: Family or friends for care and decision making Disclosure of medical information and diagnosis Nutrition preferences End-of-life care, i.e., advance directives and resuscitation preferences

Nutritional Cultural Considerations

Customs, occupation, class, religion, gender, health awareness Newly arrived immigrants at risk Poverty, poor sanitation, war, political strife, General under nutrition, HTN, diarrhea, lactose intolerance, osteomalacia (soft bones), scurvy (vit C def), dental caries Unfamiliar food, storage and preparation Familiar foods difficult to obtain Low income limits access to familiar foods Nutritional consequences i.e.; Japanese immigrants increased risk of colon and breast cancer r/t high fat diet Avoid stereotyping Respect traditions (see table 11-1, p 178 text for examples) Lab variations based on culture, example; Blacks have normal Hgb of 1g lower than other groups; take into account when screening for anemia Cholesterol; blacks and whites similar at birth, Blacks higher during childhood, Whites higher in adulthood

Cycle of Violence

Cycle of Violence; three stages: 1. tension building stage; tension in the relationship gradually increases over time 2. acute battering stage; tension erupts, resulting in threats or use of violence and abuse 3. honeymoon stage; batterer may be apologetic and remorseful and promise not to be abusive again The cycle continues throughout the relationship, with the honeymoon stage becoming shorter and the episodes of battering becoming more frequent or more severe. The honeymoon stage reinforces the victim's hope that the batterer will change and contributes to the victim staying in the relationship.

Endometriosis

Cyclic or chronic pain Dysmenorrhea, dyspareunia, low back ache, irregular uterine bleeding Uterus tender to the touch, small firm nodular masses tender to palpation, ovaries enlarged May cause infertility, pelvic adhesions

You are suspicious that your patient has a distended bladder. How would you assess for this condition? a. Percuss and palpate in the lumbar region b. Inspect and palpate in the epigastric region c. Auscultate and percuss in the inguinal region d. Percuss and palpate in the hypogastric region

D

To detect diastis recti, you should have the patient a. Relax in the supine position b. Raise arms in the left lateral position c. Raise arms over the head while supine d. Raise the head and shoulders while remaining supine

D (separation of the abdominal rectus muscle)

Test the Reflexes

Deep tendon reflexes (DTRs) Measurement of stretch reflexes reveals intactness of reflex arc at specific spinal levels and normal override on reflex of higher cortical levels Limb should be relaxed and muscle partially stretched Stimulate reflex by directing short, snappy blow of reflex hammer onto muscle's insertion tendon Compare right and left sides: responses should be equal Deep tendon reflexes (DTRs) (cont.) Reflex response graded on 4-point scale 4 = very brisk, hyperactive with clonus, indicative of disease 3 = brisker than average, may indicate disease 2 = Average, normal 1 = diminished, low normal, or occurs with reinforcement 0 = no response Subjective scale requires clinical practice; scale not completely reliable; a wide range of normal exists in reflex responses Biceps reflex, C5 to C6 Support the person's forearm on yours; place your thumb on biceps tendon and strike a blow on your thumb Normal response is contraction of biceps muscle and flexion of forearm Triceps reflex, C7 to C8 Tell person to let arm "just go dead" as you strike triceps tendon directly just above the elbow Normal response is extension of forearm Brachioradialis reflex, C5 to C6 Hold person's thumbs to suspend forearms in relaxation and strike forearm directly, about 2 to 3 cm above radial styloid process Normal response is flexion and supination of forearm Quadriceps reflex, L2 to L4 ("knee jerk") Let lower legs dangle freely to flex knee and stretch tendons; strike tendon directly just below patella Normal response is extension of lower leg Achilles reflex, L5 to S2 ("ankle jerk") Position person with knee flexed; hold foot in dorsiflexion and strike Achilles tendon directly Normal response is foot plantar flexes against your hand Clonus: test when reflexes hyperactive Support lower leg in one hand and with other hand, move foot up and down to relax muscle; then stretch muscle by briskly dorsiflexing foot; hold the stretch Normal response: you feel no further movement When clonus present, you will note rapid rhythmic contractions of calf muscle and movement of foot Superficial (cutaneous) reflexes Sensory receptors in skin rather than in muscles; motor response is localized muscle contraction Abdominal reflexes: upper: T8 to T10; lower: T10 to T12 Person in supine position, knees slightly bent; use handle end of reflex hammer to stroke skin Move from each corner toward midline at both upper and lower abdominal levels Normal response is ipsilateral contraction of abdominal muscle with observed deviation of umbilicus toward stroke Cremasteric reflex, L1 to L2 (not routinely done) On male, lightly stroke inner aspect of thigh with reflex hammer or tongue blade Note elevation of ipsilateral testicle Plantar reflex, L4 to S2 Position thigh with slight external rotation With reflex hammer, draw a light stroke up lateral side of sole of foot and inward across ball of foot, like an upside-down "J" Normal response is plantar flexion of toes and inversion and flexion of forefoot

Osteoarthritis

Degenerative joint disease (DJD), OA, Osteoarthrosis most common form of arthritis causes pain, swelling and reduced motion in joints; Asymmetric can occur in any joint, but usually it affects hands, knees, hips or spine. breaks down cartilage in joints. Loss of cartilage causes bones to rub together Osteoarthritis (OA) painful, degenerative joint disease often involves the hips, knees, neck, lower back, or the small joints of the hands. usually develops in joints that are injured by repeated overuse from performing a particular task or playing a favorite sport, or from carrying around excess body weight. repeated impact thins or wears away the cartilage that cushions the ends of the bones in the joint the bones rub together, causing a grating sensation joint flexibility reduced, bony spurs develop, and the joint swells usually, the first symptom of OA is pain that worsens following exercise or immobility. treatment includes analgesics, topical creams, or NSAIDs; appropriate exercises or physical therapy; joint splinting; or joint replacement surgery for seriously damaged larger joints, such as the knee or hip. Risk factors obesity age Injury to a joint Therapies that manage osteoarthritis pain and improve function include exercise, weight control, rest, pain relief, alternative therapies and surgery. Hands: hereditary Women are more likely than men to have hand involvement and, for most, it develops after menopause. When osteoarthritis involves the hands, small, bony knobs may appear on the end joints (those closest to the nails) of the fingers. They are called Heberden's (HEBerr-denz) nodes. Similar knobs, called Bouchard's (boo-SHARDZ) nodes, can appear on the middle joints of the fingers. Fingers can become enlarged and gnarled, and they may ache or be stiff and numb. The base of the thumb joint also is commonly affected by osteoarthritis. Knees: The knees are among the joints most commonly affected by osteoarthritis. Symptoms of knee osteoarthritis include stiffness, swelling, and pain, which make it hard to walk, climb, and get in and out of chairs and bathtubs. Osteoarthritis in the knees can lead to disability. Hips: The hips are also common sites of osteoarthritis. As with knee osteoarthritis, symptoms of hip osteoarthritis include pain and stiffness of the joint itself. But sometimes pain is felt in the groin, inner thigh, buttocks, or even the knees. Osteoarthritis of the hip may limit moving and bending, making daily activities such as dressing and putting on shoes a challenge. Spine: Osteoarthritis of the spine may show up as stiffness and pain in the neck or lower back. In some cases, arthritis-related changes in the spine can cause pressure on the nerves where they exit the spinal column, resulting in weakness or numbness of the arms and legs. Signs and Symptoms Gradual onset Early, joints ache after exercise Then aches first thing in the morning and after being in one position for awhile The Warning Signs of Osteoarthritis stiffness in a joint after getting out of bed or sitting for a long time swelling in one or more joints a crunching feeling or the sound of bone rubbing on bone About a third of people whose x rays show evidence of osteoarthritis report pain or other symptoms. For those who experience steady or intermittent pain, it is typically aggravated by activity and relieved by rest. Four Goals of Osteoarthritis Treatment to control pain to improve joint function to maintain normal body weight to achieve a healthy lifestyle Treatment Approaches to Osteoarthritis exercise weight control rest and relief from stress on joints Alternative or complementary therapy pain relief techniques medications to control pain surgery Treatment Approaches to Osteoarthritis exercise weight control rest and relief from stress on joints Alternative or complementary therapy pain relief techniques medications to control pain surgery

When should MMSE be performed?

Dementia is present in about 1% people at age 60 Prevalence doubles every 5 years By age 85, prevalence of dementia is about 30-50% A reasonable time to begin is age 70, unless suspicions are high in the younger patient

Hair Growth in the Elderly

Diminishes with age After menopause Caucasian women may develop bristly hairs on the chin or upper lip Men develop coarse hair growth in ears, nose, eyebrows...beards do not change Male pattern balding is genetic Hair turns gray in both sexes (melanocytes)

Abnormal Findings: Retraction and Inflammation

Dimpling Nipple retraction Fixation Edema (peau d'orange) Deviation in nipple pointing

Abnormal Findings Adventitious Lung Sounds

Discontinuous sounds Crackles—fine Crackles—course Atelectatic crackles Pleural friction rub Continuous sounds Wheeze—sibilant Wheeze—sonorous rhonchi Stridor

Ear: Structure and function

External ear Auricle or pinna External auditory canal Tympanic membrane Middle ear Malleus, incus, and stapes Eustachian tube Functions; conducts sound, protects inner ear, equalizes pressure Inner ear Vestibule and semicircular canals Cochlea; central hearing apparatus Sensory organ for hearing and maintaining equilibrium, Has 3 parts. External ear serves to funnel sound waves into the opening called the external auditory canal. Canal is 2.5 to 3 cm long and ends at the ear drum or tympanic membrane. Canal lined with glands that secrete cerumen that lubricates and protects the ear. Cerumen migrates out by the movements of chewing and talking Tympanic membrane separates the external and middle ear. Normal color is pearly gray and reflects a cone of light when the otoscope is shined into the canal. Middle ear- contains tiny bones. Eustachian tube connects the middle ear with the nasal pharynx and allows for the passage of air. The E tube is normally closed but opens with swallowing or yawning. Middle ear has 3 functions: conducts sound, protects ear by decreasing the amplitude of loud sounds and E tube allows for equalization of pressure so that the tympanic membrane doesn't rupture during altitude changes such as airplane rides. Inner ear- holds the sensory organs for equilibrium and hearing—the central hearing apparatus

Phimosis

Foreskin is advanced or tight and is impossible to retract over the glans Congenital or acquired from adhesions secondary to infection Poor hygiene leads to retained dirt and smegma which increases the risk of inflammation

Abnormalities of the External Ear

Frostbite- blisters, pain, tenderness and necrosis Otitis externa ("swimmer's ear")- painful movement of the tragus and pinna, discharge, redness, alcohol eardrops can help dry the canal Brachial remnant and ear deformity- skin tags and associated with renal problems Cerebrospinal fluid otorrhea- with skull fracture and tests positive for glucose

What is functional ability?

Functional ability refers to one's ability to perform activities necessary to live in modern society Includes driving, using telephone, and performing personal tasks such as bathing and toileting Also incorporates older adult's physiologic and psychological status and physical and social environment Functional status: individual's actual performance of activities and tasks associated with his or her current life roles and dependent on motivation, vision and hearing, degree of assistance needed to accomplish tasks, and cognition Functional status is not static; older adults may move continuously through varying stages of independence and disability Lack of social support or safe physical setting are environmental issues affecting functional status and ability to live independently Interaction of these components provides a snapshot of an older adult's functional status at a given point in time Assessment of function is important with the geriatric population to provide a baseline For continuing comparison Predict prognosis Determine efficacy of treatments Basis for care planning, goal setting, and discharge planning Needed for eligibility to obtain services such as durable medical equipment, home modifications, and inpatient or outpatient rehabilitation services For older adult and family, a functional assessment can identify areas for current and future planning

Sinus Node (SA node)

Functions as the normal pacemaker of the heart

Instrumental activities of daily living (IADLs)

Goal of measuring functional abilities necessary for independent community living IADLs include shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, and using transportation These instruments may have cultural and gender biases, especially in older cohorts IADL instruments measure tasks historically done by women, and most do not address activities done primarily by men, such as home repairs and working in yard

Objective Data: Infants & Children

In neonate, breasts may be enlarged and visible due to maternal estrogen crossing placenta May secrete a clear or white fluid, called "witch's milk" This is not significant and are resolved within a few days to a few weeks Note position of nipples on prepubertal child Should be symmetric, just lateral to midclavicular line, between fourth and fifth ribs Nipple is flat, and areola is darker pigmented

Development: Children

Includes mother's health during pregnancy, labor & delivery, perinatal Lists developmental history and nutritional status as separate- important! Biographic data: name, nickname, demographics, age & birthdate, birthplace, race, other children at home Source of history: Provider of info and relationship; reliability; special circumstances Reasons for seeking care: spontaneous statement; well-visit vs. "hidden agenda" Present health/HPI: Usual health; health concerns; Describe presenting symptoms (8 critical characteristics or PQRTU) Parent's intuition Coping

Urinary Urea Nitrogen

Index of protein status Interpret through formula nitrogen = nitrogen intake - nitrogen excretion

Developmental Considerations

Infancy- undescended testes Adolescents- Puberty begins between 9 to 13 years of age, development completed on average 3 years Aging Adult- sperm begins to decrease at age 40, although continues until 80's to 90's; testosterone production declines after age 55 to 60 years of age

Developmental Considerations

Infants Meconium passed 24-48 hrs. The nerves of the rectal area become myelinated at between 1½ and 2 years Voluntary control of sphincter control at 18 mos. to 2 yrs. , potty training can begin Puberty Prostate gland undergoes rapid increase in size and remains constant Middle Adult Starts to enlarge BPH 1:10 males Urine flow: frequency, urgency, hesitancy of flow, weak stream, nocturia PSA starting age 50

Developmental Considerations: Infants

Infants Neurologic system not completely developed at birth Movement directed primarily by primitive reflexes Sensory and motor development proceed with gradual acquisition of myelin needed to conduct most impulses As myelinization develops, infant able to localize stimulus more precisely and make more accurate motor response Persistence of primitive reflexes is an indication of CNS dysfunction

Developmental COnsiderations: Infants

Infants Note if milestones normally expected for each month achieved, and more primitive reflexes eliminated from baby's repertory when expected Observations of infant's spontaneous waking activity, responses to environmental stimuli, and social interaction with parents and others By 2 months, baby smiles and recognizes parent's face Babbling occurs at 4 months, and one or two words (mama, dada) used nonspecifically after 9 months Reflexes Infantile automatisms: reflexes that have predictable timetable of appearance and departure For screening examination, just check rooting, grasp, tonic neck, and Moro reflexes Reflexes (cont.) Palmar grasp: place baby's head midline to ensure symmetric response; offer finger from baby's ulnar side, away from thumb; note tight grasp of all baby's fingers Present at birth; strongest at 1 to 2 months; disappears at 3 to 4 months Plantar grasp: touch your thumb at ball of baby's foot; note that toes curl down tightly Reflex present at birth; disappears at 8 to 10 months Tonic neck reflex: with baby supine, turn head to one side with chin over shoulder; note ipsilateral extension of arm and leg, and flexion of opposite arm and leg; the "fencing" position; turning head to opposite side, positions will reverse Appears by 2 to 3 months; decreases at 3 to 4 months; disappears by 4 to 6 months Moro reflex: startle infant by jarring crib, making a loud noise, or supporting head and back in semi-sitting position and quickly lowering infant to 30 degrees Baby looks as if he or she is hugging a tree; symmetric abduction and extension of arms and legs, fanning fingers, and curling of index finger and thumb to C position; infant then brings in both arms and legs Present at birth; disappears at 1 to 4 months

Developmental Considerations

Infants and children Inner ear develops 4th wk of gestation Infant and child's external canal is shorter and slopes opposite of adult Eustachian tube is shorter, wider and more horizontal than adult Lumen surrounded by lymphoid tissue; easily occluded Increased risk of ear infections Infants and children hearing acuity Newborn- startle 3-4 mos- acoustic blink reflex, stops movement ie. Stops sucking to hear sound, quiets if crying, cries if quiet 6-8 mos- infant turns to localize sound, responds to name Preschool-school age; screened with audiometry at school and primary care Adult Conductive hearing loss common (otosclerosis) age 20-40 r/t gradual hardening of stapes impeding transmission of sound Causes progressive deafness caused by loud noises over long period of time Seeing more in younger ages r/t ear phones Aging Adult Cilia become course and stiff Impedes sound waves traveling toward TM; decreases hearing Also causes cerumen to accumulate Hx of frequent ear infections may have produced scarring over the years. Presbycusis; natural part of aging; gradual nerve degeneration in meddle er or auditory nerve; usually starts age 50 First notice high frequency loss, ability to localize sound more difficult; background noise worsens ability to hear After age 70 takes longer to process sound and respond to it; auditory reaction time May have pendulous ear lobes Coarse wiry hairs at opening of ear canal Ear drum may be whiter and more opaque

Pneumonia

Infection and/or inflammation of the lungs. air sacs in the lungs fill with pus or other liquid Can affect lungs in two ways Lobar pneumonia affects a section (lobe) of a lung Bronchial pneumonia (or bronchopneumonia) affects patches throughout both lungs five main causes of pneumonia: Bacteria Viruses Mycoplasmas Other infectious agents, such as fungi -- including pneumocystis Various chemicals Bacterial pneumonia tissue of part of a lobe of the lung, an entire lobe, or most of the lung's five lobes becomes completely filled with liquid ("consolidation"). The infection quickly spreads through the bloodstream and the whole body is invaded. streptococcus pneumoniae most common cause Vaccine preventable Symptoms: onset varies gradual to sudden, may experience shaking chills, severe chest pain, cough that produces rust-colored or greenish mucus. temp may rise as high as 105 degrees F diaphoreses, tachycarida, tachynea, cyanotic nailbeds, Viral Pneumonia Symptoms: same as influenza symptoms: fever, a dry cough, headache, muscle pain, and weakness. Within 12 to 36 hours, increasing breathlessness; cough worsens and produces a small amount of mucus. High fever Treatment: antibiotics if bacterial Rarely antivirals may be ordered for viral supportive treatment: proper diet, oxygen, analgesics, rest Prevention: Annual flu vaccine because pneumonia is a common complication of influenza. A vaccine for pneumococcal pneumonia, one type of bacterial pneumonia; given only to high risk/older adult Highest risk groups: chronic illnesses such as lung disease, heart disease, kidney disorders, sickle cell anemia, or diabetes. recovering from severe illness nursing homes or other chronic care facilities age 65 or older Most important preventive measure is to be alert to any symptoms of respiratory symptoms that linger longer than a few days. Health promotion-; proper diet and hygiene, rest, regular exercise

Bronchitis

Inflammation of the lining of the bronchial tubes Less air is able to flow Productive cough with heavy mucus or phlegm May be acute (usually associated with URI and no fever) or chronic Chronic bronchitis presence of a mucus-producing cough most days of the month, three months of a year for two successive years without other underlying disease inflammation eventually leads to scarring of the lining of the bronchial tubes once the bronchial tubes have been irritated over a long period of time, excessive mucus is produced constantly, the lining of the bronchial tubes becomes thickened, an irritating cough develops, and air flow may be hampered, the lungs become scarred. The bronchial tubes then make an ideal breeding place for infections. Risk factors URI or viral infection Smoking exposure to industrial dusts and fumes Air pollution Treatment: Antibiotics if associated with bacterial infection Bronchodilators Corticosteroids Eliminate sources of irritation and infection in the nose, throat, mouth, sinuses, and bronchial tubes; avoid polluted air and dusty working conditions, smoking cessation

Objective Data: Legs

Inspect and palpate the legs Uncover the legs Inspect both legs together, noting skin color, hair distribution, venous pattern, size (swelling or atrophy), and any skin lesions or ulcers Normally hair covers legs; even if leg hair is shaved, you will still note hair on dorsa of toes Venous pattern normally flat and barely visible; note obvious varicosities, but are best assessed standing Both legs should be symmetric in size without any swelling or atrophy If lower legs look asymmetric, measure leg at widest point, taking care to measure other leg in exactly same place, same number of centimeters down from patella or other landmark If deep venous thrombosis suspected, measure calf circumference with nonstretchable tape measure If lymphedema suspected, measure also at ankle, distal calf, knee, and thigh Record findings in centimeters In presence of skin discoloration, skin ulcers, or gangrene, note size and exact location Palpate for temperature along legs down to feet, comparing symmetric spots Skin should be warm and equal bilaterally; bilateral cool feet may be due to environmental factors such as cool room temperature, apprehension, and cigarette smoking If any increase in temperature present higher up leg, note if it is gradual or abrupt Flex person's knee, then gently compress gastrocnemius (calf) muscle anteriorly against tibia; no tenderness should be present Or you may sharply dorsiflex foot toward tibia Flexing knee first exerts pressure on posterior tibial vein; normally this does not cause pain Palpate inguinal lymph nodes; not unusual to find palpable nodes that are small (1 cm or less), movable, and nontender Palpate these peripheral arteries in both legs: femoral, popliteal, dorsalis pedis, and posterior tibial Grade force Locate femoral arteries just below inguinal ligament halfway between pubis and anterior superior iliac spines To help expose femoral area, ask person to bend his or her knees to side in a froglike position Press firmly and then slowly release, noting pulse tap under your fingertips Should this pulse be weak or diminished, auscultate site for a bruit Popliteal pulse more diffuse and difficult to localize With leg extended but relaxed, anchor your thumbs on knee, and curl your fingers around into popliteal fossa Press your fingers forward hard to compress artery against bone (lower edge of femur or upper edge of tibia); often it is just lateral to the medial tendon If you have difficulty, turn person prone and lift up lower leg; let leg relax against your arm and press in deeply with your two thumbs Often normal popliteal pulse is impossible to palpate For posterior tibial pulse, curve your fingers around medial malleolus Feel the tapping right behind it in groove between malleolus and Achilles tendon Dorsalis pedis pulse requires a very light touch Normally it is just lateral to and parallel with extensor tendon of big toe Do not mistake pulse in your own fingertips for person's In adults over 45 years, occasionally either dorsalis pedis or posterior tibial pulse may be hard to find, but not both on the same foot Check for pretibial edema Firmly depress skin over tibia or medial malleolus for 5 seconds and release Normally, your finger should leave no indentation, although a pit commonly is seen if person has been standing all day or during pregnancy If pitting edema is present, grade it on following scale: 1+ Mild pitting, slight indentation, no perceptible swelling 2+ Moderate pitting, indentation subsides rapidly 3+ Deep pitting, indentation remains, leg looks swollen 4+ Very deep pitting, indentation lasts long time, leg very swollen Scale is subjective and qualitative The amount of pressure used is arbitrary, as is judgment of depth and rate of pitting Clinicians need a standard quantified scale to ensure consistent clinical measurements and management Many classify the edema by measuring the depth of the pitting in centimeter Some measure with a millimeter scale, others by an increase in weight; still others try to quantify rate of time pitting remains after release of pressure Check with your institution to determine a consistently used scale Ask the person to stand so that you can assess venous system Note any visible, dilated, and tortuous veins

Hip Assessment

Inspect as person stands Palpate with person supine Motion and expected range Raise leg Knee to chest Flex knee and hip; swing foot out, in Swing leg laterally, medially Stand and swing leg back

Shoulders Assessment

Inspect joint Palpate shoulders and axilla Motion and expected range Arms forward and up Arms behind back and hands up Arms to sides and up over head Touch hands behind head

Knee Assessment

Inspect joint and muscle Palpate Bulge sign Ballottement of patella Motion and expected range Bend knee Extend knee Check knee while ambulate McMurray's test

Temporomandibular Joint Assessment

Inspect joint area Palpate as person opens mouth Motion and expected range Open mouth maximally Protrude lower jaw and move side to side Stick out lower jaw Palpate muscles of mastication

Elbow Assessment

Inspect joint in flexed and extended positions Palpate joint and bony prominences Motion and expected range Bend and straighten elbow Pronate and supinate hand

Wrist and Hand Assessment

Inspect joints on dorsal and palmar sides Palpate each joint Motion and expected range Bend hand up, down Bend fingers up, down Turn hands out, in Spread fingers, make fist Touch thumb to each finger Phalen's test Tinel's sign

Characteristics

Location- point to it ("head pain" is vague) Character or quality- specific, descriptive Quantity or severity- pain scale; how does it impact daily activities; numbers Timing- onset, duration, frequency Setting- what was patient doing Aggravating or relieving- what makes it worse or better Associated factors- is primary symptom related to others; review the body symptom Patient's perception- how does it affect daily activities

Immediate Priorities

Look at meds, medical problems, allergies, reason for seeking care- what are the relationships (what causes what)? Priorities are always changing! ABCs plus V (exception: CPR) Second-level: mental status, acute pain, abnormal labs, any many more... Third-level: i.e.- lack of knowledge, rest

Atria

Low-pressure filling chambers Contraction "kick" contributes to 25-30% to cardiac output Right Atrium: Receives systemic blood from the IVC, SVC and coronary sinus Left Atrium: Receives oxygenated blood from the lungs via the pulmonary veins

Objective Data

Main components of a mental status examination A—Appearance B—Behavior C—Cognition T—Thought processes Appearance Posture Body movements Dress Grooming and hygiene Behavior Level of consciousness Facial expression Speech Mood and affect Cognitive functions Orientation Attention span Recent memory Remote memory New learning—the four unrelated words test Judgment Thought processes and perceptions Thought processes Thought content Perceptions Screen for suicidal thoughts

Abnormal results of MMSE

May include evidence of: Indication of organic brain damage Evidence of thought disorders Inappropriate mood/affect to its context Thoughts of suicide Disturbed speech patterns Dissociative symptoms Delusions or hallucinations Mid to low 20s—mild impairment Between 10 and 20—moderate impairment Less than 9—severe impairment

Cardiac Output

Measurement of the heart's efficiency to pump an adequate blood supply to meet the bodies demand. Cardiac Output (CO) depends on stroke volume (SV), amount of blood pumped out of one ventricle with a single beat and heart rate. CO=SV×HR Average cardiac output 3.5-8ml/minз

Hematocrit

Measures cell volume, used to detect iron status infants 1-3days=44-72%, 2mos= 9.0-14.0g/dl, 6-12yrs= 11.5-15.5 g/dl, adult males= 14-18 g/dl, females= 12-16 g/dl

Total lymphocyte count

Measures immune function Norm b/t 1800-3000 cells/ mm3

Urinary Creatinine

Measures muscle breakdown or meas. of skeletal muscle mass Use calculation and table for interpretation (creatinine ht index= actual 24 hr urine creatinine / ideal 24 hr urine creatinine for ht X 100

Hypospadias

Meatus opening on ventral side of shaft with a groove that extends to the normal opening Congenital anomaly Surgical correction

Health Effects of Elder Abuse

Minor pain and discomfort to life-threatening injuries Bleeding r/t trauma can lead to shock and death Localized infection can lead to sepsis Cardiac complications Sexual abuse sequelae same as younger and post menopausal have more friable vaginal mucosa secondary to deestrogenation Abuse often couples with neglect; intentional or unintentional Self neglect also reportable

S1 Sound

Mitral and tricuspid valve closure Beginning of ventricular systole, S1 precedes arterial pulsation M1=mitral valve closure, T1=tricuspid valve closure (MV produces most of sound) Diaphragm of stethoscope, apical area-5th, left ICS/mid-clavicular line T1 4th-5th ICS/left sternal border "Lub" of the "lub-dub"

Dating of bruising

No scientific evidence of accuracy Some guidelines can assist in determining if bruise is approximate age consistent with the history given by patient New bruise will start with red appearance Turns blue-purple within 12-36 hours Progresses to bluish-green to greenish-brown to brownish-yellow before fading away. Elderly bruise more readily and more severely r/t meds, abnormal blood values, hematologic disorders

Cardiovascular Assessment:Nocturia

Nocturia: Do you awaken at night w/an urgent need to urinate? How long has this been occurring? Any change? Rationale: Recumbency at night promotes fluid reabsorption and excretion, this occurs with HF in the individual who is ambulatory during the day.

Confrontation Test

Normal Measures peripheral vision Able to see object when examiner does Watch positioning i.e. temporal Abnormal Unable to see object when examiner does Indicates peripheral visual loss a gross measure of peripheral vision. Position yourself level with patient (2 feet away); cover one eye and you cover the opposite. Ask person to tell you when they see your finger move. Measure the patient against your own ability to see. Very gross test.

Snellen Results

Normal 20/20 Wear glasses or contacts if used for distance Occlude one eye Must read line easily No more than 1 error, if 2 referral Allow eye to get acclimated Abnormal Squinting, or delay (uhmmm) Peeking Refer it vision less than 20/30 20 feet from the chart; sheild one eye at a time; remove only reading glasses...otherwise leave eye glasses and contact lenses in; ask person to read the smallest line. Normal vision is 20/20. Top number is how many feet person stands form chart and bottom number gives the distance at which the normal eye could have read that line. The larger the denominator, the poorer the vision.

Infancy

Normal skin variations: erythema toxicum, milia, mongolian spot, acrocyanosis, physiologic jaundice, bruising, pilonidal cyst and sacrococcygeal dimple Thickness: epidermis is thin but will also note subcutaneous fat Turgor: assess for dehydration Scalp: lost in first few weeks, seborrheic dermatitis

Respirations

Normal: relaxed, regular, automatic, silent Count for 30 seconds or full minute- don't tell! Normal (per Jarvis) Neonate 30-40 1 yr. 20-40 2 yr. 25-32 8-10 yr. 20-26 12-14 yr. 18-22 16 yr. 12-20 Adult 10-20

The Aging Adult

Not normal part of aging Less aggressive treatment by providers Concerns: dependency, invasive procedure, taking pain meds, financial burden Common: arthritis, OA, osteoporosis, PVD, cancer, peripheral neuropathies, angina & chronic constipation

Aging Adult

Not normal, but does happen (OA, PVD, cancer, osteoporosis, angina) May fear meds (dependency or cost) Look for changes in functional status May note slowness, rigidity, fatigue, sudden onset confusion If dementia, less able to describe, but still have pain (PAINAD scale)

Clinical Judgement

Novice: no experience; rules guide Competent: 2-3 years; goals/daily plans make sense Proficient: patient as a whole (not list of tasks); see long term goals Expert: uses intuition

Abnormal Findings-Palpation (Distention)

Obesity-Tympany, scaterted dullness Air or gas-Tympany Ascites-central tympany, dullness on sids Ovarian cyst-ovarian areas Pregnancy-lower midline Feces-sigmoid colon area Tumor

Abnormal Facial Appearances: Chronic Illnesses

Parkinson Syndrome Cushing Syndrome Graves' Disease Hyperthyroidism Myxedema (hypothyroidism) Bell's Palsy Brain attack or cerebrovascular accident Cachectic appearance Scleroderma

Nutritional Assessment

Obtain health history Obtain dietary history Inspect skin, hair nails, MS, neuro Obtain Ht, Wt and anthropometric measurements as indicated Review lab tests

Syphilitic Chancre

Occurs within 2-4 weeks of infection Small solitary papule Red, oval or round Erodes with yellow serous discharge Lymph nodes enlarge

Cardiac Cycle

One contraction and one relaxation phase=cardiac cycle Systole or contraction forcefully moves blood out of the ventricles. 1st heart sound S1 Closure of the mitral and tricuspid valve Correlates with electrical depolarization of the conduction system Diastole or relaxation allows blood to fill into the ventricles 2nd heart sound Closure of the atrial and pulmonic valves Correlates with electrical repolarization of the conduction system

Sounds

Percussion causes vibrations= notes Amplitude (intensity)= loud or soft Pitch (frequency)= vibrations per second (more rapid= high-pitched and slower= low-pitched tone) Quality (timbre)= subjective difference due to overtones Duration= length the note lingers

Abnormalities in the Eyelids

Periorbital edema Exophthalmos (protruding eyes)- thyrotoxicosis Enophthalmos (sunken eyes)- Cachexia Ptosis (drooping upper lid)- nerve damage (CNIII); Horner's Syndrome Upward palpebral slant (Brushfield's spots and Down's Syndrome) Ectropion- lower lid loose and rolls out, tears drain and do not moisture the eye; aging or trauma Entropion- lower lid rolls in due to spasm person fells foreign body sensation

CLassic Symptoms of Vascular Disorders

Peripheral artery disease: PAD: claudication, rest pain Acute Arterial Occlusion: six "P's": pain, poikilothermia, paresthesia, paralysis, pallor, pulselessness Abdominal Aortic Aneurysm: AAA: bruit, laterally pulsating abdominal mass AAA Dissection / Rupture: chest pain, abdominal pain, back pain, shortness of breath Raynaud's Phenomenon or Disease: numbness, tingling, pain, coolness, extreme pallor Chronic venous insufficiency: edema of extremity Deep vein thrombosis: DVTunilateral edema, pain or achiness, erythema, warmth Thrombophlebitis: as with DVT, palpable mass or cord along vein Neuropathy: burning pain, numbness, paresthesias Lymphedema: unilateral edema

Objective Data: arms

Preparation During a complete physical examination, examine arms at very beginning when you are checking vital signs and person is sitting Examine legs directly after abdominal examination while person is still supine; then stand person up to evaluate leg veins Examination of arms and legs includes peripheral vascular characteristics Room free of drafts to prevent vasodilatation or vasoconstriction Use inspection, then palpation Compare your findings with opposite extremity Equipment needed Occasionally need: Paper tape measure Tourniquet or blood pressure cuff Stethoscope Doppler ultrasonic stethoscope Inspect and palpate the arms Lift both person's hands in your hands Inspect, then turn person's hands over, noting color of skin and nail beds; temperature, texture, and turgor of skin; and the presence of any lesions, edema, or clubbing Use profile sign (viewing finger from side) to detect early clubbing Normal nail bed angle is 160 degrees With person's hands near level of their heart, check capillary refill Depress and blanch nail beds; release and note time for color return Usually, vessels refill within a fraction of a second Normal if color returns in less than 1 or 2 seconds Note conditions that can skew your findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia The two arms should be symmetric in size Note presence of any scars on hands and arms Many occur normally with usual childhood abrasions or with occupations involving hand tools Palpate both radial pulses, noting rate, rhythm, elasticity of vessel wall, and equal force Grade force (amplitude): 3+, increased, full, bounding 2+, normal 1+, weak 0, absent It usually is not necessary to palpate ulnar pulses Palpate the brachial pulses: their force should be equal bilaterally Check epitrochlear lymph node in depression above and behind medial condyle of humerus Do this by "shaking hands" with person and reaching your other hand under person's elbow to groove between biceps and triceps muscles, above medial epicondyle This node is not palpable normally Modified Allen test used to evaluate collateral circulation prior to cannulating radial artery Firmly occlude both ulnar and radial arteries of one hand while person makes a fist several times; this causes hand to blanch Ask person to open hand without hyperextending it; then release pressure on ulnar artery while maintaining pressure on radial artery Adequate circulation is suggested by a return to hand's normal color in approximately 2 to 5 seconds Although test is simple and useful, it is relatively crude and subject to error

Objective Data

Preparation Lithotomy position and draping Measures to enhance comfort during exam Mirror pelvic examination Equipment needed Gloves Protective clothing for examiner Goose-necked lamp with a strong light Vaginal speculum of appropriate size Large cotton-tipped applicators (rectal swabs) Materials for cytologic study Lubricant External Genitalia—Inspection Skin color Hair distribution Labia majora Any lesions Clitoris Labia minora Urethral opening Vaginal opening Perineum Anus External Genitalia—Palpation Skene's glands Bartholin's glands Support of pelvic musculature Internal Genitalia—Speculum Examination Technique of insertion Cervix and os—Inspect Color Position Size Os Surface Any Nabothian cysts Cervical secretions Inspect vaginal wall Obtain cervical smears and cultures Vaginal pool Ectocervical scrape Endocervical specimen Data to include for the laboratory Internal Genitalia—Bimanual Examination Palpation technique Cervix Consistency Contour Mobility Uterus Adnexa Rectovaginal examination Rectovaginal septum Posterior uterine wall Cul-de-sac Rectum

Objective Data

Preparation Perform screening neurologic examination on well persons with no significant findings from history Perform complete neurologic examination on persons with neurologic concerns, e.g., headache, weakness, loss of coordination, or who have shown signs of neurologic dysfunction Perform neurologic recheck examination on persons with demonstrated neurologic deficits who require periodic assessments, e.g., hospitalized persons or those in extended care Preparation (cont.) Equipment needed: Penlight Tongue blade Cotton swab Cotton ball Tuning fork: 128 Hz or 256 Hz- we do not use tuning fork in our exam Percussion hammer

Objective Data

Preparation Position Apprehension regarding exam Equipment needed Gloves Occasionally need: Glass slide for urethral specimen Materials for cytology FlashlightPenis—inspect and palpate Skin Glans- smooth without lesions Urethral meatus- central Pubic hair- free of pests Urethral discharge- lab analysis if any present Shaft- smooth, firm, nontender Scrotum—inspect and palpate Skin- swelling or lesions Testis- gently palpate, oval shaped, bilateral Epididymis- softer than the testes, smooth, nontender Spermatic cord- smooth, nontender Any mass Note characteristics- tenderness, reduce when laying down Transillumination- normally scrotal contents do not illuminate Check for hernia—inspect and palpate Person standing and straining down Palpation technique- pt. shift weight to opposite side, palpate up the length of the spermatic cord, palpate for a bulge, does it easily reduce Inguinal lymph nodes Along the inguinal ligament Vertical chain along the upper inner thigh Palpate up the length of the spermatic cord Invaginate the tissue Palpate the bulge

Frequency of Screening

Primary Care; Every first visit for a new chief complaint, every new patient encounter, every new intimate relationship and all periodic exams ER and UC; All women, all visits OB/GYN; Each prenatal and postpartum visit, each new intimate relationship, all routine GYN visits (periodic and symptom based), all family planning visits, and all visits in STD and abortion clinics Mental Health; Every initial assessment, each new intimate relationship ,and annually if ongoing or periodic treatment Inpatient; Part of all admissions and discharge

Objective Data:posterior chest

Preparation Position Draping Male Female Timing during a complete examination After thyroid palpation Posterior then anterior Cleaning stethoscope endpiece Posterior Chest—Inspect Thoracic cage Shape and configuration of chest wall Anteroposterior:transverse diameter Position of person Skin color and condition Posterior Chest—Palpate Symmetric expansion Tactile (or vocal) fremitus Technique Factors that affect normal intensity of tactile fremitus Tactile Fremitus Demonstration Palpate the entire chest wall Posterior Chest—Percuss Predominant note over lung fields Diaphragmatic excursion Posterior Chest—Auscultate Breath sounds Technique Bronchial breath sounds—characteristics Bronchovesicular breath sounds—characteristics Vesicular breath sounds—characteristics Adventitious sounds Crackles Wheeze Stridor Rales rhonchi Voice sounds Bronchophony Egophony Whispered pectoriloquy

Eyes: Objective Data

Preparation Position Equipment Snellen eye chart Handheld visual screener Opaque card or occluder Penlight Applicator stick Ophthalmoscope Central visual acuity Snellen eye chart Visual fields Confrontation test Inspect external ocular structures: General Eyebrows Eyelids and lashes Eyeballs Conjunctiva and sclera Eversion of the upper lid Lacrimal apparatus General visual difficulties Eyebrows Symmetry Scaling Absence of Eyelids and lashes Lid lag Ptosis Periorbital edema Inspect anterior eyeball structures Cornea and lens Iris and pupil Size and shape Pupillary light reflex Accommodation Eyeballs: Aligned, no bulging or sunken appearance Exothalmus Ectropion / entropion Conjunctiva and sclera: Conjunctiva clear showing normal numerous small blood vessels' Sclera china white, blacks may have gray- blue or "muddy" color May see brown macules (freckles) on sclera or yellowish fatty deposits beneath lids in dark-skinned people Scleral icterus; yellowing, jaundice Lacrimal Apparatus: Monitor for blockage Bulge in upper lid Red, tender, puncta Drainage when palpated Anterior Eyeball: Cornea and lens Shine light from side Should look smooth Corneal abrasion looks shattered Arcus senilis: Normal finding in aging adult Gray or white arc or circle around limbus Iris and pupil: Iris flat and round Pupils equal and round Normal adult size 3-5 mm May be smaller in older adult Pupillary Response: To light and accommodation Accommodation Look at object far then near Abnormal; absence of constriction or convergence or asymmetry Light Direct and consensual Abnormal; dilated, fixed, unreactive May be slowed in older adult Inspect the ocular fundus: Use of the ophthalmoscope Red reflex Optic disc (you will not be doing) Color Shape Retinal vessels Number Color A:V ratio Caliber General background of the fundus Macula

Objective Data: Nose, mouth, throat

Preparation Positioning Equipment needed Otoscope with short, wide-tipped nasal speculum attachment Pen light Two tongue blades Cotton gauze pad (4 x 4 inches) Gloves Long-stem light attachment for otoscope (occasionally) Nose—Inspect and Palpate External nose Test patency of nostrils Nasal cavity Holding the otoscope Nasal septum Turbinates Sinus Areas—Palpate Frontal and maxillary sinuses Transillumination Mouth—Inspect Lips Teeth and gums Tongue U-shaped area under the tongue Buccal mucosa Palate Hard and soft palate Torus palatinus; benign nodular bony ridge on hard palate Uvula Throat—Inspect Grade tonsils 1-4+ according to size Use of tongue blade Posterior pharyngeal wall Developmental Care Infants and children Nose Mouth and throat- Epstein pearls, look like teeth, disappear over time No sinus palpation for children < 8 Pregnant female- gum hypertrophy Aging adult- previously discussed changes

Objective Data

Preparation Screening musculoskeletal examination Complete musculoskeletal examination Equipment needed Tape measure Goniometer, to measure joint angles Skin marking pen Order of the examination Inspection Size and contour of joint Skin and tissues over joint Palpation Skin temperature Muscles, bony articulations, area of joint capsule Range of motion Muscle testing Apply opposing force Grading muscle strength

Ears: Objective Data

Preparation: Position Cleaning the ear canal Equipment needed Otoscope with bright light Pneumatic bulb attachment (sometimes needed with infants or young children) Tuning forks External Ear - Inspect and Palpate: Size and shape Skin condition Tenderness External auditory meatus Otoscopic Examination Position the head and ear Method of holding and inserting otoscope External canal Color Swelling Lesions Discharge Otoscopic Examination, cont. Tympanic membrane Color and characteristics Position Integrity of membrane Test hearing acuity Conversational speech Voice test Tuning fork tests Weber test; measures sound conduction through bone to both ears bilaterally abnormal= sensorineural loss Rinne test; compares air and bone conduction; should hear twice as long through air conduction; heard longer with bone conduction in conductive hearing loss Vestibular apparatus Romberg test; assesses ability of inner ear apparatus to maintain balance Stand with eyes closed, arms at sides for 20 secs.; should have no problems with balance

Subjective Data-Adolescents

Present wt How they feel about wt What they want to weigh On diet? Past diets? Do they constantly think about feeling fat? Intentionally vomit or use laxatives or diuretics after eating? Use of steroids Snacks menstruation

GUARDING

Press on the abdomen. If the muscles tighten this is guarding. Voluntary guarding is when the patient makes their muscles flex. Sometimes it is necessary to distract the patient to be able to evaluate this correctly.

Plantar grasp

Press thumb at ball of foot. Toes curl down tightly Present at birth Disappears at 8-10 months

Developmental Competence-Aging Adult

Prevalence of current alcohol use decreases with increasing age 67.4% among those 26 to 29 50.3% among those 60 to 64 39.7% among those 65 or older Older adults have numerous characteristics that increase risk of alcohol use Liver metabolism and kidney functioning decreases, increase availability of alcohol in blood for longer periods Less tissue mass means increased alcohol concentration in blood Older adults on multiple medications that can interact adversely with alcohol, including benzodiazepines, antidepressants, antihypertensives, and aspirin Drinking alcohol increases risk of falls, depression, and gastrointestinal problems

Types of Abuse

Psychological abuse; mental anguish Making or carrying out threats to do something to hurt partner emotionally In gay, lesbian, bisexual and transgender relationships, threatening to expose ("out") the victim's sexual orientation Threatening to commit suicide Threatening to take away or harm the children Threatening to harm the family of origin (for example, parents and siblings) Threatening to report partner to a governmental agency (the Internal Revenue Service and the Immigration and Naturalization Service) Threatening to harm, injuring or killing pets Emotional abuse; Putting partner down (commenting about perceived shortcomings, name calling) Playing mind games; making partner think she/he is crazy Making partner feel bad about themselves Playing mind games Treating partner as if he/she is a servant Making all the major decisions (control) Physical abuse; Pinching Tripping Punching Grabbing Beating Pulling hair Slapping Shoving Biting Twisting arms Kicking Using a weapon against you Throwing you down Choking Hitting Pushing Isolation; Controlling what partner does (example, financially; monitoring activities) Limiting partner's access to others Controlling partners activities outside the home Sexual abuse; Making partner perform sexual acts against their will Treating partner as if they are a sex object Physically attacking the sexual parts of the partners body Economic; Preventing partner from getting or keeping a job Taking partner's money Making partner ask for money Giving partner an allowance

Signs of Being Abused

Psychological signs and symptoms: abuser may appear overly controlling or coercive, attempting to answer all questions for the victim or isolating him or her from others. may occur in the context of a health visit; abuser refuses to let the victim out of his sight, attempts to answer all questions for the victim, may note emotional abuse taking place. the abused may appear quiet and passive, may show outward signs of depression such as crying and poor eye contact. Other psychological signs; anxiety, depression, and chronic fatigue, suicidal tendencies and the battered woman syndrome—a syndrome similar to PTSD Substance abuse more common in the person enduring domestic violence may happen as a result of the violent relationship rather than being the cause of the violence. Physical signs and symptoms: Specific injury types and distributions. Injury types and patterns may result from things other than domestic violence but should raise suspicion of abuse when present. Injury types seen more commonly in domestic-violence: Tympanic membrane rupture Rectal or genital injury Facial scrapes, bruises, cuts, or fractures neck scrapes or bruises Abdominal cuts or bruises Body scrapes or bruises Arm scrapes or bruises The distribution of injuries may follow certain patterns. Centrally located injuries: Injury distribution is in a bathing-suit pattern, primarily involving the breasts, body, buttocks, and genitals. These areas are usually covered by clothing, concealing obvious signs of injury. Another central location is the head and neck, which is the site of up to 50% of abusive injuries.

Organs in right upper quadrant

Pyorous Duodenum Liver Right kidney and adrenal gland Hepatic fissure of colon Head of pancreas

Abnormal Findings

Shapes and configurations of lesions Annular or circular Confluent Discrete Grouped Gyrate Target or iris Linear Polycyclic Zosteriform Macules Papules Patches Plaques Nodules Wheals Tumors Urticaria (hives) Vesicles Cysts Bullas Pustules Secondary skin lesions Debris on skin surface Crusts Scales Break in continuity of skin surface Fissures Erosions Ulcers Excoriations Scars Atrophic scars Lichenifications Keloids

MMSE

Simplified version of the MSE The Mini Mental State Examination (MMSE) or Folstein test is a brief 30-point questionnaire test that is used to assess cognition . It is commonly used to screen for dementia. It is an 11-question measure that tests five areas of cognitive function

Physical Examination: Infants & Children

Skull Measure infant's head at each visit up to age 2 years; and yearly up to age 6 years Note infant's head posture and head control; infant can turn head side to side by 2 weeks Shows tonic neck reflex when supine and head turned to one side (extension of same arm and leg, flexion of opposite arm and leg); reflex disappears at 3 to 4 months Head control achieved by 4 months Two common variations in newborn cause shape of skull to look markedly asymmetric: Caput succedaneum: edematous swelling and ecchymosis of presenting part of head caused by birth trauma; gradually resolves during first few days of life and needs no treatment Cephalhematoma: subperiosteal hemorrhage, a result of birth trauma appears several hours after birth and gradually increases in size; will be reabsorbed during first few weeks of life without treatment Face Check facial features for symmetry, appearance, and swelling Note symmetry of wrinkling when infant cries or smiles, e.g., both sides of lips rise and both sides of forehead wrinkle Normally, no swelling is evident Parotid gland enlargement best seen when child looks up; swelling appears below angle of jaw Atopic (allergic) facies Allergic salute and crease Neck An infant's neck looks short; it lengthens during the first 3 to 4 years Assess muscle development with gentle passive ROM Cradle infant's head with your hands and turn it side to side and test forward flexion, extension, and rotation Note resistance to movement, especially flexion During infancy, cervical lymph nodes are not palpable normally; but child's lymph nodes are palpable Palpable nodes less than 3 mm are normal Children have a higher incidence of infection, so you will expect a greater incidence of inflammatory adenopathy; no other mass should occur in neck Special procedures: percussion With an infant, you may directly percuss with your plexor finger against head surface; this yields a resonant or "cracked pot" sound, which is normal before closure of fontanels Auscultation Bruits are common in skull of children under 4 or 5 years of age or children with anemia Systolic or continuous; heard over temporal area

The Role of the Nurse in Promoting Optimal Nutrition

Teaching/Health Promotion Healthy Atmosphere & Role Modeling Informal Instruction Oral Hygiene Timing of Meds Special diets, supplements, & enteral feedings Assess, Monitor, & Enhance good nutrition Principles of normal nutrition Growth & Development Primary preventative screening Pre & Post-Operative Assessment Teaching Diet review Nutritional therapies Monitor lab values Relieve illness s/s that depress appetite Provide familiar food the client likes Small portions Avoid treatments before or after meals Clean environment free of sights & odors Avoid isolating the client at mealtime Provide oral hygiene before meals Reduce psychological stress

Physical Environment

Temperature Lighting Noise Distracting equipment Distance between you and the patient Equal status seating

Lymphatics "Helpers"

Tonsil, Spleen, Thymus

Procedure of Nutritional Assessment

Start with screening Quick easy way to identify risk i.e. wt loss, recent illness or inadequate food intake Wt, wt hx, Diet info Lab data Identify risks If at risk, undergo comprehensive assessment Diet hx Weight Food intake 24 hr recall Food frequency questionnaire Food diaries Direct observation Symptoms Functional capacity Recent illness / disease Physical exam Edema Muscle wasting Loss of subcue tissue Ascites Calculate wt loss/gain

Moro Reflex (startle reflex)

Startle infant Symmetric abduction and extension of arms and legs, fanning fingers Present at birth Disappears 1-4 months

Paiget's disease of the breast

Starts with a rash

Skin Exam: Palpation

Temperature- dorsa of your hands Moisture- diaphoresis on face, axilla, skin folds dehydration in the mucous membranes Tenderness- dorsal surfaces of hands and fingers Skin surfaces should not be tender, may indicate infection, illness, or allergic reaction Texture- smooth and firm except where there is significant hair growth Thickness- epidermis thin, calluses may be normal on hands and feet Mobility and Turgor Vascularity (cherry angiomas) Bruising (ecchymosis) Lesions Color Elevated or flat Pattern/shape Size in centimeters Location/Distribution Any exudate (note color and odor)

Aging Adult

Temporal arteries may look twisted and prominent In some aging adults, a mild rhythmic tremor of head may be normal Senile tremors are benign and include head nodding and tongue protrusion If some teeth have been lost, lower face looks unusually small, with mouth sunken in Neck may show concave curve when head and jaw are extended forward to compensate for kyphosis of spine During examination, direct aging person to perform ROM slowly; they may experience dizziness with side movements Aging person may have prolapse of submandibular glands, which may be mistaken for a tumor; but drooping submandibular glands will feel soft and be present bilaterally

Scrotal Edema

Tenderness Enlarged and reddened Taut with pitting, unable to feel scrotal contents Occurs with marked edema in lower body of CHF, renal failure, obstruction Locally with epididymitis Obstruction of inguinal lymphatics

Purkinje Fibers

Terminal branches of the bundle system, innervate all aspects of the ventricular tissue

The CAGE questionnaire

The CAGE questionnaire (Cutdown, Annoyed, Guilty, Eye opener) Works well in primary care settings because it takes less than 1 minute to complete The CAGE tests for lifetime alcohol abuse and/or dependence Does not clarify past problem drinking from present Less effective with women and minority groups NOTE: If "yes" to 2 or more questions, suspect alcohol abuse - therefore, a more complete substance abuse assessment is warranted. 1. Have you ever felt you ought to Cut down on drinking? 2. Have people Annoyed you by criticizing your drinking? 3. Have you ever felt bad or Guilty about your drinking? 4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eye-opener)

Stages of the Interview

The Opening Establish rapport/trust Who you are and what you are doing How long it will take The Body Patient responds to question Nurse uses appropriate communication techniques The Closing Nurse terminates when needed information obtained Patient may also terminate Ask if any questions Tell patient what will happen next

TWEAK

The TWEAK questions; combination of items from two questionnaires which help identify at-risk drinking in women, especially pregnant women Tolerance: How many drinks can you hold? Or How many drinks does it take to make you feel high? Worry: Have close friends or relatives complained about your drinking? Eye-opener: Do you sometimes take a drink in morning when you first get up? Amnesia: Has a friend or family member told you about things you said but could not remember? Kut down: Do you sometimes feel need to cut down? Scoring: 2 points each for Tolerance and Worry. 1 point each for others. Interpretation: 1 point = low risk. Taking 3 drinks to feel high = tolerance. 2 points or greater = a drinking problem

Stroke Volume

The amount of blood pumped out of the left ventricle with each beat, depends on preload, afterload, and contractility

Ejection Fraction

The amount of blood, percent, ejected with each systole, when compared to end diastolic volume. This measures the effectiveness of the contraction. Normal ejection fraction is 65-70%

After administration of MMSE

The patient may need additional tests for follow up: Blood (toxicology, anemia, diabetes, vit or thyroid deficiencies, etc) Urine (toxicology subst. use screen) CT/MRI (seizures, strokes, head trauma, brain tumors, etc) Spinal tap (if suspecting CNS infection)

Planning the interview

Timing Place Seating Arrangement Distance (8-12" in Arab countries, 18" in USA, 24" in Britain, 36" in Japan) Language

Anthropomorphic Measures

To depict wt change 3 methods are used 1. Body Wt as % of Ideal Body Wt % IBW= Wt / Ideal Wt X 1002. 2. Percent Usual Body Weight % usual body wt = current wt/usual wt X100 3. Recent Wt change Usual wt - current wt/usual wt X100 Mild Malnutrition Current wt is 80%-90% of Ideal Wt Moderate Malnutrition 70-80% Severe Malnutrition <70% Unintended Wt loss of >5% of body wt over 1 mo >7.5% of body wt over 3 months or >10% of body wt over 6 months is clinically significant

Developmental Considerations: Aging Adults

Use same examination as with younger adults Cranial nerves mediating taste and smell not usually tested, may show some decline in function Decrease in muscle bulk most apparent in hand; dorsal hand muscles often look wasted, even with no apparent arthropathy; grip strength remains relatively good Senile tremors occasionally occur; these benign tremors include an intention tremor of hands, head nodding, and tongue protrusion Dyskinesias: repetitive stereotyped movements in jaw, lips, or tongue may accompany senile tremors; no associated rigidity present After 65 years of age, loss of sensation of vibration at ankle malleolus common; loss of ankle jerk; tactile sensation may be impaired; may need stronger stimuli for light touch; and especially for pain DTRs less brisk; those in upper extremities usually present, but ankle jerk commonly lost; knee jerks may be lost; because aging people find it difficult to relax limbs, always use reinforcement when eliciting DTRs Plantar reflex may be absent or difficult to interpret; often, you will not see a definite normal flexor response; still should consider definite extensor response abnormal Superficial abdominal reflexes may be absent, probably because of stretching of musculature through pregnancy or obesity Neurologic check (cont.) Use abbreviation of neurologic examination in following sequence: Level of consciousness Motor function Pupillary response Vital signs

Height

Use wall-mounted device or measuring pole on scale Align extended headpiece with top of head Person should be shoeless, standing straight, looking straight ahead, with feet and shoulders on hard surface

Hemoglobin

Used to detect iron deficiency Not indicator of early malnutrition r/t long ½ life Norm infants 1-3days= 14.5-22.5 g/dl, 2mos=28-42%, 6-12yrs=35-45% adult males= 37-49%l, females= 36-46%

Frame size

Used to determine appropriate range of IBW Elbow breadth is most accurate Pt extends right arm forward perpendicular to body with elbow bent 90 degrees with palm lateral, calipers on condyle of humerus Record in cm use chart for norms

Iliopsoas Muscle Test

Used when acute abdominal pain or appendicitis is suspected Lift R leg straight up, flexing at the hip then push done while having patient resist When test negative, person feels no change; when positive, pain felt in R lower quadrant

Arm Span or Total Arm Length

Useful if ht difficult to measure Arm span is close to height Pt holds arms straight out from body Measure from tip of middle finger to same in other hand

Ovarian cyst

Usually asymptomatic Smooth, round, mobile, some resolve spontaneously Some cause pain and heaviness during rupture

Gonorrhea

Vaginal discharge, dysuria, abnormal uterine bleeding, abscess in Bartholin's or Skene's glands Diagnose by positive culture If untreated it may progress to PID

Myomas (Uterine Fibroids)

Varies depending on size and location Usually no symptoms or vague discomfort, bloating, heaviness, pelvic pressure Uterus irregularly enlarged, firm, mobile, and nodular Usually benign myomas are estrogen dependent

Manual compression test

While person is still standing, test length of varicose vein to determine whether its valves are competent Place one hand on lower part of varicose vein, and compress vein with your other hand about 15 to 20 cm higher Competent valves prevent a wave transmission and your distal (lower) fingers will feel no change Color changes If you suspect an arterial deficit, raise legs about 30 cm (12 inches) off table and ask person to wag feet for 30 seconds to drain off venous blood Skin color now reflects only contribution of arterial blood Light-skinned person's feet normally will look a little pale but still should be pink Dark-skinned person's feet are more difficult to evaluate, but soles should reveal extreme color change Now have person sit up with legs over side of table Compare color of both feet and note time it takes for color to return to feet; normally, this is 10 seconds or less Color changes (cont.) Note also time it takes for superficial veins around feet to fill Normal time is about 15 seconds This test is unreliable if person has concomitant venous disease with incompetent valves Test lower legs for strength Test lower legs for sensation

The Clock Drawing Test

Widely used to screen patients with cognitive impairment and memory loss. Simple test that can be used as part of a neurological examination or as a screening tool for Alzheimer's Disease and other types of dementia Advantages takes less than 2 min to administer Accepted by patients Simple to score Independent of educational/cultural background Reliable Tests Comprehension Planning Visual memory Visual-spatial ability Motor programming Motor execution Reconstruction Numerical knowledge Interpreting commands Technique Give patient blank sheet of paper Patient is told to draw a clock Draw the clock face Draw the numbers in correct position Draw clock hands to show time of 11:10 Interpretation Drawing a closed circle: 1 point Drawing 12 numbers: 1 point Positioning numbers correctly: 1 point Place clock hands at designated time: 1 point Can not be given to: Patients unable to speak/understand Comatose/semi conscious state

Ganglion Cyst

a mass of tissue that is filled with a jelly-like fluid. word "ganglion" means "knot" and is used to describe the knot-like mass or lump of cells that forms below the surface of the skin. most common benign soft-tissue masses often occur on the wrist, they also frequently develop on the foot—usually on the top, but elsewhere as well vary in size, may get smaller and larger over time and may even disappear, only to possibly return later. adults between 15 and 40 years old are most likely to be affected. Women are affected three times as often as men. Children do not usually have ganglions, but if they do, the ganglion will very likely go away without any treatment. Signs and Symptoms A noticeable lump—often this is the only symptom experienced. Tingling or burning, if the cyst is touching a nerve. Dull pain or ache, which may indicate the cyst is pressing against a tendon or joint. Difficulty wearing shoes due to irritation between the lump and the shoe. Causes usually caused by some type of injury might develop after something drops on the foot, if the foot was twisted while walking, or after too much stress was placed on a joint or tendon. the trauma sometimes not recalled the cyst appears soon after the trauma occurs. Diagnosis should move freely underneath the skin Treatment Monitoring the cyst causes no pain and does not interfere with walking may carefully watch the cyst over a period of time. Shoe modifications. Wearing shoes that do not rub the cyst or cause irritation may be advised. In addition, placing a pad inside the shoe may help reduce pressure against the cyst. Aspiration and injection. draining the fluid and then injecting a steroid medication into the mass. More than one session may be needed. Although this approach is successful in some cases, in many others the cyst returns. Surgery. When other treatment options fail or are not appropriate, the cyst may need to be surgically removed. While the recurrence rate associated with surgery is much lower than that experienced with aspiration and injection therapy, there are nevertheless cases in which the ganglion cyst returns.

Dupuytren's Contracture

rare hand deformity in which the fascia under the skin of the palm thickens and scars. Knots (nodes) and cords of tissue form under the skin, often pulling one or more of the fingers into a bent (contracted) position. the fingers affected by Dupuytren's contracture bend normally, they can't be straightened, rarely painful Men more likely than women more common in older adults, usually developing in people in their 50s and 60s. more common in whites of Northern European heritage. The condition rarely affects people of color. Signs and Symptoms usually begins as a thickening of the skin on the palm of your hand. As contracture progresses, the skin on the palm may appear dimpled. A firm lump of tissue may form palm. lump may be sensitive to the touch, but usually isn't painful. later stages, cords of tissue form under the skin palm. Cords may extend up to fingers. As these cords tighten, fingers may be pulled toward palm, sometimes severely. The ring finger and the little finger are most commonly affected, though the middle finger may also be involved. Only rarely are the thumb and index finger affected. often affects both hands, though one hand is usually affected more severely than the other. usually progresses slowly, over several years. Occasionally it can develop over weeks or months. In some people it progresses steadily and in others it may start and stop. However, Dupuytren's contracture never regresses. Cause; unknown Risk factors Family history. Alcoholism. It isn't clear whether drinking itself or the liver damage that can result increases the risk of Dupuytren's contracture. Epilepsy. Dupuytren's contracture is more common in people who've had epilepsy for many years. Diabetes. People with type 1 diabetes or type 2 diabetes have an increased risk of tender tissue lumps on the palms of the hands, but they usually don't develop contracted fingers. It isn't clear if these tissue lumps form because of Dupuytren's contracture Treatment Many never require treatment. Often the disease progresses slowly and has little impact Surgery for Dupuytren's contracture is reserved for people who experience pain and disability from the disease. surgery can improve hand function, it doesn't necessarily prevent a recurrence of Dupuytren's contracture. Sometimes the disease returns to the same spot on the hand, other times it reappears in other places on the hand. Nonsurgical options none has proved helpful. Cortisone injections may ease the pain of a tender nodule, but usually doesn't affect the progression of Dupuytren's contracture.

Scoloisis

sideways curve of the spine Curves are often S-shaped or C-shaped. In most people, there is no known cause for this curve. The most common type is idiopathic scoliosis in children aged 10-12 and in their early teens. This is the time when children are growing fast. Girls are more likely than boys to have this type of scoliosis. Scoliosis can be inherited classify curves as: Nonstructural, which is when the spine is structurally normal and the curve is temporary. Structural, which is when the spine has a fixed curve. The cause could be a disease, injury, infection, or birth defect. Treatment for scoliosis is based on: age How much more he or she is likely to grow The degree and pattern of the curve The type of scoliosis. Treatment Observation; check every 4 to 6 months to see if the curve is getting better or worse. Observation is used for those who have a curve of less than 25 degrees and are still growing. Bracing: Bracing may be used when: still growing and has a curve of more than 25 to 30 degrees. still growing and has a curve between 20 and 29 degrees that is getting worse. at least 2 years of growth remaining and has a curve that is between 20 and 29 degrees Surgery: still growing, the curve is more than 45 degrees, and the curve is getting worse. often involves fusing together two or more bones in the spine may also put in a metal rod or other device

Traumatic Bonding

strong emotional connections develop between the victim and the perpetrator during the abusive relationship. emotional ties develop due to the imbalance of power and because the treatment is intermittently good and bad power imbalance; as the abuser gains more power, the abused individual feels worse about him/herself, is less able to protect him/herself, and is less competent. The abused person therefore becomes increasingly dependent on the abuser. intermittent and unpredictable abuse; abuse is offset by an increase in positive behaviors such as attention, gifts, and promises. The abused individual feels relief that the abuse has ended. Thus, there is intermittent reinforcement for the behavior, which is difficult to extinguish and serves instead to strengthen the bond between the abuser and the individual being abused.

Succession Splash

the sound elicited by shaking the body of a person who has free fluid and air or gas in a hollow organ or body cavity. This sound may be present over a normal stomach but also may be heard with hydropneumothorax, large hiatal hernia, or intestinal or pyloric obstruction.

Cholesterol

total; evaluates fat metabolism and risk of cardiac disease Norm 120-200mg/dl Triglycerides; screen for hyperlipidemia, determine risk of CAD Norm age 0-19= 10-100mg/dl, 20-65= 40-200 mg/dl

Closed Questions-

used in directive interview. Generally require "Yes" or "No" answers Often begin with: who, what, when, where or are Highly stressed person and person with difficulty communicating will find closed questioning easier than open ended questioning