NSG 114 SHEDLOCK EXAM 2
Schamroth technique
- used to check for clubbing - hold thumbs together, normal should form a triangle - abnormal, broken triangle ***clubbing can indicate hypoxia, impaired tissue perfusion over long pds of time, COPD pts even long-term smokers
rhonchi
-"junk in the lungs" -expiration/inspiration -low-pitched, snoring, rattling sound -fluid blocked airway -coughing/deep breath can clear this up and lungs can sound normal afterwards
point of maximum impulse
-5th intercostal space, midclavicular line
salmon patches
-AKA stork bites -small macules/patches caused by visible intradermal capillaries. -occur in 30-50% of newborns -common on forehead, eyelids, upper lip, nasal bridge and nape of neck -spontaneously resolve during infancy in all but a few
palpation of the chest
-precordium at the right and left second intercostal spaces -left third intercostal space -left fourth intercostal space -left fifth intercostal space at the midclavicular line(PMI) -palpation of the carotid pulses
eye assessment
-PERRLA -visual acuity -test visual fields -inspect extra-ocular muscle function -corneal light reflex (Hirschberg test) -visual reflexes -inspect external eye structures -inspect anterior eyeball structures -inspect the ocular fundus
ear assessement
-Weber and Rinne tests -inspect internal and external: -size and shape of auricle, skin condition, check movement of auricle, and tragus for tenderness, evaluate external auditory meatus for size, swelling, redness, discharge etc. -otoscopic -hearing acuity
bruit
-a soft blowing sound auscultated that my indicate turbulent blood flow. -This may be a sign of stenosis or narrowing of the vessel -heard over carotid -have pt take deep breath and hold it-use bell and diaphragm
Rinne hearing test
-compares air and bone conduction -normal response is bilaterally sound equal, which is recorded as "no lateralization" -if the sound is heard louder on one side it is "lateralized" -starts on bone behind ear until they can't hear any more than move tuning fork beside ear canal
respiratory percussion
-anterior and posterior chest-use indirect -percuss lung fields to determine prominent note
Semilunar valves
-aortic and pulmonic -closure of these valves causes the 2nd heart sound
Mongolian spots
-areas of dark bluish pigmentation -common in African American, Asian, & Hispanic -caused by an increase concentration of melanocytes -can be found anywhere but common at the base of spine -can be mistaken for bruising
infant or child skin assessment
-ask about: -birthmarks -changes in newborns skin color -and diaper rashes
pregnant female eye assessment
-asses for dry eyes and vision changes
vascularity
-assess capillary refill -normal is less than 3 seconds -decreased supply is often initially found in the lower extremities -delayed return of skin color indicates poor circulation
heart assessment
-assess for abnormal pulsations -recognize characteristics of the client's respiratory effort -knowledge of normal parameters and expected findings is essential in determining the meaning of the data during a physical health assessment
Respiratory Palpation
-assess the entire chest wall, anterior and posterior -confirm symmetric expansion -feel with metacarpal phalangeal joints & ulnar surface
texture of skin
-assess using palmer surface and finger pads -normal varies-smooth, firm and even
temperature of skin
-assess using palpation with dorsal side of hand -palpation direction is superior to inferior -compare R to L -normal is warm or dry and appropriate for the environment
stridor
-asthma attack untreated can turn into this -inspiration -loud, audible high-pitched (don't need stethoscope to hear) -obstructed upper airway
respiratory auscultation
-auscultate posterior & anterior breath/lung sounds -8>10 anterior and 10 posterior -right lung has 3 lobes, left has 2
missed areas of assessment
-between the toes -skin folds -behind ears
Cardiac in pregnancy
-blood volume increases by 30-50% thus increasing the stroke volume, cardiac output, and pulse rate -heart maybe displaced up and to the left b/c of the growing fetus -resting pulse may increase -murmurs may be auscultated
Weber hearing test
-bone conduction to evaluate hearing -in a person who hears better in one ear than the other, the ear they hear sound louder on is actually the probably the "bad ear"
puberty breast development
-breasts enlarge, duct systems grows, and masses of small solid cells develop at duct endings -Tanner's stages of development
normal respiratory assessment
-breathing (labored or unlabored) -O2 sat -rate (normal 12-20) -cycle (inspiration/expiration, ratio 1:2, varies w/ activity) -pattern (even, regular, coordinated) -both sides of chest rise/fall at same time
bruising or lesions
-inspect and palpate the skin and DOCUMENT! -primary=develop on previously unaltered skin, the lesion is the problem -secondary=change over time or because of scratching, abrasion or infection -healthy skin is typically smooth, but some lesions like freckles, insect bites, healed scars, certain birthmarks, are a normal finding
moisture
-inspect and palpate: -face -skin folds -axillae -palms and soles -assess for diaphoresis or unusual dryness
rales/crackles
-can be fine or coarse -heard at end of inspiration -collapsed or fluid filled alveoli open
dyspnea
-change in this pattern producing shortness of breath or difficulty breathing
Homan's sign
-checking for DVT -"toes to nose" -pain in calf may mean DVT ***do not do if you think pt has a clot already
Cardiac subjective data
-chest pain -dyspnea -orthopnea (sob relieved by position change) -cough -fatigue -cyanosis/pallor -edema -nocturia -cardiac hx -family cardiac hx -personal habits (smoking, unhealthy diet, no exercise)
documentation of skin assessment
-color -shape and configuration -size -location and distribution on body -cancerous lesions ABCDE appraisal of pigmented lesions (improves rate of identification, dx, and trx melanomas): asymmetry, boarder irregularity, color variations, diameter >6mm, evolving changes, -fungal=related to ATB's-oral/groin-yeast infections -allergic-related to new medicine ****always include IV site!
inspection of skin
-color and pigment -lesions -locations of concern
edema
-decrease in skin mobility caused by an accumulation of fluid in the intercellular spaces (swelling/inflammation) -inspection: most noticeable in hands, feet, ankles, and sacral areas -palpation- Is it pitting? use a 4 point scale for pitting - 1= 2mm, 2=4mm, 3=6mm, and 4=8mm (count in seconds) -can be seen in CHF, allergic reaction, lymphedema, injury
Aging adult mouth nose throat
-decrease smell and taste -losing teeth -decreased SQ fat makes nose look more prominent -weight gain/loss can effect denture fit
geriatric eye assessment
-decreased tear production -pupil size decreases and lens loses elasticity causing presbyopia> hold things @ further distance to see -transparent fibers of the lens begin to thicken and yellow resulting in cataract
how well heart is functioning
-determined by heart rate -quality and characteristics of the heart sounds
pregnancy respiratory
-diaphragm elevates approx. 4 cm -decrease in vertical diameter of the thoracic cage -increase in the horizontal diameter -more rapid and shallow respiration -fetus increases maternal O2 demands, which are met by an increased tidal volume -hormonal change: ribs relax, ligaments of thorax relax, horizontal diameter expands, costal angle increases
hair assessment
-inspect and palpate: part the hair -color -texture -distribution -any scalp lesions, including infestations: pediculosiscapitis= head lice -grey scaly patches=fungal infection -red scales=psoriasis -drainage? -male patterned balding=normal finding
physical examination of mouth, nose and throat
-inspect external -palpation -inspect with speculum -palpate -grade tonsils 1>4 -assess gag reflex -look at palate and uvula
neonate mouth nose throat
-integrity of the palate -sucking reflex -by age 2 and 1/2- 20 deciduous teeth
normal nail
-is at a 160 degree angle between the skin and the nail base when viewed laterally -smooth, strong, and regular and are firmly attached to the nail bed with only a slight degree of mobility
lower respiratory system
-distal trachea -bronchi -lungs -pleural membranes -mediastinum -muscles of resp.
treatment for edema
-diuretic 1st drug of choice -elevating extremities -watch sodium intake -wear support stockings
purpose of respiratory system
-divided into upper/lower -primary purpose is gas exchange -CNS functions-maintains acid/base balance, maintains body fluids, and assists with speech
elasticity of skin
-elasticity=turgor +mobility -mobility is the skin's ability to be lifted -turgor is the ability to return to its normal position/shape -pinch area of skin(wrist or hand) -normal= mobile and turgor less than 3 seconds
throughout childhood
-epidermis thickens -pigmentation increases -more SQ fat is deposited, especially in females during puberty.
thoracic cage inspection
-even expansion -shape (anterior/posterior ratio, barrel chest, sunken) -symmetry (asymmetry may indicate postural problems or underlying resp. problems) -height of the scapulae should be even -vertebrae should be midline ( lateral deviation/elevation of one scapula is indicative of scoliosis) -angle of ribs -development of neck trapezius muscles
pregnancy and breasts
-expansion of the ductal system and supporting fatty tissue and the development of the true secretory alveoli -breast enlarge and feel more nodular -nipples are larger, areolae are more erectile -areolae enlarge become darker brown, and have more prominent tubercles -colostrum may be expressed after the 4th month: *starts out yellow in color due to antibodies, then becomes more white after awhile due to increase in fat present in breast milk
wheezes
-expiration (could be insp. when severe) -high pitched -blocked airflow as in asthma, infection or foreign body stuck
pediatric eye assessment
-eye function is limited -iris has little color, changes to permanent color by 3mo -red reflex should be elicited from birth -binocular vision develops at 6 weeks of age -lateral deviations are normal until 2 months (going cross-eyed) -use age appropriate tools to assess visual acuity EX picture chart or Snellen E chart
inspection of the neck and heart vessels
-face, lips, ears, and scalp -jugular veins-suprasternal notch> jugular vein pressure -carotid arteries-look/palpate 1 at a time then auscultate -hands and fingers -chest, abdomen, legs and skeletal structure
Beginning the physical assessment
-focused interview -setting the stage
FEP
-forced expiratory time -test using peek flow meter when consolidation is indicated
spoon nails
-form a concave curve and are thought to be associated with iron deficiency -palpate the nails to determine their thickness, regularity, and attachment to the nail bed
thickness of skin
-generally thin & firm over most parts of the body -thicker over palms, soles of feet, elbows and knees -thinnest over eyelids and lips
subjective data of peripheral vascular system
-leg pain/cramps (claudication) -skin changes on arms or legs -swelling in the arms or legs -lymph node enlargement -medication
acrocyanosis
-hands and feet appear cyanotic in times of stress/cold -true cyanosis would be seen in the tongue, lips, and oral mucosa
Stage IV pressure sore
-has become so deep that there is damage to the muscle and bone, sometimes even tendons and joints -requires packing, wound vac, needs to be moist for healing but not too moist
geriatric ear
-hearing acuity may be decreased -tympanic membrane looks white or dull
risk factors for heart disease and stroke
-high blood pressure -smoking -high cholesterol -obesity -DMII ***lifestyle changes can modify the development of cardiovascular disease
lung development
-in utero during 1st 5 weeks of fetal life primitive lung bud emerges -by 16 weeks the conducting airways reach the same number as adults -32 weeks-surfactant is present in adequate amounts for birth for baby to breath on their own
Healthy people 2020 objectives
-incorporate health promotion in your assessment of the nose, mouth and throat -explain tobacco product use increasing risk of oral cancer -review early signs of oral cancer w/ pt and discuss other effects of smokeless tobacco such as gum recession, bad breath, tooth discoloration, nicotine-dependence, and poor eating habits -smokeless tobacco=not healthy alternative to smoking
secondhand smoke
-increases the pt's risk of adverse health effects can be sidestream or exhaled mainstream
nail assessment
-inspect and palpate nails -shape and contour -consistency=doesn't move -color (pink/white dots=normal can be past trauma) -thick, discolored -capillary refill-less than 3 seconds -push back cuticles to inspect and palpate
geriatric heart
-loss of ventricular compliance, vascular rigidity, and the conduction system of the older adult heart may lose automaticity -in aging adults systolic pressure increases and the left ventricular wall may thicken -the heart has a decreased ability to augment cardiac output with exercise (may get SOB, fatigue easier) -supraventricular and ventricular arrhythmias are more likely and some electrocardiographic changes may occur
bronchial sounds
-loud/high pitches -upper airways and area of trachea -expiration is longer in duration than inspiration
newborns and breasts
-may have gynecomastia or a thin milky discharge from the nipple due to maternal hormones
bronchovesicular sounds
-medium in loudness -large central airways towards peripheral lungs -inspiration/expiration are equal
AV valves
-mitral and tricuspid -closure of these causes the 1st heart sound
cyanosis
-mottle blue color in skin due to inadequate tissue perfusion w/ oxygenated blood -light skinned: skin of lips, mucous membranes, conjunctiva and nail beds appear blue -dark skinned: may appear a shade darker. cyanosis may be undetectable except for lips, tongue, and oral mucous membranes, nailbeds, and conjunctivae which appear pale or blue-tinged
pregnant woman mouth nose throat
-nasal stuffiness -rhinitis -epistaxis -heightened sense of smell -edema of vocal chords-deeper voice -gingivitis
peripheral vascular system assessment
-neck: inspect for jugular venous distension, palpate carotid pulses separate, auscultate for bruit -hands/arms: inspect skin color, temp, texture, turgor, size changes, lesions, edema, clubbing/capillary refill, palpate pulses radial and brachial -legs: inspect color, hair distribution, venous pattern, size, presence of lesions or skin changes, palpate temp or edema, perform strength tests
Healthy people 2020 key objectives
-reduce tobacco use by adults and adolescents -increase the number of adults and adolescents who participate in smoking cessation programs -reduce the proportion of nonsmokers exposed to secondhand smoke Focused areas: asthma, COPD, chronic sleep apnea, tobacco use and chronic bronchitis
Stage I pressure sore
-non-blanchable -reddened area -indicates that a pressure ulcer is starting
upper respiratory system
-nose/nostrils -nasal cavity -mouth -throat (pharynx) -larynx (voice box)
Stage III pressure sore
-now looks like a crater -damage to the tissue below the skin
breast screen for retraction
-observe the breasts as the woman raises her arms overhead, pushes her hands on her hips, and leans forward -watch for skin dimpling
shotti lymph nodes
-occur in ages 4 to 8 -not infected, not tender, but can feel enlarged and can be palpated
hints for setting the stage
-organized and professional approach -comfortable and private setting -explain each step and give specific instructions about procedure -pay attention to nonverbal cues -have equipment ready
color and pigment of skin
-pallor -cyanosis -erythema -jaundice
tactile fremitus
-palpable vibration on the chest wall when the client speaks -strongest over the trachea -diminishes over the bronchi -almost nonexistent over the alveoli of the lungs
breast palpation
-palpate all 4 quadrants -include the tail of Spence, nipples, and areolae -if you feel a lump/mass, note its location, size, shape, consistency, mobility, and distinctness -also notice any related nipple changes, skin changes, tenderness, or lymphadenopathy
unusual dryness
-parched mucous membranes of the mouth are indicators of systemic dehydration -dry skin over the lower legs may be due to vascular insufficiency -localized areas w/ itching may indicate a skin allergy
steroid therapy
-patients can have bruising of the skin if treated with this for long periods of time
developmental considerations include
-pediatric -pregnant females -geriatric groups
diaphoresis
-perfuse sweating -may be caused by exertion, fever, pain, emotional stress, impeding medical crisis such as MI or hypoglycemia
systole
-phase of ventricular contraction -begins with closure of the AV valves -ends with the closure of the aortic/pulmonic valves -closure of these valves (tricuspid/mitral) occurs when the ventricles have been filled -best heard at the apex w/ the diaphragm
diastole
-phase of ventricular relaxation -begins with the closure of the aortic and pulmonic valves -ends with the closure of the AV valves
head and neck lymph nodes
-preauricular -occipital -postauricular -submental -submaxillary(submandibular) -retropharyngeal -superficial cervical -deep cervical -supraclavicular
functions of the skin, hair and nails
-protection from injury or infection -barrier against microorganisms and loss of water -perception/sensory function -temperature regulation -identification/ prints, skin color, hair color -communication -wound repair -absorption and excretion -production of vitamin D
skin assessment
-provides valuable info about pt's health -inspection -palpation
adventitious lung sounds
-rales/crackles -rhonchi -wheezes -stridor -friction rub
erythema
-redness of the skin due to increased visibility of normal oxyhemoglobin or oxygen loaded form of hemoglobin -local inflammation and redness are accompanied by higher temp at the site -light skinned: readily identifiable over the entire body or in localized areas. -dark skinned: generalized redness may be difficult to detect. Localized areas appear purple or darker than surrounding skin
Geriatric Respiratory
-respiratory muscle strength declines after age 50 -costal cartilage becomes more calcified -lung elasticity decreases lessoning their collapse/recoil -chest compressions on elderly isn't as effective bc ^^^ -decreased vital capacity and increased residual volume -decreased respiratory efficiency and cough ability -changes in resp. depth-more shallow -increase in resp. rate
birth lung development
-respiratory system changes from intrauterine to extra uterine breathing -respiratory system is present in utero, but doesn't function until birth (practice breathing) -normal respiratory rate of newborn 30-60
first breath and increase in chest expansion
-results in closure of the foramen ovale and ductus arteriosus
respiration assessment
-rise and fall -signs of difficulty -quality (deep or shallow) -should be smooth and even (may be shallow & rapid)
Right main bronchus
-shorter, wider, and more vertical than the left main bronchus -where aspiration usually takes place
ductus venosus
-shunts a portion of the left umbilical vein blood flow directly to the inferior vena cava, -thus allowing oxygenated blood from the placenta to bypass the liver -can remain open up to 72 hours after birth
geriatric skin assessment
-skin elasticity decreases with age -sebum production-decreases causing dryness -perspiration decreases -decrease in melanin production results in grey hair -increase sensitivity to sunlight -nails tend to get thicker and brittle -senile lentigines= age spots, liver spots, solar lentingo, lentigo senilis, macules-more on skin exposed to sun more
pregnant female skin assessment
-skin pigmentation increases and the development of: -stretch marks(striae gravidarum) start out as red/pink and to a grey/white -melasma: hyperpigmentation patches on the face "mask of pregnancy", mostly disappears, but may be permanent for some -linea nigra: dark line running from the umbilicus to the pubic area (pregnancy line) starts out as linea alba which is white
vesicular sounds
-soft and low pitched -periphery -inspiration is longer
Stage II pressure sore
-started to open -area around the sore may be red/irritated
friction rub
-sticking of lung membrane -inhalation/exhalation -low pitched grating, rubbing sound -pleural inflammation -"metal rake over gravel" -hurts to breath>seen in pleurisy
respiratory subjective data
-symptoms/behaviors ex; cough -SOB -chest pain -pain (OLDCARTICE) -age, family hx -smoking hx -environment (job- at risk for chemical inhalation?) -self-care behaviors (ex: pneumonia/flu immunization)
Healthy People 2020 health promotion
-teach self breast exams -establish regular schedule-best AFTER period when breasts are smallest -familiar date -review ACS's recommendations for mammos and clinical breast exams -for male pt: combine breast exam w/ the anterior thorax exam -inspect the chest wall, palpate nipple area, and palpate axillary lymph nodes
palpation of skin
-temperature -moisture -texture -thickness -turgor -inflammation -vascularity -hair presence and pattern
newborn skin
-thin and soft -temp regulation is inefficient due to less SQ fat, an immature nervous system and the lack of efficient methods to control temp. -can't shiver or sweat -increased risk of heat and water loss
milia
-tiny smooth white cysts of hair follicle -found on forehead and nose -may be confused with newborn acne
childhood lung development
-use abdominal muscles for breathing during infancy and early childhood -respiratory system reaches adult size: adolescence(6) -risks include: SIDS, infections, suffocation, aspiration
auscultation of the chest
-use diaphragm and bell in various positions to include the following locations: Aortic area Pulmonic area Erb's point Tricuspid area Mitral (apex/apical) area
thrill
-vibratory sensation felt (palpated) on the skin overlying an area of turbulent flow. -can feel vibration over hemodialysis pt who has a catheter
focused interview questions
-what brought you in? -general info -illness/infection -symptoms/behaviors -pain -age -environment
vernix caseosa
-white cheese like mixture of sebum and epidermal cells -coats babies body's at birth -see an increase of this when baby is premature
lanugo
-white covering of fine hair in newborns -most prominent on upper chest, shoulder and back -replaced with denser hair later on
jaundice
-yellow undertone due to increased bilirubin in the blood -bilirubin is from breakdown of RBCs -a build up of bilirubin can mean a dysfunction with the breakdown and excretion of it from the body-usually the liver -light skinned: may be generalized -for both light/dark skin: visible in the sclera (white part) of eyes, oral mucosa, hard palate, fingernails, palms of hands and soles of feet.
physiologic jaundice
-yellowing of the skin 3-4 days after birth -treat w/ fluids and phototherapy (bili-light) -considered normal and usually due to liver immaturity
pulmonic area
2nd intercostal space, left sternal border. S2 louder than S1
Healthy people 2020
Assessment of the NOSE, MOUTH & THROAT physical assessment techniques and normal findings
Valves
AV-tricuspid(right) and mitral (left) Semilunar- pulmonary (right) aortic (left)
Erb's point
Left sternal border at the 3rd intercostal space S1 and S2 are heard equal
supraclavicular lymph nodes
above the clavicle
apnea
absence of breathing
developmental stage
adjust your assessment technique or expected findings around what...
superficial cervical lymph nodes
anterior to the sternocleidomastoid muscle
extra ocular muscle function
assessment of these include using the 6 cardinal points of tracking -tests cranial nerves 3,4 and 6
occipital lymph nodes
at the base of the skull
retropharyngeal lymph nodes
at the junction of the posterior and lateral walls of the pharynx at the angle of the jaw
whispered pectoriloquy
auscultation of voice sounds pt whispers "1,2,3" normal lung sounds will be faint, almost indistinguishable
egophony
auscultation of voice sounds when client says "E" -normal lung sound like "eee" -abnormal may sound like "A"
bronchophony
auscultation of voice sounds, pt says "99" and normal lung sound will sound muffled -if not muffled it is an abnormal finding
postauricular lymph nodes
behind the ear, over the outer surface of the mastoid bone
submental lymph nodes
behind the tip of the mandible at the midline
near sighted
cannot see objects far away
far sighted
cannot see objects up close (reading)
function of the heart
circulates blood continuously throughout the body to deliver oxygen and nutrients to the body's organs and tissues and to dispose of their excreted wastes
lymph nodes
clumps of tissue located along the lymphatic vessels either deep or superficially in the body. (they're covered in connective tissue) -their job is to filter lymph fluid, removing any pathogens before the fluid is returned to the bloodstream -not usually palpable
age and weight loss
decreased turgor maybe occur with these
visual acuity test
distance vision-use Snellen eye chart near vision- have them read something smaller
breast assessment
do as woman sits and look at: -general appearance -symmetry -color -texture -integrity of skin -symmetry/shape/abnormalities of nipples and areolae -inspect/palpate axillae & regional lymph nodes -palpate all 4 quadrants of breast
infant ear
eustachian tube is short, wide and horizontal
Healthy People 2020
eye objective -increase the # of persons who have dilated eye exams -increase vision screening in preschool children -reduce visual impairment due to disease -sun glasses use through the lifespan
Healthy people 2020 heart
focus on: -CAD -hyperlipidemia -heart disease and women Key objectives: -education-on risks, diet, and exercise, & health screens -symptoms -wt reduction -increase physical activity
percussion of the chest
for cardiac border-resonant, flat, dull
Health promotion and teaching
healthy people 2020 -objectives include-reducing occupational skin diseases or disorders among full-time workers and reducing rate of sunburns
9 sets
how many lymph nodes drain the head and neck
preauricular lymph nodes
in front of the ear
scleroderma
increased turgor may be seen with this skin condition where the underlying CT becomes scarred and immobile
betamethasone
injection given if mom goes into preterm labor to help baby's body release surfactant for lung development
hypoventilation
irregular, shallow, <10 bpm
ductus arteriosus
is a blood vessel connecting the pulmonary artery to the proximal descending aorta. -this allows blood to go from the right ventricle to (bypass the lungs) to the aorta in fetus'
Tricuspid area
left 4th intercostal space S1 is louder than S2
Mitral (apex/apical) area
left 5th intercostal space at the midclavicular line
deep lymph nodes
located in the abdomen and the thoracic cavity
superficial lymph nodes
located in the neck, axillary region and inguinal region
tympany
loud, drum like quality, heard over stomach, gas filled intestines, or pneumothorax AKA collapsed lung
hyperresonance
loud, lower pitched than normal resonance, heard over hyperinflated lungs like in COPD and asthma
resonance
low pitched sound heard over normal lungs
3 common causes of decreased visual functioning
mainly in geriatric population 1) cataracts-clouding of lens 2) glaucoma-damage to optic nerve (ex: u/c DM) 3) macular degeneration- loss of vision in center d/t retina damage
pregnant female ear
may experience fullness or earaches
dull
medium intensity in pitch and duration, hear over "mixed" solid organ and lung tissue, such as over the top area of the liver, partially consolidated lung tissue (pneumonia), and fluid filled pleural space
eupnea
normal respiration: -regular, even, rhythmic pattern of breathing
developmental differences
nurse must identify developmental, psychosocial, cultural, and environmental factors reflecting the client's state of health.
skin color and temperature
observe for signs of appropriate cardiac function in relation to O2 perfusion by assessing...
submaxillary lymph nodes
on the medial border of the mandible
foramen ovale
opening between the atrial chambers, allows oxygenated blood from the placenta to be shunted to the left side of the heart and out to the general circulation
pallor
paleness or loss of color in skin due to the absence of oxygenated hemoglobin -light skin loses its rosy tones, skin w/ natural yellow tones appear more yellow may be mistaken for jaundice. -dark skinned: loses its red undertones and appears ash grey. -brownish skin becomes yellow-tinged and skin may appear dull
poor lung expansion
patients with scoliosis may have
tympanic membrane assessment
position: bulging-fluid behind ear flat-normal retracted-blown out color: pearly, grey or red integrity: intact or ruptured?
deep cervical lymph nodes
posterior to the sternocleidomastoid muscle
hyperventilation
rapid, deep, >24 bpm
tachypnea
rapid, shallow, >24 bpm
agonal
rate intermittent, depth variable -also seen in dying patient's
Cheyne-stokes
rate variable, depth variable, periods of apnea -seen in dying patient's
lymphatic system
retrieves excess fluid, called lymph, from the tissue spaces and carries it to the lymph nodes throughout the body.
aortic area
right second intercostal space. S2 is louder than S1
admission assessment
should be the most thorough assessment so we know everything about the patient physically
bradypnea
slow, regular, <10 bpm
sidestream smoke
smoke released from the burning end of a cigarette, cigar, or pipe (chemical constituents of sidestream smoke are different from those directly inhaled, mainstream smoke; class A carcinogen EPA
flat
soft high pitched sound heard over very dense tissue where air is not present (bones)
physical abuse
special considerations -bruises or welts in a pattern -burns with sharply demarcated edges suggestive of injury from cigarettes, irons, or immersion of body part in boiling water -additional injuries -multiple injuries -fear -trust your gut feeling -nurses are mandatory reporters even if it is just a suspicion
the obese client
special considerations -risk for rashes and skin breakdown -pressure on bladder/bowel from weight of abdomen as well as reduced mobility may contribute to an increased incidence of incontinence -yeast infections (intertrigo)
glaucoma
the leading cause of preventable blindness in the US, encourage early screenings for prevention
exhaled mainstream smoke
the smoke exhaled by the smoker -when a cigarette is smoked about 1/2 of the smoke is inhaled/exhaled (mainstream) by the smoker and the other half floats around in the air.
skin breakdown risk assessment
turn q2hrs to relieve pressure, free of moisture
assessing lymph nodes
use light pressure and use fingertips
braden scale
used for predicting pressure sore risk
setting the stage
warm comfortable private remove clothing, jewelry, wigs etc. -lighting should be strong and direct
