NSG303 Exam 1
Physical Examination: Percussion Purposes
- Eliciting pain -Determining location, size, and shape -Determining density -Detecting abnormal masses -Eliciting reflexes Physical Examination: Percussion Types · Direct · Blunt · Indirect or mediate
Factors that Affect Disease, Illness, and Health State
-->Biomedical variations · Nutrition/dietary habits · Family roles and organization, patterns · Workforce issues · High-risk behaviors · Pregnancy and childbirth practices · Death rituals · Religious and spiritual beliefs and practices · Health care practices · Health care practitioners · Environment
PIAAA - General Health Survey and Vital Signs
1. Prepare the client for a survey of general health status and vital signs. 2. Interview the client for an accurate survey of his or her general health status and vital signs. 3. Correctly perform an accurate general survey. 4. Assess accurate vital signs. 5. Discuss the assessment of pain as a fifth vital sign. 6. Describe findings often seen when assessing an older client's general health status and vital signs. 7. Differentiate between normal and abnormal findings in the general survey and vital signs. 8. Analyze general survey and vital sign assessment data to formulate valid nursing diagnoses, collaborative problems, and/or referrals.
Bruits
A bruit (pronounced "broo'-ee,") is an abnormal whooshing sound of blood through an artery that usually indicates that the artery has been narrowed, causing a turbulent flow, as in arterioscleroisis. Bruits are abnormal - if the patient is healthy and "normal," you should not hear any bruits. Bruits can be detected in the neck (carotid bruits), umbilicus (abdominal aortic bruits), kidneys (renal bruits), femoral, iliac, and temporal arteries.
Phases of Nursing Process 1. Assessment: Collecting subjective and objective data 2. Diagnosis: Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral) 3. Planning: Determining outcome criteria and developing a plan 4. Implementation: Carrying out the plan 5. Evaluation: Assessing whether outcome criteria have been met and revising the plan as necessary
ADPIE!
Abdomen Structures
Abdomen • Bordered superiorly by the costal margins • Bordered inferiorly by the symphysis pubis and inguinal canals • Bordered laterally by the flanks Abdominal Quadrants • Four quadrants: right upper quadrant (RUQ), right lower quadrant (RLQ), left lower quadrant (LLQ), left upper quadrant (LUQ) • Two imaginary lines (vertical/midline; horizontal/lateral) • Regions commonly used: epigastric, umbilical, hypogastric, or suprapubic Abdominal quadrants ABDOMINAL REGIONS Right Upper Quadrant • Ascending and transverse colon • Duodenum, gallbladder, hepatic flexure of colon, liver • Pancreatic head, pylorus, right adrenal gland • Right kidney, right ureter Right Lower Quadrant • Appendix • Ascending colon, cecum • Right kidney • Right ovary and tube • Right ureter • Right spermatic cord Left Upper Quadrant • Left adrenal gland • Left kidney • Left ureter • Pancreas, spleen, stomach • Transverse descending colon Left Lower Quadrant • Left kidney • Left ovary and tube for women • Left ureter • Left spermatic cord for men • Descending and sigmoid colon Abdominal Wall Muscles • Three muscle layers from back, around flanks, to front: external and internal abdominus oblique, transverse abdominus • Abdominal wall muscles protect internal organs; allow normal compression of internal organs during functional activities Internal Anatomy • Parietal peritoneum; visceral peritoneum • Different body systems: - Gastrointestinal - Reproductive (female) - Lymphatic and urinary Internal Anatomy (cont.) • Solid viscera: liver, pancreas, spleen, adrenal glands, kidneys, ovaries • Hollow viscera: stomach, gallbladder, small intestine, colon, bladder • Palpation of abdominal viscera depends on location, structural consistency, size Internal Anatomy (cont.) • Viscera normally not palpable: - Pancreas, spleen, stomach, gallbladder, small intestine • Vascular structures: abdominal aorta; right and left iliac arteries Collecting Subjective Data: The Nursing Health History Current Symptoms • Abdominal pain • Indigestion • Nausea and vomiting • Appetite • Bowel elimination History • Past: - Abdominal surgery, trauma, injury, medications - Abdominal pain and treatment - Lab work or gastrointestinal studies • Family: - Stomach, colon, liver cancer - Abdominal pain, appendicitis, colitis, bleeding, hemorrhoids - Nutritional habits in family
Analysis Phase of Nursing Process (Steps)
Analysis Phase of Nursing Process · Identify abnormal data and strengths. · Cluster the data. · Draw inferences and identify problems. · Propose possible nursing diagnoses. · Check for defining characteristics of those diagnoses. · Confirm or rule out nursing diagnoses. · Document conclusions.
Is the following statement true or false? The pulmonary artery returns oxygenated blood to the left atrium.
Answer False. The pulmonary artery carries blood to the lungs.
Peripheral vascular system
Arteries ・ Carry oxygenated, nutrient-rich blood from the heart to the capillaries ・ Major arteries of arm: brachial, radial, ulnar ・ Major arteries of the leg: femoral, popliteal, dorsalis pedis, posterior tibial Veins ・ Carry deoxygenated, nutrient-depleted, waste-laden blood from the tissues back to the heart ・ Types of veins: Pulmonary veins, Systemic veins, Deep veins, and superficial veins Lymphatic System ・ Lymphatic capillaries, lymphatic vessels, lymph nodes ・ Capillaries and fluid exchange ・ Small blood vessels ・ Form the connection between the arterioles and venules ・ Allow the circulatory system to maintain vital equilibrium The lymphatic system collects excess fluid that drains from cells and tissue throughout the body and returns it to the bloodstream, which is then recirculated through the body.
Risk Factors for Methicillin-Resistant Staphylococcus aureus
Assess for hospital-acquired MRSA risk factors: - Having an invasive medical device - Residing in a long-term care facility - Presence of an MRSA-positive person in the facility Risk Factors for Methicillin-Resistant Staphylococcus aureus Cont' • Assess for community-acquired MRSA risk factors: - Participating in contact sports - Sharing personal items such as towels or razors - Suppression of immune system function (e.g., HIV, cancer, or chemotherapy) - Residing in unsanitary or crowded living conditions (e.g., dormitories or military barracks) - Working in the health care industry - Receiving antibiotics within the past 3 to 6 months - Young or advanced age - Men having sex with men - Hemodialysis Measures to Reduce Risk Factors for Methicillin-Resistant Staphylococcus aureus • Keep wounds covered. • Do not share personal items. • Avoid unsanitary or unsafe nail care practices. • If treatment has been started, do not stop until recovery is complete. • Use universal precautions when touching others to avoid contact with contaminated body fluids. Wash your hands. • Clean sports equipment between uses to avoid spread of infection. • Wash clothes, sheets, towels, razors, and other personal items before and after use. • Clean hands often.
NORMAL LIVER SIZE
Assessed by percussion. Should be 6-12 cm high in the right midclavicular line. 4-8 cm high in the midsternal line.
The nurse's role in health assessment - collecting and analyzing data
Assessment: Important for Every Situation Current focus on managed care and internal case management has had a dramatic impact on the assessment role of the nurse. Acute care Critical care Ambulatory care Home health
Blood Pressure
BLOOD PRESSURE • Blood pressure measurement Sphygmomanometer Cuff width and size • Blood pressure measurement in the arm Position of person Palpate brachial artery Proper inflation and deflation technique Blood Pressure • Systolic blood pressure is a measurement of the pressure of the blood in the arteries when the ventricles are contracted. • Diastolic blood pressure is a measurement of the pressure of the blood in the arteries when the ventricles are relaxed. Factors Affecting Blood Pressure • Cardiac output • Elasticity of arteries • Blood volume • Blood velocity (heart rate) • Blood viscosity (thickness) Measuring Blood Pressure with a Sphygmomanometer • Common errors in blood pressure measurement - Orthostatic (or postural) hypotension - Blood pressure measurement in the thigh Thigh pressure higher than in the arm BP CUFFS - Important to fit size appropriate to arm width
Temperature
Body Temperature • Heat produced - heat lost = body temperature Hypothalamus as thermostat mechanism • Acceptable temperature range: - 98.6° F to 100.4° F - or 36° C to 38° C - Elderly patients run low 95-97 • Temperature sites: Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery *The rectal temperature is between 0.4°C and 0.5°C (0.7°F and 1°F) higher than the normal oral temperature* Using thermometer to take oral temperature Using an Tympanic Membrane Thermometer Rise in Temperature • Strenuous exercise • Stress • Ovulation - temp goes up • Menopause - temp goes down • Hyperthermia - Viral or bacterial infections - Malignancies - Trauma - Various blood, endocrine, immune disorders
Health Assessment: (illness assessment) • Interview Approach
Character, Onset, Location, Duration, Severity, Pattern and Associated Factors (COLDSPA) + - History of current health problem, past health, family - Lifestyle and health practices
Radial Pulse
Characteristics of Radial Pulse • Rate • Rhythm • Amplitude and contour
Client Approach and Preparation to PE
Client Approach and Preparation to PE - Establish nurse-client relationship. · Explain the procedure and the physical assessment that will follow, describing the steps of the examination. · Respect client's requests and desires. · Explain the importance of the examination. Client Approach and Preparation (Continued) · Leave room while client changes clothes. · Provide necessary container in case of need for sample. · Begin exam with less intrusive procedures. · Explain procedure being performed. · Explain to client why position changes are necessary. Client Positioning · Sitting position · Supine position · Dorsal recumbent position · Sims' position - laying on side and leg is adjusted · Standing position · Prone position · Knee-chest position · Lithotomy position
Client Positioning Con't
Client Positioning · Sitting position · Supine position · Dorsal recumbent position · Sims' position - laying on side and leg is adjusted · Standing position · Prone position · Knee-chest position · Lithotomy position Bolded to be reviewed
Skin Assessment: Inspection
Client Preparation • Ask the client to remove all clothing and jewelry. • Have the client sit comfortably. • Ensure privacy. • Maintain comfortable room temperature. Equipment for Skin, Hair, and Nail Assessment • Gloves • Examination light and penlight • Mirror for client's self-examination of skin • Magnifying glass • Centimeter ruler • Wood light • Examination gown or drape Skin Assessment: Inspection • Note any distinctive odor • Generalized color variations • Skin breakdown • Primary, secondary, or vascular lesions •Capillary refill assessment Skin Assessment: Palpation • Lesions • Texture • Temperature and moisture • Thickness of skin • Mobility and turgor • Edema Pressure Ulcer Risk Factors • Perception • Mobility • Moisture • Nutrition • Friction or shear against surfaces • Tissue tolerance decreased • Assessment Tool 14-1, Braden Scale For Predicting Pressure Sore Risk • Assessment Tool 14-2, PUSH Tool to Measure Pressure Ulcer Healing PUSH Tool. The Pressure Ulcer Scale for Healing (PUSH) tool is a fast and accurate tool, used to measure the status of pressure wounds over time. The Braden Scale is a scale made up of six subscales, which measure elements of risk that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. These are: sensory perception, moisture, activity, mobility, friction, and shear. Pressure Ulcer Risk Reduction • Inspect the skin at least daily and more often if at greater risk using risk assessment tool (such as Braden Scale or PUSH tool) and keep flow chart to document. • Bathe with mild soap or other agent; limit friction; use warm, not hot, water; set bath schedule that is individualized. • For dry skin: use moisturizers; avoid low humidity and cold air. • Avoid vigorous massage. Pressure Ulcer Risk Reduction (cont.) • Use careful positioning, turning, and transferring techniques to avoid shear and friction or prolonged pressure on any point. • Refer nutritional supplementation needs to primary care provider or dietitian, especially if protein deficient. • Refer incontinence condition to primary care provider. • Use incontinence skin cleansing methods as needed: frequency and methods of cleaning, avoiding dryness with protective barrier products.
Use of open-ended questions vs close ended questions o Effective communication vs ineffective
Closed= used in directive interviews, yes or no answers, usually factual Open= non-directive interviews, clients freedom to divulge information. Leading questions vs neutral questions Neutral= a question the client can answer without direction or pressure, is open ended, ex: "How do you feel about that?"Leading=usually closed, directive, directs the clients answer, ex: "You're stressed about surgery tomorrow, aren't you?"
Regular eye examinations
Collecting Subjective Data • History of present health concern • Past health history • Family history • Lifestyle and health practices Collecting Objective Data • Preparing the client • Equipment - Snellen or E chart - Hand-held Snellen card or near-vision screener - Jaeger test - also a near visual acuity test - Penlight - Opaque cards - Cover and uncover test. This test checks the alignment of the eyes when a child is focusing on an object. One eye is covered with an opaque card while the child stares straight ahead. The examiner then observes the uncovered eye for movement. - Ophthalmoscope Distant Visual Acuity • Snellen chart • Normal acuity is 20/20 with or without corrective lenses Near Visual Acuity • Handheld vision chart • Jaeger test (pocket screener) • Normal acuity is 14/14 with or without corrective lenses *** Confrontation Test Testing Extra-ocular Muscle Function • Corneal light reflex test: Use penlight to observe parallel alignment of light reflection on corneas. • Cover test: Use opaque card to cover an eye to observe for eye movement. • Positions test: Observe for eye movement.
Collection of Objective Data - (Prior to PE)
Collection of Objective Data · Physical characteristics · Body functions · Appearance · Behavior · Measurements · Results of laboratory testing
collection of subjective data
Collection of Subjective Data · Biographical information · History of present health concern; physical symptoms related to each body part or system · Personal health history · Family history · Health and lifestyle practices · Review of systems
Common Nail Disorders
Common Nail Disorders • Longitudinal ridging - deficiency in zinc? • Half-and-half nails • Pitting - psoriasis • Koilonychia • Yellow nail syndrome • Paronychia - fungal infection
Structure and Function: The Head
Cranium—8 bones • Frontal (1) • Parietal (2) • Temporal (2) • Occipital (1) • Ethmoid (1) • Sphenoid (1) Face—14 bones • Maxilla (2) • Zygomatic (2) • Inferior conchae (2) • Nasal (2) • Lacrimal (2) • Palatine (2) • Vomer (1) • Mandible (1)
cues vs inferences
Cues= are subjective or objective data that can be directly observed by the nurseInferences= nurse interpretations or conclusions made based on the cues
Culture (Intro)
Culture · Purnell: "the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteristic of a population or people that guide their worldview and decision making." Basic Characteristics · Learned · Shared · Associated with adaptation to the environment · Universal What is the verbal and behavioral system of culture, when it is transmitted from one generation to the other? A culture is Learned
How is Culture Adopted?
Culture is ___ when it is transmitted from one generation to the other Learned Culture is ___ when norms for behaviors, values, and beliefs are ___ by the cultural group Shared Culture is ___ with adaptation to the environment Associated Culture is ___ as it may vary but humans cannot exist without culture Universal These are factors affecting ___ to providers: ethnicity, generational status, education, religion, previous health care experiences, occupation and income level; beliefs about time and space, communication needs/preferences Approach to Providers
PVS - Complications
Deep Vein Thrombosis: Risk Factors ・ Reduced mobility ・ Dehydration ・ Increased viscosity of the blood ・ Venous stasis Risk Factors for Lower Extremity PAD ・ Age younger than 50 in people who have diabetes and one additional risk factor, such as smoking, dyslipidemia, hypertension, or hyperhomocysteinemia ・ Ages 50 to 64 in people with a history of smoking or diabetes ・ Age 65 or older ・ Leg symptoms with exertion (suggesting claudication) or ischemic rest pain ・ Atherosclerotic coronary, carotid, or renal artery disease ・ Smoking, or history of smoking ・ Diabetes ・ Obesity ・ High blood pressure ・ High cholesterol ・ Family history of peripheral artery disease, heart disease, or stroke ・ Excess levels of homocysteine ・ African American Risk Factors for Venous Stasis ・ Long periods of standing still, sitting, or lying down. ・ Lack of muscular activity causes blood to pool in the legs, which, in turn, increases pressure in the veins. ・ Varicose (tortuous and dilated) veins, which increase venous pressure. Damage to the vein wall can also contribute to venous stasis. Reduce Risk Factors Associated with Peripheral Vascular Disease ・ Quit smoking if you're a smoker. ・ If you have diabetes, keep your blood sugar under control. ・ Exercise regularly. Aim for 30 minutes at least three times a week after you've gotten your doctor's OK. ・ Lower your cholesterol and blood pressure levels, if necessary. Reduce Risk Factors Associated with Peripheral Vascular Disease (cont.) ・ Eat foods that are low in saturated fat. ・ Maintain a healthy weight. ・ Ask your health care provider about screening with an ankle-brachial index (ABI) measurement once you reach 50 years of age. Subjective Data: Current Symptoms ・ Skin changes ・ Leg pain, heaviness, or aching ・ Leg veins ・ Leg sores or open wounds ・ Swelling in legs or feet ・ Men: sexual activity changes ・ Swollen glands or nodules Subjective Data: History ・ Past ・ Previous problems with circulation in arms or legs ・ Heart or blood vessel surgeries or treatments ・ Family ・ Varicose veins, diabetes, hypertension, coronary heart disease, or elevated cholesterol or triglyceride levels Subjective Data: Lifestyle and Health Practices ・ Tobacco use ・ Regular exercise ・ Oral contraceptives use ・ Degree of stress ・ Peripheral vascular problems interfering with ADLs ・ Medications to improve circulation or control blood pressure ・ Support hose Client Preparation ・ Explain procedure to client. ・ Ask client to put on a gown. Equipment ・ Gloves ・ Centimeter tape ・ Stethoscope ・ Doppler ultrasound probe ・ Tourniquet ・ Gauze ・ Waterproof pen ・ Blood pressure cuff OBJECTIVE DATA: Arms: Inspection ・ Size, presence of edema, venous patterning ・ Skin color ・ Fingertips for clubbing OBJECTIVE DATA: Arms: Palpation ・ Fingers, hands, and arms for temperature ・ Capillary refill time ・ Radial, ulnar, and brachial pulses ・ Allen test OBJECTIVE DATA: Legs: Inspection ・ Skin color ・ Distribution of hair ・ Lesions or ulcers ・ Edema ・ Varicose veins OBJECTIVE DATA: Legs: Palpation ・ Temperature ・ Superficial inguinal lymph nodes ・ Femoral pulse, listening for bruits ・ Popliteal, dorsalis pedis, posterior tibial pulses Question Which pulse should a nurse palpate in the arm during a vascular assessment of the client? A. Popliteal pulse B. Femoral pulse C. Posterior tibial pulse D. Ulnar pulse Answer D. Ulnar pulse. The nurse should palpate the ulnar pulse in the arm during a vascular assessment. The popliteal, femoral, and posterior tibial pulses are located in the legs. Arterial Insufficiency ・ Pain: intermittent claudication to sharp, unrelenting, constant ・ Pulses: diminished or absent ・ Skin characteristics: dependent rubor Venous Insufficiency ・ Pain: aching, cramping ・ Pulses: present, but may be difficult to palpate through edema Older Adult Findings ・ Hair loss on the lower extremities occurs with aging and is, therefore, not an absolute sign of arterial insufficiency in the older client. ・ With aging, lymphatic tissue is lost, resulting in smaller and fewer lymph nodes. ・ Varicosities are common in the older client.
religion vs spirituality
Definition of Religion · Rituals, practices, and experiences involving a search for the sacred · Shared within a group · Some faiths, this idea of religion encompasses the concept of spirituality and is a natural outflow of that idea · Others may view spirituality as a separate concept, possibly disconnected from any religious institution Religion · Defining characteristics · Formal · Organized · Group oriented · Ritualistic · Objective, as in easily measurable (e.g., church attendance) Spirituality · Definition · A search for meaning and purpose in life · Seeks to understand life's ultimate questions in relation to the sacred · Defining Characteristics · Informal · Nonorganized · Self-reflection · May involve spiritual experiences · Subjective, as in difficult to consistently measure (e.g., daily spiritual experiences, spiritual well-being, etc.)
Discussing Sensitive Issues
Discussing Sensitive Issues · Be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality. · Ask simple questions in a nonjudgmental manner. · Allow time for ventilation of client's feelings as needed. · If you do not feel comfortable or competent discussing personal, sensitive topics, you may make referrals as appropriate.
Near-sightedness vs far-sightedness
Distant Visual Acuity • Snellen chart • Normal acuity is 20/20 with or without corrective lenses Near Visual Acuity • Handheld vision chart • Jaeger test (pocket screener) • Normal acuity is 14/14 with or without corrective lenses ***
Nursing process definition
Dynamic, client-centered, problem solving, decision making, interpersonal, collaborative, universally applicable Definition of Assessment the systematic and continuous collection, organization, validation, and documentation of data
Electrical Conduction System
Electrical Conduction of the Heart • Sinoatrial node • AV node • AV bundle (bundle of His) • Purkinje fibers THE ELECTRICAL CONDUCTION SYSTEM Electrocardiogram • Electrical activity of heart measured by electrocardiography (ECG) • Phases of ECG: P, Q, R, S, T • Records depolarization and repolarization ELECTROCARDIOGRAM Cardiac Cycle • Filling and emptying of the heart's chamber • Two phases: diastole and systole - Diastole: relaxation of the ventricles - Systole: contraction of the ventricles
Physical Examination: Auscultation
Eliminate distracting noise. · Expose the body part being auscultated. Correct Use of a Stethoscope · Warm diaphragm and bell before use. · Explain what you are listening to and answer any questions. · Don't apply too much pressure when using the bell as it will cause the bell to work like the diaphragm. · Avoid listening through clothes. -high-pitched sounds; lung sounds, and heart sounds (normal) (wheezing) - Bell, low-pitched sounds - heart murmurs, bowel sounds Diaphragm vs. Bell. The diaphragm is best for higher pitched sounds, like breath sounds and normal heart sounds. The bell is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds. It is used for the detection of bruits, and for heart sounds (for a cardiac exam, you should listen with the diaphragm, and repeat with the bell). If you use the bell, hold it to the patient's skin gently for the lowest sounds, and more firmly for the higher ones. · Place earpieces into outer ear canal. · Angle the two binaural down toward nose. diaphragm, which is larger, flatter side of the chest piece, and the bell, which has the smaller, concave piece with a hole in it.
Equipment for Heart and Neck Vessels Assessment
Equipment for Heart and Neck Vessels Assessment • Stethoscope with a bell and diaphragm • Small pillow • Penlight or movable examination light • Watch with second hand • Centimeter rulers Assessment of Precordium and Heart Sounds • Inspect pulsations. • Palpate the apical impulse. • Palpate for abnormal pulsations. • Auscultate heart rate and rhythm. • If you detect an irregular rhythm, auscultate for a pulse rate deficit. • Auscultate to identify S1 and S2. • Listen to S1 and S2. • Auscultate for extra heart sounds. • Auscultate for murmurs. • Auscultate with the client assuming other positions.
External Eye Structures
External Eye Structures • Inspect the eyelids and eyelashes. • Observe the position and alignment of the eyeball in the eye socket. • Inspect the bulbar conjunctiva and sclera. • Inspect the palpebral conjunctiva. • Inspect the lacrimal apparatus. • Palpate the lacrimal apparatus. • Inspect the cornea and lens. • Inspect the iris and pupil. • Test pupillary reaction to light. • Test accommodation of pupils. Pupillary Reaction to Light • Darkened room • Have client focus on a distant object • Shine light obliquely into the pupil and observe the pupil's reaction to light • Normally, pupils constrict Accommodation • Shifting gaze from far to near •Normally, pupils constrict
Structures of the Eye
External Structure of the Eye • Eyelids • Lateral (outer) and medial (inner) canthus • Eyelashes, conjunctiva • Lacrimal apparatus • Extraocular muscles Structure of the Eye Internal Structure of the Eye • Sclera, cornea, iris, ciliary body • Pupil, lens, choroid, retina, optic disc • Physiologic cup, retinal vessels • Anterior chamber, posterior chamber Vision • Visual fields • Visual pathways - how the light goes into retina and transformed into nerve impulses • Visual reflexes - Pupillary light reflex - Accommodation Cataract • Opacity or clouding of the eye's lens • Leading cause of blindness worldwide
Abnormalities on Eye examination
Extraocular Muscle Dysfunction • Corneal light reflex test abnormalities - Pseudostrabismus, strabismus (or tropia) • Test abnormalities - Phoria (mild weakness) • Positions test abnormalities - Paralytic strabismus, 6th, 4th, 3rd nerve paralysis - LAZY EYE Abnormalities of External Eye • Ptosis • Exophthalmos • Entropion • Ectropion • Chalazion • Blepharitis • Conjunctivitis • Hordeolum • Diffuse episcleritis Visual Field Defects • Unilateral blindness • Bitemporal hemianopia • Left superior quadrant anopia • Right visual field loss • Lesion in optic nerve • Lesion of optic chiasm • Partial lesion of temporal loop • Lesion in right optic tract or lesion in temporal loop Abnormalities of Cornea and Lens • Corneal abnormalities - Corneal scar - Pterygium • Lens abnormalities - Nucleus cataract - Peripheral cataract Abnormalities of Iris and Pupil • Irregularly shaped iris • Miosis - fixed and constricted (drugs, brain damage CNS) • Anisocoria - unequal pupil size (number of causes) • Mydriasis - fixed and dilated (drugs (anesthesia), brain damage CNS) Abnormalities of Retinal Vessels and Background • Constricted arteriole • Copper wire arteriole • Silver wire arteriole • Arteriovenous nicking • Arteriovenous tapering • Arteriovenous banking Abnormalities of Retinal Vessels and Background (cont.) • Cotton wool patches - diabetic retinopathy/hypertension • Hard exudate - diabetic retinopathy/hypertension Superficial (flame-shaped) retinal hemorrhages • Deep (dot-shaped) retinal hemorrhages - diabetic retinopathy • Microaneurysms • Hypertension could also cause papilledema (pressure on the ocular nerve) • Glaucoma and deterioration of the optic nerve - also abnormalities Abnormalities of the Optic Disc • Papilledema • Glaucoma • Optic atrophy
Is the following question true or false? In 3rd nerve paralysis, the eyes cannot look down when turned inward.
False. Three nerves control how your eyes move, where your eyelids are, and how large your pupils are. These 3 nerves are: Third cranial nerve (oculomotor nerve) Fourth cranial nerve (trochlear nerve) Sixth cranial nerve (abducens nerve) ON TOP ALWAYS 3, 4, 6 The fourth cranial nerve controls the actions of one of the external eye muscles, the superior oblique muscle. This muscle runs from the back of the eye socket to the top of the eye. It passes through a loop of tissue near the nose known as the trochlea. It turns the eye inward and downward. Diseases or injuries to the fourth cranial nerve can cause the superior oblique muscle to be paralyzed. The name for this condition is fourth nerve palsy. Other names for it are superior oblique palsy and trochlear nerve palsy. *ooottafvgvsn* THIRD, FORTH AND SIXTH NERVE PALSEY
Findings in Older Adults
Findings in Older Adults • Older clients who have arthritis or osteoporosis may experience neck pain and a decreased ROM. • In older clients, facial wrinkles are prominent because subcutaneous fat decreases with age. In addition, the lower face may shrink and the mouth may be drawn inward as a result of resorption of mandibular bone, also an age-related process. • The strength of the pulsation of the temporal artery may be decreased in the older client. • In older clients, cervical curvature may increase because of kyphosis of the spine. Moreover, fat may accumulate around the cervical vertebrae (especially in women). This is sometimes called a "dowager's hump." • Older clients usually have somewhat decreased flexion, extension, lateral bending, and rotation of the neck. This is usually due to arthritis. • If palpable, the older client's thyroid may feel more nodular or irregular because of fibrotic changes that occur with aging; the thyroid may also be felt lower in the neck because of age-related structural changes. Validating and Documenting Findings • Health promotion diagnoses • Risk diagnoses • Actual diagnoses • Collaborative problems • Medical problems
Palpation Con't
Five sounds elicited by percussion resonance, hyper-resonance, tympany, dullness, flatness resonance intensity: loud pitch: low length: long quality: hollow example:normal lung (normal air-filled lung, without presence of fluid) hyper-resonance intensity: very loud pitch: low length: long quality: booming example: lung with emphysema (Air-filled excessively) tympany intensity: loud pitch: high length: moderate quality: drum-like example: gastric bubble (drum sound when you puff out your cheek) dullness intensity: medium pitch: medium length: moderate quality: thud-like example: liver (dullness on percussion for infiltrates in lung) - Note that pleural fluid and clear lungs would elicit a hyper-resonant sound flatness intensity: soft pitch: high length: short quality: flat example:bone
Health History
Health History—Biographical Data · Name · Address · Phone · Gender · Provider of history (patient or other) · Birth date · Place of birth Health History · Biographical data · Reasons for seeking health care · History of present health concern · Past health history · Family health history · Review of systems for current health problems · Lifestyle and health practices · Developmental level
Validating and Documenting Findings
Health promotion diagnoses Risk diagnoses Actual diagnoses Collaborative problems Medical problems
The purpose of the health assessment
Holistic nursing assessment - Collects holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment Physical medical assessment - Focuses primarily on the client's physiologic development status
Altered Thyroid Function
Hypothyroidism • Increased sensitivity to cold • Constipation • Depression • Fatigue • Heavier menstrual periods • Pale, dry skin • Thin, brittle hair or nails • Weakness • Unintentional weight gain Hyperthyroidism • Sudden weight loss, without changes in appetite and diet • Increased appetite • Rapid heartbeat (tachycardia) greater than 100 beats a minute, irregular heartbeat (arrhythmia), or palpitations • Nervousness, anxiety, and irritability • Tremor in the hands and fingers • Sweating Hyperthyroidism (cont.) • Changes in menstrual patterns • Increased sensitivity to heat • Changes in bowel patterns, more frequent bowel movements • Enlarged thyroid gland (goiter) • Fatigue, insomnia • Muscle weakness
Collecting Objective data: The Physical Examination
Inspection, Auscultation, Palpation, Percussion (IPPA Method) Review of Body Systems · Skin, hair, nails · Head, neck · Eyes · Ears · Mouth, throat, nose, sinuses · Thorax, lungs · Breasts, regional lymphatics · Heart, neck vessels · Peripheral vascular · Abdomen · Genitalia · Anus, rectum, prostate · Musculoskeletal · Neurologic
Special Considerations Populations · Emotional variations
Interacting with an Anxious Client · Provide the client with simple, organized information in a structured format. · Explain who you are and your role and purpose. · Ask simple, concise questions. · Avoid becoming anxious like the client. · Do not hurry. · Decrease any external stimuli. Interacting with an Angry Client · Approach the client in a calm, reassuring, in-control manner. · Allow the client to vent feelings. · Avoid any arguments with or touching the client. · Obtain help from other health care professionals as needed. · Facilitate personal space so that the client does not feel threatened or cornered. · Never allow the client to position him or herself between you and the door. Interacting with a Depressed Client · Express interest in and understanding of the client and respond in a neutral manner. · Take care not to communicate in an upbeat, encouraging manner. Interacting with a Manipulative Client · Provide structure and set limits. · Differentiate between manipulation and a reasonable request. · Obtain an objective opinion from other nursing colleagues. Interacting with a Seductive Client · Set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors. · Encourage client to use more appropriate methods of coping in relating to others. · If the overt sexuality continues, do not interact without a witness. · Report inappropriate behavior to a supervisor
Retinal examination
Internal Eye Structures • Inspect the optic disc. • Inspect the retinal vessels. • Inspect the retinal background. • Inspect the fovea and macula. - FOVER IS PHYSIOLOGIC CUP • Inspect the anterior chamber.
Phases of Assessment: Interviewing, Introductory Phase, Working Phase, Summary and Closing Phase
Interviewing In the pre-introductory phase, the nurse reviews the medical record which may reveal the client's past health history and reason for seeking health care before meeting with the client to assist with conducting the interview. · Phases of the interview · Introductory · Working · Summary and closing Introductory Phase · Introduction · Explaining the purpose of the interview · Discussing the types of questions that will be asked · Explaining the reason for taking notes · Assuring the client that confidential information will remain confidential · Making sure that the client is comfortable and has privacy · Developing trust and rapport using verbal and nonverbal skills Working Phase · Biographical data · Reasons for seeking care · History of present health concern · Past health history · Family history · Review of body systems for current health problems · Lifestyle and health practices and developmental level · Listening, observing cues, and using critical thinking skills to interpret and validate information received from the client · Collaborating with the client to identify the client's problems and goals Summary and Closing Phase · Summarizing information obtained during the working phase · Validating problems and goals with the client · Identifying and discussing possible plans to resolve the problem with the client *Making sure to ask if anything else concerns the client and if there are any further questions
Lifestyle and Health Practices
Lifestyle and Health Practices · Description of typical day (AM to PM) · Nutrition and weight management · 24-hour dietary intake (foods and fluids) · Who purchases and prepares meals · Activity on a typical day and exercise habits and patterns · Rest and sleep habits and patterns · Medication and substance use · Self-concept and self-care responsibilities Lifestyle and Health Practices (cont.) · Social activities · Relationships · Values and belief system · Past, present and future education and work · Type of work, level of job satisfaction, work stressors · Stress levels and coping strategies · Residency, environment, neighborhood, environmental risks
Abdominal complications and PE
Lifestyle and Health Problems • Smoking • Alcohol use • Diet • Antacid • Medications • Fluid intake • Exercise • Stress Preparing the Client • Empty the bladder. ****** • Remove clothes and put on a gown. • Lie supine with the arms folded across the chest or resting by the sides. • Drape the client. • Breathe through the mouth; take slow, deep breaths. Equipment • Small pillow or rolled blanket • Centimeter ruler • Stethoscope (warm the diaphragm and bell) • Marking pen Collecting Objective Data: Physical Examination Inspection • Observe the coloration of the skin. • Note the vascularity of abdominal skin. • Note any striae. • Inspect for scars. • Assess for lesions and rashes. Inspection (cont.) • Inspect: - Umbilicus, abdominal contour, abdominal movements when client breathes • Assess abdominal symmetry. • Observe aortic pulsations. • Observe for peristaltic waves. Abdominal Contours Collecting Objective Data: Physical Examination • Auscultate for: - Bowel sounds - Vascular sounds - Friction rub over the liver and spleen Vascular sounds and friction rubs areas • Vascular sounds and friction rubs can best be heard over these areas. AUSCULTATION • Auscultation is useful in evaluating sounds from the heart, lungs, abdomen, and vascular system. • The bell of the stethoscope is more sensitive to low-pitched sounds (e.g., heart murmurs). • The diaphragm of the stethoscope is more sensitive to high-pitched sounds (e.g., bowel sounds). Collecting Objective Data: Physical Examination Percussion • Percuss for tone. • Percuss the span or height of the liver by determining its lower and upper borders. • Percuss the spleen. • Perform blunt percussion on the liver. PERCUSSION • Percussion is tapping of the patient's skin with the middle finger or striking finger of the dominant hand. Hyperextend the middle finger of the non dominant hand and place its distal joint and tip firmly on the patient's skin. Normal percussion sounds: liver percussion • liver percussion in the RLQ and percuss upward toward the chest. The normal liver span at the MSL is 4-8 cm. Percussion of the spleen Percussion of the kidney • Percussing for kidney tenderness at the costovertebral angle. Collecting Objective Data: Physical Examination Palpation • Perform light palpation. • Deeply palpate all quadrants to delineate abdominal organs and detect subtle masses. • Palpate for masses. • Palpate the umbilicus and surrounding area for swellings, bulges, or masses. Palpation (cont.) • Palpate: - Aorta - Liver - Spleen - Kidneys - Urinary bladder PALPATION • Using light and deep palpation can yield information related to masses, pulsations, organ enlargement, tenderness or pain, swelling, muscular spasm or rigidity, elasticity, vibration of voice sounds, crepitus, moisture, and differences in texture Abdomen Palpation • Light palpation • Deep Palpation Palpating the Aorta • Palpating the Aorta Liver palpation • Liver palpation liver palpation. • Hooking technique for liver palpation. Spleen Palpation • Palpating the spleen. • Palpating the spleen with the client in side-lying position. Kidney Palpation • Palpating the kidney. Bladder Palpation • Palpating distended bladder Mechanism and Sources of Abdominal Pain • Types of pain: - Visceral - Parietal - Referred Abdominal Distention - Pregnancy (normal) - Fat - Feces - Fibroids and other masses - Flatus - Ascitic fluid Abdominal Bulges - Umbilical hernia - Epigastric hernia - Diastasis recti - separation of abdominal muscles - Incisional hernia - An incisional hernia is a protrusion of tissue that forms at the site of a healing surgical scar. Enlarged Abdominal Organs - Enlarged liver - Enlarged nodular liver - Liver higher than normal - Enlarged spleen - Aortic aneurysm - Enlarged kidney - Enlarged gallbladder Older Client • Dilated superficial capillaries without a pattern may be seen in older clients. They are more visible in sunlight. • Assess older adult clients carefully for acute abdominal conditions as sensitivity to pain may diminish with aging.
Physical Examination: Palpation
Light palpation, fingertips are used for very little or no depression. used for pulses, tenderness, surface skin texture, temperature and moisture Moderate palpation - Depress the skin surface 1-2 cm. used to feel for easily palpable body organs and masses. note size, consistency, and mobility of structures Deep palpation - surface depression between 2.5-5 cm. allows you to feel very deep organs or structures that are covered by thick muscle Bimanual palpation - using two hands placing one on each side of the body part being palpated.
TBI
Lymph Nodes Traumatic Brain Injury • Presence of transportation accidents involving automobiles, motorcycles, bicycles, and pedestrians • Presence of violence, such as firearm assaults and child abuse or self-inflicted wounds • Falling • Excessive alcohol ingestion • Infants and elderly being cared for by caregivers Infant and Toddlers Risk Factors • Environmental risks (for falls) • Lack of parental knowledge of shaken baby syndrome • Caregivers risk of shaken baby syndrome Children and Teens Risk Factors • Knowledge and use of protective equipment in sports and bicycle use • Knowledge and use of safety practices when driving Adults and Older Adults Risk Factors • Knowledge and use of safety practices when driving • Impairment of physical or mental stability • Potential for maltreatment or domestic violence Risk Reduction • Buckling your child in the car using a child safety seat, booster seat, or seat belt (according to the child's height, weight, and age). Know the stages: - Birth through age 2 - Between ages 2 and 4/until 40 lb - Between ages 4 and 8 or until 4' 9" tall - After age 8 and/or 4' 9" tall • Wearing a seat belt every time you drive or ride in a motor vehicle Risk Reduction (cont.) • Never driving while under the influence of alcohol or drugs • Wearing a helmet and making sure your children wear helmets when: - Riding a bike, motorcycle, snowmobile, scooter, or all-terrain vehicle - Playing a contact sport, such as football, ice hockey, or boxing - Using in-line skates or riding a skateboard - Batting and running bases in baseball or softball - Riding a horse - Skiing or snowboarding Risk Reduction (cont.) • Making living areas safer for seniors, by: - Removing tripping hazards such as throw rugs and clutter in walkways - Using nonslip mats in the bathtub and on shower floors - Installing grab bars next to the toilet and in the tub or shower - Installing handrails on both sides of stairways - Improving lighting throughout the home Risk Reduction (cont.) • Maintaining a regular physical activity program, if your doctor agrees, to improve lower body strength and balance • Making living areas safer for children, by: - Installing window guards to keep young children from falling out of open windows - Using safety gates at the top and bottom of stairs when young children are around - Making sure that the surface on your child's playground is made of shock-absorbing material, such as hardwood mulch or sand.
Measurement - General Survey
MEASUREMENT • Weight • Height • Body mass index (BMI)= BMI = kg/m2 where kg is a person's weight in kilograms and m2 is their height in metres OR calculate BMI by dividing weight in pounds (lb) by height in inches (in) squared and multiplying by a conversion factor of 703. (Healthy BMI =19-25) WHR >1 is too high Calculate your WHR by dividing your waist circumference by your hip circumference. Vital Signs *Hands-on physical examination begins with vital signs* Provide data that reflect body systems status - Cardiovascular - Neurologic (brain stem and hypothalamus controls vital signs - abnormal vitals could be neurologic) - Peripheral vascular - Respiratory Order of Vital Signs • Temperature • Pulse • Respirations • Blood pressure TBRB
These are ___: time, space, eye contact and face positioning, body language and hand gestures, silence, and touch
Modifications to be considered for a culturally competent interview
Skin Cancer
Most common of cancers • Three types: melanoma, basal cell carcinoma, squamous cell carcinoma Cultural Variations in Skin Cancer • Asians are less susceptible to skin cancer • African Americans, Asians, and Hispanics are susceptible to melanoma • Asian Americans and African Americans tend to present with more advanced disease at diagnosis Risk Factors of Skin Cancer • Sun exposure • Non-solar sources of ultraviolet radiation • Medical therapies • Family history and genetic susceptibility • Moles • Pigmentation irregularities • Fair skin that burns and freckles easily; light hair • Age • Actinic keratosis • Male gender • Chemical exposure • Human papillomavirus • Xeroderma pigmentosum • Long-term skin inflammation or injury • Alcohol intake; smoking • Inadequate niacin in diet • Bowen disease (scaly or thickened patch) (SCC) • Depressed immune system Risk Reduction in Skin Cancer • Reduce skin exposure. • Always use sunscreen when sun exposure is anticipated. • Wear long-sleeve shirts and wide-brimmed hats. • Avoid sunburns. • Wear sunglasses that wrap around. • Understand the link between sun exposure and skin cancer and the accumulating effects of sun exposure on developing cancers. • Have annual skin cancer screenings. • Ensure that diet is adequate in vitamin B3 (niacin). • Examine the skin for suspected lesions using the ABCDE mnemonic to assess suspicious lesions: - Asymmetry - Border - Color - Diameter - Evolution (changes over time)
Neck Vessels
Neck Vessels • Carotid artery • Jugular veins Neck Vessels Assessment • Inspection: - Observe the jugular venous pulse. - Evaluate jugular venous pressure. • Auscultation and palpation: - Auscultate the carotid arteries. - Palpate the carotid arteries. Older Client • Be cautious with older clients because atherosclerosis may have caused obstruction, and compression may easily block circulation. In older clients, the apical impulse may be difficult to palpate because of increased anteroposterior chest diameter.
Non-verbal and Verbal Commuication
Nonverbal Communication · Appearance · Demeanor · Facial expression · Attitude · Silence · Listening Nonverbal Communication to Avoid · Excessive or insufficient eye contact · Distraction and distance · Standing Verbal Communication · Open-ended questions · Closed-ended questions · Laundry list · Rephrasing · Well-placed phrases · Inferring · Providing information Verbal Communication to Avoid · Biased or leading questions · Rushing through the interview · Reading the questions Special Considerations · Gerontologic variations · Cultural variations · Emotional variations
Older Client Considerations
Older Client Considerations • Temperature may range from 95.0°F to 97.5°F. Therefore, the older client may not have an obviously elevated temperature with an infection or be considered hypothermic below 96°F. • Osteoporotic thinning and collapse of the vertebrae secondary to bone loss may result in kyphosis. • In older men, gait may be wider based, with arms held outward. Older women tend to have a narrow base and may waddle to compensate for a decreased sense of balance. Steps shorten, with decreased speed and arm swing. Mobility may be decreased, and gait may be rigid. Older Client Considerations (cont.) • The older client's artery may feel more rigid, hard, and bent. • In the older adult, the respiratory rate may range from 15 to 22. The rate may increase with a shallower inspiratory phase because vital capacity and inspiratory reserve volume decrease with aging. • More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults. Systolic pressure over 140 with diastolic pressure under 90 is called isolated systolic hypertension. • Widening of the pulse pressure is seen with aging due to less elastic peripheral arteries.
opthalamascope
Ophthalmoscope Do's and Don'ts • Do - Begin about 10 to 15 in from the client at a 15-degree angle to the client's side. - Pretend that the ophthalmoscope is an extension of your eye. - Stay focused on the red reflex as you move in closer, then rotate the diopter setting to see the optic disc. Ophthalmoscope Do's and Don'ts (cont.) • Don't - Do not use your right eye to examine the client's left eye or your left eye to examine the client's right eye (your noses will bump). - Do not move the ophthalmoscope around; ask the client to look into the light to view the fovea and macula. - Do not get frustrated—the ophthalmologic examination requires practice.
Pulse
PULSE Pulse rate = HR Pulse Quality and Rate = CO CO = HR X SV Technique of measurement Taking a Radial Pulse Taking a Carotid Pulse when would you use each? Pulse Amplitude • 0: Absent • 1+: Weak, diminished (easy to obliterate) • 2+: Normal (obliterate with moderate pressure) • 3+: Bounding (unable to obliterate or requires firm pressure)
Physical Examination: Palpation (cont.)
Palpation consists of using parts of the hand to touch and feel for the following characteristics: · Texture (rough/smooth) · Temperature (warm/cold) · Moisture (dry/wet) · Mobility (fixed/movable/still/vibrating) · Consistency (soft/hard/fluid filled) · Strength of pulses (strong/weak/thready/bounding) · Size (small/medium/large) · Shape (well defined/irregular) ·Degree of tenderness
Pain Continued
Pathophysiology · Transduction · A-delta primary afferent fibers · Transmission · Perception · Modulation Definition: Acute Pain · Usually associated with a recent injury. Definition: Chronic Nonmalignant · Usually associated with a specific cause or injury and described as a constant pain that persists for more than 6 months. Definition: Cancer Pain · Often due to the compression of peripheral nerves or meninges, or from the damage to these structures following surgery, chemotherapy, radiation, or tumor growth and infiltration. Pain Descriptors Cutaneous pain: skin or subcutaneous Visceral pain: abdominal cavity, thorax, cranium Deep somatic pain: ligaments, tendons, bones, blood vessels, nerves Radiating: perceived both at the source and extending to other tissues Referred: perceived in body areas away from the pain source Phantom pain: perceived in nerves left by a missing, amputated, or paralyzed body part Neuropathic pain: causes an abnormal processing of pain messages and results from past damage to peripheral or central nerves due to sustained neurochemical levels Nociceptive: response to noxious insult or injury of tissues such as skin, muscles, visceral organs, joints, tendons, or bones Inflammatory: a result of activation and sensitization of the nociceptive pain pathway by a variety of mediators released at a site of tissue inflammation
PERCUSSION
Percussion is tapping of the patient's skin with the middle finger or striking finger of the dominant hand. Hyperextend the middle finger of the non dominant hand and place its distal joint and tip firmly on the patient's skin. Normal percussion sounds:
General Survey
Physical development and body build • Gender and sexual development • Apparent age as compared to reported age • Skin condition and color • Dress and hygiene • Posture and gait General Survey (cont.) • Level of consciousness • Behaviors, body movements, and affect • Facial expression • Speech • Vital signs Interview • General survey questions • History of present health concern • Personal history • Family history • Lifestyle and health practices Accurate General Survey • Preparing the client • Equipment - Thermometer - Protective, disposable covers for type of thermometer - Aneroid or mercury sphygmomanometer or electronic blood pressure measuring equipment - Stethoscope - Watch with second hand Accurate General Survey (cont.) • General impression - Observe physical development, body build, and fat distribution. - Compare client's stated age with apparent age and developmental stage. - Observe skin condition and color. - Observe posture and gait.
Pain Rating
Physiologic Responses to Pain · Anxiety, fear, hopelessness, sleeplessness, thoughts of suicide · Focus on pain, reports of pain, cries and moans, frowns and facial grimaces · Decrease in cognitive function, mental confusion, altered temperament, high somatization, and dilated pupils · Increased heart rate; peripheral, systemic, and coronary vascular resistance; and blood pressure Physiologic Responses to Pain (cont.) · Increased respiratory rate and sputum retention, resulting in infection and atelectasis · Decreased gastric and intestinal motility · Decreased urinary output, resulting in urinary retention, fluid overload, depression of all immune responses · Increased antidiuretic hormone, epinephrine, norepinephrine, aldosterone, glucagons, decreased insulin, testosterone · Hyperglycemia, glucose intolerance, insulin resistance, protein catabolism · Muscle spasm resulting in impaired muscle function and immobility, perspiration Seven Dimensions of Pain · Physical · Sensory · Behavioral · Sociocultural · Cognitive · Affective · Spiritual Subjective Data · Review past and family histories in terms of pain. · Review lifestyle and health habits to determine how the pain interferes with the client's life. Tips for Collecting Subjective Data · Maintain a quiet and calm environment that is comfortable for the client being interviewed. · Maintain the client's privacy and ensure confidentiality. · Ask the questions in an open-ended format. · Listen carefully to the client's verbal descriptions and quote the terms used. Tips for Collecting Subjective Data · Watch for the client's facial expressions and grimaces during the interview. · DO NOT put words in the client's mouth. · Ask the client about past experiences with pain. · Believe the client's expression of pain. Objective Data Visual Analog Scale (VAS) Numeric Rating Scale (NRS) Numeric Pain Intensity Scale (NPI) Verbal Descriptor Scale Simple Descriptive Pain Intensity Scale Graphic Rating Scale Verbal Rating Scale Faces Pain Scale Hierarchy of Pain Assessment Techniques · Self-report · Search for potential causes of pain · Observe client behaviors · Surrogate reporting · Attempt an analgesic trial QUESTT Principles for Pain in Children · Question the child. · Use pain-rating scales. · Evaluate behavior and physiologic changes. · Secure parents' involvement. · Take cause of pain into account. · Take action and evaluate results.
Assessing Heart Sounds
Positioning left and right of the sternum at the level of the 2nd rib, left of the sternum at the 4th rib, and on the left nipple line at the level of the 5th rib. Remember these with the mnemonic "2-2-4-5." The names of the valves that you are hearing in these locations are: (2 right) aortic, (2 left) pulmonic, (4) tricuspid, (5) mitral. Remember these with the mnemonic "All Patients Take Meds."
Braden Scale
Predicts the risk for developing a hospital- or facility-acquired pressure ulcer or injury. The Braden Scale uses a scores from less than or equal to 9 to as high as 23. The lower the number, the higher the risk is for developing an acquired ulcer or injury. 19-23 = no risk15-18 = mild risk 13-14 = moderate risk less than 9 = severe risk There are six categories within the Braden Scale: sensory perception, moisture, activity, mobility, nutrition, and friction or shear.
Steps of Health Assessment
Preparing for the assessment · Review client's record · Review client's status with other health care team members · Educate about client's diagnosis and tests performed Steps of Health Assessment Continued · Validation of assessment data · Documentation of data · Analysis of data
Pressure Ulcer Stages • Stage I • Stage II • Stage III • Stage IV • Unstagable
Pressure Ulcer Stages • Stage I • Stage II • Stage III • Stage IV • Un-Stageable
types of skin lesions
Primary Skin Lesions • Macule and patch • Papule and plaque • Nodule and tumor • Vesicle and bulla • Wheal • Pustule • Cyst Secondary Skin Lesions • Erosion • Ulcer • Scar • Fissure Vascular Skin Lesions • Petechia • Ecchymosis • Hematoma • Cherry angioma • Spider angioma • Telangiectasis
RESPIRATIONS
Respirations Technique of measurement Normal rate for age group Ratio of pulse rate to respiratory rate should be approximately 4:1 O2 saturation (healthy normal 97-98%) Respiration • Ventilation = Movement of gases into and out of the lung. • Diffusion= Movement of oxygen and carbon oxide between alveoli and red blood cells. • Perfusion = Distribution of red blood cells to and from the pulmonary capillaries. Assessment of Ventilation - Respiratory rate: breaths/minute - Ventilatory depth: deep, normal, shallow - Ventilatory rhythm: regular/irregular
Cataracts
Risk Factors for Cataracts • Increasing age • Diabetes mellitus • Excessive alcohol use • Exposure to sunlight (ultraviolet B light) • Exposure to ionizing radiation, such as that used in X-rays and cancer radiation therapy Risk Factors for Cataracts (cont.) • High blood pressure • Obesity • Previous eye injury, inflammation, surgery • Prolonged steroid use • Cigarette smoking Risk Reduction • Wear sunglasses that block UVB rays. • Avoid smoking or quit smoking. • Avoid excessive alcohol intake. • Avoid eye injuries. • Maintain healthy weight. • Use eye protectant equipment if necessary. • Seek medication treatment for prolonged or unusual eye inflammation or any eye injury.
Scalp, Hair, and Nails Assessment
Scalp and Hair • Inspection and palpation - General color and condition, cleanliness, dryness or oiliness, parasites, and lesions - Amount and distribution of scalp, body, axillae, and pubic hair • Nails - Inspection: Nail grooming and cleanliness, nail color and markings, shape of nails - Palpation: Assess texture and consistency, capillary refill Nails Risk Factors • Nails in moist environment, especially walking in damp public locales or continuously wearing closed shoes; excessive perspiration • Nail injury, trauma, or irritation • Repeated irritation (especially water, detergents) • Immune system disorders such as diabetes mellitus and AIDS or on immunosuppressive medications • Skin conditions such as psoriasis or lichen • Some trades or professions • Contagion from one digit to another or one person to another • Possibly family predisposition Nails Risk Reduction Tips • Wear leather shoes except for sports. • Avoid wearing closed shoes all the time. • Wear socks that wick away moisture. • Avoid going barefoot in damp public areas. • Avoid too much perspiration or water (wear gloves for hands). • Avoid trauma to nails. • Avoid unsanitary or unsafe nail care practices. • If treatment is started, do not stop until recovery is complete.
Common Changes in Aging Skin, Hair, and Nails
Skin -Pale -Skin lesions -Dry -Loses turgor Hair: Thinner Nails: Thickened, yellow, brittle
Spirituality
Spiritual Assessment · Active and ongoing conversation that assesses the spiritual needs of the client Spiritual Assessment Characteristics · Formal or informal · Respectful · Nonbiased Spiritual Care · Addressing the spiritual needs of the client as they unfold through spiritual assessment Spiritual Care Characteristics · Individualistic · Client oriented · Collaborative Techniques of Spiritual Assessment · Nonformal technique · S—Spiritual belief system · P—Personal spirituality · I—Integration with a spiritual community · R—Ritualized practices and restrictions · I—Implications for medical care · T—Terminal events planning Spiritual Assessment Tool · Explore the client's religious and spiritual background · Observe nonverbal and verbal communication patterns in the presence of others · Focus questions · Daily spiritual experiences · Brief religious coping questionnaire Spiritual Beliefs ·In whatever form spirituality is incorporated into client care, the nurse should be respectful, open, and willing to discuss spiritual issues if seen as appropriate. The nurse should avoid conveying a judgmental attitude toward the client's spiritual beliefs and religious practices. It is useful to define the concepts of religion and spirituality as interconnected but separate ideas. · Religion is defined as the rituals, practices, and experiences shared within a group that involve a search for the sacred. · Spirituality is defined as a search for meaning and purpose in life; it seeks to understand life's ultimate questions in relation to the sacred. Spiritual Beliefs and Bias · Consistently, nurses who are more aware of their spirituality are more comfortable discussing the potential spiritual needs of the client. Introspective reflection on one's own beliefs and biases about the relationship between spirituality and health can be undertaken through journaling, meditation, or discussions with interested persons.
National Standards for Culturally and Linguistically Appropriate Services in Health Care
Standard 1: Ensure that patients/consumers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language. · Standard 2: Implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area. · Standard 3: Ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery. · Standard 4: Offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. · Standard 5: Provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services. · Standard 6: Assure the competence of language assistance provided to limited English-proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer). · Standard 7: Make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area. · Standard 8: Develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services. · Standard 9: Conduct initial and ongoing organizational self-assessments of CLAS-related activities and integrate cultural and linguistic competence-related measures into internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations. · Standard 10: Ensure that data on the individual patient's/consumer's race, ethnicity, and spoken and written language are collected in health records, integrated into the organization's management information systems, and periodically updated. · Standard 11: Maintain a current demographic, cultural, and epidemiologic profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area. · Standard 12: Develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities. · Standard 13: Ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers. · Standard 14: Regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and provide public notice in their communities about the availability of this information.
Structure and Function
Structure and Function • Heart: - Hollow, muscular organ - Located in mediastinum - Four chambers: left atrium and ventricle, right atrium and ventricle - Two atrioventricular valves, two semilunar valves - Three layers: epicardium, myocardium, endocardium Direction of Blood Flow • deoxygenated red blood drains into venacava, follows route of venous blood. • From liver to right atrium (RA) through inferior venacava • From RV, venous blood flows through pulmonic valve to pulmonary artery. • Lungs oxygenate blood. • From left atrium (LA), arterial blood travels through mitral valve to left ventricle (LV). • From LA, arterial blood travels through mitral valve to LV. • Aorta delivers oxygenated blood to body. • Circulation is continuous loop; moving by continuous shifting pressure gradients.
Genogram Symbols
Symbols A horizontal dotted line (spouse) A vertical dotted line (adoption) An X in a circle An X in a square
The Neck
The Neck - Hyoid bone (attached to tongue) - Several major blood vessels - Larynx - Trachea - Thyroid gland HTCT - Happy to Come Together
Structure and Function of Skin
The skin is a physical barrier that protects the underlying tissues and structures from microorganisms, physical trauma, ultraviolet radiation, and dehydration. • Vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis. Skin, Hair, and Nails • Skin: epidermis, dermis, sebaceous glands, sweat glands, subcutaneous layers • Hair: vellus, terminal • Nails: nail body, lunula
Types of Assessments
Types of Assessments · Initial comprehensive assessment: Collection of subjective data about the client's perception of health of all body parts or systems, past medical history, family history, and lifestyle and health practices. · Ongoing or partial assessment: Data collection that occurs after the comprehensive database is established. · Focused/problem-oriented assessment: Thorough assessment of a particular client problem, which does not cover areas not related to the problem. · Emergency assessment: Very rapid assessment performed in life-threatening situations.
Validating and Documenting Findings
Validating and Documenting Findings · Health promotion diagnoses · Risk diagnoses · Actual diagnoses · Collaborative problems · Medical problems
Validating and Documenting Findings - STEPS
Validating and Documenting Findings · Health promotion diagnoses · Risk diagnoses · Actual diagnoses · Collaborative problems · Medical problems
Pain - Fifth vital sign
WHATEVER THE PERSON EXPERIENCING IT SAYS IT IS, AND EXISTING WHENEVER THE PERSON SAYS IT DOES •Observe comfort level Numeric Pain scale Face/Visual Charts Verbal Pain Scale Three types of unidimensional pain measurement tools were considered, visual analogue scales (VAS), categorical verbal rating scales (VRS), and categorical numerical rating scales (NRS).
Abdominal Regions
right hypochondriac, epigastric, left hypochondriac, right lumbar, umbilical, left lumbar, right iliac, hypogastric, left iliac
Physical Examination Preparation and Standard Precautions - IPPA Method
· Comfortable, warm temperature · Private area free of interruption · Quiet area with adequate lighting · Firm examination table or bed · Beside table/tray to hold equipment Standard Precautions · Hand hygiene · Gloves · Mask, eye protection, face shield · Gown · Patient care equipment; patient placement · Linen; occupational health and blood-borne pathogens
Cultural Competence
· Cultural awareness · Cultural skill · Cultural knowledge · Cultural encounter · Cultural desire
Physical Examination: Inspection
· Room at comfortable temperature · Good lighting · Look and observe before touching · Completely expose part being examined while draping the rest of client as appropriate · Note characteristics · Compare appearance
Stereotyping and Ethnocentrism
· Stereotyping: All members of a particular culture expecting group members to hold the same beliefs and behave in the same way. · Ethnocentrism: Perception that one's worldview is the only acceptable truth and that one's beliefs, values, and sanctioned behaviors are superior to all others.
Abnormal Findings of the Head and Neck
• Acromegaly - enlargement of bone and cartilage • Cushing syndrome • Scleroderma • Hypothyroidism • Bell palsy - Bell's palsy is an unexplained episode of facial muscle weakness or paralysis. It begins suddenly and worsens over 48 hours. This condition results from damage to the facial nerve (the 7th cranial nerve). Pain and discomfort usually occur on one side of the face or head. Bell's palsy can strike anyone at any age.
Present Health Concern - HPI
• Body odor problems • Skin problems (rashes, lesions, dryness, oiliness, drainage, bruising, swelling, pigmentation) • Changes in lesion appearance • Feeling changes (pain, pressure, itch, tingling) • Hair loss or changes • Nail changes Nursing History (cont.) • Personal health history • Family history • Lifestyle and health practices - Exposure to sun or chemicals - Daily care of skin, hair, and nails -Usual diet and exercise patterns
Equipment for Head and Neck Examination
• Gloves • Penlight or flashlight • Small glass of water • Stethoscope Physical Assessment: Head • Inspect the size, shape, configuration • Consistency • Involuntary movement • Palpate the head Physical Assessment: Face • Inspect the face - Symmetry - Features - Movement - Expression - Skin condition Physical Assessment: Face (cont.) • Palpate - Temporal artery: tenderness and elasticity - Temporomandibular joint (TMJ): range of motion (ROM), swelling, tenderness, crepitation Physical Assessment: Neck • Inspect movement of neck structures - Cervical vertebrae - Neck ROM Physical Assessment: Neck (cont.) • Palpate - Trachea - to palpate use thumb and pads of forefingers and note if it is midline - Thyroid gland • Thyroid cartilage - lower than cricoid cartilage • Cricoid cartilage • Auscultate an enlarged thyroid gland - looking for thyroid bruit. Physical Assessment: Neck (cont.) • Palpate lymph nodes of head and neck - Preauricular - Postauricular - Occipital - Tonsillar - Submandibular - Submental - Superficial cervical - Posterior cervical - Deep cervical - Supraclavicular Normal and Abnormal Findings • Review and discuss findings of assessment of client's head and neck with peers.
Older Adult Considerations
• Presbyopia (far-sightedness) is a common condition in clients over 45 years of age. • Yellowish nodules on the bulbar conjunctiva are called pinguecula. These harmless nodules are common in older clients, appearing first on the medial side of the iris and then on the lateral side. • Arcus senilis, a normal condition in older clients, appears as a white arc around the limbus. - small ring around eyes white • Though usually abnormal, entropion and ectropion are common in older clients. Validating and Documenting Findings • Health promotion diagnoses • Risk diagnoses • Actual diagnoses • Collaborative problems • Medical problems
Coronary Heart Disease
• Risk factors: - Overview of coronary heart disease - Risk factors - Risk reduction teaching tips - Cultural considerations Collecting Subjective Data • History of present health concern: chest pain, palpitations • Past health history • Family history • Lifestyle and health practices Heart Sounds • Produced by valve closure - Normal heart sounds: "lub dub" (S1 and S2) -high-pitch sounds is the closing of mitral and tricuspid S1 - split sound mitral closes before the tricuspid. S2 - closure of the aortic and pulmonic valves (semilunar valves) - Extra heart sounds (S3 and S4) - Murmurs AREAS OF AUSCULTATION Heart Murmurs • Turbulent blood flow with a swooshing or blowing sound when doing auscultation • Conditions that contribute to heart murmurs - Increased blood velocity - Structural valve defects - Valve malfunction - Abnormal chamber openings Types of Heart Murmurs • Systolic Murmur - muscle contraction from LA/RA to LV/RV - swishing blowing sound • Diastolic Murmur - relaxation - when ventricles fill • Continuous Murmur Collecting Objective Data • Briefing on physical examination • Preparing the client - Explain the procedures. - Client must assume different positions. • Equipment • Physical assessment
Headache Impact Test
• When you have headaches, how often is the pain severe? • How often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities? • When you have a headache, how often do you wish you could lie down? • In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches? • In the past 4 weeks, how often have you felt fed up or irritated because of your headaches? • In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities? Types of Headaches • Sinus • Cluster • Tension • Migraine • Tumor related