Health Assessment Exam 1, Health Assessment - MS, Neuro, & GU, Health Assessment Exam 2

Is the information in the health history subjective or objective data?

Subjective

Stage 1 pressure ulcer

intact skin appears red but unbroken; does not blanch

Bronchovesicular breath sounds

intermediate/medium intensity and pitch; usually heard over the 1st and 2nd interspaces (Upper Sternum, Scapula)

Herpes zoster (shingles)

small, group vesicles emerge along route of cutaneous sensory nerve, then pustules, then crust. caused by the varicella zoster virus, a reactivation of the dormant virus chickenpox.

Vesicular breath sounds

soft and low pitched; usually heard over most of both lungs (peripheral lung fields)

Normal voice sounds

soft, muffled, indistinct

Papules

something you can feel. solid, elevated, circumscribed, less than 1 cm in diameter. caused by superficial thickening in the epidermis. ex: elevated nevus (mole), wart (verruca)

What is the purpose of the general survey?

study of the whole person, covering the general health state and any obvious physical characteristics. Begin general survey when you 1st encounter the person.

Differentiate between subjective data from objective data.

subjective data- what the patient says about himself or herself. This is what the patient says ("S") Establish rapport so the patient can trust you Make sure the patient understands- speak in a way they understand Make sure you make them want to have you again Start the interview with "what brings you in today?" objective data- what you obtain through physical examination

Lymph nodes: posterior auricular (mastoid)

superficial to the mastoid process

Wheals

superficial, raised, transient, & erythematous; slightly irregular shape from edema ex: mosquito bite, allergic reaction

Emergency assessment

urgent, rapid collection of crucial information & often is compiled concurrently w/ lifesaving measures. emergency rooms or emergency situation

functional use of space: public

12+ feet. interaction with others impersonal speaker's voice must be projected. subtle facial expressions imperceptible

Allen eye test

(2/3 y/o) picture cards

Snellen E eye test

(3-6 y/o) show capital E in varying sizes pointing in different directions

Snellen test

(7 y/o-up) alphabet chart with 20/20

Myopia

*nearsightedness* the globe is longer than normal and light rays focus in front of the retina

Tubing for stethoscope should be how long?

14 to 18 in long

What population of men (by age) is at the highest risk for testicular cancer?

15-35

What is the normal angle of the nail beds?

160 degrees normally slightly curved or flat, smooth, rounded & clean

Benign (fibrocystic) breast disease

*Multiple tender masses* that occur with: 1. swelling & tenderness (cyclic discomfort) 2. mastalgia (severe pain, both cyclic & noncyclic) 3. nodularity (significant lumpiness) 3. dominant lumps (cysts & fibroadenoma) 4. nipple discharge 5. infections & inflammation -nodularity occurs *bilaterally*; regular, firm nodules are *mobile, well demarcated, & feel rubbery.* -pain may be dull, heavy, & cyclic as nodules enlarge. -cysts are discrete, fluid-filled sacs -nodularity is not premalignant but produces difficulty in detecting other cancerous lumps

How are heart murmurs graded? How is each grade described?

*They are graded by how loud they are* Grade 1: barely audible, heard only in a quiet room & then with difficulty Grade 2: clearly audible, but faint Grade 3: moderately loud, easy to hear Grade 4: loud, associated with a thrill palpable on the chest wall Grade 5: very loud, heard with one corner of the stethoscope lifted off the chest wall Grade 6: loudest, thrill, hear with stethoscope completely off chest

Arcus senillis

*a gray-white arc or circle around the limbus*; it is due to deposition of lipid material. It is a common degenerative change in which the outer edge of the cornea gradually becomes opaque, generally in both eyes, affects people over the age of 50.

Cataracts

*clouding of lens.* Lens opacity, resulting from a clumping of proteins in the lens. Expected by age 70

Wheezes

*continuous musical snoring, moaning sounds.* predominate in expiration but may occur in both expiration & inspiration high pitched: acute asthma, emphysema low pitched: bronchitis

Strabismus

*cross eyed*. the eye muscles are unable to focus together.

Coarse rhonchi

*loud, low-pitched bubbling and gurgling sound* that start in early inspiration & may be present in expiration *(Pneumonia, pulmonary edema)*

Stage 2 pressure ulcer

*partial thickness* skin erosion with loss epidermis or also the dermis. superficial ulcer looks shallow like an abrasion or open blister with red pink wound bed

S2 happens with the closure of the ____

*semilunar valves (aortic & pulmonic).* You can hear it with the diaphragm over the entire pericardium, although S2 is loudest at the base.

Astigmatism

*unequal curvatures* in different parts of the cornea or lens lead to blurred vision

Migraine headache

- HA of genetically transmitted vascular origin. Plus prodrome, aura, other symptoms - Commonly one sided but may occur on both sides. Pain is often behind the eyes, the temples, or forehead. - Throbbing, pulsating - Rapid onset, peaks 1-2 hours, last 4-72 hours, sometimes longer - Moderate to severe pain. - Hormonal fluctuations (premenstrual), foods, hunger, letdown after stress, sleep deprivation, sensory stimuli, changes in weather, physical activity.

Cluster headache

- HA that is intermittent, excruciating, unilateral with autonomic signs - Always one sided. Often behind or around the eyes, temple, forehead, cheek - Continuous burning, piercing, excruciating - Abrupt onset, peaks in minutes, last 45-90 minutes - Can occur multiple times a day and lasts weeks, severe stabbing pain - Exacerbated by alcohol, stress, daytime napping, wind, or heat exposure.

Tension headache

- Headache of musculoskeletal origin, less disabling form of a migraine. - Usually both sides, across frontal, temporal, and or occipital region of the head - Bandlike tightness, viselike, nonthrobbing, nonpulsatile - Gradual onset, last 30 minutes to days - Mild to moderate pain - Situational in response to overwork, posture - Stress, anxiety, depression, poor posture and not worsened by physical activity

How do you record pregnancies, live births, & abortions?

-Pregnancies- Gravida -Live Births- Para -Abortions- interrupted pregnancies, including elective abortions and spontaneous miscarriages

Fibroadenoma

-*Benign tumors*; most commonly present as self detected in late adolescence. -Solitary nontender mass that is *solid, firm, rubbery, & elastic.* Round, oval, or lobulated; 1 to 5 cm. *Freely movable, slippery*; fingers slide it easily through tissue. -Usually no axillary lymphadenopathy. *Diagnose by triple test (palpation, ultrasound, & needle biopsy)*

How are DTR's (deep tendon reflex) graded?

-4+ very brisk, hyperactive with clonus, indicative of disease -3+ brisker than average, may indicate disease, probably normal -2+ average, normal 1+ diminished, low normal, or occurs only with reinforcement -0 no response

How are DTR's assessed?

-Biceps- support forearm, place thumb on bicep tendon and strike finger; contraction of bicep muscle and flexion of forearm -Triceps- tell person to relax arm while holding it suspended from upper arm, strike just above elbow; extension of the forearm -Brachioradialis- hold person's thumb to suspend forearm in relaxation, strike forearm directly about 2 to 3 cm above the radial styloid process; flexion and supination of the forearm -Quadriceps- dangle lower legs, strike tendon direct just below patella; extension of lower leg -Achilles- knee flexed and hip externally rotated, hold foot in dorsiflexion, strike Achilles tendon directly; foot plantar flexes against hand.

How is cerebellar function tested?

-Observing gait -Romberg test- ask person to stand with feet together and arms at their side, close eyes and wait 20 seconds. Positive is a loss of balance -Ask person to perform a shallow knee bend or hop in place, first on one leg then the other.

How can the nurse best obtain objective neuro data when assessing an infant?

-Optical blink reflex -rooting effect -sucking reflex -facial movements -acoustic blink reflex -swallowing -coordinated sucking and swallowing -pinch nose

What are positive nonverbal behaviors that promote communication during an interview? (7)

-Physical appearance -Posture -Gestures -Facial expression -Eye contact -Voice -Touch. Make sure you look good and put together. No wrinkles or dingey scrubs 2. looking like you're easy to talk to, be inviting not closed off 3. encouraging, smiling, hand movements, being engaged

How does the nurse assess for skin mobility & turgor & what is an abnormal finding? What conditions are associated with abnormal findings?

-Pinch up a large fold of skin on the anterior chest under the clavicle; mobility is the ease of rising and turgor is ability to return to place promptly when released. -Edema- decreased mobility -Severe dehydration or extreme weight loss- poor turgor -Scleroderma- hard skin, decreased mobility.

How is coordination of the extremities tested?

-Rapid alternating movements (RAM)- pat knees with palms of hand, lift up and pat with back of hands, then ask to do faster -Finger to nose- close eyes, stretch arms and touch finger to nose -Finger to Finger- have pt touch your finger and then their nose and then repeat only moving your finger. -Heel to shin- supine, place heel on opposite knee and run down the shin to ankle, should be in a straight line

Procedure for taking blood pressure

-avoid smoking or drinking caffeinated beverages 30 min prior to measurement -ensure the room is quiet & comfortably warm -pt should be seated quietly in a chair with feet on the floor for at least 5 min -pts arm should be FREE of clothing -palpate the brachial artery -position the arm so that the brachial artery is at heart level -rest the arm on a table a little above the pts waist, or support the pts arm with your own at his mid-chest level

Normal female genital findings found in newborns

-external genitalia are engorged -ovaries located in abdomen -uterus is small with straight axis and no anteflexion -may have sanguineous discharge -labia majora flat; labia minora thin -clitoris is relatively small -hyeman is tissue paper thin -no irritation or fowl smelling discharge

Crackles

-fine: *discontinuous, high-pitched, short crackling popping sounds* heard during early inspiration that are not cleared by coughing -late inspiratory crackles occur with restrictive disease (pneumonia, heart failure) -early inspiratory crackles occur with obstructive disease: (chronic bronchitis, asthma, emphysema) -atelectatic crackles: sound like fine crackles but don't last/are not pathologic (in aging adults or bedridden)

Lateral lobes of the lungs

-right upper lope extends from apex to axilla down to horizontal fissure at 5th rib -right middle lobe: from horizontal fissure to the 6th rib -right lower lobe: continues from 5th rib to 8th -left upper lobe extends from apex to axilla to 5th rib -left lower lobe continues down to 8th rib

What are normal findings of the male genitalia in adulthood?

-skin looks wrinkled, hairless, and without lesions -glans looks smooth and without lesions -uretheral meatus is positioned just about centrally -base of penis has hair distribution consistent with age and hair is without pests -meatus edge is pink, smooth, and without discharge -asymmetry is normal in the scrotum -testicles are oval, movable and equal bilateral

Breast Cancer

-solitary, *unilateral*, nontender mass. -solid, hard, dense, & fixed to underlying tissues or skin as cancer becomes invasive. *Borders are irregular & poorly delineated.* -grows constantly. often painless -*most common in upper outer quadrant* As cancer advances, signs include: 1. firm or hard irregular axillary nodes 2. skin dimpling 3. nipple retraction, elevation, and discharge.

What are normal findings of elderly male genitalia?

-thinner, graying pubic hair & decreased size of the penis -the size of the testes may be decreased & may feel less firm -the scrotal sac is pendulous with less rugae -scrotal skin may become excoriated if the man continually sits on it

Normal female genital findings in aging women

-uterus shrinks -ovaries atrophy -vagina is shorter, narrower, and less elastic -vaginal epithelium atrophies -uterus drops as sacral ligaments relax and pelvic musculature weakens -cervix shrink -mons pubis looks smaller -labia and clitoris gradually decrease in size -pubic hair becomes thin and sparse -pendulous breast

Describe the procedure for using the otoscope & assessing the nose internally.

-view each nasal cavity with the person's head erect & then with the head tilted back -inspect nasal mucosa, noting its normal red color & smooth, moist surface -note any swelling, discharge, bleeding, or foreign body. -observe septum for deviation -avoid touching septum with otoscope

Procedure for performing light palpation

-with the first four fingers close together, depress the skin about 1 cm. -make a gentle rotary motion, sliding the fingers & skin together -then lift the fingers (do not drag them) & move clockwise to next location. This avoids pain. Objective is not to search for organs, but to form an overall impression of the skin surface & superficial musculature.

functional use of space: intimate

0 to 1.5 feet. visual distortion occurs, best for assessing breath & other body odors

A sluggish capillary refill color return takes longer than

1 or 2 seconds

How are tonsils graded and what does each grade mean?

1+ visible "normal in healthy people" 2+ halfway between tonsillar pillars and uvula "normal in healthy people" 3+ touching the uvula 4+ touching each other

12 cranial nerves & how each is tested

1- olfactory: different smells 2- optic: visual acuity with Snellen chart 3- oculomotor: PERRLA, 6 cardinal directions 4-Trochlear: 6 cardinal directions 5- Trigeminal: test forehead, cheek, and jaw for sharp and dull sensation 6- Abducens: 6 cardinal directions 7- Facial: raise eyebrows, smile, puff cheeks 8- Acoustic: hearing test 9- Glossopharyngeal: movement of palate as patient says Ah 10- Vagus: movement of palate as patient says AH 11- Spinal Accessory: shrug shoulders and turn head against resistance 12- Hypoglossal: protrude tongue

What are the 7 major risk factors for breast cancer?

1. Age 65+ 2. Biopsy confirmed atypical hyperplasia 3. Certain inherited genetic mutations for breast cancer (BRCA1 and/or BRCA2) 4. Lobular carcinoma in situ (LCIS is an indication that a person is at higher than average risk for getting breast cancer at some point in the future) 5. Mammographically dense breasts 6. Personal history of early onset (<40 years) breast cancer 7. Two or more 1st degree relatives with breast cancer diagnosed at early age

Anatomical landmarks for auscultation of the heart

1. Aortic valve- 2nd intercostal right side 2. Pulmonic valve- 2nd intercostal left side 3. Tricuspid - 5th intercostal lower left sternal border 4. Mitral valve -5th intercostal around midclavicular left side

5 Conditions that cause altered chest expansion

1. Atelectasis 2. pneumonia 3. pleural effusion 4. fractured ribs 5. pneumothorax after trauma

Rebound tenderness (Blumberg sign)

1. Choose a site away from the painful area. 2. Hold your hand 90 degrees (perpendicular) to the abdomen. 3. Push down slowly & deeply then lift up quickly pain on release of pressure confirms rebound tenderness, which is a sign of *peritoneal inflammation & appendicitis*

How is the Allen test performed?

1. Firmly occlude both the ulnar and radial arteries of one hand while the person makes a fist several times, this causes the hand to blanch 2. Ask the person to open the hand without hyperextending it, then release pressure on the ulnar artery while maintaining pressure on the radial artery.

Questions to ask a patient in the subjective history about new-onset cough

1. How long have you had it? 2. How often do you cough? 3. At any special time of day or just on arising? 4. Cough wake you up at night? 5. Do you cough up any phlegm or sputum? How much? what color is it? 6. Cough up any blood? 7. How would you describe the cough: hacking, dry, barking, coarse, congested, bubbling? 8. Does the cough seem to come with anything: activity, position, fever, congestion, talking, anxiety? 9. Does activity make it worse?

What is taught to patients to promote breast health? (6)

1. Keep teaching clear and simple. The simpler the plan, the more likely the person is to comply. 2. Describe correct technique and rationale and expected finding to note as woman inspects her own breasts. 3. Teach woman to do this in front of a mirror while she is disrobed to waist. 4. At home, she can start palpation in the shower, where soap and water assist with palpation. 5. Then palpation should be performed while lying supine 6. Encourage woman to palpate her own breasts while you monitor her technique. *teach males too*

How does the nurse correctly chart a breast lump found on examination? (10)

1. Location: as with clock face, describe distance in centimeters from nipple; or diagram breast in woman's record and mark in location of lump 2. Size: judge in centimeters in three dimensions: width, length, and thickness 3. Shape: state whether lump is oval, round, lobulated, or indistinct 4. Consistency: state whether lump is soft, firm, or hard 5. Movability: is lump freely movable or fixed when you try to slide it over chest wall? 6. Distinctness: is lump solitary or multiple? 7. Nipple: is it displaced or retracted? 8. Skin over lump: is it erythematous, dimpled, or retracted? Discharge? Recent inversion? 9. Tenderness: is lump tender to palpation? 10. Lymphadenopathy: are any regional lymph nodes palpable?

10 warning signs of Alzheimer disease

1. Memory loss- forgetting recently learned info 2. Losing track- difficulty performing familiar tasks 3. Forgetting words 4. Getting lost- disorientation to time & place 5. poor judgement- dress inappropriately 6. abstract failing- unusual difficulty performing complex mental tasks 7. Losing things- put things in unusual places 8. Mood swings 9. Personality change 10. Growing passive- loss of initiative

What 5 instructions are given to the patient prior to starting the abdominal exam?

1. Patient should empty the bladder 2. Lay in supine position, flexing knees 3. Arms at their sides 4. Pillow under knees 5. Expose abdomen as much as you can

Fluid wave test

1. Stand on the person's right side. 2. Place the ulnar edge of another examiner's hand or the patient's own hand firmly on the abdomen in the midline. 3. Place your left hand on the person's right flank. With your right hand, reach across the abdomen & give the left flank a firm strike. 4. If *ascites* is present, the blow will generate a fluid wave through the abdomen *A positive fluid wave test occurs with large amounts of ascitic fluid*

Three types of breath sounds

1. Vesicular 2. Bronchovesicular 3. Bronchial

4 components of percussion

1. amplitude- intensity, loud or soft 2. pitch- number of vibrations per second and may be high or low pitched 3. quality (timbre)- subjective difference due to a sounds distinctive overtones 4. duration- the length of time the note lingers

What are the rules of using an interpreter?

1. before locating an interpreter, identify the language the person speaks at home. it may differ from the language spoken publicly 2. when possible, use a trained interpreter, preferably one who knows medical terms 3. avoid interpreters from a rival tribe, state, region, or nation 4. be aware of gender, age, & socioeconomic differences bw the interpreter & the client

What are the components of the health history? (4)

1. biographic data- name, address, phone #, age & birth date; birthplace, gender, marital partner status, race, ethnic origin, & occupation. primary language & change in occupation 2. source of history- record who furnishes the info. judge how reliable & how willing he or she is to communicate. note if they appear well or ill 3. chief complaint (CC)- reason for seeking care using pts own words. ask about symptoms. NOT A DIAGNOSIS 4. history of present illness (HPI)- statement of general health. a. Past medical history (PMH) b. Family history (FH) c. Review of systems (ROS) d. Functional assessment (FA)

Past medical history (PMH) (11)

1. childhood illnesses 2. accidents/injuries 3. serious/chronic illnesses 4. hospitalizations- cause, name of hospital, how the condition was treated, how long the pt was hospitalized, & name of physician 5. operations- type of surgery, date, name of surgeon, hospital, & how person recovered 6. obstetric history- # of pregnancies (gravida), # of deliveries in which fetus reached full term (para), # of preterm pregnancies, # of incomplete pregnancies (AB abortion), # of children living 7. immunizations 8. last exam date- physical, dental, vision, hearing, ECG, chest xray, mammogram, pap test, stool, serum cholesterol 9. allergies- allergen & reaction 10. current medications- prescription & over the counter 11. last menstrual period

The 4 types of assessment data that nurses collect

1. complete 2. problem focused 3. follow up 4. emergency

5 common assessment findings in the breasts of pregnant women

1. delicate blue vascular pattern is visible over the breast 2. breasts increase in size, as do the nipples 3. jagged linear stretch marks develop if the breasts have a large increase 4. nipples become darker & more erectile 5. areola widen, grow darker and contain small, scattered, elevated Montgomery glands

What are the 7 major cardiac risk factors?

1. elevated LDL 2. high blood pressure 3. diabetes 4. obesity 5. smoking 6. sedentary lifestyle (modifying factor in the development of cardiovascular disease) 7. family history

Contours of abdomen

1. flat 2. scaphoid- abdominal wall is sunken & presents a concave rather than convex contour 3. rounded 4. protuberant- unusual convexity caused by poor muscle tone or excessive subcutaneous fat

5 common assessment findings in the breasts of elderly

1. increasing age is the primary risk factor for developing breast cancer 2. pendulous, flattened, and sagging 3. nipples may be retracted but can be pulled outward 4. breasts feel more granular, terminal ducts around the nipple feel more prominent & stringy 5. thickening of the inframammary ridge at the lower breast is normal & feels more prominent with age

Sequence for assessing the abdomen

1. inspection 2. auscultation 3. percussion 4. palpation

Sequence of steps in an exam of all joints & muscles in the MS system

1. inspection 2. palpation 3. ROM 4. muscle testing

What are the 4 assessment techniques & what techniques are used in assessing each system?

1. inspection- always 1st & continual. it is close, careful observation of the patient as a whole & of each body system. Use the pt's body as the control & compare the right & left sides of the body *to determine symmetry.* Requires good lighting 2. Palpation- *Use of touch to assess texture, temp, moisture, organ location & size* Helps identify swelling, vibrations, pulsations, lumps or masses, tenderness/pain 3. Percussion- tapping the pt's skin with short, sharp strokes to create percussion sounds. *used to assess the location, size, and density of an organ, detect an abnormal mass, or elicit a deep tendon reflex* 4. Auscultation- *listening to sounds made by the body* using a stethoscope. Heart, blood vessels, lungs, & abdomen are commonly auscultated areas

Common assessment findings in the lungs and thorax of elderly patients

1. less chest expansion 2. larger anteroposterior diameter 3. marked, bony prominences. 4. Aging is associated with kyphosis, use of accessory muscles, and hyperresonance

8 critical characteristics of health history

1. location- ask pt to point to location of pain 2. character/quality of pain- burning, sharp, dull, aching, etc. 3.severity/quantity- using pain scale 0-10 4. timing- onset, duration, frequency 5. setting- where was the person or what was the person doing when the symptom started? what brings it on? 6. aggravating/relieving factors- what makes the pain worse? 7. associated factors- is this primary symptom associated with others? 8. patient's perception- find out the meaning of the symptom by how it affects daily activity

2 tests for carpal tunnel syndrome

1. phalen test 2. tinel sign

What are the four areas that must be considered in the general survey?

1. physical appearance- age, sex, level of consciousness, skin color, facial features, signs of distress 2. body structure- stature, nutrition, symmetry, posture, position, & body build or contour. In this area, obvious physical deformities are noted 3. mobility- concerned with gait & range of motion 4. behavior- considers facial expression, mood and affect, speech, dress & personal hygiene

9 topics to include when teaching someone about hepatitis prevention & liver health

1. practice safe sex 2. watch diet & weight 3. travel wisely 4. use medications wisely 5. drink in moderation 6. don't mix medications & alcohol 7. no illegal drugs 8. vaccinations are available for hep. A & hep. B 9. good resources for patients can be found at CDC.gov website

What are the ten traps of interviewing?

1. providing false assurance or reassurance 2. giving unwanted advice 3. using authority: "your dr/nurse knows best" 4. using avoidance language- "passed on" to avoid reality or hide their feelings 5. distancing- impersonal speech to put space bw a threat & the self. ex: "there is a lump in the left breast" 6. using professional jargon- adjust your vocab to ensure understanding 7. using leading or biased questions 8. talking too much 9. interrupting 10. using "why" questions- answer to why questions is "because"

Procedure for assessing the lungs and thorax (4)

1.) Examine the posterior thorax and lungs while the patient is sitting 2.) Examine the anterior thorax and lungs with the patient supine 3.) Compare one side of the thorax and lungs with the other 4.) Proceed in an orderly fashion: *inspect, palpate, percuss, and auscultate*

functional use of space: personal

1.5 to 4 ft. perceive as an extension of the self, similar to bubble. voice moderate, body odors inapparent, no visual distortion, much of physical assessment occurs at this distance

Inflate the cuff ___ to ___ millimeters of mercury above the point where the arterial pulsation is obliterated

20 to 30 millimeters

How does the cervix appear after pregnancy?

2nd month of pregnancy it looks blue; os is a porous- horizontal irregular slit that may show healed lacerations on the sides; may have cervical eversions, may have nabothian cysts that are small, smooth, yellow nodules

How is the force of a pulse recorded?

3+ full bounding 2+ normal 1+ weak thread 0- absent

How is the force of a pulse graded?

3+: increased, full, bounding 2+: normal 1+: weak 0: absent

functional use of space: social

4 to 12 ft. used for impersonal business transactions. perceptual info much less detailed. much of the interview occurs at this distance.

The width of the cuff's bladder should equal __% of the circumference of the person's arm. The length of the bladder should equal __% of this circumference.

40; 80

How is muscle strength recorded?

5- full ROM against gravity, full resistance (normal) 4- full ROM against gravity, some resistance (good) 3- full ROM with gravity (fair) 2- full ROM with gravity eliminated (passive motion) (poor) 1- slight contraction (trace) 0- No contraction (zero)

Deep vein thrombosis

A deep vein is occluded by a thrombus, causing inflammation, blocked venous return, cyanosis, & edema. Cause may be prolonged bed rest, history of varicose veins, trauma, infection, cancer, obesity, immobility, heart failure, or the use of estrogen hormones.

What is the purpose of the genogram? What do the symbols mean?

A pedigree or genogram is a graphic family tree that uses symbols to depict the gender, relationship, & age of immediate blood relatives in at least 3 generations, such as parents, grandparents, & siblings. useful in showing info concisely males- square females- circle deceased- line through it

What does a functional assessment measure?

A person's self-care ability in the areas of general physical health or absence of illness. Includes self concept & coping & home environment

What are the danger signs for cancerous lesions (ABCDE)?

A- asymmetry (not regularly found oval, two halves of lesion do not look the same) B- border irregularity (notching, scalloping, ragged edges, poorly defined margins) C- color variation (areas of brown, tan, black, blue, red, white, or combination) D- diameter greater than 6 mm E- elevation or enlargement

What is included in a functional assessment? (3)

ADLs- bathing, dressing, toileting, eating, walking IADLs (instrumental activities of daily living)- housekeeping, shopping, laundry, using the telephone, & cooking Social history- marital status, # of children, religious preference, occupation, hobbies, alcohol consumption, tobacco use, street drugs

Leading questions

Asking a man, "you dont smoke, do you?" implies that one answer is better than another. if a person wants to please you, either he is forced to answer in a way corresponding to your values or he feels guilty when he must admit to the other answer.

What is the procedure for palpating an abdomen when a patient reports having an area of tenderness or pain?

Assess rebound tenderness when the person reports abdominal pain or when you elicit tenderness during palpation. Perform test *at the end of exam* because it can cause severe pain & muscle rigidity

Describe what crepitus feels like

Audible and palpable crunching or grating that accompanies movement

Procedure for assessing the carotid arteries, particularly if the patient is elderly

Auscultate each carotid artery for the presence of a bruit. Keep the neck in a neutral position. Lightly apply the *bell of the stethoscope* over the carotid arteries at 3 levels: angle of the jaw, midcervical area, & the base of the neck. Avoid compressing the artery because this can cause an artificial bruit

Procedure for auscultating heart sounds

Auscultate heart sounds with patient sitting, supine, on left side. Move in a Z pattern from base to apex. Listen over aortic, pulmonary, tricuspid, and mitral areas. 1. note the rate & rhythm (rate normally 50-95; rhythm should be normal) 2. identify S1 & S2 3. assess S1 & S2 separately 4. listen for extra heart sounds 5. listen for murmurs

When is hand hygiene performed during a patient assessment? (3)

Before & after physical contact with each patient after contact with body fluids or contaminated equipment after removing gloves

Arterial ischemic ulcer

Buildup of fatty plaques on intima plus hardening & calcification of arterial wall Ulcers occur at toes, metatarsal heads (toes), heels, and lateral ankle. Characterized by pale ischemic base, well defined edges and no bleeding

How is accommodation tested?

By asking the person to focus on a distant object. This dilates the pupils, then have the person shift their gaze to a near object, such as your finger held about 7-8 cm from nose

Conditions associated with cyanosis?

CYANOSIS= BLUISH SKIN -increased amount of unoxygenated hemoglobin -central chronic heart failure & lung disease cause arterial desaturation -peripheral exposure to cold, anxiety

What questions are important to ask when someone presents with a complaint of vaginal discharge?

Character or color? Onset? Associated with any other symptoms? Medications? Part of menstrual cycle? Family history of diabetes? Douche? Hygiene spray? Non-ventilating undies? Treated with anything?

How is peripheral vision assessed?

Confrontation method

Neuropathic Ulcer

Diabetes hastens changes described with arterial ischemic ulcer, with generalized dysfunction in all arterial areas: peripheral, coronary, cerebral, retinal, & renal Common location is plantar aspect of foot, where excessive moisture increases risk. Pain & sensation are decreased, and surrounding skin is calloused.

Which part of the stethoscope is used to auscultate the lungs (bell or diaphragm or both)?

Diaphragm

Procedure for screening women for nipple and skin retraction during a breast exam

Direct woman to change position to check breasts for skin retraction signs; first ask her to lift arms slowly overhead; both breasts should move up symmetrically. 1. Lift arms over head; upward movement symmetrically 2. Inspect with hands on hips 3. Inspect with palms pushed together

Conditions associated with erythema?

ERYTHEMA= REDNESS -hyperemia -polycythemia -carbon monoxide poisoning -Venous stasis

What are the landmarks which should be identified during the otoscopic exam? (2)

External canal & tympanic membrane

What are the techniques for promoting therapeutic communication & building rapport? (8)

Facilitation encourages patient to go on and continue with what they are saying Silence- become comfortable with silence Reflective- "I'm worried all the time" "you're worried all the time" Empathy- recognize feelings and put them into words "it must be hard to see your loved one suffer" Clarification- "so what I'm hearing you say is" Confrontation- focus on what the patient is not telling you but is what you observe Interpretation- piece together what they said and come up witha synopsis "so every time you drink it seems as though you become stressed" Explanation- explain to your patient "education" Summary- summarize what happened within the appointment, make sure you recorded everything correctly

Which sinuses are accessible to examination and how are they assessed? (2)

Frontal- in the frontal bone above and medial to the orbitis (pressing up & under the eyebrows) Maxillary- in the maxilla (cheekbones) along the side walls of the nasal cavity (pressing below cheek bones) person should feel firm pressure with no pain

Stage 4 pressure ulcer

Full thickness pressure ulcer involves all skin layers & extends into supporting tissue. *Exposes muscle, tendon or bone and may show slough or eschar*

Sinus headache

HA associated with pressure behind the forehead or cheek bones

Tension headache

HA of musculoskeletal origin; may be mild to moderate; less disabling form of migraine usually on both sides, across forehead, sides, & back of head bandlike tightness, nonthrobbing, nonpulsatile gradual onset

Cluster headaches

HA that is intermittent, excruciating, unilateral always one sided. often behind or around the eye, temple, forehead, cheek abrupt onset, can occur multiple times a day. severe, stabbing pain

What would the nurse expect the AP ratio to be in a healthy adult? An infant? A person with emphysema?

Healthy adult- 1:2 Infant- 1:1 up to age of 6 Emphysema- 1:1, barrel chested. chest appears as if held in continuous inspiration.

Apices (apex) of the lungs

Highest point, lies 3 or 4 cm above the inner third of the clavicles

How is the otoscopic exam performed

Hold pinna gently but firmly, do not release traction on ear until you have finished examination and removed otoscope. Once in place, you may need to rotate otoscope slightly to visualize the entire TM; do this gently. Perform otoscopic examination before you test hearing. Canals with impacted cerumen give the erroneous impression of pathologic hearing loss

Mongolian spots

Hyperpigmentated, *blue-black to purple macular area* at the sacrum or buttocks but sometimes the abdomen, thighs, shoulders, or arms. *Most common in black, native american, asian, & hispanic newborns*

What condition is an S3 associated with in adult patients?

Indicates congestive heart failure (CHF) -volume overload, high cardiac output

What instructions does the nurse give the patient regarding how to breathe during auscultation of the lungs?

Instruct the patient to breathe through the mouth, a little bit deeper than usual, but stop if he or she begins to feel dizzy.

Conditions associated with jaundice?

JAUNDICE= YELLOW Increased serum bilirubin, more than 2 to 3 mg/100 ml from liver inflammation or hemolytic disease such as after severe burns, some infections

Deflate the cuff slowly & note the points at which you hear ___ sounds

Korotkoff's sounds

Tripod position

Leaning forward with arms braced against their knees, chair, or bed. This gives them the leverage so the abdominal, intercostal, and neck muscles all can aid in expiration.

Superficial Varicose Veins

Normal leg veins have dilated as result of chronic increased venous pressure (obesity, multiple pregnancies) & incompetent valves that permit reflux of blood back toward leg instead of forward toward the heart. 3 times more common in women than men. older age increases risk. Size ranges from 1 mm to 1 cm in diameter; color changes from red to blue or purple.

When is an S3 normal & abnormal

Normal: in children and pregnant women. it occasionally may persist after age 40, especially in women, usually disappears when the person sits up. Abnormal: in adults over 35, does not go away when sitting up

Inspiratory Arrest (Murphy Sign)

Normally palpating the liver causes no pain. In a person with *inflammation of the gallbladder (cholecystitis)*, pain occurs. 1. Hold your fingers under the liver border. 2. Ask the person to take a deep breath. A normal response is to complete the deep breath without pain.

8 critical components of HPI "OLD CARTS"

O-onset L-location D-duration C-character A-aggravating factors R-relief T-timing S-severity

OU, OD, OS meaning

OU- both eyes OD- right eye (oculus dexter) OS- left eye (oculus sinister)

How do you examine the prostate? What finding would you expect in cancer of the prostate?

On anterior wall of rectum, note the elastic bulging prostate gland. Palpate the entire prostate in a systematic manner, note that only the superior and part of the lateral surfaces are accessible to examination. Press into the gland at each location surface should feel smooth and muscular a firm or hard mass with irregular shape or rolled edges may signify carcinoma.

What does PERRLA mean?

P-pupils E-equal R-round R-react to l-light A-accomodation

What conditions are associated with pallor?

PALLOR= PALE SKIN -anemia -local arterial insufficiency -albinism -vitiligo

Patients with which type of condition typically assume tripod position?

Patients with COPD

Iliopsoas Muscle test

Perform when the acute abdominal pain of *appendicitis* is suspected. With the person supine, lift the right leg up, flexing at the hip; then push down over the lower part of the right thigh as the person tries to hold the leg up. When the test is negative, the person feels no change.

Anatomical landmarks used when performing *palpation* of the lungs

Posterior: hands on the posterolateral wall with thumbs pointing together at the level of T9 or T10 Anterior: place hands on the anterolateral wall with thumbs along the costal margins & pointing toward the xiphoid process. -any limitation in thoracic expansion is easier to detect on the anterior chest because greater range of motion exists with breathing here

Anatomical landmarks used when performing *percussion* of the lungs

Posterior: start at the apices & percuss the band of normally resonant tissue across the tops of both shoulders. then, percussing in the interspaces, make a side to side comparison all the way down the lung region. *Percuss at 5 cm intervals.* Anterior: begin percussing the apices in the supraclavicular areas. then, percussing the interspaces & comparing one side with the other, move down the anterior chest.

PQRSTU

Provocative or palliative- what brings it on? Quality or quantity- how does it look, feel, sound? how intense/severe is it? Region or radiation- where is it? does it spread anywhere? Severity scale- how bad is it (on a scale of 1-10?) Timing- onset, duration, frequency Understands pt's perception of the problem

What percussion note would the nurse expect to hear over normal lung tissue in a healthy adult?

Resonance: low pitched, clear & hollow

Best time of the month for women to do BSE (Breast Self-Exam)

Right after menstrual period (day 4-7 of the cycle) when the breast are smallest and least congested If they don't have a menstrual period chose a familiar date as a reminder (such as 1st of the month)

Location & quadrant of the appendix

Right lower quadrant

Where is S1 heard loudest?

S1 is louder than S2 *at the apex* S1 coincides with the carotid artery pulse "lub" sound

Where is S2 heard loudest?

S2 is louder than S1 *at the base* "dup" sound

Venous stasis ulcer subjective & objective findings

S: Aching pain in calf or lower leg, worse at end of the day, worse with prolonged standing or sitting, itching with stasis dermatitis O: Lower leg edema that does not resolve with diuretic therapy, firm/brawny edema, coarse, thickened skin, pulses normal, brown pigment discoloration, petechiae, dermatitis, ulcers are shallow and may contain granulation tissue

Superficial varicose veins subjective & objective findings

S: Aching, heaviness in calf, easy fatigability, restless legs, burning, throbbing, cramping O: Dilated, tortuous veins, new varicosities sit on surface of muscle or bone, older ones are deep and feel spongy

Arterial ischemic ulcer subjective & objective findings

S: Deep muscle pain in calf or foot, claudication (pain with walking), pain at rest indicates worsening of condition O: Coolness, pallor, elevational pallor, and dependent rubor (dependent meaning below heart & rubor meaning red), diminished pulses, systolic bruits, signs of malnutrition (thin, shiny skin, thick-ridged nails, atrophy of muscles); distal gangrene

Deep Vein Thrombosis subjective & objective findings

S: Sudden onset of intense, sharp, deep muscle pain O: Increased warmth, swelling (to compare swelling, observe usual shoe size), redness, dependent cyanosis is mild or may be absent, tender to palpation

Inspection of the nipple

Should be symmetric on same plane and both breasts Nipples usually protrude, although some are flat and some are inverted

What is the best technique for palpating lymph nodes?

Start at the preauricular lymph nodes in front of the ear and palpate the 10 groups in routine order. *Palpate symmetrically with gentle pressure*

How to test a Babinski in adults

Stroke lateral aspect & across ball of foot. If the reflex is present (extension of great toe, fanning of toes), it is an abnormal response. -positive indicates corticospinal (pyramidal) tract disease (stroke, trauma)

How is the patient positioned to promote relaxation of the abdominal wall during the exam?

Supine with arms at their side with knees/legs flexed and pillow under knees and head

Symptoms vs. signs

Symptoms- subjective sensation that the person feels from the disorder. Sign- objective abnormality; **seen** by examiner

How long do you have to count to determine that bowel sounds are really absent?

The nurse must listen for *5 minutes* before deciding that bowel sounds are completely absent

How many lobes does the right & left lung have?

The right lung has *3 lobes* (upper, middle, & lower) the left lung has *2 lobes* (upper & lower)

What is meant by accommodation?

This is an adaptation of the eye for *near vision*, and is accomplished by increasing the curvature of the lens through the muscles of the ciliary body. *maintain a clear image or focus on an object as distance varies*

Most predominant percussion sound heard over the abdomen

Tympany

What is the purpose of performing a health assessment?

To make a clinical judgment or diagnosis about the individual's health state or response to actual or risk health problems and life processes, as well as diagnosis about higher levels of wellness.

At what site is oral cancer most likely to appear?

U-shaped area under the tongue behind the teeth. Occurs particularly at sides, base, and under tongue. Can be white patches, nodules, or ulcerations.

Venous stasis ulcer

Ulcer may occur at medial malleolus (outer ankle) and are characterized by bleeding, uneven edges. These account for 80% of lower leg ulcers

Deep palpation of an obese abdomen

Use a bimanual technique. Place your two hands on top of one another, the top hand does the pushing while the bottom hand is relaxed and can concentrate on the sense of palpation. *With either technique note the location, size, consistency, and mobility of any palpable organ and the presence of any abdominal enlargement, tenderness, or masses*

How do you prepare yourself & the patient for an examination of the skin?

Use strong direct lighting. Know the persons normal skin coloring. At the beginning of the exam, assess persons hands and fingernails to accustom them to your touch. Help the person remove clothing & assess skin as one entity. Stand back to get an overall impression & then inspect lesions carefully.

What are the guidelines for recording the reason for seeking care?

Use the patient's "own words"

Allen test

Used to evaluate the adequacy of collateral circulation before cannulating the radial artery.

What is the procedure for taking a pulse?

Using the pads of first 3 fingers, palpate the radial pulse, if rhythm is regular, count the number of beats in 30 seconds and multiply by 2. If rhythm is irregular count for a full minute. Start first beat at 0. normal is 50-95 bpm. ratio of pulse rate to respiratory rate should be approximately 4:1

What is the procedure for testing auditory acuity?

Whispered voice test - Test one ear at a time while masking hearing in other ear by placing one finger on tragus and rapidly pushing it in & out of auditory meatus - Shield your lips so the person cannot compensate for a hearing loss (consciously or unconsciously) by lip reading or using the "good" ear - With your head 30 -60 cm (1-2 ft) from persons ear, exhale & whisper slowly some two-syllable words - Normally, a person repeats each word correctly after you say it.

In which part of the breast are most malignancies found in women? In men?

Women: upper outer quadrant; which contains the axillary tail of spence Men: usually under the nipple

Linea nigra

a brownish black line down the midline of the abdomen in pregnant women

Cheyne-Strokes respirations

a cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing Breathing periods last 30- 45 seconds, with 20 second periods of apnea

sinus headache

a headache resulting from congestion or infection in the paranasal sinuses.

Cafe au lait spots

a large round or oval patch of light brown pigmentation (hence the name "coffee with milk") which is usually present at birth *most common in people of color*

Linear lesions

a scratch, streak, line or stripe

Pleural friction rubs

a very superficial sound that is coarse & low pitched, it has a grating quality as if *two pieces of leather are being rubbed together (pleuritis)*

Radial pulse

inside of wrist, place two fingers on area

Graphesthesia

ability to read a number by having it traced on the skin

Stereognosis

ability to recognize objects by feeling their forms, size, and weights

Amenorrhea

absence of menstruation primary- failure of menstruation to be initiated secondary- cessation of periods after they previously existed.

Diagnostic position test

design is to inspect *extraocular muscle function.* Ask person to hold the head steady and follow the movement of your finger with only eyes. Hold about 12 cm away and move in the 6 directions clockwise.

Oral temperature

accurate & convenient. It may not be appropriate for a patient who is comatose or confused, has a wired mandible or facial dysfunction, or cannot close the mouth. **Use blue tip of electronic probe**

How would a node with infection feel & appear?

acute onset, <14 days duration, nodes are bilateral enlarged, warm, tender, and firm but freely moveable.

Presbycusis

age related hearing loss

Palpation- fingers & thumb are ideal for

detecting position, shape and consistency of an organ or mass

Posterior lobes of the lungs

almost all lower lobe. upper lobe occupy tissue from their apices at T1 down to T3 or T4. lower lobes begin & their border reaches down to T10 on expiration & T12 on inspiration

Diastolic murmur

always indicates heart disease

Family history (FH)

an accurate family history will highlight those diseases & conditions for which a particular pt may be at increased risk.

Cholasma

an irregular brown patch of hyperpigmentation on the face, common in pregnancy or people taking oral contraceptives; disappears after delivery or when stop taking pills

Glaucoma

an optic nerve neuropathy characterized by *loss of peripheral vision, caused by increased intraocular pressure.* Adults over 40 have this.

what would you do if a patient complains of the worst headache of their life

aneurism true emergency

How to perform the Phalen Test

ask person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand; produces numbness and burning in a person with carpal tunnel

Where do you put the stethoscope to assess the apical pulse rate

assess at mitral valve

Where do you put the stethoscope to assess an aortic & pulmonic murmur

assess at the 2nd intercostal space, right and left

Where do you put the stethoscope to assess S3, S4

assess at the apex

Corneal light reflex/Hirshberg test

assesses the *parallel alignment* of the eye axes by shining the light toward the person's eye. Direct the person to stare straight ahead as you hold the light about 30 cm away. Note the reflection of the light on the cornea; it should be the same spot in both corneas.

Palpation- base of fingers & ulnar surface of hand is best for

assessing vibration

Lymph nodes: occipital

at the base of skull

Palpation- back of hand (dorsal) & fingers are good for

determining temperature

Macular degeneration

breakdown of cells in the macula of retina. *Loss of central vision*, the area of clearest vision, *most common cause of blindness.* Affects ages 75-85. *Women are more affected.* The person is unable to read fine print, sew, or do fine work and may have difficulty distinguishing faces. Peripheral vision is not affected.

Popliteal pulse

behind the knee, put thumbs on the knee and curl your fingers around the popliteal fossa, press your fingers forward hard to compress the artery against the bone. Normally this is impossible to palpate

Flexion

bending limb at joint

Seborrheic keratoses

benign, greasy wart like lesions that are yellow brown in color. can appear anywhere on body but are seen frequently on neck, chest, & back

Metorrhagia

bleeding from the uterus at any time other than normal menstruation

Murmur

blowing, swooshing sound as blood flows across narrowed or abnormal valve; occurs when there's an increase in the velocity of blood flow/ change in viscosity of the blood, and structural defects in the valves/ or unusual openings in the chambers.

Bimanual palpation is the use of

both hands to envelop or capture certain body parts or organs, such as the kidneys

Base of the heart

upper portion of the heart

What is the structure that is visualized when an internal pelvic exam is done?

cervix

Menopause

cessation of menstruation

Annular lesions

circular begins in center & spreads to periphery (ex: ringworm, tinea versicolor, pityaris rosea)

How are nail beds affected by chronic lung disease such as emphysema? What finding related to the nails is commonly associated with COPD?

clubbing is a deformity of the finger or toe nails, angle is more than 160 degrees. cyanosis or marked pallor nail beds or sluggish color return

Grouped lesions

cluster of lesions (vesicles of contact dermatitis, herpes, chiggers)

If you see a lesion, note its: (6)

color elevation shape size location & distribution on the body any exudate

Procedure for examining the breasts of the male

combine the breast examination with the anterior thorax examination. Inspect the chest wall, palpate the nipple area, and palpate the axillary lymph nodes.

Complete assessment

complete health history & full physical exam. describes the current & past health state & forms a baseline. collected by a primary physician

Hydrocele

cystic, circumscribed collection of serous fluid in tunica vaginalis surrounding testes. S: painless swelling, although person may complain of weight & bulk in scrotum O: inspection- enlarged mass does transilluminate with a pink or red glow palpation- nontender mass; able to get fingers above mass

lymph nodes: deep cervical chain

deep under the sternomastoid muscle

What is normal capillary refill?

depress the nail edge to blanch and then release, noting the return of color. less than 1-2 sec

Know your stethoscope. When and how do use the diaphragm & bell properly?

diaphragm- for high pitched sounds, such as breath, bowel, and normal heart sounds. *hold it firmly against patients skin, firm enough to leave a ring.* bell- for soft, low pitched sounds, such as heart murmurs. *hold lightly against patient's skin*

Dyspnea

difficult to breath; subjective- perceived & reported by an affected patient

How to perform the Tinel Sign

direct percussion of the location of the median nerve at the wrist produces no symptoms in the normal hand; burning and tingling along its distribution with carpal tunnel

Otosclerosis

disorder causing *progressive deafness due to overgrowth of bone* around stapes in the inner ear. common cause of conductive hearing loss in young adults between ages 20-40 years.

Percussion note heard over the lungs with pneumonia

dull (soft, muffled thud signals abnormal density in the lungs)

What percussion sound is heard over the liver?

dullness

reflection

echoes the clients words by repeating part of what a person has just said. Mirroring clients words can help person elaborate on a problem. Reflective- "I'm worried all the time" "you're worried all the time"

Vesicles

elevated cavity containing free fluid, up to 1 cm; a "blister" clear serum flows if wall is ruptured

Facilitation

encourage client to say more, shows a person that you are interested

When & how is testicular self examination (TSE) performed?

encourage self-care by teaching every male from 13-14 years old through adulthood. T= timing, once a month S= shower, warm water relaxes scrotal sac E= examine, check for changes, report changes immediately

Normal chest expansion

equal bilaterally

Review of systems (ROS) purpose is to:

evaluate the past & present health state of the body system to double check in case any significant data was omitted & to evaluate health promotion practices. subjective data-told to the nurse by the patient

How is the chief complaint correctly recorded?

ex: "chest pain" for 2 hours. "sore throat for 3 days now & just getting worse" "ear ache & fussy all night" "need yearly physical for work" "want to start jogging & need check up". 2-3 words in the patients words quoted

Menorrhagia

excessive bleeding during menstruation or increased duration of flow

Lordosis

excessive inward curvature of the spine present in maternal MS system due to increased size & weight of uterus

Palpation- fingertips are used for

fine tactile discrimination

Normal heart sounds

first heart sound *(S1) occurs with closure of AV valves (mitral & tricuspid) and thus signals beginning of systole*; can hear S1 over all pericardium, loudest at apex

Menarche

first menstrual period. mean age at onset of periods usually 12-13

Macules

flat non-palpable lesions that you cant see and are less than 1 cm. Solely a color change, flat, and circumscribed. ex: freckles, measles, petechiae, hypopigmentation

Hip ROM

flexion with knee bent and knee flexed, internal rotation, external rotation, abduction, adduction, hyperextension

Knee ROM

flexion, extension, hyperextension

Elbow ROM

flexion, extension, pronation, supination

Cervical spine ROM

flexion, hyperextension, lateral bending, rotation

Hypoactive or absent bowel sounds

follow abdominal surgery or with inflammation of the peritoneum. <5

Shoulder ROM

forward flexion, hyperextension, internal rotation, external rotation, abduction, adduction

Stage 3 pressure ulcer

full thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see fat

What is the purpose of silence during an interview?

gives the patients time to collect his or her thoughts gives you an opportunity to observe the pt unobtrusively & note nonverbal cues. Silence also gives you time to plan your next approach

Lymph nodes: submaxillary (submandibular)

halfway between the angle of the mandible

How would a cancerous node feel on palpation and appear?

hard >3 cm unilateral, nontender, matted, and fixed

Urge incontinence

have the sudden urge to go & lose control

How is the physical exam altered for an elderly pt?

health history- focus on ADLs & IADLs, medications, emotional status, sleep pattern, bowel habits, and home safety physical exam- organize the exam with less movement to avoid over exertion

How is the physical exam altered for a child?

health history- source of history, CC in parents words, PI, PMH (prenatal care, labor & delivery, postnatal course), developmental history (milestones), nutritional history, & functional assessment physical exam- work fast, examine eyes, ears, & throat last, pray for sleep, use parent, & keep developmental stages in mind

With the pt's arm supported at ____ level, center the cuff about ___ inch above the ____ artery & wrap it evenly

heart level 1 inch brachial artery

A cuff that is too narrow yields a falsely

high pressure

Percussion: tympany

hollow, high, drumlike sounds. Tympany is normally heard over the stomach, but is not a normal chest sound. Tympanic sounds heard over the chest indicate excessive air in the chest

Wrist & hand ROM

hyperextension, flexion, extension, ulnar deviation, radial deviation, abduction, touch thumb to each finger and base of pinky

Percussion note heard over the lungs with emphysema

hyperresonance (lower-pitched booming sound found when too much air is present)

Lymph nodes: preauricular

in front of the ear

lymph nodes: posterior cervical

in the posterior triangle along the edge of the trapezius muscle

What does anteroposterior transverse diameter of the chest mean?

increases or decreases by the elevation or depression of the ribs (expiration/ inspiration)

Normoactive bowel sounds

indicating normal activity. High pitched, gurgling, cascading sounds, occurring irregularly 5 to 30 times per minute.

Brachial pulse

inner elbow, place two fingers on area

Femoral pulse

inner thigh, place two fingers on area

Hypoventilation

irregular shallow pattern caused by an overdose of narcotics or anesthetics. May also occur with prolonged bed rest or conscious splitting of the chest to avoid respiratory pain

Striae

jagged linear "stretch marks" of silver to pink color that appear during the second trimester on the abdomen, breasts, & sometimes thighs

Lymph nodes: supraclavicular

just above and behind the clavicle, at the sternomastoid muscle

Location & quadrant of the kidneys

kidneys are retroperitoneal or posterior to the abdominal contents. They are well protected by the posterior ribs & musculature *right kidney- right upper quadrant* *left kidney- left upper quadrant*

Bulla

larger than 1 cm diameter; usually single chambered; superficial in epidermis; thin walled so ruptures easily. ex: friction blister, burns

Scoliosis

lateral S-shaped curvature of the thoracic and lumbar spine, usually involved in vertebrae rotation

Spine ROM

lateral bending, hyperextension, rotation

The ___ lung is narrower than the ___ lung

left lung is narrower than the right because the heart bulges to the left

closed-ended questions

limit the pt's answers to yes or no or a number or frequency of symptoms. elicit cold facts

problem focused assessment

limited or short term problem. collect a "mini" database, smaller in scope & more targeted than the complete database. Concerns mainly one problem, one cue complex, or one body system. used in all settings.

Zosteriform lesions

linear arrangement along a unilateral nerve route (herpes zoster)

Senile lentigines

liver spots, small, flat, brown macules after extensive sun exposure

Hyperactive bowel sounds

loud, high pitched, rushing, tinkling sounds that signal increased motility. >35

Bronchial breath sounds

louder and higher in pitch; usually heard over the manubrium (Trachea, Larynx)

Percussion: hyperresonance

louder and lower pitched than resonant sounds are normally heard when percussing the chests of children and very thin adults may be heard when lungs are hyperinflated with air or pts having an acute asthma attack

Percussion: resonance

low pitched, hollow sounds heard over normal lung tissue.

A cuff that is too wide yields a falsely

low pressure

Social history (SH)

marital status, # of children, religious pref., occupation, hobbies, alcohol consumption, tobacco use, street drugs

Nipple inversion

may be unilateral or bilateral and usually can be pulled out. Note any dry scaling, any fissure or ulceration, and bleeding or other discharge. *Recent inversion is abnormal*

Systolic murmur

may occur benign (healthy heart) or pathologic (heart disease)

Confrontation test

measure of *peripheral vision*. It compares the person's peripheral vision with your own. Position yourself eye to eye with patient about 2 feet away. Direct the person to cover one eye with card and look straight at you with the other eye. Slowly advance in from the periphery in several directions, ask the person to say now as the target is first seen this should be when you see it as well.

Epispadias

meatus opens on dorsal (upper) side of glans or shaft above a broad, spadelike penis. Rare; less common than hypospadias but more disabling bc of associated urinary incontinence and separation of pubic bones.

Papanicolaou test

method of examining stained cells in cervical smear for early diagnosis of uterine cancer

Lymph nodes: submental

midline, behind the tip of the mandible

What are the most common causes of cheyne-stroke respirations?

most common cause is severe heart failure; other causes are renal failure, meningitis, drug overdose, & increased ICP -occurs normally in infants & aging people during sleep

Abduction

moving limb away from the midline of body

Adduction

moving limb toward midline of body

Inversion

moving sole of foot inward at ankle

Eversion

moving the sole of the foot outward at the ankle

Boogers

mucous, dirt, and debris that are collected in your nose so they do not go to the lungs

empathy

names a feeling and allows its expression. allows a person to feel accepted & strengthens rapport Empathy- recognize feelings and put them into words "it must be hard to see your loved one suffer"

Phimosis

non-retractable foreskin forming a pointy tip with a tiny orifice. Foreskin is advanced so tightly it is impossible to retract over glans.

Percussion: dullness

normally heard over dense areas such as the heart or liver. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung tissues

Percussion: flatness

normally heard over solid areas such as bones.

Epistaxis

nose bleeds; occurs with trauma, vigorous nose blowing, & foreign body

Perforation

o *Drum rupture* from increased pressure or trauma o *Appears as a round or oval darkened area* on the drum

Otitis media with effusion

o An *amber yellow drum* suggests serum in middle ear that transudes to relieve negative pressure from the blocked Eustachian tube o *Feeling of fullness, transient hearing loss, popping sound with swallowing*

Excessive cerumen

o Produced or impacted because of *narrow, tortuous canal or poor cleaning method.* o May show as *round bell partially obscuring drum or totally occluding canal.*

Otitis externa

o Severe *swelling of canal*, inflammation, tenderness o Canal lumen is narrowed to one fourth normal size

Acute otitis media

o This results when the *middle ear fluid is infected* o *Redness and bulging* along with earache and fever

Is the data collected during general survey objective or subjective data?

objective

Anterior lobes of the lungs

oblique fissure crosses the 5th rib in the midaxillary line & ends at 6th rib -horizontal fissure: divides right upper & middle lobes. extends from 5th rib to the 4th

Location & quadrant of the spleen

on the posterolateral wall of the abdominal cavity, immediately under the diaphragm. it lies obliquely with its long axis behind & parallel to the 10th rib, lateral to the midaxillary line. its width extends from the 9th-11th rib *Left upper quadrant*

Deep palpation assesses an

organ or mass deeper in body cavity

Kyphosis

outward curvature of thoracic spine (humpback)

Lymph nodes: superficial cervical

overlying the sternomastoid muscle

Dysmenorrhea

painful periods with cramping or aching in lower pelvis and lower back

Thrill

palpable vibration; feels like the throat of a purring cat. The thrill signifies turbulent blood flow & directs you to locate the origin of loud murmurs.

Complete neurological exam

perform on people who have neurologic concerns (HA, weakness, loss of coordination) or who have shown signs of dysfunction.

Neurological recheck

perform on people who have neurological deficits and require periodic assessments (hospitalized people or those in extended care) 1. level of consciousness 2. motor function 3. pupillary response 4. vital signs

Screening neurological exam

perform on seemingly well people who have no significant subjective findings from the history 1. mental status 2. cranial nerves 3. motor function 4. sensation 5. reflexes

How does the cervix appear normally?

pink and even color, midline either anterior or posterior projects 1 to 3 cm into vagina, 1 in diameter, Os is small and round, surface is normally smooth, secretions are always odorless and nonirritating

Apical pulse

place two fingers on your mitral valve

Ankle & foot ROM

plantar flexion, dorsiflexion, eversion, inversion, flex and straighten toes

Ankle flexion (plantar flexion)

point toes toward floor at 45 degree angle

Ankle extension (dorsiflexion)

point toes toward nose at 20 degree angle

How do you position the patient to auscultate an S3, S4?

position patient on the left lateral side, *using the bell* of the stethoscope

Anatomical landmarks used when performing *auscultation* of the lungs

posterior: from the apices at C7 to the bases (around T10) moving from one side to the other laterally from the axilla down to the 7th or 8th rib anterior: from the apices in the supraclavicular areas down to the 6th rib. progress from side to side & listen to full respiration in each location

Lichenification

prolonged, intense scratching eventually thickens skin and produces tightly packed sets of papules; looks like surface of moss (or lichen)

open-ended questions

prompts pt's to describe a situation in more than one or two words. leads to discussion in which pt's actively describe their health status

How is the otoscopic exam performed on a child

pull pinna straight down; child under 3

How is the otoscopic exam performed on an adult

pull pinna up & back

Normal response to accommodation test includes: (2)

pupillary constriction & convergence of axes of eyes

Tachypnea

rapid, shallow breathing; increased rate, > 24/minute

Migraines

recurrent headaches usually described as throbbing pain with accompanying nausea & vomiting, sweating, & photosensitivity commonly one sided but may occur on both sides pain is often behind eyes, temples or forehead rapid onset, moderate to severe pain

What structures are assessed in the fundoscopic exam and in what order? (5)

red reflex optic disc retinal vessels general background macula

Discrete distinct individual lesions

remain separate (acrochordon or skin tags, acne)

Base (lower border) of the lungs

rests on the diaphragm at about the 6th rib in the midclavicular line

Nipple retraction

retraction signs are caused by fibrosis in the breast tissue, usually caused by growing neoplasms. -note a lag in the movement of one breast -note a dimpling or pucker, which indicates retraction -note fixation to chest wall

The ____ lung is shorter than the ____ lung because of the underlying ____

right lung is shorter than the left because of the underlying liver

Confluent lesions

run together (urticarial hives)

What patient complaints or problems would indicate the need to do a screening or a complete musculoskeletal exam?

screening- no complaints complete- people with known or suspected joint disease, a history of musculoskeletal problems, any problems with ADLs

PND (Paroxysmal nocturnal dyspnea)

shortness of breath that awakens the patient in the middle of the night; usually relieve in the upright position

Posterior tibial pulse

side of ankle. Curve your fingers around the medial malleolus, press softly

What senses are relied upon to interpret the findings of each technique?

sight smell touch hearing

How do you position the patient to auscultate a pulmonic or aortic murmur?

sit the patient up and have them lean forward, *listen with diaphragm*

Bradypnea

slow breathing; a decreased but regular rate <10pm; as in drug induced depression of the respiratory center in the medulla, increased cranial pressure, and diabetic coma

Lobes of lungs

stack in diagonal sloping segments & are separated by *fissures*

Symptoms associated with Osteoarthritis

stiffness, swelling with hard, bony protuberances, pain with motion, limitation of motion

Extension

straightening limb at joint

How to test a Babinski in children

stroke finger up lateral edge and across the ball of infants foot. Note fanning of toes (positive Babinkski reflex). The reflex is present at birth & disappears (changes to adult response) by 24 months of age -positive after 2 occurs with pyramidal tract disease

Light palpation evaluates

surface characteristics & identifies areas of tenderness

Symptoms associated with Rheumatoid Arthritis

symmetric and bilateral, heat, redness, swelling, and painful motion of affected joints, fatigue, weakness, anorexia, weight loss, low grade fever, lymphadenopathy

Normal tactile fremitus

symmetric bilaterally, vibrations decreases as you go down

Cryptorchidism (absent testis)

testes that have never descended. Empty scrotal half, no testis, atrophic scrotum on affected side

What does 20/30 mean?

that the patient can see at 20 feet what a person with normal vision can see 30 feet away from the chart.

Hypospadias

urethral meatus opens on the ventral (under) side of glans, shaft, or at the penoscrotal junction. A groove extends from the meatus from the normal location at the tip. This congenital defect is important to recognize at birth. the newborn should not be circumcised because surgical correction may need foreskin

Presbyopia

the lens loses elasticity, becoming hard & glasslike. *decreases the lenses ability to change shape to accommodate for near vision.* *occurs as one ages*

Location & quadrant of the liver

the liver fills most of the *right upper quadrant* & extends over to the midclavicular line

Apex of the heart

the narrower lower tip of the heart; (5th intercostal space-under breast)

Apical pulse

the pulsation created as the left ventricle rotates against the chest wall during systole

Follow-up assessment

the status of any identified problems should be evaluated at regular & appropriate intervals. What change has occurred? is the problem getting better or worse? use in all settings to follow up both short term & chronic health problems

Bruit

the swishing sound heard because of blood going through a constricted vessel. A bruit indicates turbulent blood flow

Purulent nasal discharge

thick, yellow, and green discharge; sign of infection

Rhinnorhea

thin, watery discharge from the nose; occurs with colds, allergies, sinus infection & trauma

Confrontation

this response includes your own thoughts & feelings. You have observed a certain action, feeling, or statement & you now focus the person's attention on it. you give your honest feedback on what you see or feel. ex: "you say it doesn't hurt but when i touch you here, you grimace". Confrontation- focus on what the patient is not telling you but is what you observe

What is the procedure for assessing the thyroid? what do you instruct the patient to do during the procedure?

tilt the head back to stretch the skin against the thyroid. supply the person with water & first inspect the person takes a sip & swallows. Thyroid moves up with a swallow & then falls into its resting position

What instruction to the client is essential when testing sensory perceptions?

to close their eyes

Dorsalis pedis pulse

top part of feet, requires a very light touch, do not mistake the pulse in your own fingertips for that person

Orthopnea

trouble breathing while lying down; relieved by sitting or standing

Pronation

turning forearm so that arm is down

Supination

turning forearm so that palm is up

Gyrate lesions

twisted, coiled spiral, snakelike scabies

Lymph nodes: jugulodigastric (tonsillar)

under the angle of the mandible

clarification

use this when the person's word choice is ambiguous or confusing. Also used to summarize the person's words to make them clearer & ask if you're on the right track. Clarification- "so what I'm hearing you say is"

Rectal temperature

use when other routes are not practical. (comatose, confused pts, pts in shock, people who cant close mouth with breathing or oxygen tubes) disadvantages are pt discomfort & time consuming & disruptive nature of the activity *use red tip of electronic probe. insert 2-3 cm (1 in) into rectum, directed toward umbilicus. Hold in place*

What is the bell used for in a cardiac exam?

used for listening to S3, S4, midsystolic click, or murmur. It is *lightly applied*, is best for low-pitched sounds and murmurs.

What is the diaphragm used for in a cardiac exam?

used to note *rate and rhythm.* Identify S1 and S2 and listen to each. Listen for a split S2 during inspiration. It is *firmly applied*, for high-pitched sounds as in heart and bowel sounds.

Procedure for performing deep palpation

using the same steps for light palpation but push down about 5 to 8 cm (2 to 3 inches) & move clockwise, explore the entire abdomen

What does prolongation suggest? (3)

vasoconstriction, respiratory dysfunction, or decreased cardiac output

Temporomandibular joint ROM

vertical motion, lateral motion, protrusion without deviation

Stress incontinence

when abdominal stress is put on and there is a small amount of leakage

Overflow incontinence

when your brain does not get the signal that your bladder is full and leaks

Distinguish between xerosis, seborrhea, & pruritus.

xerosis- dry skin seborrhea- oily skin pruritus- skin itching

How is edema in the extremities graded?

•1+: mild pitting, slight indentation, no perceptible swelling of the leg •2+: moderate pitting, indention subsides rapidly •3+: deep pitting, indentation remains for a short time, leg looks swollen •4+ very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted

How is the female client positioned for inspection of the breast and palpation of the breast?

•Inspection- the woman is sitting up, facing the examiner •Palpation- woman is in supine position

Hyperventilation

•increase in rate and depth, rapid and deep; normally occurs with extreme exertion, fear, or anxiety, also with diabetic ketoacidosis (Kussmaul respirations) Blows off CO2, causing a decreased level in the blood (alkalosis)