NRS 208-- Health Assessment

ABCDE Skin Lesion Assessment

-Promoting health and self-care <> Teach skin self-examination using ABCDE rule to detect suspicious lesions A: asymmetry B: border C: color D: diameter E: elevation and enlargement

Family History

-Age and health or cause of death of relatives -Health of close family members -Family history of various conditions such as heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease, and tuberculosis -Family tree (genogram) to show this information clearly and concisely

Shapes and Configurations of Lesions

-Annular or circular -Confluent -Discrete -Grouped -Gyrate -Target or iris -Linear -Polycyclic -Zosteriform

Perception of Health Questions

-Ask questions such as the following: How do you define health? How do you view your situation now? What are your concerns? What do you think will happen in the future? What are your health goals? What do you expect from us as nurses, physicians, or other health care providers?

Process of Communication: Internal Factors

-Awareness of internal and external factors and their influence allows you to maximize communicating skill -internal factors <> liking others <> empathy <> ability to listen

Process of Communication: External Factors

-Ensure privacy -Refuse interruptions -Physical environment -Dress -Note-taking may be unavoidable <> Cannot rely completely on memory for details of previous illnesses or review of body systems <> Shifts attention away from person, diminishing his or her sense of importance <> Interrupts patient's narrative flow <> Impedes observation of patient's nonverbal behavior <> May be threatening to patient's discussion of sensitive issues <> Breaks eye contact too often -Tape and video recording

Child: Developmental Competence

-Health history adapted to include information specific for age and developmental stage of child <> Biographic data <> Source of history [] Person providing information and relation to child [] Your impression of reliability of information [] Any special circumstances (e.g., use of an interpreter) <> Reason for seeking care -History of present Illness -Severity of pain: note effect on usual behavior (e.g., does it stop child from playing?) -Associated factors, such as relation to activity, eating, and body position -Parent's intuitive sense of problem often accurate -Parent's coping ability and reaction of other family members to child's symptoms or illness

Developmental Competence

-Position, preparation, and sequence will vary across the life cycle <> Infants <> Toddler <> Preschool child <> School-age child <> Adolescent <> Aging adult

Process of Communicating: Sending

-communication is behavior, conscious and unconscious, verbal and nonverbal -all behavior has meaning -body language: posture, gestures, facial expression, eye contact, foot tapping, touch, even where you place your chair

The Clinical Setting: General Approach

-consider your emotional state and that of the person being examined <> The patient is usually anxious due to the anticipation of being examined by a stranger and the unknown outcome of the examination <> If anxiety can be reduced, the person will feel more comfortable and data gathered will more closely describe the person's natural state

Nursing Process-- Implementation

-determine patient readiness and involve patients in health care process -review planned interventions with interdisciplinary health care team members to facilitate collaborative effort -utilize principles of delegation, being mindful of supervision and evaluation -counsel person and significant others -refer for continuing care -document care provided

Frequency of Assessment

-interval of assessment varies with illness and wellness need -for well persons, opinions are changing about assessment intervals

Techniques of Communication

-introducing the interview -working phase <> data gathering phase <> verbal skills include questions to patient and your responses to what is said <> two types of questions [] open ended [] closed

Biographical Data

-name, address, phone number -age, birthdate, birthplace -sex -marital status -race -ethnic origin -occupation: usual and present

Ten Traps of Interviewing

1. providing false assurance or reassurance exp: "don't worry, I'm sure you'll be fine" 2. giving unwanted advice exp: "if i were you..." 3. using authority "your doctor/nurse knows best" 4. using avoidance language exp: "passed on'' instead of dying 5. engaging in distancing exp: "there is a lump in THE (not my) left breast" 6. using professional jargon 7. using leading or biased question exp: "you don't ever have unprotected sex, do you?" 8. talking too much 9. interrupting 10. using "why" questions exp: "why did you take so much medication?"

Steps of the Nursing Process

A: Assessment D: Diagnosis O: Outcome Identification P: Planning I: Implementation E: Evaluation -nursing process: the standards of practice in nursing

Health History Questions about Infants and Children

Does the child have any birthmarks? Any change in skin color as a newborn? Does the child have any rash or sores? Does the child have diaper rash? Does the child have any burns or bruises? Has the child been exposed to contagious or communicable disease? Does the child have habits such as nail biting or twisting hair? What steps are taken to protect the child from sun exposure?

Initial Pain Assessment Questions

Where is your pain? When did your pain start? What does your pain feel like? Burning, stabbing, aching Throbbing, fire like, squeezing Cramping, sharp, itching, tingling Shooting, crushing, sharp, dull How much pain do you have now? What makes your pain better or worse? Include behavioral, pharmacologic, nonpharmacologic interventions How does pain limit your function or activities? How do you usually behave when you are in pain? How would others know you are in pain? What does this pain mean to you? Why do you think you are having pain?

Abnormal Findings: Prostate Gland

Benign prostatic hypertrophy (BPH) Prostatitis Carcinoma

Subjective Data

Leg pain or cramps Skin changes on arms or legs Swelling Lymph node enlargement Medications Smoking history

Adventitious Breath Sounds

-Additional sounds that are not normally heard in lungs: <> Crackles: fine, medium, coarse <> Rhonchi <> Wheezes <> Friction rub

Abnormalities of Shoulder

-Atrophy -Dislocated shoulder -Joint effusion -Tear of the rotator cuff -Frozen shoulder

Abnormalities of Teeth and Gums

-Baby bottle tooth decay -Malocclusion -Dental caries -Gingival hyperplasia -Gingivitis -Meth mouth

Subjective Data: Nose

-Discharge -Frequent colds, upper respiratory infections -Sinus pain -Trauma -Epistaxis, nosebleeds -Allergies -Altered smell

Equilibrium

-Labyrinth in inner ear constantly feeds information to brain about body's position in space

AADL Instruments

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

Abnormal Findings: Lumps and Lesions on External Ear

-Sebaceous cyst -Tophi -Keloid -Carcinoma

Equipment

-Stethoscope -Small centimeter ruler -Skin-marking pen -Alcohol wipe to clean stethoscope

Additional History for Infants and Children

Ear infections? Hearing well?

Midline Organs

-Aorta -Uterus, if enlarged -Bladder, if distended

Abnormal Findings: Abnormalities in Ear Canal

-Excessive cerumen -Otitis externa -Foreign body

Developmental Competence: Adolescents and Pregnant Women

-Gum hypertrophy (surface looks smooth) may occur normally at puberty or during pregnancy (pregnancy gingivitis)

Sequence

-Inspection -Auscultation -Percussion -Palpation

ADL Instruments

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

Abnormalities of Knee

-Mild synovitis -Swelling of menisci -Post polio atrophy -Osgood-Schlatter disease - painful swelling of tibial tubercle just below the knee

Abnormal Findings: Configurations of the Thorax

-Barrel chest -Pectus excavatum -Pectus carinatum -Scoliosis -Kyphosis

Adolescent: HEEADSSS

Psychosocial Interview Questions: -Home -Education and employment -Eating -Activities -Drugs -Sexuality -Suicide and depression -Safety

Abnormal Findings: Vascular Disorders of External Eye

-Conjunctivitis -Herpes infection -Subconjunctival hemorrhage -Acute glaucoma <> Sudden clouding of vision <> Sudden eye pain <> Halos around lights

Developmental Competence: Preschool and School-Age Children

- Back: note posture; you should note a "plumb line" from back of head, along spine, to middle of sacrum -Shoulders: level within 1 cm; scapulae symmetric; lordosis common throughout childhood -Observe legs and feet for various deformities, such as <> Bowleg - "genu varum" - knees apart <> Knock knees - "genu valgum" - knees together <> Flatfoot <> Pigeon toed -Particularly, check arm for full ROM and presence of pain <> Look for subluxation of elbow (head of radius) -Palpate bones, joints, and muscles of extremities as in adult examination

Abnormal Findings: Adventitious Lung Sounds

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

Percussion of the Abdomen: Costovertebral Angle Tenderness

-(with posterior thoracic assessment when person is sitting up and you are standing behind) -Indirect fist percussion causes tissues to vibrate instead of producing a sound -To assess kidney, place one hand over 12th rib at costovertebral angle on back -Thump that hand with ulnar edge of your other fist -Person normally feels thud but no pain

Spinal Nerves

-31 pairs of spinal nerves named for region of spine from which they exit: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal -"Mixed" - contain both sensory and motor fibers -Each innervates a particular segment of the body -Dermal segmentation is cutaneous distribution of various spinal nerves

Health Literacy

-A patient may be literate but not have health literacy -Tools for determining literacy <> Test of Functional Health Literacy (TOFHLA) <> Rapid Estimate of Adult Literacy in Medicine (REALM) <> Newest Vital Sign (NVS)

Developmental Considerations: Newborn

-A sanguineous vaginal discharge or leukorrhea (mucoid discharge) normal during first few weeks due to maternal estrogen effect; may also cause transient breast engorgement and secretion -During early weeks, genital engorgement resolves, and labia minora atrophy and remain small until puberty -Between the ages of 2 months and 7 years, labia majora are flat, labia minora thin, clitoris relatively small, and hymen is tissue-paper thin -Normally, no irritation or foul-smelling discharge is present

Activities of Daily Living (ADLs)

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

Abdomen and Genitourinary

-Abdomen <> Assess contour of abdomen: flat, rounded <> Listen to bowel sounds in all four quadrants <> Check any tube placement for drainage and insertion site integrity <> Inquire whether passing flatus or stool -Genitourinary <> Inquire whether voiding regularly <> Check urine for color, clarity <> If urine output is below expected value, perform a bladder scan according to agency protocol

Abdomen Surface Landmarks

-Abdomen is a large oval cavity extending from diaphragm down to brim of pelvis <> It is bordered in back by vertebral column and paravertebral muscles and at sides and front by lower rib cage and abdominal muscles <> Four layers of large, flat muscles form ventral abdominal wall <> These are joined at midline by a tendinous seam, the linea alba <> One set, rectus abdominis, forms a strip extending length of midline, and its edge is often palpable

SBAR for Staff Communication

-Acronym for verbal communication -Situation <> Providing specific information relative to patient issue -Background <> Providing context and assessment data relative to patient issue -Assessment <> Nurse's interpretation of data relative to patient issue -Recommendation <> Expectation of physician's orders relative to patient issue

Interviewing People

-Across age-span <> in case of children-- toddlers use 'telegraphic speech': a combination of a noun and a verb and includes only words with concrete meaning -Other gender -Other sexual orientation -Non-English-speaking -Hearing impaired -Under influence of street drugs or alcohol -Those who must be asked personal questions -Sexually aggressive -Crying or anxious -Angry and threatening violence -Non-verbal -Acutely ill

Advanced Activities of Daily Living (AADLs)

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

Skin Presentations: Life Cycle

-Adolescent <> Acne <> Open and closed comedones -Pregnancy <> Striae <> Linea nigra <> Chloasma <> Vascular spiders -Aging <> Senile lentigines <> Keratoses <> Xerosis <> Skin tags or acrohordons <> Thin parchment skin <> Decreased hair growth <> Decreased nail growth and brittle nails

Health History Questions for Adolescents and Adults

-Adolescents <> Skin problems such as pimples, blackheads? -Aging adults <> What changes have you noticed in your skin in past few years? <> Any delay in wound healing? <> Any change in feet: toenails, bunions, wearing shoes? <> Falling: bruises, trauma? <> History of diabetes or peripheral vascular disease?

Afterload

-Afterload: opposing pressure ventricle must generate to open aortic valve against higher aortic pressure <> Resistance against which ventricle must pump its blood <> Once ventricle is filled with blood, ventricular end diastolic pressure is 5 to 10 mm Hg, whereas that in aorta is 70 to 80 mm Hg. [] To overcome this difference, ventricular muscle tenses (isovolumetric contraction) [] After aortic valve opens, rapid ejection occurs

Objective Data: Physical Appearance

-Age -Sexual development appropriate for gender and age -Level of consciousness: person alert and oriented, attends to your questions and responds appropriately -Skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesion -Facial features: symmetric with movement Any signs of acute distress present

Developmental Competence

-Aging Woman <> After menopause, ovarian secretion of estrogen and progesterone decreases, causing breast glandular tissue to atrophy. <> Decreased breast size makes inner structures more prominent.

Developmental Competence

-Aging adult <> Visual acuity [] Central acuity may decrease, particularly after 70 years of age [] Peripheral vision may be diminished [] Presbyopia (decrease in the power of accommodation) <> Ocular structures [] Eyebrows may show loss of outer one third to one half of hair [] As result of atrophy of elastic tissues, skin around eyes may show wrinkles or crow's feet <> Ocular structures [] Lacrimal apparatus may decrease tear production [] Cornea may look cloudy with age [] Arcus senilis commonly seen around cornea [] Yellowish nodules (pingueculae) commonly show on sclera

Assessment of Caregiver Burden

-All caregivers should be screened for caregiver burden <> Caregiver burden is perceived strain by person who cares for an elderly, chronically ill, or disabled person <> Caregiver burden is linked to caregiver's ability to cope and handle stress <> Level of care older adult requires may exceed caregiver ability <> Signs of possible caregiver burnout include multiple somatic complaints, increased stress and anxiety, social isolation, depression, and weight loss

Characteristics of Heart Sounds

-All heart sounds are described by <> Frequency or pitch: described as high pitched or low pitched <> Intensity or loudness: loud or soft <> Duration: very short for heart sounds; silent periods are longer <> Timing: systole or diastole

Tympanic Membrane (TM)

-Also called the eardrum, separates external and middle ear <> Translucent membrane with a pearly gray color <> Oval and slightly concave, pulled in at its center by one of middle ear ossicles, the malleus

Culture and Genetics

-American Heart Association (AHA) considers PAD a CAD risk equivalent, thus screening and treatment are essential -PAD is associated with several genes interacting with themselves as well as the environment -Smoking is the strongest risk factor associated with PAD -PAD disproportionally affects Blacks: the ethnic group with the highest PAD risk factors are non-Hispanic Blacks. -Ankle brachial index (ABI) is a noninvasive screening tool for PAD -AHA recommends screening for all people over age 70 and/or who are between ages 50 and 69 who have a history of smoking or diabetes

Ankle and Foot

-Ankle or tibiotalar joint: articulation of tibia, fibula, and talus -Hinge joint: limited to flexion (dorsiflexion) and extension (plantar flexion) in one plane -Landmarks are two bony prominences on either side <> Medial malleolus and the lateral malleolus <> Strong, tight medial and lateral ligaments extend from each malleolus onto foot to help lateral stability of ankle <> May be torn in eversion or inversion sprains of ankle -Joints distal to ankle give additional mobility to foot <> Subtalar joint permits inversion and eversion of foot <> Foot has longitudinal arch, with weight-bearing distributed between parts that touch ground, the heads of metatarsals and calcaneus (heel)

Inspection of Palate

-Anterior hard palate white with irregular transverse rugae -Posterior soft palate is pinker, smooth, and upwardly movable <> Torus palatinus: normal variation, is a nodular bony ridge down middle of hard palate; benign growth arises after puberty and is more common finding in American Indians, Inuits, and Asians -Observe uvula; normally looks like fleshy pendant hanging in midline; ask person to say "ahhh" and note soft palte and uvula rise in midline; this tests one function of cranial nerve X, the vagus nerve.

Abdominal Pain Questions

-Any abdominal pain? Please point to it. <> Is pain in one spot or does it move around? <> How did it start? How long have you had it? <> Is it constant, or does it come and go? Does it occur before or after meals? Does it peak? When? <> How would you describe the character of the pain: cramping (colic type), burning in pit of stomach, dull, stabbing, or aching? <> Is pain relieved by food, or worse after eating? -Is pain associated with menstrual period or irregularities, stress, dietary indiscretion, fatigue, nausea and vomiting, gas, fever, rectal bleeding, frequent urination, or vaginal or penile discharge? <> What makes the pain worse: food, position, stress, medication, or activity? <> What have you tried to relieve pain: resting, using a heating pad, changing position, or taking medication?

Chest Pain Questions

-Any chest pain or tightness? <> Onset: When did it start? How long have you had it this time? Had this type of pain before? How often? <> Location: Where did the pain start? Does the pain radiate to any other spot? <> Character: How would you describe it? Is it crushing, stabbing, burning, or viselike? (Allow the person to offer adjectives before you suggest them.) (Note if uses clenched fist to describe pain.) <> Is pain brought on by activity (what type), rest, emotional upset, eating, sexual intercourse, or cold weather? -Any associated symptoms, such as sweating, ashen gray or pale skin, heart skipping a beat, shortness of breath, nausea or vomiting, or racing of heart? <> Is the pain made worse by moving the arms or neck, breathing, or lying flat? <> Is the pain relieved by rest or nitroglycerin? How many tablets?

Additional History for Aging Adult

-Any dryness in the mouth? Are you taking any medications? (Note prescribed and over-the-counter medications.) -Have you had any loss of teeth? Can you chew all types of food? -Are you able to care for your own teeth or dentures? -Have you noticed a change in your sense of taste or smell?

Leg Pain or Cramps Questions

-Any leg pain (cramps)? Where? -Describe the type of pain; is it burning, aching, cramping, stabbing? Did this come on gradually or suddenly? -Is it aggravated by activity or walking? -How many blocks (stairs) does it take to produce this pain? -Has this amount changed recently? -Is pain worse with elevation or cool temperature? -Does pain wake you up at night? -Have you had any recent change in exercise? -What relieves this pain: dangling, walking, rubbing? Is leg pain associated with any skin changes? -Is the leg pain associated with any change in sexual function (males)? -Do you have any history of vascular problems, heart problems, diabetes, obesity, pregnancy, smoking, trauma, prolonged standing, or bed rest?

Nausea and Vomiting Questions

-Any nausea or vomiting? <> How often? How much comes up? What is the color? Is there an odor? <> Is it bloody? <> Is nausea and vomiting associated with colicky pain, diarrhea, fever, or chills? <> What foods did you eat in last 24 hours? Where did you eat? At home, school, restaurant? Is there anyone else in the family with the same symptoms in the last 24 hours? -Bowel habits <> How often do you have a bowel movement? [] What is the color and consistency? [] Any diarrhea or constipation? How long? [] Any recent change in bowel habits? [] Use laxatives? Which ones? How often do you use them? -Abdominal history <> Any history of gastrointestinal problems, such as ulcer, gallbladder disease, hepatitis/jaundice, appendicitis, colitis, or hernia? [] Ever had any operations in abdomen? Please describe. [] Any problems after surgery? [] Any radiation therapy? [] Any abdominal x-ray studies? What were results? -Medications <> What medications are you currently taking? -Habits <> How much alcohol do you drink each day? Each week? When was your last alcoholic drink? Do you smoke? How many packs per day? For how long? -Nutrition <> Please tell me all food you ate yesterday, starting with breakfast <> Are markets for fresh produce located in your neighborhood?

Additional History: Aging Adult

-Any problem with dizziness? <> Does it occur when you first sit or stand up, when you move your head, get up and walk, or after eating? Does it occur with any medications? <> (For men) Do you ever get up at night and feel faint while standing to urinate? <> How does dizziness affect your daily activities? <> Are you able to drive safely and maneuver within your house safely? <> What safety modifications have you applied at home? -Any decrease in memory or a change in mental function? Have you felt any confusion? Does it come on suddenly or gradually? -Any tremor in hands or face? Is it worse with anxiety, activity, or rest? Does it seem to be relieved with alcohol, activity, or rest? Does it interfere with daily or social activities? -Any sudden vision change or fleeting blindness? Did this occur along with weakness? Did you have any loss of consciousness?

Health History Questions: Muscles

-Any problems in muscles, such as any pain or cramping? Which muscles? -If in calf muscles: Is pain with walking? Does it go away with rest? -Are your muscle aches associated with fever, chills, or flu? -Do you have any weakness in your muscles? -Location: Where is the weakness? How long have you noticed the weakness?

Dyspnea Questions

-Any shortness of breath? <> What type of activity, and how much brings on shortness of breath? How much activity brought it on 6 months ago? <> Onset: Does the shortness of breath come on unexpectedly? <> Duration: Is it constant or does it come and go? <> Does it seem to be affected by position, such as lying down? <> Does it awaken you from sleep at night? <> Does the shortness of breath interfere with activities of daily living?

Abnormalities of Buccal Mucosa

-Aphthous ulcers (canker sore) -Leukoplakia (chronic irritation) -Candidiasis or monilial infection

Subjective Data Questions I

-Appetite <> Any change in appetite? Is this a loss of appetite? <> Any change in weight? How much weight gained or lost? Over what time period? Is the weight loss due to diet? -Dysphagia <> Any difficulty swallowing? When did you first notice this? -Food intolerance <> Are there any foods you cannot eat? What happens if you do eat them: allergic reaction, heartburn, belching, bloating, or indigestion? <> Do you use antacids? How often?

Self-Care Behaviors

-Are there any occupational hazards that could affect muscles and joints? Do they involve heavy lifting? Are there any repetitive motions or chronic stress to joints? Have you made any efforts to alleviate these? -Tell me about your exercise program: describe type of exercise, frequency, warm-up program -Have you had any recent weight gain? Please describe your usual daily diet. -Are you taking any medications such as aspirin, anti-inflammatories, muscle relaxants, or pain relievers? -If person has chronic disability or crippling illness: <> How has your illness affected your interaction with family, friends, and the way that you view yourself?

Additional History for Infants and Children

-Are you breastfeeding or bottle-feeding your baby? If bottle-feeding, how does your baby tolerate formula? -How does your baby tolerate new foods? -How often does your toddler/child eat? Does he or she eat regular meals? How do you feel about your child's eating problems? <> Please describe all that your child had to eat yesterday, starting with breakfast; what foods does child eat for snacks? <> Does your toddler/child ever eat non-foods, such as grass, dirt, or paint chips? -Does your child have constipation? If so, for how long? -Does the constipation seem to be associated with toilet training? -What are number of stools per day? Stools per week? -How much water and juice is in your child's diet? -What have you tried to treat constipation? -Does child have abdominal pain? Please describe what you have noticed and when it started. -For an overweight child: <> How long has weight been a problem? <> At what age did your child first seem overweight? Did any change in diet pattern occur then? <> Describe diet pattern now. <> Do any others in family have similar problem? <> How does child feel about his or her weight?

Abnormal Findings: Peripheral Vascular Disease

-Arms <> Raynaud phenomenon <> Lymphedema -Legs <> Arterial-ischemic ulcer <> Venous (stasis) ulcer <> Superficial varicose veins <> Deep vein thrombophlebitis -Aneurysms -Occlusions

Assessment: Inspect for Apical Impulse

-Arrange tangential lighting to accentuate any flicker of movement -May or may not see apical impulse <> Pulsation created as left ventricle rotates against chest wall during systole <> When visible, it occupies the fourth or fifth intercostal space, at or inside midclavicular line

Structure and Function: Arterial System

-Arteries <> Deliver freshly oxygenated blood to all body tissues [] Pumping heart makes this a high-pressure system [] Artery walls are strong, tough, and tense to withstand high-pressure demands [[[]]] Contain elastic fibers, which allow their walls to stretch with systole and recoil with diastole [[[]]] Contain muscle fibers (vascular smooth muscle) which contract or relax to change the diameter of arteries to control the rate of blood flow <> Each heartbeat creates a pressure wave, which makes arteries expand and then recoil [] It is recoil that propels blood through like a wave [] All arteries have this pressure wave, or pulse, throughout their length, but it can only be felt at body sites where artery lies close to skin and over a bone <> Function of arteries is to supply oxygen and essential nutrients to tissues [] Complete blockage leads to ______ of distal tissue [] Partial blockage [[[]]] Creates an insufficient supply, and ________ of distal tissue [[[]]] May be apparent only with exercise when oxygen needs increase

Temporomandibular Joint (TMJ)

-Articulation of mandible and temporal bone -In the depression anterior to tragus of ear -TMJ permits speaking and chewing <> Allows three motions: [] Hinge action to open and close jaws [] Gliding action for protrusion and retraction [] Gliding for side-to-side movement of lower jaw

Inspect with Otoscope

-As you inspect external ear, note size of auditory meatus <> Pull pinna up and back on an adult or older child to straighten S-shape of canal [] Pull pinna down on an infant or child under 3 <> Hold pinna gently but firmly; do not release traction on ear until you have finished examination and removed otoscope -Insert speculum slowly and carefully along axis of canal <> Avoid touching inner "bony" section of canal wall covered by a thin epithelial layer because it is sensitive to pain <> Once in place, you may need to rotate otoscope slightly to visualize all the TM; do this gently <> Last, perform otoscopic examination before you test hearing [] Canals with impacted cerumen give the erroneous impression of pathologic hearing loss

Auscultation of the Abdomen: Vascular Sounds

-As you listen to abdomen, note presence of any vascular sounds or bruits. -Using firmer pressure, check over aorta, renal arteries, iliac and femoral arteries, especially in people with hypertension. -Usually no such sound is present.

Range of Motion (ROM)

-Ask for active voluntary ROM while stabilizing the body area proximal to that being moved Familiarize yourself with the type of each joint and its normal ROM so that you can recognize limitations -For limitations, gently attempt passive motion; anchor joint with one hand while other hand slowly moves it to its limit; normal ranges of active and passive motion should be same -Joint motion normally causes no tenderness, pain, or ____________ -Do not confuse crepitation with normal discrete "crack" heard as tendon or ligament slips over bone during motion

Assess Sensory System

-Ask person to identify various sensory stimuli in order to test intactness of peripheral nerve fibers, sensory tracts, and higher cortical discrimination <> Routine screening procedures include testing superficial pain, light touch, and vibration in few distal locations, and testing stereognosis <> Complete testing of sensory system warranted in those with neurologic symptoms (e.g., localized pain, numbness, and tingling) or if you discover abnormalities -Compare sensations on symmetric parts of body <> When you find definite decrease in sensation, map it by systematic testing in that area <> Proceed from point of decreased sensation toward sensitive area; ask person to tell you where sensation changes; you can map exact borders of deficient area; draw results on diagram <> Person's eyes should be closed during tests <> Take time to explain what will be happening and exactly how you expect person to respond

Developmental Competence: Pregnant Woman

-Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract. -Gums may be hyperemic and softened and may bleed with normal toothbrushing.

Lacrimal Apparatus

-Ask person to look down; with thumbs, slide outer part of upper lid up along bony orbit to expose under lid; inspect for any redness or swelling -Normally puncta drain tears into lacrimal sac -Presence of excessive tearing may indicate blockage of nasolacrimal duct -Check by pressing index finger against sac, just inside lower orbital rim, not against side of the nose -Pressure will slightly evert lower lid, but there should be no other response to pressure

Conjunctiva and Sclera

-Ask person to look up; using thumbs, slide lower lids down along orbital rim, being careful not to push against eyeball <> Inspect exposed area; eyeball should look moist and glossy <> Numerous small blood vessels normally show through transparent conjunctiva <> Otherwise, conjunctivae clear and show normal color of structure below; pink over lower lids and white over sclera <> Note any color change, swelling, or lesions -Sclera is china white, although African Americans occasionally have gray-blue or "muddy" color to sclera -Also in dark-skinned people, you normally may see small brown macules (like freckles) on sclera, which should not be confused with foreign bodies or petechiae -Last, African Americans may have yellowish fatty deposits beneath lids away from cornea

Standing Assessment

-Ask the person to stand so that you can assess venous system <> Note any visible, dilated, and tortuous veins <> If present, varicose veins cause pain, swelling, fatigue, and cramping

Corneal Light Reflex

-Assess parallel alignment of eye axes by shining a light toward person's eyes -Direct person to stare straight ahead as you hold the light about 30 cm (12 inches) away -Note reflection of light on corneas; should be in exactly same spot on each eye

Developmental Considerations: Preschool and School-Age Children

-Assess the child's general behavior during play activities, reaction to parent, and cooperation with parent and with you -Much of motor assessment can be derived from watching child undress and dress and manipulate buttons; indicates muscle strength, symmetry, joint range of motion, and fine motor skills -Note child's gait both walking and running; allow for normal wide-based gate of toddler and normal knock-kneed walk of preschooler -Observe child as rising from supine position to sitting position, then to a stand; <> Normally child curls up midline to sit up, then pushes off with both hands against floor to stand -Assess fine coordination using finger-to-nose test <> Demonstrate procedure first, then ask child to do test with the eyes open, then closed <> Fine coordination not fully developed until child is 4 to 6 years; consider it normal if younger child can bring finger to within 2 to 5 cm of nose -Testing sensation very unreliable in toddlers and preschoolers -May test light touch by asking child to close eyes and point to spot where you touch -When you need to test DTRs in young child, use your finger to percuss tendon -Use reflex hammer only with an older child; coax child to relax, or distract and percuss discreetly when child not paying attention -Knee jerk present at birth; then ankle jerk and brachial reflex appear; and triceps reflex present by 6 months

External Genitalia: Palpation I

-Assess urethra and Skene's glands <> Dip gloved finger in bowl of warm water to lubricate <> Insert index finger into vagina, and gently milk urethra by applying pressure up and out <> Procedure should produce no pain <> If any discharge appears, culture it -Assess Bartholin's glands <> Palpate posterior parts of labia majora with index finger in vagina and your thumb outside; normally, labia feel soft and homogeneous

Assessment of Cognition

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

Developmental Considerations: Infants & Adolescents

-At birth, external genitalia are engorged because of presence of maternal estrogen -At puberty, estrogens stimulate growth of cells in the reproductive tract and development of secondary sex characteristics -First signs of puberty are breast and pubic hair development, beginning between ages 8 and 10 -Menarche occurs during latter half of this sequence, just after peak of growth velocity -Ovaries are now in pelvic cavity

Abnormal Findings: Common Respiratory Conditions

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

Developmental Considerations: Aging Adult

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

Assessment: Auscultate the Heart

-Auscultate over valve areas <> Aortic valve area: Second right interspace: <> Pulmonic valve area: Second left interspace <> Tricuspid valve area: Left lower sternal border <> Mitral valve area: Fifth interspace around left midclavicular line -Before you begin, alert person that you always listen to the heart in a number of places on chest, and just because you are listening a long time does not necessarily mean that something is wrong -Use a Z pattern to auscultate over the heart -Begin with diaphragm endpiece and use following routine <> Note rate and rhythm <> Identify S1 and S2 <> Assess S1 and S2 separately <> Listen for extra heart sounds <> Listen for murmurs

Cardiovascular System

-Auscultate rhythm at apex: Is it regular? -Check apical pulse against radial pulse, noting perfusion of all beats -Assess heart sounds in all auscultatory areas: first with diaphragm, then with bell -Check capillary refill for prompt return -Check pretibial edema -Palpate posterior tibial and dorsalis pedis pulse bilaterally -Verify that the proper IV solution is hanging and flowing at the proper rate, according to the physician's orders and your own assessment of the patient's needs

Auscultation of the Abdomen: Bowel and Vascular Sounds

-Auscultation follows because percussion and palpation can increase peristalsis, giving a false interpretation of bowel sounds. <> Use diaphragm of the stethoscope, because bowel sounds are relatively__________. <> Hold stethoscope lightly against skin; pushing too hard may stimulate more bowel sounds. <> Begin in RLQ at ileocecal valve area because bowel sounds are normally always present here.

Infants and Children: Auscultation

-Auscultation normally yields bronchovesicular breath sounds in peripheral lung fields of infant and young child up to ages 5 to 6 years. -Relatively thin chest walls with underdeveloped musculature do not dampen sound as do thicker walls of adults, so breath sounds are louder and harsher. -Fine crackles are adventitious sounds commonly heard in immediate newborn period from opening of airways and clearing of fluid.

Examination Findings Requiring Immediate Assistance

-BP>160 systolic or <90 -Temperature 97° or 100° F -Heart rate 60 or 90 beats/min -Respirations 12 or 28/min -O2 saturation <92% -Urine output <30 or <240 mL/8 hours -Dark amber or bloody urine (*urology patients) -Postoperative nausea or vomiting -Surgical pain not controlled with medication and/or chest pain -Bleeding -Altered level of consciousness (LOC), confusion, or difficulty arousing -Sudden restlessness and/or anxiety

Cerebellar Function Tests

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

Central Nervous System Components

-Basal ganglia <> Large bands of gray matter in two cerebral hemispheres that form subcortical associated motor system (extrapyramidal system) [] Initiate and coordinate movement [] Control automatic associated movements of body <> Thalamus [] Main relay station where sensory pathways of spinal cord, cerebellum, and brain stem form synapses

Functional Assessment

-Basis for care planning, goal setting, and discharge planning -Needed for eligibility to obtain services, such as durable medical equipment, home modifications, and inpatient or outpatient rehabilitation services -Functional assessment includes three overarching domains <> Activities of daily living (ADLs) <> Instrumental activities of daily living (IADLs) <> Mobility

Pain Assessment: Infants and Children

-Because infants are preverbal and incapable of self-report, pain assessment is dependent on behavioral and physiologic cues <> It is important to underscore understanding that infants do feel pain <> Children 2 years of age can report pain and point to its location <> They cannot rate pain intensity at this developmental level <> It is helpful to ask parent or caregiver what words the child uses to report pain

Infants and Children: Auscultation II

-Because newborn's chest wall is so thin, transmission of sounds is enhanced and sound is heard easily all over chest, making localization of breath sounds a problem. -Even bowel sounds are easily heard in chest. -Try using smaller pediatric diaphragm endpiece, or place bell over infant's interspaces and not over ribs. -Use pediatric diaphragm on an older infant or toddler.

Percussion of Anterior Chest

-Begin percussing apices in supraclavicular areas. <> Then, percussing interspaces and comparing one side to other, move down anterior chest. <> Interspaces are easier to palpate on anterior chest than on back. <> Do not percuss directly over female breast tissue because this would produce a ______ note; shift breast tissue over slightly using edge of your stationary hand. -Note borders of cardiac dullness normally found on anterior chest. -On right, upper border of liver dullness is located in fifth intercostal space in right midclavicular line. -On left, tympany is evident over gastric space.

Inspection of the Mouth

-Begin with anterior structures and move posteriorly; use tongue blade to retract structures and bright light for optimal visualization. -Inspect lips for color, moisture, cracking, or lesions; retract lips and note inner surface. <> African Americans normally may have bluish lips and a dark line on gingival margin.

Light Palpation of Abdomen

-Begin with light palpation -With first four fingers close together, depress skin about 1 cm -Make gentle rotary motion, sliding fingers and skin together -Then lift fingers (do not drag them) and move clockwise to next location around abdomen -Objective is not to search for organs but to form an overall impression of skin surface and superficial musculature -Examination of any identified tender areas should be done __________ -This method avoids pain and resulting muscle rigidity that would obscure deep palpation later in examination -As you circle abdomen, discriminate between voluntary muscle guarding and involuntary rigidity -Voluntary guarding occurs when person is cold, tense, or ticklish; it is bilateral, and you will feel muscles relax slightly during exhalation; use relaxation measures to try to eliminate this type of guarding -If rigidity persists, it is probably involuntary

Testing Reflexes

-Biceps reflex, C5 to C6 <> Support the person's forearm on yours; place your thumb on biceps tendon and strike a blow on your thumb [] Normal response is contraction of biceps muscle and flexion of forearm -Triceps reflex, C7 to C8 <> Tell person to let arm "just go dead" as you strike triceps tendon directly just above the elbow [] Normal response is extension of forearm -Brachioradialis reflex, C5 to C6 <> Hold person's thumbs to suspend forearms in relaxation and strike forearm directly, about 2 to 3 cm above radial styloid process [] Normal response is flexion and supination of forearm -Quadriceps reflex, L2 to L4 ("knee jerk") <> Let lower legs dangle freely to flex knee and stretch tendons; strike tendon directly just below patella [] Normal response is extension of lower leg -Achilles reflex, L5 to S2 ("ankle jerk") <> Position person with knee flexed; hold foot in dorsiflexion and strike Achilles tendon directly [] Normal response is foot plantar flexes against your hand

Culture and Genetics

-Bifid uvula: a condition in which uvula is split either completely or partially; occurs in 10% of some American Indian groups -Cleft lip and cleft palate: most common in Asians, intermediate in Whites, and least common in Blacks. -Torus palatinus: a bony ridge running in middle of hard palate is seen in 20% to 35% of the U.S. population. -Leukoedema: a benign lesion occurring on buccal mucosa, is seen more often in Blacks.

Extra Heart Sounds: Murmurs

-Blood circulating through normal cardiac chambers and valves usually makes no noise -Some conditions create turbulent blood flow and collision currents -These result in a murmur, much like a pile of stones or a sharp turn in a stream creates a noisy water flow -A murmur is a gentle, blowing, swooshing sound that can be heard on chest wall

Developmental Considerations: Pregnant Woman

-Blood volume increases by 30% to 40% during pregnancy <> Most rapid expansion occurs during second trimester <> Creates an increase in stroke volume and cardiac output and an increased pulse rate of 10 to 15 beats per minute <> Despite increased cardiac output, arterial blood pressure decreases in pregnancy as a result of peripheral vasodilation <> Blood pressure drops to lowest point during second trimester, then rises after that <> Blood pressure varies with person's position

General Appearance of Infant

-Body symmetry: spontaneous position, flexion of head and neck, and spontaneous movement -Skin color and characteristics: note any obvious deformities -Symmetry and positioning of facial features -Alert, responsive effort -Strong, lusty cry

Developmental Considerations: Aging Adult

-Bone remodeling is cyclic process of resorption and deposition; after age 40, resorption occurs more rapidly than deposition -Postural changes are evident with aging, and __________height is most noticeable -Other postural changes are kyphosis, backward head tilt to compensate for kyphosis, and slight flexion of hips and knees -Distribution of subcutaneous fat changes through life; contour different, even if weight is same as when younger

Structure and Function: Arteries in the Arm

-Brachial artery <> Major artery supplying the arm <> Runs in biceps-triceps furrow of upper arm <> Surfaces at antecubital fossa in elbow medial to biceps tendon <> Immediately below elbow, brachial artery bifurcates into ulnar and radial arteries -Ulnar and radial arteries <> Run distally and form two arches supplying hand; these are called superficial and deep palmar arches <> Radial pulse lies just medial to radius at wrist <> Ulnar artery lies deeper so the ulnar pulse is often difficult to feel

HPV Vaccine

-Breakthrough in cancer prevention <> In June, 2006, the Advisory Committee on Immunization Practices (ACIP) voted to recommend first vaccine developed to prevent cervical cancer [] CDC recommendation for girls or boys starting at age 11 or 12 years of age with a series of 3 injections within a 6 month period [] One of most important advances in women's health in recent years [] Vaccine targets HPV, responsible for most cases of cervical cancer <> It is recommended for girls and women before they become sexually active because it is not effective if individual is already infected with HPV

Subjective Data

-Breast <> Pain <> Lump <> Discharge <> Rash <> Swelling <> Trauma <> History of breast disease <>Surgery <> Self-care behaviors <> Perform breast self-examination <> Last mammogram -Axilla <> Tenderness, lump, or swelling <> Rash

Lymphatics

-Breast has extensive lymphatic drainage. -Four groups of axillary nodes are present <> Central axillary nodes <> Pectoral (anterior) <> Subscapular (posterior) <> Lateral -From the central axillary nodes, drainage flows up to infraclavicular and supraclavicular nodes.

Internal Anatomy of the Breast

-Breast is composed of <> Glandular tissue <> Fibrous tissue, including suspensory ligaments <> Adipose tissue -The relative proportion of glandular, fibrous, and fatty tissue varies depending on age, cycle, pregnancy, lactation, and general nutritional state. -Glandular tissue contains 15 to 20 lobes radiating from nipple, and these are composed of lobules. <> Within lobules are clusters of alveoli that produce milk. -Suspensory ligaments, or Cooper's ligaments, support breast tissue and become contracted in cancer of breast, producing dimpling in overlying skin. -upper outer quadrant is site of most breast tumors. <> Cancerous tumors are typically: [[[]]] Solitary, unilateral, non-tender [[[]]] Solid, hard, dense, fixed [[[]]] With irregular, poorly differentiated borders

Structure and Function: Inner Ear

-Contains the bony labyrinth, which holds sensory organs for equilibrium and hearing <> Vestibule and semicircular canals within bony labyrinth compose the vestibular apparatus <> Cochlea contains central hearing apparatus -Although the inner ear is not accessible to direct examination, its functions can be assessed

Developmental Considerations: Infants and Children

-By 3 months, fetus has formed skeleton of cartilage -Bone growth continues rapidly during infancy and steadily in childhood, until adolescent growth spurt -Longitudinal growth continues until closure of epiphyses; last closure occurs about age 20 -Although skeleton contributes to linear growth, muscles and fat are significant for weight increase -Muscles vary in size and strength in different people due to genetics, nutrition, and exercise -All through life, muscles increase with use and atrophy with disuse

Abnormalities in Cranial Nerves

-CN I, olfactory nerve <> Anosmia -CN II, optic nerve <> Defect or absent central vision <> Defect in peripheral vision, hemianopsia <> Absent light reflex <> Papilledema <> Optic atrophy <> Retinal lesions -CN III, oculomotor nerve <> Dilated pupil, ptosis, eye turns out and slightly down <> Failure to move eye up, in, down <> Absent light reflex -CN IV, trochlear nerve <> Failure to turn eye down or out -CN V, trigeminal nerve <> Absent touch and pain, paresthesias <> No blink <> Weakness of masseter or temporalis muscles -CN VI, abducens nerve <> Failure to move laterally, diplopia on lateral gaze -CN VII, facial nerve <> Absent or asymmetric facial movement <> Loss of taste -CN VIII, acoustic nerve <> Decrease or loss of hearing -CN IX, glossopharyngeal nerve <> No Gag Reflex -CN X, vagus nerve <> Uvula deviates to side <> No gag reflex <> Voice quality: <> Hoarse or brassy, nasal twang or husky <> Dysphagia, fluids regurgitate through nose -CN XI, spinal accessory nerve <> Absent movement of sternomastoid or trapezius muscles -CN XII, hypoglossal nerve <> Tongue deviates to side <> Slowed rate of tongue movement

CRC Screening Tests

-CRC screening tests include <> Fecal occult blood test (FOBT) <> Flexible sigmoidoscopy <> Combination of FOBT and flexible sigmoidoscopy <> Colonoscopy <> Double-contrast barium enema

Structure and Function: External Ear

-Called the auricle or pinna <> Consists of movable cartilage and skin <> Serves to funnel sound waves into its opening -Auditory canal <> A cul-de-sac 2.5 to 3 cm long in adults that terminates at eardrum, or tympanic membrane <> Lined with glands that secrete cerumen, a yellow waxy material that lubricates and protects ear [] Forms sticky barrier to keep foreign bodies from entering and reaching sensitive tympanic membrane <> Outer one third of auditory canal is cartilage <> Inner two thirds consists of bone covered by thin sensitive skin <> Lymphatic drainage of external ear flows to parotid, mastoid, and superficial cervical nodes

Inspection

-Careful scrutiny, first of individual as a whole and then of each body system -Inspection always comes first -Inspection requires <> Good lighting <> Adequate exposure <> Occasional use of instruments: otoscope, ophthalmoscope, penlight, or nasal and vaginal specula

Neck Vessels: Carotid Artery Pulse

-Carotid artery <> In groove between trachea and sternomastoid muscle, medial to and along-side that muscle <> Close to heart, so timing closely coincides

Culture and Genetics

-Causes of CVD include an interaction of genetic, environmental, and lifestyle factors -Increased risk factors for CVD attributed to hypertension in terms of certain ethnic, racial, gender groups -Even though smoking has declined, it is still the leading cause of preventable disease, disability, and death in the U.S. -High levels of LDL lead to an increased risk of CVD and are associated with certain ethnic groups -Obesity is also an associated risk factor for CVD as well as other comorbidities -CVD risk is increased twofold greater in those patients who have diabetes -Sex differences still place women with CVD with the highest death rate

Brainstem

-Central core of the brain: <> Cranial nerves (CN) III through XII originate in brain stem <> Midbrain: [] Most anterior part of brain stem with tubular structure of spinal cord [] Merges into thalamus and hypothalamus [] Contains many motor neurons and tracts <> Pons: enlarged area containing ascending sensory and descending motor tracts <> Medulla: [] Continuation of spinal cord in brain [] Contains vital autonomic centers

Cerebral Cortex

-Cerebral cortex is cerebrum's outer layer of nerve cells -Cerebral cortex is center of functions governing thought, memory, reasoning, sensation, and voluntary movement <> Two hemispheres <> Each hemisphere divided into four lobes: [] Frontal [] Parietal [] Temporal [] Occipital

Culture and Genetics: Cerumen

-Cerumen: genetically determined <> Dry cerumen: gray, flaky, and frequently forms thin mass in ear canal <> Wet cerumen: honey brown to dark brown and moist [] Wet cerumen phenotype (chromosome 16) occurs more often in Caucasians and African Americans whereas the dry type occurs more often in Asians and American Indians [] Presence and composition of cerumen are not related to poor hygiene; take caution to avoid mistaking flaky, dry cerumen for eczematous lesions

Abdomen: Aging Adult

-Changes of the GI system occur with aging, but most do not significantly affect function as long as no disease is present -Salivation decreases, leading to a dry mouth and decreased sense of taste -Esophageal emptying and gastric acid secretion are delayed -Incidence of gallstones increases with age -Although liver size decreases, most liver functions remain normal; however, drug metabolism is impaired -Aging adults frequently report constipation

Pretibial Edema and Pitting Edema Scale

-Check for pretibial edema <> Firmly depress skin over tibia or medial malleolus for 5 seconds and release <> Normally your finger should leave no indentation, although a pit commonly is seen if person has been standing all day or during pregnancy <> If pitting edema is present, grade it on following scale: 1+ Mild pitting, slight indentation, no perceptible swelling 2+ Moderate pitting, indentation subsides rapidly 3+ Deep pitting, indentation remains, leg looks swollen 4+ Very deep pitting, indentation lasts long time, leg very swollen

Inspection of Tongue I

-Check tongue for color, surface characteristics, and moisture. -Ask person to touch tongue to roof of mouth; its ventral surface looks smooth, glistening, and shows veins. -With a glove, hold tongue with a cotton gauze pad for traction and swing tongue out and to each side; inspect for any white patches or lesions; normally none are present. -If any occur, palpate these lesions for induration. <> Always wear gloves to examine mucous membranes; this follows standard precautions to prevent spread of possible communicable disease.

Infants and Children: Visual Acuity

-Child's age determines screening measures used -In newborn, test visual reflexes and attending behaviors <> Birth to 2 weeks: refusal to reopen eyes after exposure to bright light; increasing alertness to object; infant may fixate on an object <> By 2 to 4 weeks: infant can fixate on an object <> By 1 month: infant can fixate and follow light or bright toy <> By 3 to 4 months: infant can fixate, follow, and reach for toy <> By 6 to 10 months: infant can fixate and follow toy in all directions

Past Medical History

-Childhood illnesses -Accidents or injuries -Serious or chronic illnesses -Hospitalizations -Operations -Obstetric history -Immunizations -Last examination date -Allergies -Current medications <> medication reconciliation: comparison of a list of current meds with a previous list

Internal Anatomy: Middle Layer

-Choroid: has dark pigmentation to prevent light from reflecting internally and is heavily vascularized to deliver blood to retina -Iris: functions as a diaphragm, varying opening at its center, the pupil <> Controls amount of light admitted into retina <> Muscle fibers of iris contract pupil in bright light and to accommodate for near vision, and dilate pupil when light is dim and for far vision -Lens: <> biconvex disc located just posterior to pupil <> serves as a refracting medium, keeping a viewed object in focus on retina

Abnormalities of Ankle and Foot

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

Abnormalities of the Lips

-Cleft lip -Herpes simplex I -Angular cheilitis -Carcinoma

Abnormalities of the Oropharynx

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

Clonus

-Clonus: test when reflexes hyperactive <> Support lower leg in one hand and with other hand, move foot up and down to relax muscle; then stretch muscle by briskly dorsiflexing foot; hold the stretch [] Normal response: you feel no further movement [] When clonus present, you will note rapid rhythmic contractions of calf muscle and movement of foot

Cerebellum

-Coiled structure located under occipital lobe for coordination of voluntary movements, equilibrium, and muscle tone -Does not initiate, but coordinates and smooths, movements entirely below conscious level

Inspection and Palpation: Skin

-Color <> General pigmentation, freckles, moles, birthmarks <> Vascularity or bruising <> Widespread color change [] Note color change over entire body skin, such as pallor, erythema, cyanosis, or jaundice [] Note if color change is transient or due to pathology -Temperature <> Use backs of hands to palpate for temperature <> Skin should be warm, and temperature equal bilaterally: warmth suggests normal circulatory status <> Hands and feet may be slightly cooler in a cool environment [] Hypothermia [] Hyperthermia -moisture <> diaphoresis <> dehydration -mobility and turgor (say no tenting, skin is mobile and elastic) -texture -thickness (soft skin) -edema <> pitting, non pitting (indentation vs. not) -lesions: if any present, note the following <> Color, Elevation, Pattern or shape, Size <> Location and distribution on body <> Any exudate: note color and odor

Inspection and Palpation: Hair

-Color <> Due to melanin production -Texture <> Characteristics range from fine to thick to curly to straight and may be affected by use of hair care products -Distribution <> Tanner staging identifies gender patterns of hair distribution -Lesions <> Identification by looking at scalp and dividing hair into sections

Tympanic Membrane

-Color and characteristics <> Systematically explore landmarks <> Normal TM shiny and translucent, with a pearl-gray color <> Cone-shaped light reflex prominent in anteroinferior quadrant, a reflection of the otoscope light <> Sections of malleus are visible through translucent drum: the umbo, manubrium, and short process <> At periphery annulus looks whiter and dense -Position <> TM is flat, slightly pulled in at center, and flutters when person performs Valsalva maneuver or holds nose and swallows (insufflation) [] Avoid such maneuvers with an aging person because they may disrupt equilibrium [] Avoid middle ear insufflation in person with upper respiratory infection because it could propel infectious matter into middle ear -Integrity of membrane <> Inspect TM and entire circumference of annulus for perforations <> Normal TM is intact <> Some adults may show scarring, which is a dense white patch on TM, a sequela of repeated ear infections

Wells Score for Deep Vein Thrombosis (DVT)

-Combination of assessment findings categorized into low, moderate, or high probability of DVT -Scoring system developed as assessment findings for DVT is often unreliable because DVT often occurs with other comorbidities -Clinical model includes 10 categories focusing on malignancy, mobility limitations, swelling, non-varicose veins, previous history of DVT, and alternative medical diagnosis at least as likely as DVT -Score of 0 or less indicates a low probability, 1 or 2 indicates moderate probability, and 3 points or higher indicates high probability

Pediatric Abnormalities

-Common congenital or pediatric abnormalities <> Congenital dislocated hip <> Talipes equinovarus (clubfoot) <> Spina bifida

Altered Cognition in Older Adults

-Commonly attributed to three disorders <> Dementia <> Delirium <> Depression

Inspection of Teeth and Gums

-Condition of teeth is an index of person's general health. -Compare number of teeth with number expected for person's age. -Ask person to bite as if chewing something, and note alignment of upper and lower jaw. -Normal occlusion in back is upper teeth rest directly on lowers; in front, upper incisors slightly override lower incisors.

Conjunctiva and Cornea

-Conjunctiva: transparent protective covering of exposed part of eye <> Palpebral conjunctiva: lines lids, is clear, with many small blood vessels <> Bulbar conjunctiva: overlies eyeball, with white sclera showing through -Cornea: covers and protects iris and pupil

Corneal Reflex

-Corneal reflex: if person has abnormal facial sensation or movement, is unconscious, or is chemically paralyzed -Remove any contact lenses; with person looking forward, bring wisp of cotton in from side (to minimize defensive blinking) and lightly touch cornea, not conjunctiva <> Normally person will blink bilaterally <> Corneal reflex may be decreased or absent in those who have worn contact lenses -This procedure tests sensory afferent in cranial nerve V (trigeminal) and motor efferent in cranial nerve VII (facial) -If abnormal/ absent, need to protect cornea

Motor Pathways

-Corticospinal or pyramidal tract fibers mediate voluntary movement, particularly very skilled, discrete, purposeful movements, such as writing <> Motor nerve fibers travel to brain stem crossing to opposite, contralateral side and then pass down in lateral column of spinal cord <> Crossed or uncrossed <> Permit very skilled and purposeful movements <> Arranged in pattern called somatotopic organization (homunculus) [] Parts whose movements are relatively more important occupy proportionally more space on this brain map -Extrapyramidal tracts include motor nerve fibers originating in motor cortex, basal ganglia, brain stem, and spinal cord outside pyramidal tract <> For muscle tone and control body movements, especially gross automatic movements, such as walking <> Cerebellar system coordinates movement, maintains equilibrium and posture; receives information on position of muscles and joints, body's equilibrium, and kind of motor messages sent from cortex to muscles

Changes with Aging

-Costal cartilages become calcified -> less mobile thorax. -Lungs become more rigid -> harder to inflate. -These changes result in an increase in small airway closure and less ventilated lung bases. -Histologic changes -> <> Less surface area is available for gas exchange. <> Increased risk of post-operative complications.

Assessment: Subjective Data

-Cough: timing, quality, productivity (hemoptysis?) -Shortness of breath (dyspnea): timing, aggravating/ alleviating (orthopnea) -Chest pain with breathing -History of respiratory infections -Smoking history -Environmental exposure -Self-care behaviors <>TB skin test <> Pneumonia or influenza immunization

Structure and Function: Veins

-Course of veins parallels that of arteries <> Body has more veins, and they lie closer to skin surface -Veins in leg <> Legs have three types of veins <> Deep veins - run alongside deep arteries and conduct most of venous return from the legs <> Superficial veins - great and small saphenous vein <> Perforators - connecting veins that join the deep and superficial veins

Cranial Nerves III, IV, and VI

-Cranial Nerves III (oculomotor), IV (trochlear), and VI (abducens) nerves <> Palpebral fissures usually equal in width <> Check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation (CN III) <> Assess extraocular movements by cardinal positions of gaze <> Nystagmus is back-and-forth oscillation of eyes -Doll's Eyes Test (occulocephalic reflex) <> Reflex is intact: eyes move opposite of head <> Reflex is absent: eyes don't move (brainstem dysfunction) -Cold Caloric Test (occulovestibular reflex) <> Reflex is intact: eyes move away from cold water <> Reflex is absent: no eye movement

Cranial Nerve I

-Cranial nerve I: olfactory nerve (not tested routinely) <> Test sense of smell in those who report loss of smell (anosmia), head trauma (basal skull fractures), and abnormal mental status, and when presence of intracranial lesion suspected <> With person's eyes closed, occlude one nostril and present familiar aromatic substance, e.g., coffee, orange, vanilla, soap, or peppermint <> Normally person can identify an odor on each side of nose; normally decreased with aging; any asymmetry in sense of smell is important

Cranial Nerve II

-Cranial nerve II: optic nerve <> Test visual acuity and visual fields by confrontation <> Using ophthalmoscope, examine ocular fundus to determine color, size, and shape of optic disc

Cranial Nerve V

-Cranial nerve V (trigeminal nerve) <> Motor function: as person clenches teeth try to separate jaws by pushing down on chin; normally you cannot <> Sensory function: with person's eyes closed, test light touch sensation by touching a cotton wisp to designated areas on person's face: forehead, cheeks, and chin (three divisions of CN V: ophthalmic, maxillary, and mandibular)

Cranial Nerve VII

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

Cranial Nerve VIII

-Cranial nerve VIII: acoustic nerve (Vestibulocochlear) <> Test hearing acuity by ability to hear normal conversation and by whispered voice test

Cranial Nerve XI

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

Cranial Nerve XII

-Cranial nerve XII: hypoglossal nerve <> Inspect tongue; no wasting or tremors should be present <> Note forward thrust in midline as person protrudes tongue <> Ask person to say "light, tight, dynamite," and note that lingual speech (sounds of letters l, t, d, n) is clear and distinct

Cranial Nerves IX and X

-Cranial nerves IX (glossopharyngeal) and X (vagus) nerves: <> Motor function [] Depress tongue with tongue blade, and note pharyngeal movement as person says "ahhh" or yawns; uvula and soft palate should rise in midline, and tonsillar pillars should move medially [] Touch posterior pharyngeal wall with tongue blade, and note gag reflex; voice should sound smooth, not strained <> Sensory function [] Cranial nerve IX does mediate taste on posterior one third of tongue, but technically too difficult to test -CN X can be stimulated by carotid massage, tracheal suctioning - leads to acetylcholine release and drop in HR

Pathways of CNS

-Crossed representation is notable feature of nerve tracts <> Left cerebral cortex receives sensory information from and controls motor function to right side of the body <> Right cerebral cortex likewise interacts with left side of body

Colorectal Cancer (CRC) Screening

-Currently second leading cancer killer in the U.S. <> However, it should not be; if everyone age 50 or older had regular screening tests, 60% deaths from this cancer could be avoided <> Screening identifies precancerous polyps so they can be removed before they become cancer <> Screening can also find CRC early, when treatment can be effective <> CRC is most often found in people age 50 and older <> Older you get the higher your risk; both men and women get CRC

Damage to Cerebral Cortex

-Damage to specific cortical areas produces a corresponding loss of function: <> Motor weakness <> Paralysis <> Loss of sensation <> Impaired ability to understand and process language -Damage occurs when highly specialized neurologic cells are deprived of blood supply

Secondary Skin Lesions

-Debris on skin surface <> Crusts <> Scales -Break in continuity of skin surface <> Fissures <> Erosions <> Ulcers <> Excoriations <> Scars <> Atrophic scars <> Lichenifications <> Keloids

Abnormal Posturing

-Decorticate posturing - cerebral cortex lesion -Decerebrate posturing - brain stem lesion -Flaccid quadriplegia <> Complete loss of muscle tone and paralysis of all four extremities, indicating nonfunctional brain stem -Opisthotonos <> Prolonged arching of back, with head and heels bent backward; indicates meningeal irritation

Aging Adult: Causes of Constipation

-Decreased physical activity -Inadequate intake of water -Low-fiber diet -Side effects of medications -Irritable bowel syndrome -Bowel obstruction -Hypothyroidism -Difficulty ambulating to toilet may cause a person to deliberately retain stool until it becomes hard and difficult to pass

Subjective Data: Pain

-Defined as an unpleasant sensory and emotional experience -Associated with actual or potential tissue damage or described in terms of such damage <> Pain is always subjective <> Pain is whatever the experiencing person says it is, existing whenever he or she says it does <> Subjective report is most reliable indicator of pain <> Because pain occurs on a neurochemical level, clinician cannot base diagnosis of pain exclusively on physical examination findings, although these findings can lend support

Dermatomes

-Dermatome <>Circumscribed skin area supplied mainly from one spinal cord segment through particular nerve <> Dermatomes overlap; if one nerve is severed, most of sensations are transmitted by one above and one below -Useful dermatome landmarks <> Thumb, middle finger, fifth finger are C6, C7, and C8; <> Axilla at T1 <> Nipple at T4 <> Umbilicus at T10 <> Groin in region of L1 <> Knee at L4

Upper Motor Neurons

-Descending motor fibers that can influence or modify lower motor neurons -Located completely within CNS; convey impulses from motor areas of cerebral cortex to lower motor neurons -Examples of upper motor neuron diseases are cerebrovascular accident, cerebral palsy, and multiple sclerosis

Cover Test

-Detects small degrees of deviated alignment by interrupting fusion reflex that normally keeps two eyes parallel -Ask the person to stare straight ahead at your nose -With an opaque card, cover one eye; uncovered eye should maintain a fixed gaze -Now uncover eye and observe it for movement

Auscultation of Voice Sounds

-Determine quality of voice sounds or vocal resonance. -Voice can be auscultated over chest wall. -Ask person to repeat a phrase, such as "ninety-nine" while you listen over chest wall. -Normal voice transmission is soft, muffled, and indistinct; you can hear sound through stethoscope but cannot distinguish exactly what is being said. -Pathology that increases lung density enhances transmission of voice sounds. -Eliciting voice sounds usually not done in routine examination. -Abnormal consolidation manifests as -bronchophony - clearer "ninety-nine" -egophony - "eeee" sounds like "aaaa" -whispered pectoriloquy - clear "1,2,3"

Common Skin Conditions in Children

-Diaper dermatitis -Intertrigo (candidiasis) -Impetigo -Atopic dermatitis (eczema) -Measles (rubeola) -German measles (rubella) -Chickenpox (varicella)

Abnormal Findings: Murmurs Due to Valvular Defects

-Diastolic rumbles of atrioventricular valves <> Mitral stenosis <> Tricuspid stenosis -Early diastolic murmurs <> Aortic regurgitation <> Pulmonic regurgitation

Additional History: Infants and Children

-Did mother have any health problems during pregnancy, such as infections or illnesses,, toxemia, hypertension, alcohol or drug use, medication effects, or diabetes? -Was infant premature or full term? What was the infant's birth weight? -Was there any birth trauma? Did infant breathe immediately? <> Were you told infant's Apgar scores? <> Were there any congenital defects? -Reflexes: What have you noticed about infant's behavior? Do infant's sucking and swallowing seem coordinated? Does infant turn head toward touch? Does infant startle with a loud noise? Does infant grasp your finger? -Does child seem to have problem with balance? Has there been any unexplained falling clumsy or unsteady gait, progressive muscular weakness, or problems going up or down stairs or getting up from lying position? -Has child had any seizures? Did it occur with high fever? Was there any loss of consciousness? How long? -Did motor or developmental milestones come at about right age? Does child seem to be growing normally? How does development compare to that of siblings or age-mates? -Has child had any environmental exposure to lead? -Is there any family history of seizure disorder, cerebral palsy, or muscular dystrophy

Palpation Techniques

-Different parts of hands are best suited for assessing different factors <> Fingertips: best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps <> Fingers and thumb: detection of position, shape, and consistency of an organ or mass <> Dorsum of hands and fingers: best for determining temperature because skin here is thinner than on palms <> Base of fingers or ulnar surface of hand: best for vibration

Other Abnormal Findings: Retraction and Inflammation

-Dimpling -Nipple retraction -Fixation -Edema (peau d'orange) -Deviation in nipple pointing -Mastitis in lactating woman

Maneuvers to Screen for Retraction

-Direct the woman to change position to check breasts for skin retraction signs. <> Lift arms slowly over head - symmetrical upward movement of both breasts <> Push hands onto hips - slight lifting of both breasts <> Push two palms together - slight lifting of both breasts -Ask the woman with large pendulous breasts to lean forward while you support her forearms; note symmetric free-forward movement of both

Subjective Data Questions

-Dizziness - Do you ever feel a lightheaded, swimming sensation, like feeling faint? When have you noticed this? How often does it occur? Does it occur with activity or a change in position? -Vertigo - Do you ever feel a sensation called vertigo, a rotational spinning sensation? Do you feel as if the room spins (________vertigo), or do you feel you are spinning (_________vertigo)? Does it come on suddenly or gradually? Does it cause you to be unstable as you walk (ataxia)? -Seizures (cont.) <> Postictal phase: After having a seizure, do you sleep? Do you have confusion, weakness, headache, or muscle ache? <> Treatment: Are you on any medication for seizures? <> Coping strategies: How have seizures affected daily life and your occupation? -Tremors <> Any shakes or tremors in hands or face? When did these start? <> Do they seem to grow worse with anxiety, intention, or rest? Do they affect daily activities? -Weakness <> Is this generalized or local? <> Does weakness occur with particular movement? <> Is it hard to get up out of a chair or reach for an object? <> (With distal or small muscle weakness, it is hard to open a jar, write, use scissors, or walk without tripping) -Incoordination <> Do you have any problem with balance when walking? Any falling? Which way? Do your legs seem to give way? Any clumsy movement? -Numbness or tingling <> Does it ever feel like pins and needles? When did this start? Where do you feel it? Does it occur with activity? -Difficulty swallowing (__________) Do you have difficulty swallowing solids or liquids? Have you experienced excessive saliva or drooling? Difficulty speaking (___________) Do you have difficulty forming words or saying what you intend? When did you first notice this? How long did it last? Difficulty communicating Are you able to speak? (absence of language function - aphasia) Receptive aphasia - inability to comprehend speech; problem in Wernicke's area of the temporal lobe Expressive aphasia- inability to speak/ form words; problem in Broca's area of the frontal Environmental and occupational hazards Are you exposed to insecticides, organic solvents, or lead? Are you taking any medications now? How much alcohol do you drink? Each week? Each day? How about mood-altering drugs, such as marijuana, cocaine, barbiturates, and tranquilizers? Significant neuro history Do you have a history of stroke (cerebrovascular accident), spinal cord injury, Parkinson's, meningitis or encephalitis, congenital defect, or alcoholism?

Functional Assessment of ADLs

-Do joint (muscle, bone) problems create any limits on your usual ADLs? Which ones? -Bathing: Do you have trouble getting in and out of tub or using faucets? -Toileting: Do you have trouble urinating or moving bowels? Are you able to get on and off toilet and to wipe yourself? -Dressing: Can you do buttons, zippers, fastening behind neck, pulling dress or sweater over head, pulling up pants, tying shoes, and can you get shoes that fit? -Communicating: Can you talk, use the telephone, and write? -Grooming: Can you shave, brush teeth, brush or fix hair, and apply makeup? -Eating: Can you prepare meals, pour liquids, cut up foods, bring food to mouth, and drink? -Mobility: Can you walk, walk up or down stairs, get in and out of bed, get out of house?

Cough Questions

-Do you have a cough? <> Duration: How long have you had it? <> Frequency: Is it related to time of day? <> Type: Is it dry, hacking, barky, hoarse, or congested? <> Do you cough up mucus? What color is it? Does it have any odor? Is it blood-tinged? <> Associated with activity, position (lying down), anxiety, or talking? <> Does activity make it better or worse (sit, walk, exercise)? <> Is it relieved by rest or medication?

Cardiac History Questions

-Do you have a history of hypertension, elevated cholesterol or triglycerides, heart murmur, congenital heart disease, rheumatic fever or unexplained joint pains as child or youth, recurrent tonsillitis, or anemia? -Have you ever had heart disease? When was this? Was it treated by medication or heart surgery? -When was your last ECG, stress ECG, serum cholesterol measurement, or other heart tests? -Any family history of hypertension, obesity, diabetes, coronary artery disease (CAD), sudden death at younger age?

Health History Questions: Bones

-Do you have any bone pain? Is pain affected by movement? Do you have any deformity of bones or joint? Is it due to injury or trauma? Does it affect ROM? Have any accidents or trauma ever affected your bones or joints: fractures, joint strain, sprain, or dislocation? Which ones? When did it occur? What treatment was given? Any problems or limitations as a result? Do you have any back pain? In which part of your back? Is pain felt anywhere else, like shooting down leg? Do you have any numbness and tingling? Any limping?

Additional History for Aging Adult

-Do you have any known heart or lung disease, such as hypertension, CAD, chronic emphysema, or bronchitis? -Do you take any medications for your illness, such as digitalis? Are you aware of side effects? Have you recently stopped taking your medication? Why? -Environment <> Does your home have any stairs? How often do you need to climb them? Does this have any effect on activities of daily living?

Health History Questions: Joints

-Do you have any pain in or problems with your joints? -Location: Which joints? On one or both sides? -Quality: What does pain feel like? Is it aching, stiff, sharp or dull, or shooting? Severity: How strong is the pain? -Onset: When did pain start? -Timing: What time of day does pain occur? How long does it last? How often does it occur? -Is pain aggravated by movement, rest, position, or weather; is it relieved by rest, medications, or application of heat or ice? -Is pain associated with chills, fever, recent sore throat, trauma, or repetitive activity? -Do you have any stiffness in your joints? -Do you have any swelling, heat, or redness in the joints? -Do you have any limitation of movement in joint? -Which joint? -Which activities give you problems?

Edema Questions

-Do you have any swelling of your feet and legs? <> Onset: When did you first notice this? Any recent change? <> What time of day does the swelling occur? Do your shoes feel tight at the end of day? <> How much swelling would you say there is? Are both legs equally swollen? <> Does swelling go away with rest, elevation, or after a night's sleep? <> Do you have any associated symptoms, such as shortness of breath? If so, does shortness of breath occur before leg swelling or after?

Fatigue Questions

-Do you seem to tire easily? Able to keep up with your family or co-workers? <> Onset: When did it start? Sudden or gradual? Any recent change in energy level? <> Fatigue related to time of day? All day? Morning, evening?

Smoking History Questions

-Do you smoke cigarettes? -How many packs per day? -At what age did you start? -How many years have you smoked? -Have you tried to quit? If so, what worked for you or what didn't work for you? -Pack years = # of cigarettes X # of years day

Additional History for Infants and Children

-Does child have any mouth infections or sores, such as thrush or canker sores? How frequently? <> Does child have frequent sore throat or tonsillitis? How often? How are these treated? Have they ever been documented as streptococcal infections? -Did child's teeth erupt on time? <> Do teeth seem straight to you? <> Is child using a bottle? Does child sleep with a bottle? <> Noticed any thumb sucking after child's secondary teeth came in? <> Have you noticed child grinding his or her teeth? -Self-care behaviors <> How are child's dental habits? Use a toothbrush regularly? How often does child see a dentist? <> Do you use fluoridated water or fluoride supplement?

Physical Examination: Preparation

-During a complete physical examination, examine arms at very beginning when you are checking vital signs and person is sitting <> Examine legs directly after abdominal examination while person is still supine; then stand person up to evaluate leg veins <> Examination of arms and legs includes peripheral vascular characteristics <> Room temperature should be about 22°C and free of drafts to prevent vasodilation or vasoconstriction <> Use inspection and palpation <> Compare your findings with opposite extremity

Culture & Genetics: Circumcision

-During pregnancy or immediate neonatal period, parents may ask whether or not to circumcise male infant -There are religious and cultural indications for circumcision, also prevention of phimosis and inflammation of glans penis and foreskin, decreasing incidence of cancer of penis, and slightly decreasing incidence of urinary tract infections in infancy -Circumcision lowers risk of certain STIs, specifically syphilis, chancroid, and somewhat reduced risk of genital herpes -Circumcised men have a significantly lowered risk of acquiring genital HPV infection, and their partners have a lower risk of cervical cancer -Finally, epidemiological studies now suggest a potential reduction in acquisition of HIV in circumcised men

Electrocardiograph (ECG)

-ECG waves arbitrarily labeled PQRST, which stand for -P wave: depolarization of atria -P-R interval: from beginning of P wave to beginning of QRS complex - time necessary for atrial depolarization plus time for impulse to travel through AV node to ventricles -QRS complex: depolarization of ventricles -T wave: repolarization of ventricles -Electrical events slightly precede mechanical events in heart

Cost Containment Principles

-Efforts at cost containment result in hospital populations composed of people with increased acuity, shorter stays, and earlier discharges than in the past <> nurses make faster more efficient assessments <> nurses required to go to peoples home for follow up <> first rate assessment skills grounded in holistic approach and knowledge of age specific problems are required

Elbow

-Elbow joint contains three bony articulations: humerus, radius, and ulna of forearm <> Hinge action moves forearm (radius and ulna) on one plane, allowing flexion and extension -Palpable landmarks are medial and lateral epicondyles of humerus and large olecranon process of ulna between them -Radius and ulna articulate with each other at two radioulnar joints, one at elbow and one at wrist <> Permit pronation and supination of hand and forearm

Types of Verbal Responses

-Empathy <> recognizes a feeling and puts it into words <> names the feeling and allows expression of it -Clarification <> Use when person's words are ambiguous or confusing <> You are asking for agreement, and the person can then confirm or deny your understanding -Confrontation <> Frame of reference shifts from patient's perspective to yours [] May focus on discrepancy or inconsistency in person's narrative [] You have observed a certain action, feeling, or statement and now focus person's attention on it [] You give honest feedback about what you see or feel -Interpretation <>Based on your inference or conclusion <> Links events, makes associations, implies cause, ascribes feelings <> Helps person understand his or her own feelings in relation to the verbal message <> If your inference is incorrect, the patient may correct it and thus prompt further discussion of topic -Explanation <> These statements inform the person; you share factual and objective information, offering reasons for requirements or actions -Summary <> Final review of what person has said; it condenses facts and presents your view of health problem <> Is a type of validation that person can agree with or correct; both you and patient should participate <> Occurring at the end of the interview, it signals that termination of the interview is near

Testicular Self-Examination (TSE)

-Encourage self-care by teaching every male from 13 to 14 years old through adulthood how to examine his own testicles <> Overall incidence of testicular cancer is still rare, but testicular cancer most commonly occurs in young men age 15 to 35 -Early detection of cancer enhanced if male is familiar with his normal consistency -Points to include during health teaching are: T - timing, once a month S - shower, warm water relaxes scrotal sac E - examine, check for and report changes immediately

Knee

-Enhance palpation with knee in supine position; start high on anterior thigh above patella <> Palpate with left thumb and fingers in grasping fashion; proceed toward knee, exploring region of suprapatellar pouch; note consistency of tissues. <> Muscles and soft tissues should feel solid, and joint should feel smooth, with no warmth, tenderness, thickening, or nodularity. <> When swelling occurs, need to distinguish if due to soft tissue swelling or increased fluid in joint; tests for bulge sign and ballottement of patella aid this assessment.

Inspection of Throat II

-Enlarge your view of posterior pharyngeal wall by depressing tongue with tongue blade. <> Scan posterior wall for color, exudate, or lesions. [] Touching posterior wall with tongue blade elicits gag reflex; this tests cranial nerves IX and X, the glossopharyngeal and vagus. <> Test cranial nerve XII, hypoglossal nerve, by asking person to stick out tongue; should protrude in midline; note any tremor, loss of movement, or deviation to side. <> Notice any breath odor, halitosis. [] Usually due to local cause; poor oral hygiene, consumption of odoriferous foods, alcohol, smoking, or dental infection.

Abnormal Findings: On Palpation of Enlarged Organs

-Enlarged liver (hepatomegaly) -Enlarged nodular liver -Enlarged gallbladder -Enlarged spleen (splenomegaly) -Enlarged kidney -Aortic aneurysm

Cranial Nerves

-Enter and exit brain rather than spinal cord -12 pairs of cranial nerves supply primarily head and neck, except vagus nerve, which travels to heart, respiratory muscles, stomach, and gallbladder -CN I and II extend from cerebrum -CN III to XII extend from lower diencephalon and brain stem

Culture and Genetics: Obesity

-Epidemic of obesity in U.S. is well known <> Among Americans age 20 or older, prevalence of overweight or obesity [] Overall 68% are overweight or obese [[[]]] Of which 73% are men and [[[]]] 64% are women [] Obesity increases the risk of comorbid conditions, such as but not limited to HTN, hyperlipidemia, type II diabetes

Abnormalities of the Nose

-Epistaxis -Foreign body -Perforated or deviated septum -Acute rhinitis -Allergic rhinitis -Sinusitis -Nasal polyps -Carcinoma

Assessment: Jugular Venous Pressure

-Estimate jugular venous pressure <> Use angle of Louis as arbitrary reference point, and compare it with highest level of venous pulsation <> Read level of intersection on vertical ruler; normal jugular venous pulsation is 2 cm or less above sternal angle <> State person's position, for example, "internal jugular vein pulsations 3 cm above sternal angle when elevated 30 degrees"

Auscultation of Breath Sounds

-Evaluate presence and quality of normal breath sounds. -Instruct person to breathe through mouth, a little bit deeper than usual. -Use flat diaphragm of stethoscope and hold it firmly on person's chest wall to listen to at least one full respiration in each location. <> Posterior from apices at C7 to bases around T10 <> Laterally from axilla down to seventh or eighth rib -Side-to-side comparison is important. -Do not confuse other noises with lung sounds (e.g., your breathing, tubing bumping, hairy chest) -You should expect to hear three types of normal breath sounds in adult and older child. <> Bronchial, sometimes called tracheal or tubular [] Over trachea and larynx [] High-pitched, loud, harsh, hallow <> Bronchovesicular [] Over bronchi [] Moderate-pitched, moderately loud, mixed <> Vesicular [] Over peripheral lung fields [] Low, soft

Inspection and Palpation of the Axillae

-Examine axillae while woman is sitting. <> Inspect skin, noting any rash or infection; lift woman's arm and support it, so that her muscles are loose and relaxed; use right hand to palpate left axilla. <> Reach fingers high into axilla; move them firmly down in four directions. <> Move woman's arm through range-of-motion to increase surface area you can reach. <> Usually nodes are not palpable, although you may feel a small, soft, non-tender node in central group. <> Note any enlarged and tender lymph nodes.

Developmental Competence: Infants

-Examine infant fully undressed and lying on back; take care to place newborns on warming table to maintain body temperature -Feet and Legs <> Note any positional deformities, a residual of fetal positioning <> Note relationship of forefoot to hindfoot <> Check for tibial torsion, a twisting of the tibia -Hips <> Check hips for congenital dislocation; most reliable is Ortolani's maneuver, which should be done at every visit until infant is 1 year old <> Allis test is also used to check for hip dislocation -Hands and arms <> Inspect hands, noting shape, number, and position of fingers and palmar creases <> Palpate length of clavicles; the bone most frequently is fractured during birth -Back <> Lift infant and examine back; note normal single C-curve of newborn's spine Inspect length of spine for any tuft of hair, dimple in midline, cyst, or mass; normally none is present -Observe ROM through spontaneous movement <> Test muscle strength by lifting up the infant with your hands under the axillae; baby with normal muscle strength wedges securely between your hands

Inspection and Palpation: Nose

-External nose <> Normally nose is symmetric, in midline, and in proportion to other facial features. <> Inspect for any deformity, asymmetry, inflammation, or skin lesions; if an injury is reported or suspected, palpate gently for any pain or break in contour. <> Test patency of nostrils by pushing each nasal wing shut with your finger while asking person to sniff inward through other naris; this reveals any obstruction, to be explored using the nasal speculum. <> Sense of smell, mediated by cranial nerve I, is usually not tested in a routine examination. -Nasal cavity <> View each nasal cavity with person's head erect and then with head tilted back. [] Inspect nasal mucosa, noting its normal red color and smooth moist surface. [] Note any swelling, discharge, bleeding, or foreign body. -Nasal septum <> Observe nasal septum for deviation <> Note any perforation or bleeding in septum. -Nasal turbinates

Neurologic System

-Eyes open spontaneously to name -Motor response -Verbal response -Pupil size in millimeter and reaction, right and left -Muscle strength, right and left upper; right and left lower -Any ptosis, facial droop -Sensation -Communication -Ability to swallow

Inspection of the Face

-Facial expression and appropriateness -Symmetry of facial structures -Note any abnormal facial structures (coarse facial features, exophthalmos, changes in skin color or pigmentation), or abnormal swellings -Any involuntary movements (tics) in facial muscles; normally none occur

General Appearance

-Facial expression, appropriate to the situation -Body position, relaxed and comfortable or tense, in pain -Level of consciousness, alert and oriented, attentive to your questions, responds appropriately -Skin color, even tone consistent with racial heritage -Nutritional status, weight appears in healthy range, even fat distribution, hydration appears healthy -Speech: articulation clear and understandable, pattern fluent and even, content appropriate -Hearing: responses and facial expression consistent with what you have said

Objective Data: Behavior

-Facial expression: person maintains eye contact (unless a cultural taboo exists), expressions appropriate to situation (e.g., thoughtful, serious, or smiling) -Mood and affect: person comfortable and cooperative with examiner and interacts pleasantly -Speech: articulation (ability to form words) clear and understandable <> Stream of talking is fluent, with an even pace <> Conveys ideas clearly <> Word choice appropriate to culture and education <> Person communicates in prevailing language easily by himself or herself or with interpreter -Dress: appropriate to climate, looks clean and fits body, and is appropriate to person's culture and age group -Personal hygiene: person appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group

Responses: Assisting the Narrative

-Facilitation <> Encourages patients to say more and shows you are interested and will listen further -Silent attentiveness -Reflection <> Echoes patient's words, repeating what person has just said, focuses further attention on a specific phrase, and helps person continue in his or her own way

Developmental Considerations: Aging Woman

-Female's hormonal milieu decreases rapidly in contrast with slow decline in aging male <> Menopause: cessation of menses [] Usually this occurs around 48 to 51, although a wide variation of ages from 35 to 60 years exists [] Stage of menopause includes preceding 1 to 2 years of decline in ovarian function, shown by irregular menses that gradually become farther apart and produce lighter flow [] Ovaries stop producing progesterone and estrogen [] Because cells in the reproductive tract are estrogen dependent, decreased estrogen levels during menopause bring dramatic physical changes

Structure and Function: Arteries in the Leg

-Femoral artery, <> Major artery to leg is which <> Passes under inguinal ligament <> Travels down the thigh <> At lower thigh, courses posteriorly, then is termed the popliteal artery -Popliteal artery <> Divides below knee [] Anterior tibial artery travels down front of leg on to dorsum of foot, where it becomes the dorsalis pedis [] In back of leg, posterior tibial artery travels down behind medial malleolus and in the foot forms the plantar arteries <> Peripheral arterial disease (PAD) affects non-coronary vessels and refers to arteries affecting the limbs

Pediatric Facial Abnormalities

-Fetal alcohol syndrome -Down syndrome -Atopic (allergic) facies

Developmental Considerations: Infants and Children

-Fetal heart begins to beat after 3 weeks' gestation -Right and left ventricles equal in weight and muscle wall thickness and both pumping into systemic circulation -Inflation and aeration of lungs at birth produces circulatory changes -Now blood is oxygenated through lungs rather than through placenta -Now left ventricle has greater workload of pumping into systemic circulation

Lower Motor Neurons

-Final common pathway, providing final contact with muscle -Located in anterior gray column of spinal cord, but nerve fibers extend to muscle -Movement must be translated into action by lower motor neuron fibers <> Examples are cranial nerves and spinal nerves of peripheral nervous system <> Examples of lower motor neuron diseases are spinal cord lesions, poliomyelitis, and amyotrophic lateral sclerosis

Rapid Alternating Movements (RAM)

-Finger-to-finger test: with eyes open, ask person to use index finger to touch your finger, then their own nose; then move your finger to continue test <> Person's movement should be smooth and accurate -Finger-to-nose test: with eyes closed and stretch out arms and touch tip of their nose with each index finger, alternating hands and increasing speed <> Normally this is done with accurate and smooth movement -Heel-to-shin test: ask person in supine position to place heel on opposite knee and run it down shin to ankle <> Normally person moves heel in straight line down shin

Structure and Function: Nose

-First segment of respiratory system <> Warms, moistens, and filters inhaled air <> Is sensory organ for smell -Upper third made up of bone; rest is cartilage -Nasal cavity <> Much larger than external nose would indicate - extends back over roof of mouth [] Mucous blanket filters out dust and bacteria -Nasal cavity divided medially by septum into two slit-like air passages <> Anterior part of septum holds a rich vascular network, Kiesselbach's plexus, most common site of nosebleeds. <> Lateral walls of each nasal cavity contain three parallel bony projections (turbinates). <> Underlying each turbinate is a cleft, the meatus, which is named for turbinate above. <> Sinuses drain into middle meatus, and tears from nasolacrimal duct drain into inferior meatus. -Olfactory receptors, hair cells, lie at roof of nasal cavity and upper third of septum. These receptors for smell merge into the ___________ _______, _____________which transmits to temporal lobe of brain.

Percussion of Posterior Chest: Diaphragmatic Excursion

-First, ask the person to "exhale and hold it" briefly while you percuss down scapular line until sound changes from resonant to dull. <> This estimates level of diaphragm separating lungs from abdominal viscera; <> It may be somewhat higher on right side because of presence of liver. -Mark the spot. -Repeat for the other side. -Now ask person to "take a deep breath and hold it." -Continue percussing down from your first mark and mark level where sound changes to dull on deep inspiration. -Measure the difference; this diaphragmatic excursion should be equal bilaterally and measure about 3 to 5 cm in adults, although it may be up to 7 to 8 cm in well-conditioned people.

Abnormalities of the Tongue

-Fissured or scrotal tongue -Smooth, glossy tongue (atrophic glossitis) -Black hairy tongue (fungal infection) -Carcinoma

Nonverbal Behaviors

-Five types of nonverbal behaviors convey information about person 1. Vocal cues: pitch, tone, and quality of voice, including moaning, crying, and groaning 2. Action cues: posture, facial expression, and gestures 3. Object cues: clothing, jewelry, and hairstyles 4. Personal space: interpersonal transactions and care of belongings 5. Touch: involves use of personal space and action

Abnormalities in Muscle Tone

-Flaccidity -Spasticity -Rigidity -Cogwheel rigidity

Auscultation of Anterior Chest

-Follow pattern of percussion -Similar to auscultation of posterior chest

Open Ended Questions

-For narrative responses -General -Use them in the following situations: <> To begin interview ("Why did you come in today?") <> To introduce a new section of questions <> Whenever the patient introduces a new topic

Assessment: Auscultate Carotid Artery

-For persons middle-aged or older, auscultate each carotid artery for presence of a bruit (normally not present) -Ask person to take a breath, exhale, hold -Lightly apply bell of stethoscope over carotid artery at three levels: <> Angle of jaw <> Midcervical area <> Base of neck

Posterior Tibial and Dorsalis Pedis Pulses

-For posterior tibial pulse, curve your fingers around medial malleolus <> Feel the tapping right behind it in groove between malleolus and Achilles tendon -Dorsalis pedis pulse requires a very light touch <> Normally it is just lateral to and parallel with extensor tendon of big toe <> Do not mistake pulse in your own fingertips for person's <> In adults over 45 years, occasionally either dorsalis pedis or posterior tibial pulse may be hard to find, but not both on the same foot

Closed or Direct Questions

-For specific information -To elicit short one- or two-word answers (yes/no or a forced choice) -Use them in the following situations: <> To fill in details person may have left out <> When you need many specific facts about past health problems or during review of systems <> To move the interview along

Knee: Bulge Sign

-For swelling in suprapatellar pouch, bulge sign confirms presence of fluid as you try to move fluid from one side of joint to other. -Firmly stroke up on medial aspect of knee two or three times to displace any fluid; tap lateral aspect and watch medial side in hollow for distinct bulge from a fluid wave; normally none is present.

Test Near Vision

-For those who report increasing difficulty reading -Test near vision with handheld vision screener with various sizes of print (e.g., a Jaeger card) <> Hold card in good light about 35 cm (14 inches) from the eye; this distance equals print size on 20-foot chart <> Test each eye separately, with glasses on <> Normal result is "14/14" in each eye, read without hesitancy and without moving card closer or farther away <> When no vision screening card is available, ask person to read from a magazine or newspaper

Functional Assessment

-For those with advanced aging changes, arthritic changes, or musculoskeletal disability, perform functional assessment for ADLs -Apply ROM and muscle strength assessments to accomplishment of specific activities -Goal is to determine adequate and safe performance of functions essential for independent home life

Heart Chambers and Valves

-Four chambers separated by valves, whose main purpose is to prevent backflow of blood <> Valves are unidirectional <> Valves open and close in response to pressure gradients -Four valves in heart <> Two atrioventricular (AV) valves [] Tricuspid [] Mitral <> Two semilunar (SL) valves [] Pulmonic [] Aortic

Mechanics of Respiration

-Four major functions of respiratory system <> Supplying oxygen to the body for energy production <> Removing carbon dioxide as a waste product of energy reactions <> Maintaining homeostasis (acid-base balance) of arterial blood <> Maintaining heat exchange (less important in humans) -Body tissues are bathed by blood that normally has a narrow acceptable range of pH. -Normal stimulus to breathe for most of us is an increase of carbon dioxide in blood (hypercapnia) or, to a lesser extent, decrease in oxygen (hypoxia). <> Hypoventilation (slow, shallow breathing) causes carbon dioxide to build up in blood (increase acidity). <> Hyperventilation (rapid, deep breathing) causes carbon dioxide to be blown off (decrease acidity). -Changing chest size <> Respiration is the physical act of breathing: [] Air rushes into the lungs as chest size increases (inspiration) [] Air is expelled from the lungs as chest recoils (expiration).

Extra Heart Sounds (S4)

-Fourth heart sound (S4) <> Occurs at end of diastole, at presystole, when ventricle resistant to filling <> Atria contract and push blood into noncompliant ventricle <> This creates vibrations that are heard as S4 <> S4 occurs just before S1

Spine

-From side, note normal convex thoracic curve and concave lumbar curve <> Enhanced thoracic curve, or ___________, in aging people <> Pronounced lumbar curve, or___________, in obese people <> Spinous processes normally straight and not tender <> Palpate paravertebral muscles should feel firm with no tenderness or spasm -Check ROM of spine by asking person to touch toes; look for flexion of 75 to 90 degrees, and smoothness and symmetry of movement <> Concave lumbar curve should disappear with this motion; back should have single convex C-shaped curve <> If you suspect spinal curvature during inspection, this may be more clearly seen when person touches toes <> While person is bending over, mark a dot on each spinous process; when person resumes standing, dots should form a straight vertical line -Stabilize pelvis with your hands; check ROM <> Bend sideways: lateral bending of 35 degrees <> Bend backward: hyperextension of 30 degrees <> Twist shoulders to one side, then the other: rotation of 30 degrees, bilaterally <> Finally, ask person to walk on his or her toes for a few steps, then return walking on heels

Abnormal Findings: Abnormalities of External Ear

-Frostbite -Otitis externa, "swimmer's ear"

Objective Data: Mobility

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

Abnormalities of Wrist and Hand

-Ganglion cyst -Carpal tunnel syndrome -Ankylosis - severe RA -Dupuytren's contracture -Conditions caused by chronic rheumatoid arthritis: Swan-neck and boutonniere deformities -Acute rheumatoid arthritis -Ulnar deviation or drift -Degenerative joint disease or osteoarthritis -Syndactyly -Polydactyly

Inspection of the Breast

-General appearance <> Note symmetry of size and shape; common to have a slight asymmetry in size; often left breast is slightly larger than right. -Skin <> Normally smooth and of even color <> Note any localized areas of redness, bulging, or dimpling; also any skin lesions or focal vascular pattern. <> Normally no edema is present. -Lymphatic drainage areas <> Observe axillary and supraclavicular regions; note any bulging, discoloration, or edema. -Nipple <> Should be symmetric on same plane on both breasts <> Nipples usually protrude, although some are flat and some are inverted. <> Normal nipple inversion may be unilateral or bilateral and usually can be pulled out. <> Note any dry scaling, any fissure or ulceration, and bleeding or other discharge. -Supernumerary nipple is normal variation. <> An extra nipple along embryonic "milk line" on thorax or abdomen is congenital finding. <> Usually below breast near midline and has no associated glandular tissue; looks like a mole, although a close look reveals a tiny nipple and areola.

Cultural Considerations

-In some racial groups, lactase activity is high at birth but declines to low levels by adulthood -Lactase is the digestive enzyme necessary for absorption of carbohydrate lactose (milk sugar) -Estimated incidence of lactose intolerance is <> 15% of Whites, <> 50% of Mexican Americans, and <> 80% of Blacks -These people are lactose intolerant and have abdominal pain, bloating, and flatulence when milk products are consumed

Review of Systems

-General overall health state (present weight, fatigue, weakness, fever, chills, sweats, night sweats) <> Skin [] history of skin diseases, pigment changes, changes in moles, etc. <> Hair [] recent loss or change in texture <> Head [] headaches or dizziness or injuries <> Eyes [] difficulty with vision, redness or swelling, glaucoma or cataracts, etc. <> Ears [] earaches, discharge, etc. <> Nose and sinuses [] discharge, sinus pain, nosebleeds, allergies <> Mouth and throat [] mouth pain, sore throat, toothache, etc. -Neck [] pain, limitation in motion, lumps or tender nodes -Breast [] pain, lumps, breast disease history -Axilla [] tenderness, lump, swelling, or rash -Respiratory system [] history of lung disease, chest pain when breathing, shortness of breath -Cardiovascular [] chest pain, pressure, tightness, dyspnea -Peripheral vascular [] coldness, tingling, swelling of legs, varicose veins -Gastrointestinal [] appetite, food intolerance, heartburn , nausea or vomiting -Urinary system [] frequency, urgency, hesitancy or straining -Male genital system [] penis or testicular pain -Female genital system [] menstrual history, itching, discharge, etc. -Sexual health -Musculoskeletal system [] history of arthritis or gout, pain or stiffness in joints -Neurologic system [] history of seizure, stroke, fainting, etc. -Hematologic system [] bleeding tendency of skin or mucous membranes, excessive bruising -Endocrine system [] history of diabetes

Shoulder

-Glenohumeral joint: articulation of humerus with glenoid fossa of scapula -Ball-and-socket action allows mobility of arm on many axes -Rotator cuff: group of four muscles and tendons support and stabilize shoulder -Palpable landmarks to guide your examination <> Scapula and clavicle form shoulder girdle <> Can feel the bump of the scapula's acromion process at very top of shoulder

Instrumental Activities of Daily Living

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

Developmental Competence: Aging Adult

-Gradual loss of subcutaneous fat starts during later middle adult years, making the nose appear more prominent in some people. -Atrophic tissues ulcerate easily, increasing risk for oral moniliasis and malignant lesions. -Natural tooth loss exacerbated by inadequate dental care, poor oral hygiene, and tobacco use -Diminished sense of taste and smell decreases aging person's interest in food and may contribute to malnutrition. -Trouble with mastication can lead to dietary pattern changes which may place the older adult at risk for nutritional deficits (protein, vitamins, and minerals).

Developmental Considerations: Aging Adult

-Gradual rise in systolic blood pressure common with aging -Overall size of the heart does not change but left ventricular wall thickness increases -Presence of supraventricular and ventricular dysrhythmias increases with age -Age-related ECG changes occur as a result of histologic changes in the conduction system -Incidence of CVD increases with age

Confrontation Test

-Gross measure of peripheral vision; compares person's peripheral vision with yours <> Position yourself at eye level with person about 2 feet away <> Direct person to cover one eye with an opaque card and with other eye to look straight at you <> Cover your own eye opposite to person's covered one; you are testing uncovered eye <> Hold pencil or your finger as target midline between you and person, and slowly advance it in from periphery in several directions

Additional History for Children

-Growth: Has this child grown as expected by growth charts? -Activity: Is this child able to keep up with siblings or age mates? -Has the child had any unexplained joint pains or unexplained fever? -Does the child have frequent headaches or nosebleeds? -Does the child have frequent respiratory infections? How many per year? How are they treated? Have any of these been streptococcal infections? -Does child have a sibling with heart defect? Is anyone in child's family known to have chromosomal abnormalities, such as Down syndrome?

Additional History for Pregnant Woman

-Have you had any high blood pressure during this or earlier pregnancies? <> What was your usual blood pressure level before pregnancy? How has your blood pressure been monitored during the pregnancy? <> If high blood pressure, what treatment has been started? <> Do you have any associated symptoms, such as weight gain, protein in urine, or swelling in feet, legs, or face? -Have you had any faintness or dizziness with this pregnancy?

Infant Assessment

-Head and face - Fontanels, facial expressions, rooting and sucking reflex -Chest and heart - Note movement of abdomen with respirations and any chest retractions -Abdomen -Stepping, placing and moro Reflexes

Physical Examination: Inspection and Palpation of Head

-Head size and shape -Hair -Position/ symmetry -Lumps/ bumps -Temporomandibular joint mobility

Health History Questions related to Head and Neck

-Headache -Head injury -Dizziness <> Presyncope <> Vertigo -Syncope -Neck pain/ stiffness -Lumps/ swelling -Dysphagia -For children: mother's habits in pregnancy, delivery

Subjective Data Questions

-Headache <> Have you had any unusually frequent or severe headaches? When did this start? How often does it occur? <> Where do you feel headaches? Do headaches seem to be associated with anything? -Head injury <> Have you ever had any head injury? What part of head was injured? Describe. <> Did you have loss of consciousness? For how long? What caused it?

Structure and Function: Hearing

-Hearing <> Ear transmits sound and converts its vibrations into electrical impulses, which can be analyzed by the brain <> Cranial nerve VIII from each ear sends signals to both sides of the brainstem <> Amplitude: loudness <> Frequency: pitch or number of cycles per second -Pathways of hearing <> Normal pathway of hearing is air conduction (AC) described previously; it is the most efficient <> Alternate route is by bone conduction (BC) [] Bones of the skull vibrate and are transmitted directly to inner ear and to cranial nerve VIII

Culture and Genetics: Smoking

-In the 45+ years from 1965 to 2010, U.S. smoking rates declined by 54% among adults over 18 -In 2010, 21.2% of men and 17.5% of women were smokers -Nicotine increases risk of myocardial infarction (MI) and stroke by causing <> Increase in oxygen demand with a concomitant decrease in oxygen supply <> Activation of platelets, activation of fibrinogen, and an adverse change in lipid profile

Structure and Function: Hearing Loss<>

-Hearing loss <> Anything obstructing transmission of sound impairs hearing -Conductive hearing loss involves a mechanical dysfunction of external or middle ear <> Partial loss because person is able to hear if sound amplitude is increased enough to reach normal nerve elements in inner ear <> May be caused by impacted cerumen, foreign bodies, a perforated TM, pus or serum in middle ear, and otosclerosis, which is a decrease in mobility of ossicles -Sensorineural (or perceptive) hearing loss signifies pathology of inner ear, cranial nerve VIII, or auditory areas of cerebral cortex <> Increase in amplitude may not enable person to understand words <> May be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging, and by ototoxic drugs, which affect hair cells in cochlea <> Mixed hearing loss is combination of conductive and sensorineural types in same ear

Cardiac Conduction

-Heart has a unique ability: automaticity <> Can contract by itself, independent of any signals or stimulation from body <> Specialized cells in sinoatrial (SA) node, near superior vena cava initiate an electric impulse <> Because SA node has intrinsic rhythm, it is called the pacemaker -Small amount of electricity spreads to body surface and can be measured and recorded on electrocardiograph (ECG) -Current flows in orderly sequence, first across atria to AV node low in atrial septum -There, it is delayed slightly so that atria have time to contract before ventricles are stimulated -Then, impulse travels to bundle of His, right and left bundle branches, and then through ventricles -Electric impulse stimulates heart to do its work, which is to contract

Heart Wall, Chambers, and Valves

-Heart wall has numerous layers Pericardium: tough, fibrous, double-walled sac that surrounds and protects heart Myocardium: muscular wall of heart; it does pumping Endocardium: thin layer of endothelial tissue that lines inner surface of heart chambers and valves -Heart has two pump systems -Each side of the heart has an atrium and ventricle <> Atrium: thin-walled reservoir for holding blood <> Ventricle: thick-walled, muscular pumping chamber

Palpation of the Breasts

-Help the woman to a supine position <> Tuck a small pad under side to be palpated and raise her arm over her head to flatten breast tissue and displace it medially; any significant lumps will then feel more distinct. <> Vertical strip pattern currently recommended to detect a breast mass, but two other patterns are in common use: [] From the nipple palpating out to periphery as if following spokes on a wheel [] Palpating in concentric circles out to periphery - With your thumb and forefinger, gently depress nipple tissue into well behind areola; tissue should move inward easily. - If woman reports spontaneous nipple discharge, press areola inward with your index finger; repeat from a few different directions; note color and consistency of any discharge. - If woman mentions a breast lump that she has discovered herself, examine unaffected breast first to learn a baseline of normal consistency for this woman. -In nulliparous women, normal breast tissue feels firm, smooth, and elastic. - After pregnancy, tissue feels softer and looser. - Premenstrual engorgement is normal from increasing progesterone. <> Consists of slight enlargement, tenderness to palpation, and generalized nodularity; lobes feel prominent and their margins more distinct.

Culture and Genetics: Serum Cholesterol

-High levels of low density lipoprotein gradually add to lipid core of thrombus formation in arteries, which results in MI and stroke -Age-adjusted prevalence of LDL cholesterol levels over 130 mg/dL include <> 39.9% of Mexican American men and 30.4% of Mexican American women <> 30.1% of white men and 29.3% of white women <> 33.1% of black men and 31.2% of black women

Hip

-Hip: articulation between acetabulum and head of the femur -Ball-and-socket action permits wide range of motion on many axes -Less range of motion (ROM) than shoulder, but more stability for weight-bearing function -Hip stability is due to powerful muscles that spread over joint, strong fibrous articular capsule, and deep insertion of head of femur -Three bursae facilitate movement <> Palpation of bony landmarks will guide exa [] Iliac crest, from anterior superior iliac spine to posterior [] Ischial tuberosity [] Greater trochanter of femur below iliac crest and between anterior superior iliac spine and ischial tuberosity [] Felt best when person standing, in flat depression on upper lateral side of thigh -ortolani: hip movement

Inspection of Buccal Mucosa I

-Hold cheek open with a wooden tongue blade, and check buccal mucosa for color, nodules, or lesions; looks pink, smooth, and moist, although patchy hyperpigmentation is common in dark-skinned people. -Stensen's duct: opening of parotid salivary gland is an expected finding; looks like a small dimple opposite upper second molar. -May also see a raised occlusion line on buccal mucosa parallel where teeth meet caused by teeth closing against cheek.

Developmental Considerations: Pregnant Woman

-Hormonal changes cause vasodilation and a resulting drop in blood pressure -Growing uterus obstructs drainage of iliac veins and inferior vena cava <> Causes low blood flow <> Increases venous pressure [] Dependent edema [[[]]] Expect diffuse bilateral pitting edema in the lower extremities, especially at the end of the day and into the third trimester [[[]]] Nearly 80% of pregnant women have some peripheral edema <> Varicosities in legs and vulva - often seen in the third trimester <> Hemorrhoids

Additional History for Aging Adults

-How do you acquire your groceries and prepare your meals? <> Do you eat alone or do you share meals with others? -Please tell me all that you had to eat yesterday, starting with breakfast. <> Do you have any trouble swallowing these foods? <> What do you do right after eating, such as walking or taking a nap? -How often do your bowels move? <> If constipation a problem: What do you mean by constipation? How much liquid is in your diet? How much bulk or fiber? <> Do you take anything for constipation, such as laxatives? Which ones? How often? <> What medications do you take?

Additional History for Infants

-How was mother's health during pregnancy? Was there any unexplained fever, rubella during first trimester, other infection, hypertension, or drugs taken? <> Have you noted any cyanosis while nursing or crying? Is baby able to eat, nurse, or finish bottle without tiring? <> Growth: Has this baby grown as expected by growth charts and about same as siblings or peers? <> Activity: Were this baby's motor milestones achieved as expected? Is baby able to play without tiring? How many naps does baby take each day? How long does a nap last?

HPV - Sexually Transmitted Virus

-Human papillomavirus, or HPV, is a very common sexually-transmitted virus <> Most people who have had sex, both men and women, have been infected at some point in their lives <> Most people never even know they have HPV because virus usually does not cause any symptoms and body is able to fight it off <> However, sometimes virus lingers in a woman's cervix and can cause changes that may eventually lead to cervical cancer

Abnormal Findings: Male Genitalia

-Hypospadias - Urethral meatus opens on the underside of the glans or shaft or at the penoscrotal junction -Epispadias - Urethral meatus opens on the upper side of the glans or shaft -Phimosis - Nonretractable foreskin -Paraphimosis - Foreskin retracted and fixed; emergency -Testicular torsion - Testis rotates so blood supply cut; emergency -Epididymitis - Infection of epididymis; pain relieved with elevation -Cryptorchidism - Absent testis

Inspection of Abdomen: Scars

-If a scar is present, draw its location in person's record, indicating length in centimeters. -Occasionally, a person forgets about an operation while providing the history; if you note a scar now, ask about it. -Surgical scar alerts you to possible presence of underlying adhesions and excess fibrous tissue. -Pulsation or movement <> Normally you may see pulsations from aorta beneath skin in epigastric area, particularly in thin persons with good muscle wall relaxation

Special Percussion Procedures

-If ascites (free fluid in the peritoneal cavity) suspected because of distended abdomen, bulging flanks, and an umbilicus that is protruding and displaced downward -You can differentiate ascites from gaseous distention by performing two percussion tests <> Fluid wave test <> Shifting dullness test

Shoulder

-If person reports shoulder pain, ask him or her to point to spot with hand of unaffected side <> Shoulder pain may be from local causes or may be referred pain from a hiatal hernia or cardiac or pleural condition, which could be potentially serious <> Pain from a local cause is reproducible during the examination by palpation or motion -While standing in front of person, palpate both shoulders, noting any muscular spasm or atrophy, swelling, heat, or tenderness -Start at clavicle and methodically explore acromioclavicular joint, scapula, greater tubercle of humerus, area of subacromial bursa, biceps groove, and anterior aspect of glenohumeral joint -Palpate pyramid-shaped axilla; no adenopathy or masses should be present -Test ROM by asking person to perform motions: <> Flexion, hyperextension, internal and external rotation, abduction/ adduction, shrug -Cup one hand over shoulder during ROM to note any crepitation; normally none is present -Test strength of shoulder muscles by asking person to shrug shoulders, flex forward and up, and abduct against your resistance -Shoulder shrug also tests integrity of cranial nerve XI, spinal accessory nerve

Assessment: Hepatojugular Reflex

-If venous pressure is elevated, or if you suspect heart failure, perform hepatojugular reflux -Hold your right hand on right upper quadrant of person's abdomen just below rib cage -Watch level of jugular pulsation as you push in with your hand, exerting firm pressure for 30 seconds -If heart is able to pump this additional volume (i.e., if no elevated CVP is present), jugular veins will rise for a few seconds, then recede back to previous level

Color Changes

-If you suspect an arterial deficit, raise legs about 30 cm (12 in.) off table and ask person to wag feet for 30 seconds to drain off venous blood <> Skin color now reflects only contribution of arterial blood <> Light-skinned person's feet normally will look a little pale but still should be pink <> Dark-skinned person's feet are more difficult to evaluate, but soles should reveal extreme color change <> Now have person sit up with legs over side of table <> Compare color of both feet, and note time it takes for color to return to feet; normally this is 10 seconds or less -Note also time it takes for superficial veins around feet to fill <> Normal time is about 15 seconds <> This test is unreliable if person has concomitant venous disease with incompetent valves <> Test lower legs for strength <> Test lower legs for sensation

Swelling Questions

-In arms or legs <> Swelling in one or both legs? When did this start? <> What time of day is swelling at its worst: morning, or after up most of day? <> Does swelling come and go, or is it constant? <> What seems to bring it on: trauma, standing all day, sitting? <> What relieves swelling: elevation, support hose? <> Is swelling associated with pain, heat, redness, ulceration, or hardened skin?

Developmental Competence: Infants and Children

-In early development ear is posteriorly rotated and low set; later ascends to its normal placement around eye level -Infant's eustachian tube is relatively shorter and wider and more horizontal than adult's, so it is easier for pathogens from nasopharynx to migrate through to middle ear -Infant's and young child's external auditory canal is shorter and has a slope opposite to that of adult's -These factors place infants at greater risk for middle ear infections than adults

Developmental Considerations: Aging Adult

-In eighties and nineties, fat further decreases in periphery, especially noticeable in forearms and apparent over abdomen and hips -Loss of subcutaneous fat leaves bony prominences more marked -Absolute loss in muscle mass occurs; some decrease in size, and some atrophy, producing weakness -Contour of muscles becomes more prominent, and muscles and tendons feel more distinct -Lifestyle affects musculoskeletal changes

Pumping Ability

-In resting adult, heart normally pumps between 4 and 6 L of blood per minute throughout body <> This cardiac output equals volume of blood in each systole (called stroke volume) times number of beats per minute (rate) <> Heart can alter its cardiac output to adapt to metabolic needs of body <> Preload and afterload affect heart's ability to increase cardiac output

External Canal

-Note any redness and swelling, lesions, foreign bodies, or discharge -If any discharge is present, note color and odor <> Also, clean any discharge from speculum before examining other ear to avoid contamination with possibly infectious material <> For person with hearing aid, note any irritation on canal wall from poorly fitting ear molds

Abdomen: Infants and Children

-In the newborn: <> Umbilical cord shows prominently containing two arteries and one vein <> Umbilical stump dries within a week, hardens, and falls off by 10 to 14 days; skin covers area by 3 to 4 weeks <> Liver takes up proportionately more space in abdomen at birth than in later life <> Urinary bladder located higher in abdomen than in adult -During early childhood <> Abdominal wall is less muscular, so organs may be easier to palpate

Cardiac Disease and Aging Adult

-Incidence of coronary artery disease increases sharply with advancing age and accounts for about half of deaths of older people <> Hypertension and heart failure also increase with age <> Lifestyle habits play a significant role in the acquisition of heart disease -Also, increasing physical activity of older adults associated with a reduced risk of death from cardiovascular diseases and respiratory illnesses <> Both points underscore need for health teaching as an important treatment parameter

The Older Adult: Functional Assessment

-Including ADLs <>Self-concept, self-esteem <>Occupation <>Activity and exercise <>Sleep and rest <>Nutrition and elimination <>Interpersonal relationships and resources <>Coping and stress management <>Environment and home safety hazards

Hemodynamic Changes with Aging

-Increase in systolic BP due to thickening and stiffening of the arteries -Left ventricular wall becomes thicker but the overall size of the heart does not change -Pulse pressure increases -Ability of heart to augment cardiac output with exercise is decreased -Presence of supraventricular and ventricular arrhythmias and ectopic beats increases with age -Tachyarrhythmias may not be tolerated as well

Developmental Considerations: Pregnant Woman

-Increased levels of circulating hormones (estrogen, relaxin from corpus luteum, and corticosteroids) cause _________mobility in joints -__________ mobility in sacroiliac, sacrococcygeal, and symphysis pubis joints in pelvis contributes to noticeable changes in maternal posture -Most characteristic change is progressive lordosis, which compensates for enlarging fetus by shifting weight farther back on lower extremities

Neuropathic Pain

-Indicates type of pain that does not adhere to typical phases inherent in nociceptive pain <> Neuropathic pain implies an abnormal processing <> This type of pain is most difficult to assess and treat <> Often perceived long after site of injury heals <> Electromyography and nerve-conduction studies are needed

Infants and Children: Inspection

-Infant has a rounded thorax with an equal anteroposterior-to-transverse chest diameter. -By age 6 years, thorax reaches adult ratio of 1:2. -Newborn's chest circumference is 30 to 36 cm and is 2 cm smaller than head circumference until 2 years of age. -Chest wall is thin with little musculature. -Newborn's first respiratory assessment is part of Apgar scoring system to measure successful transition to extrauterine life. -Infant breathes through nose rather than mouth and is an obligate nose breather until 3 months. -Diaphragm is newborn's major respiratory muscle. -Count respiratory rate for 1 full minute; normal rates for newborn are 30 to 40 breaths per minute but may spike up to 60 breaths per minute. -Obtain the most accurate respiratory rate by counting when the infant is asleep because infants reach rapid rates with very little excitation when awake. -Respiratory pattern may be irregular when extremes in room temperature occur or with feeding or sleeping. -Brief periods of apnea less than 10 or 15 seconds are common; this periodic breathing is more common in premature infants.

Developmental Considerations

-Infants <> First stool passed by newborn is dark green meconium; occurs within 24 to 48 hours of birth, indicates anal patency <> Gastrocolic reflex: wave of peristalsis in response to eating [] Infant passes stools by reflex -Children and adults <> At male puberty, prostate gland undergoes a very rapid increase to more than twice its prepubertal size; during young adulthood size remains fairly constant <> Prostate gland commonly starts to enlarge during middle adult years; increases with age [] Thought that hypertrophy caused by hormonal imbalance leading to proliferation of benign adenomas, which gradually impede urine output because they obstruct urethra

Color Vision and Extraocular Muscle Function (EOM)

-Infants and children <> Color vision [] Color blindness an inherited recessive X-linked trait affecting about 8% of White males and 4% of African American males; rare in females [] Test only boys for color vision, once between ages of 4 and 8 <> Extraocular muscle function [] Testing for strabismus (crossed eye) is important screening measure during early childhood [] Test malalignment by corneal light reflex and cover test

Eye Structures

-Infants and children <> Conjunctiva and sclera [] Newborn may have transient chemical conjunctivitis from instillation of silver nitrate; appears within 1 hour and lasts not more than 24 hours after birth [] Sclera should be white and clear, although it may have a blue tint as a result of thinness at birth; lacrimal glands are not functional at birth <> Iris and pupils [] Iris normally blue or slate gray in light-skinned newborns and brown in dark-skinned infants; by 6 to 9 months, permanent color differentiated

Eyelids and Lashes

-Infants and children <> Eyelids and lashes [] In newborns, setting-sun sign common; eyes appear to deviate down with white rim of sclera visible over iris [] Many infants have an epicanthal fold over inner corner of eye

Neurological Assessment

-Level of Consciousness* - Awake? Alert? Aware? -Orientation* - To person? To place? To time? -Speech* - Slurred? Unintelligible? Lacking inflection? Hoarse? Whispered? Stuttering? -New Learning - Four Unrelated Word Test -Cranial Nerves -Motor System -Reflexes *A sudden change should be treated as an emergency. *Need to determine acute confusion (________) versus chronic confusion (__________)

Testing Hearing Acuity

-Infants and young children <> Room should be silent and baby contented; make a loud sudden noise; you should note these responses: [] Newborn: startle (Moro) reflex, acoustic blink reflex [] 3 to 4 months: acoustic blink reflex, infant stops movement and appears to listen, halts sucking, quiets if crying, cries if quiet [] 6 to 8 months: infant turns head to localize sound; responds to own name [] Preschool and school-age child: child must be screened with audiometry -Infants and young children <> Note behavioral manifestations of hearing loss: [] Child is inattentive in casual conversation [] Reacts more to movement and facial expression than to sound [] Facial expression strained or puzzled [] Frequently asks to have statements repeated [] Confuses words that sound alike [] Has accompanying speech problem [] Appears shy and withdrawn and "lives in a world of his or her own" [] Frequently complains of earaches [] Hears better at times when environment more conducive

Developmental Competence: Infants

-Infants have same capacity for pain as adults <> By 20 weeks of gestation, ascending fibers, neurotransmitters, and cerebral cortex are developed and functioning to extent that fetus is capable of feeling pain <> However, inhibitory neurotransmitters are in insufficient supply until birth at full term -Infants have same capacity for pain as adults <> By 20 weeks of gestation, ascending fibers, neurotransmitters, and cerebral cortex are developed and functioning to extent that fetus is capable of feeling pain <> However, inhibitory neurotransmitters are in insufficient supply until birth at full term

Abnormalities Affecting Multiple Joints

-Inflammatory conditions <> Rheumatoid arthritis - symmetric with heat, redness, swelling <> Ankylosing spondylitis - chronic, progressive -Degenerative conditions <> Osteoarthritis (degenerative joint disease) - asymmetric with hard, bony protuberances <> Osteoporosis - increased risk for fractures See p. 620

Informal and Formal Support

-Informal support <> Includes family and close long-time friends, and is usually provided free of charge <> Services provided include tasks such as shopping, bathing, feeding, and paying bills -Formal supports <> Include programs such as social welfare and other social service and health care delivery agencies such as home health care <> Several studies conclude that presence of a caregiver is most important factor in discharge plan of older adults from an acute care hospital <> Several standardized assessment instruments are available to provide structured assessment

Abdomen: Internal Anatomy

-Inside abdominal cavity, all internal organs are called viscera -Lower edge of liver and right kidney may normally be palpable -Note that small intestine is located in all four quadrants -Spleen is a soft mass of lymphatic tissue on posterolateral wall of abdominal cavity, immediately under diaphragm -Aorta is just to the left of midline in upper part of abdomen -Pancreas is a soft, lobulated gland located behind stomach -Bean-shaped kidneys are retroperitoneal, or posterior to abdominal contents -Because of placement of liver, right kidney rests 1 to 2 cm lower than left kidney -For convenience in description, abdominal wall is divided into four quadrants by a vertical and a horizontal line bisecting umbilicus

Assessment of Cervical Spine

-Inspect alignment of head and neck <> Spine should be straight and head erect -Palpate spinous processes and sternomastoid, trapezius, and paravertebral muscles <> They should feel firm, with no muscle spasm or tenderness -Repeat motions while applying opposing force -Person normally can maintain flexion against full resistance <> This tests integrity of cranial nerve XI (spinal nerve)

Assessment of Shoulders

-Inspect and compare both shoulders posteriorly and anteriorly <> Check size and contour of joint and compare shoulders for equality of bony landmarks <> Normally no redness, muscular atrophy, deformity, or swelling is present <> Check anterior aspect of joint capsule and subacromial bursa for abnormal swelling <> Do not attempt if you suspect neck trauma

Inspection and Palpation

-Inspect and palpate external ear <> Size and shape <> Skin condition <> Tenderness [] Skin color consistent with person's facial skin color [] Skin intact, with no lumps or lesions [] On some people you may note Darwin's tubercle, a small painless nodule at the helix; this is a congenital variation and not significant -Inspect and palpate external ear <> Tenderness [] Move pinna and push on tragus; they should feel firm, and movement should produce no pain [] Palpating mastoid process should also produce no pain <> External auditory meatus [] Note size of opening to direct choice of speculum for otoscope; no swelling, redness, or discharge should be present [] Some cerumen usually present; color varies from gray-yellow to light brown and black, and texture varies from moist and waxy to dry and desiccated

Summary Checklist: Peripheral Vascular System and Lymphatic System

-Inspect arms for color, size, or any lesions -Palpate pulses: radial and brachial -Check epitrochlear node -Inspect legs for color, size, any lesions, or trophic skin changes -Palpate temperature of feet and legs -Palpate inguinal nodes -Palpate pulses: femoral, popliteal, posterior tibial, and dorsalis pedis

Inspection of Tongue II

-Inspect carefully entire U-shaped area under tongue behind teeth; oral malignancies are most likely here. -Note any white patches, nodules, or ulcerations. -If lesions are present, or with any person over 50 years old or with a positive history of smoking or alcohol use, use your gloved hand to palpate area.

Assessment of Wrists and Hands

-Inspect hands and wrists on dorsal and palmar sides <> Note position, contour, and shape; normally no swelling or redness, deformity, or nodules are present <> Skin looks smooth with knuckle wrinkles present and no swelling or lesions; muscles appear full -Palpate each joint in wrist and hands <> Facing person, support hand with your fingers under it and palpate wrist with both your thumbs on its dorsum <> Normally joint surfaces feel smooth, with no swelling, bogginess, nodules, or tenderness

Assessment of Hips

-Inspect hip joint together with spine later in examination as person stands; note symmetric levels of iliac crests, gluteal folds, and equally sized buttocks <> Smooth, even gait reflects equal leg lengths and functional hip motion -Help person into supine position and palpate hip joints; joints should feel stable and symmetric, with no tenderness or crepitation -Assess ROM <> Limitation of _____________of hip while supine is most common motion dysfunction found in hip disease

Muscles

-Muscles account for 40% to 50% of body's weight <> When muscles contract, they produce movement <> Three types of muscles are: [] Skeletal [[[]]] Voluntary [[[]]] Attached to bones via tendons [] Smooth [[[]]] Involuntary [[[]]] In _________ [] Cardiac

Inspection & Palpation: Hernia

-Inspect inguinal region for bulge as person stands and strains down; normally none is present -Palpate inguinal canal <> For right side, ask male to shift his weight onto left leg <> Place your right index finger low on right scrotal half <> Palpate up length of spermatic cord, invaginating scrotal skin as you go, to the external inguinal ring [] It feels like a triangular slitlike opening, if it will admit your finger, gently insert it into canal and ask person to "bear down;" normally you feel no change [] Repeat procedure on the left side -Palpate femoral area for a bulge <> Normally you feel none

Assessment: Inspection of Neck Vessels

-Inspect jugular venous pulse <> From jugular veins you can assess central venous pressure (CVP) and judge heart's efficiency as a pump <> Position person supine anywhere from a 30- to a 45-degree angle, wherever you can best see pulsations <> In general, the higher the venous pressure, the higher the position you need

Developmental Considerations: Infants & Children

-Inspect penis and scrotum <> If uncircumcised, foreskin normally tight during first 3 months and should not be retracted because of risk of tearing membrane attaching foreskin to shaft [] This leads to scarring and possibly to adhesions later in life [] In infants older than 3 months of age, retract foreskin gently to check glans and meatus; it should return to its original position easily <> Scrotum looks pink in white infants and dark brown in dark-skinned infants <> Rugae well formed in full-term infant

Inspection & Palpation: Scrotum

-Inspect scrotum as male holds penis out of the way; alternatively, you hold penis out of the way with back of your hand <> Scrotal size varies with ambient room temperature; asymmetry is normal, with left scrotal half usually lower than right <> Spread rugae out between your fingers; lift sac to inspect posterior surface; normally, no scrotal lesions are present, except commonly found sebaceous cysts; these are yellowish, 1-cm nodules that are firm, nontender, and often multiple -Palpate gently each scrotal half between your thumb and first two fingers <> Scrotal contents should slide easily; testes normally feel oval, firm and rubbery, smooth, and equal bilaterally, and are freely movable and tender to moderate pressure <> Each epididymis normally feels discrete, softer than testis, smooth, and nontender -Palpate each spermatic cord between your thumb and forefinger, along its length from epididymis up to external inguinal ring <> You should feel a smooth, nontender cord -Normally, no other scrotal contents are present; if you find a mass, note: <> Is there any tenderness? <> Is the mass distal or proximal to testis? <> Can you place your fingers over it? <> Does it reduce when person lies down? <> Can you auscultate bowel sounds over it? -Transillumination <> Perform this maneuver only if you note swelling or mass [] Darken room; shine flashlight from behind scrotal contents [] Normal scrotal contents do not transilluminate

Assessment of Elbows

-Inspect size and contour of elbow in both flexed and extended positions <> Look for deformity, redness, or swelling <> Check olecranon bursa and the normally present hollows on either side of the olecranon process for abnormal swelling -Palpate elbow flexed about 70 degrees and relaxed <> Using left hand to support person's left forearm and palpate extensor surface of elbow (olecranon process, and medial and lateral epicondyles of humerus) with right thumb and fingers

Assessment of Ankles and Feet

-Inspect while person is sitting and when standing and walking <> Compare both feet, noting contour of joints; foot should align with long axis of lower leg <> Weight-bearing should fall on middle of foot; most feet have a longitudinal arch, but this can vary normally from "flat feet" to high instep <> Toes point straight forward and lie flat; note locations of calluses or bursal reactions as they reveal areas of abnormal friction <> Examining well-worn shoes helps assess areas of wear and accommodation

Developmental Considerations: Infant

-Inspection <> Contour of abdomen is protuberant because of immature abdominal musculature <> Skin contains a fine, superficial venous pattern; this may be visible in lightly pigmented children up to puberty <> Abdomen should be symmetric, although two bulges common [] May note an umbilical hernia; appears at 2 to 3 weeks, is especially prominent when infant cries, usually disappears by 1 year [] Another common variation is diastasis recti, a separation of rectus muscles with a visible bulge along midline; more common with black infants, and it usually disappears by early childhood -Inspection (continued) <> Abdomen shows respiratory movement <> Only other abdominal movement you should note is occasional peristalsis, which may be visible because of thin musculature <> Make note of newborn's first stool, a sticky, greenish-black meconium stool within 24 hours of birth -Auscultation <> Auscultation yields only bowel sounds, metallic tinkling of peristalsis <> No vascular sounds should be heard -Percussion <> Percussion finds tympany over stomach and dullness over liver <> Percussing the spleen is not done <> Abdomen sounds tympanitic, although it is normal to percuss dullness over bladder; dullness may extend up to umbilicus -Palpation <> Aid palpation by flexing baby's knees with one hand while palpating with other

Summary Checklist: Abdomen Examination

-Inspection <> Contour, symmetry, umbilicus, skin, pulsation or movement, hair distribution, and demeanor -Auscultation <> Bowel sounds; note any vascular sounds -Percussion <> All four quadrants and borders of liver and spleen -Palpation <> Light and deep palpation in all four quadrants, and palpate for liver and spleen

Physical Examination: Infants and Children - Head

-Inspection <> Measure infant's head <> Note common variations [] Caput succedaneum [] Cephalhematoma <> Note infant's head posture and head control; infant can turn head side to side by 2 weeks, hold head up at 4 months <> Shows tonic neck reflex when supine and head turned to one side (extension of same arm and leg, flexion of opposite arm and leg); reflex disappears at 3 to 4 months

Order of Examination

-Inspection <> Note size and contour of joint; inspect skin and tissues over joints for color, swelling, and any masses or deformity <> Presence of swelling signals joint irritation -Palpation <> Palpate each joint, noticing any heat, tenderness, swelling, or masses which signal inflammation <> Joints normally not tender to palpation <> If tenderness occurs, localize to specific anatomic structures, for example, skin, muscles, bursae, ligaments, tendons, fat pads, or joint capsule

Summary Checklist: Musculoskeletal Examination

-Inspection <> Size and contour of joint <> Skin color and characteristics -Palpation of joint area <> Skin, muscles, bony articulations, and joint capsules -ROM <> Active <> Passive (If limitation noted in active ROM is present) <> Measure with goniometer (if abnormality in ROM is present) <> Muscle testing

Thorax and Lungs Examination

-Inspection <> Thoracic cage, respirations, skin color, and condition <> Person's level of consciousness, facial expression, work of breathing -Palpation <> Confirm symmetric expansion and tactile fremitus. <> Detection of any lumps, masses, or tenderness -Percussion <> Lung fields <> Diaphragmatic excursion -Auscultation <> Assess breath sounds, and note any abnormal/adventitious breath sounds. <> Perform bronchophony, whispered pectoriloquy, or egophony as needed.

Summary Checklist: Skin, Hair, and Nails

-Inspection of the skin, hair, and nails <> Color and pigmentation <> Texture and distribution <> Shape, contour, and consistency -Palpation of the skin, hair, and nails <> Temperature and texture <> Edema, mobility, and turgor -Note presence of lesions <> Shape, configuration, and distribution -Teach self-examination <> Health promotion

Objective Data: Preparation

-Integrate steps of neurologic examination with examination of particular part of body <> Test cranial nerves while assessing head and neck; test superficial abdominal reflexes while assessing abdomen <> Record all neurologic data together as a functional unit <> Use following sequence for complete neurologic examination [] Mental status [] Cranial nerves [] Motor system [] Sensory system [] Reflexes

Iris and Pupil

-Iris normally appears flat, with round regular shape and even coloration -Note size, shape, and equality of pupils; normally pupils appear round, regular, and of equal size in both eyes -To test pupillary light reflex, darken room and ask person to gaze into distance; this dilates pupils; advance a light in from side and note response <> Normally you will see constriction of same-sided pupil (a direct light reflex) and simultaneous constriction of other pupil (a consensual light reflex) -Test for accommodation by asking person to focus on a distant object -This dilates pupils; then have person shift gaze to near object, such as your finger held about 7 to 8 cm (3 inches) from nose -Normal response includes <> Pupillary constriction <> Convergence of axes of eyes -Record normal response to all these maneuvers as PERRLA, or Pupils Equal, Round, React to Light, and Accommodation

Developmental Considerations: Aging Adult

-It is difficult to isolate "aging process" of cardiovascular system, per se, because it is so closely interrelated with lifestyle, habits, and diseases <> Lifestyle, smoking, diet, alcohol use, exercise patterns, and stress have an influence on coronary artery disease <> Lifestyle also affects aging process; cardiac changes once thought to be due to aging are partially due to sedentary lifestyle accompanying aging <> What is left to be attributed to aging process alone?

Ulnar and Brachial Pulses

-It usually is not necessary to palpate ulnar pulses <> If indicated, palpate along medial side of inner forearm, although ulnar pulses often are not palpable in a normal person <> Palpate the brachial pulses: their force should be equal bilaterally <> Check epitrochlear lymph node in depression above and behind medial condyle of humerus [] Do this by "shaking hands" with person and reaching your other hand under person's elbow to groove between biceps and triceps muscles, above medial epicondyle [] This node is not palpable normally

Knee

-Knee joint: articulation of three bones—the femur, tibia, and patella (________)—in common articular cavity -Largest joint in body; hinge joint, permitting flexion and extension of lower leg on single plane -Synovial membrane is largest in body; forms sac at superior border of patella, suprapatellar pouch -Two wedge-shaped cartilages, called medial and lateral menisci, cushion tibia and femur -Knee stabilized by two sets of ligaments <> Cruciate ligaments give anterior and posterior stability and help control rotation <> Collateral ligaments give medial and lateral stability and prevent dislocation -Landmarks of knee joint <> Quadriceps muscle, felt on anterior and lateral thigh <> Muscle's heads merge into common tendon to enclose round bony patella; then inserts down tibial tuberosity and felt as bony prominence in midline <> Note lateral and medial condyles of tibia <> Medial and lateral epicondyles of femur are on either side of patella

Lacrimal Gland

-Lacrimal gland, in upper outer corner over eye, secretes tears <> Tears wash across eye <> Drain into puncta, on upper and lower lids at inner canthus <> Then drain into nasolacrimal sac, through ½-inch-long nasolacrimal duct, and empty into inferior meatus inside nose

Inspection of Buccal Mucosa II

-Larger patch also may be present along buccal mucosa. <> Leukoedema: a benign grayish opaque area, more common in African Americans and East Indians. [] Severity of condition increases with age, looking grayish white and thickened; cause of condition is unknown. [] Do not mistake leukoedema for oral infections, such as candidiasis, thrush. -Fordyce's granules: small, isolated white or yellow papules on mucosa of cheek, tongue, and lips <> These little sebaceous cysts are painless and not significant.

Spine

-Lateral view shows vertebral column has four curves, a double-S shape <> Cervical and lumbar curves are concave (inward or anterior) <> Thoracic and sacrococcygeal curves are convex -Balanced or compensatory nature of curves, together with intervertebral disks, allow spine to absorb shock -Each disk center has nucleus pulposus, made of soft, semifluid, mucoid material -Disks cushion spine like shock absorber and help it move -As spine moves, elasticity of disks allows compression on one side, with compensatory expansion on other -Motions of vertebral column are flexion (bending forward), extension (bending back), abduction (to either side), and rotation

IADL Instruments

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

Diagnostic Positions Test

-Leading eyes through six cardinal positions of gaze will elicit any muscle weakness during movement -Ask person to hold head steady and follow movement of your finger, pen, or penlight only with his or her eyes -Hold target back about 12 inches so person can focus comfortably, and move it to each of six positions; hold momentarily, then back to center -Progress clockwise; normal response is parallel tracking of object with both eyes without nystagmus

Palpation of Left Kidney

-Left kidney sits 1 cm higher than right kidney and is not palpable normally -Search for it by reaching your left hand across abdomen and behind left flank for support -Push your right hand deep into abdomen, and ask person to breathe deeply -You should feel no change with inhalation

Inspection of the Anterior Chest

-Level of consciousness -Person's facial expression -Skin color and condition. -Shape and configuration of chest wall. <> A/P to transverse configuration roughly 1:2. <> Ribs are sloping downward with symmetric interspaces. <> Costal angle is within 90 degrees. -Configuration of sternum <> Pectus excavatum? <> Pectus carinatum? -Assess respirations. <> Symmetrical? Any area of lag? <> Retraction or bulging of interspaces with inspiration? <> Use of accessory muscles? <> Respiratory rate normal for age? <> Regular pattern of breathing? <> Occasional sighs normally punctuate breathing.

Prostate Gland

-Lies in front of anterior wall of rectum and 2 cm behind symphysis pubis -Surrounds bladder neck and urethra and has 15 to 30 ducts that open into urethra -Two seminal vesicles project above prostate <> Secrete a fluid rich in fructose, which nourishes sperm, and contains prostaglandins

Inspect and Palpate the Arms

-Lift person's both hands in your hands <> Inspect, then turn person's hands over, noting color of skin and nail beds; temperature, texture, and turgor of skin; and the presence of any lesions, edema, or clubbing <> Use profile sign (viewing finger from side) to detect early clubbing <> Normal nail bed angle is 160 degrees <> Note presence of any scars on hands and arms

Visual Pathways and Visual Fields

-Light rays are refracted through transparent media, the cornea, aqueous humor, lens, and vitreous body, striking the retina <> Retina transforms light stimulus into nerve impulses conducted to visual cortex [] Image formed on retina is upside down and reversed [] All retinal fibers collect to form optic nerve [] At optic chiasm, fibers from both visual fields cross over [] Thus, right side of brain looks at left side of the world

Preparation for Abdominal Assessment

-Lighting should include a strong overhead light and a secondary stand light -Expose abdomen so that it is fully visible; drape genitalia and female breasts -Position for comfort to enhance abdominal wall relaxation -Empty bladder prior to examination with specimen saved if needed -Warm stethoscope and examine areas identified as painful last so as to prevent guarding -Auscultate prior to percussion and palpation -Use distraction to keep patient relaxed and facilitate muscle relaxation

Structure and Function: Mouth

-Lips: anterior border of oral cavity -Palate: arching roof of mouth divided into two parts -Hard palate: anterior part made up of bone -Soft palate: posterior part, an arch of muscle that is mobile -Uvula: free projection hanging down from middle of soft palate -Cheeks are the side walls of oral cavity. -Tongue <> Papillae: rough, bumpy elevations on its dorsal surface <> Ventral surface: smooth, shiny and has prominent veins <> Frenulum: midline fold of tissue connecting tongue to floor of mouth -Tongue's ability to change shape and position enhances its functions in mastication, swallowing, cleansing teeth, and the formation of speech. -Functions in taste sensation -Mouth contains three pairs of salivary glands. <> Parotid gland lies within cheeks in front of ear. <> Submandibular gland lies beneath mandible at angle of jaw. <> Sublingual gland, the smallest, almond-shaped, lies within floor of mouth under tongue and has many small openings along sublingual fold under tongue. -Adults have 32 permanent teeth

Auscultation

-Listening to sounds produced by body <> Most body sounds are soft and must be channeled through a stethoscope <> Stethoscope does not magnify sound, but it blocks out extraneous sounds For heart sounds, lung sounds, bowel sounds Once you can recognize normal sounds, you can distinguish the abnormal sounds and "extra" sounds

Lobes of the Cerebral Cortex

-Lobes have areas that mediate specific functions: <> Frontal lobe: personality, behavior, emotions, and intellectual function [] Frontal lobe's precentral gyrus initiates voluntary movement <> Parietal lobe's postcentral gyrus is primary center for sensation <> Occipital lobe is primary visual receptor center <> Temporal lobe behind ear, has primary auditory reception center, taste, and smell -Wernicke's area in temporal lobe associated with language comprehension <> When damaged in the person's dominant hemisphere, receptive aphasia results (like hearing a foreign language) -Broca's area in frontal lobe mediates motor speech <> When injured in dominant hemisphere, expressive aphasia results: person cannot talk (can produce only garbled sound)

Femoral Arteries

-Locate femoral arteries just below inguinal ligament halfway between pubis and anterior superior iliac spines <> To help expose femoral area, particularly in obese people, ask person to bend his or her knees to side in a froglike position <> Press firmly and then slowly release, noting pulse tap under your fingertips <> If this pulse is weak or diminished, auscultate site for a bruit

Present Health or History of Present Illness (HPI)

-Location -Character or quality -Quantity or severity -Timing -Setting -Aggravating or relieving factors -Associated factors -Patient's perception

Characteristics of Lump or Mass

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

Spinal Cord

-Long cylindrical structure of nervous tissue that occupies upper two thirds of vertebral canal from medulla to lumbar vertebrae L1 to L2 -Nerve cell bodies, or gray matter, arranged in butterfly shape with anterior and posterior "horns" -Main highway for ascending and descending fiber tracts that connect the brain to spinal nerves -Mediates reflexes

Skin Changes with Aging

-Loss of elasticity > sagging skin -Senile lentigines (age spots) -Decrease in number and function of sweat and sebaceous glands -Senile purpura -Skin breakdown due to multiple factors -Decrease in functioning melanocytes > gray hair

Lymph Node Enlargement and Medications Questions

-Lymph node enlargement <> Any "swollen glands" (lumps, kernels)? Where in body? How long have you had them? [] Any recent change? [] How do they feel to you: hard, soft? [] Are swollen glands associated with pain or local infection? -Medications <> What medications are you taking, for example, oral contraceptives, hormone replacement?

Head and Neck: Lymphatic System

-Lymphatic system: an extensive vessel system, is major part of immune system, which detects and eliminates foreign substances from body <> Vessels allow flow of clear, watery fluid from tissue spaces into circulation <> Nodes are small, oval clusters of lymphatic tissue that filter lymph and engulf pathogens In head/neck, arms, axillae, inguinal areas Should be moveable, soft and nontender

Hypothalamus

-Major respiratory center with many basic functions, such as appetite, sex drive, temperature, heart rate, blood pressure, sleep, anterior and posterior pituitary gland regulation, and coordination of autonomic nervous system, stress response, and emotional status

Percussion Posterior Chest: Lung Fields

-Make side-to-side comparison all the way down lung region. -Percuss at 5-cm intervals, avoiding scapulae and ribs. -Resonance predominates in healthy lung tissue in adult. <> Resonance is normal, low-pitched, clear, hollow sound. <> Hyperresonance indicates hyperinflation. <> Dullness indicates diminished air exchange, fluid <> Lesions must be 2 to 3 cm wide to yield an abnormal percussion note

Developmental Considerations: Adults & Aging Adults

-Male does not experience a definite end to fertility as female does -Around age 40 years, production of sperm begins to decrease, although it continues into 80s and 90s -Testosterone production declines after age 30 but continues very gradually so resulting physical changes are not evident until later in life <> Pubic hair decreases and penis size decreases <> Due to decreased muscle tone, scrotal contents hang lower, rugae decrease, and scrotum becomes pendulous <> Testes decrease in size and are less firm to palpation <> Increased connective tissue is present in tubules, so these become thickened and produce less sperm

Male Genitourinary System

-Male genital structures include: <> External [] Penis and scrotum <> Internal [] Testis, epididymis, and vas deferens <> Glandular structures accessory to genital organs: [] Prostate, seminal vesicles, and bulbourethral glands

Aging Adult

-May have pendulous earlobes with linear wrinkling because of loss of elasticity of pinna -High-tone frequency loss apparent for those affected with presbycusis -Aging adult feels that "people are mumbling" and feels isolated in family or friendship groups

Tuning Fork Tests

-Measure hearing air conduction (AC) or by bone conduction (BC), in which sound vibrates through cranial bones to the inner ear -AC route through ear canal and middle ear usually the more sensitive route -To activate tuning fork, hold it by stem and strike tines softly on back of your hand <> A hard strike makes tone too loud, and it takes a long time to fade out

Liver Span Assessment

-Measure height of liver in right midclavicular line -Begin in area of lung resonance, and percuss down interspaces until sound changes to a dull quality -Mark spot, usually in fifth intercostal space -Find abdominal tympany, and percuss up in midclavicular line -Mark where sound changes from tympany to a dull sound, normally at right costal margin -Measure distance between two marks; normal liver span in adult ranges from 6 to 12 cm -Height of liver span correlates with height of person; taller people have longer livers -Also, males have larger liver span than females of the same height -Overall, mean liver span is 10.5 cm for males and 7 cm for females -One variation occurs in people with chronic emphysema, in which liver is displaced ______________by hyperinflated lungs -Although you hear a dull percussion note well below right costal margin, overall span is still within normal limits -Clinical estimation of liver span is important to screen for hepatomegaly and to monitor changes in liver size -However, this measurement is a gross estimate; liver span may be underestimated because of inaccurate detection of upper border

The Clinical Setting: Hands On

-Measurement and vital signs -Begin with person's hands -Concentrate on one step at a time -Examination sequence -Brief health teaching -When findings are complicated -Summarize findings for person

Deep Tendon Reflexes (DTRs)

-Measurement of stretch reflexes reveals intactness of reflex arc at specific spinal levels and normal override on reflex of higher cortical levels -Limb should be relaxed and muscle partially stretched -Stimulate reflex by directing short, snappy blow of reflex hammer onto muscle's insertion tendon -Compare right and left sides: responses should be equal

Three Thoracic Spaces

-Mediastinum: middle section of thoracic cavity containing esophagus, trachea, heart, and great vessels -Two pleural cavities housing the lungs <> Lungs are paired but not precisely symmetric structures. <> Right lung shorter than left because of underlying liver <> Left lung narrower than right because heart bulges to left. <> Right lung has three lobes, and left lung has two lobes.

Abnormal Findings: Murmurs Due to Valvular Defects

-Midsystolic ejection murmurs <> Aortic stenosis <> Pulmonic stenosis -Pansystolic regurgitant murmurs <> Mitral regurgitation <> Tricuspid regurgitation

Sensory Pathways

-Millions of sensory receptors are embroidered into skin, mucous membranes, muscles, tendons, and viscera <> Monitor conscious sensation, internal organ functions, body position, and reflexes <> Sensation travels in afferent fibers in peripheral nerve, through posterior (dorsal) root, and into spinal cord -Spinothalamic tracts and posterior (dorsal) columns

Culture and Genetics: Prostate Cancer

-More common in North America and northwestern Europe; less common in Central and South Americas, Africa, and Asia <> Incidence higher for black men than other racial groups, and more likely to be diagnosed at advanced stage <> Mortality rates are two times higher for black men <> Diets heavy in red meat or high-fat dairy products may be factor <> Some evidence suggests that prostate cancer may increase with obesity

Caregiver Assessment

-Most elders with functional impairment live with help of informal support <> Spouse, daughter, or other family member <> High levels of functional dependency place a burden on caregiver and may result in caregiver [] Burnout [] Sleep disturbances [] Depression [] Morbidity [] Increased mortality -Older person's need for institutionalization often better predicted from assessment of caregiver than from severity of patient's illness <> Health and well-being of patient and caregiver are closely linked [] Part of caring for a frail elder involves paying attention to the well-being of caregiver [] Social worker may help identify programs, such as caregiver support groups, respite programs, adult day care, or hired home health aides

Abdomen: Pregnancy

-Nausea and vomiting, or "morning sickness," is an early sign of pregnancy <> starting between first and second missed periods <> Cause unknown; may be due to hormone changes, such as production of human chorionic gonadotropin (hCG) -Another symptom is "acid indigestion" or heartburn (pyrosis) caused by esophageal reflux -Decreased gastrointestinal motility causes more water to be reabsorbed from colon, which leads to constipation -Skin changes on abdomen include striae and linea nigra -Enlarging uterus displaces intestines upward and posteriorly -Appendix displaced upward and to the right -Bowel sounds are diminished -Constipation and increased venous pressure in lower pelvis may lead to hemorrhoids

Summary Checklist: Heart and Neck Vessels Examination

-Neck <> Carotid pulse - observe and palpate <> Observe jugular venous pulse <> Estimate jugular venous pressure -Precordium <> Inspection and palpation [] Describe location of apical pulse [] Note any heave (lift) or thrill -Auscultation <> Identify anatomic areas noting rate and rhythm <> Listen in systole and diastole for murmurs <> Repeat with bell <> Listen at apex and base

Nervous System Structure and Function

-Nervous system divided into two parts: <> Central nervous system (CNS) [] Brain [] Spinal cord <> Peripheral nervous system (PNS) [] Includes 12 pairs of cranial nerves, 31 pairs of spinal nerves [] Carries sensory (afferent) messages to CNS from sensory receptors [] Motor (efferent) messages from CNS to muscles and glands, also autonomic messages that govern internal organs and blood vessels

Developmental Considerations: Infants

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

Skin Development: Infants, Children, and Adolescents

-Newborn infants <> lanugo: fine downy hair of newborn infant <> Vernix caseosa: thick, cheesy substance <> Sebum: oily, waxy secretion which holds water in the skin producing milia -Children <> Epidermis thickens, darkens, and becomes lubricated <> Hair growth accelerates -Adolescents <> Secretions from apocrine sweat glands increase <> Subcutaneous fat deposits increase

Nociception Process

-Nociception can be divided into four phases: <> Transduction - noxious stimulus in the form of traumatic or chemical injury, burn, incision, or tumor takes place in the periphery (skin, somatic and visceral structures) <> Transmission - impulse moves from spinal cord to brain <> Perception - conscious awareness of pain <> Modulation - neurotransmitters slow or impede the painful impulse

Structure and Function

-Nociceptors: specialized nerve endings designed to detect painful sensations <> Located within skin; connective tissue; muscle; and thoracic, abdominal, and pelvic viscera <> Transmit sensations to central nervous system by two primary sensory (afferent) fibers: [] Aδ and [] C fibers

Nonsynovial Joints

-Nonsynovial joints: bones united by fibrous tissue or cartilage are <> Immovable, for example, sutures in skull

Musculoskeletal Assessment Components

-Nonsynovial or synovial joints -Muscles -Temporomandibular joint -Spine -Shoulder -Elbow -Wrist and carpals -Hip -Knee -Ankle and foot

Elements of the Interview Process

-Nonverbal skills -Physical appearance -Posture -Gestures -Facial expression -Eye contact -Voice -Touch -Closing the interview

Palpation of Spleen

-Normally spleen is not palpable and must be enlarged three times its normal size to be felt -To search for it, reach your left hand over abdomen and behind left side at the 11th and 12th ribs -Lift up for support; place your right hand obliquely on LUQ with fingers pointing toward left axilla and just inferior to rib margin -Push your hand deeply down and under left costal margin, and ask person to take deep breath -You should feel nothing firm -When enlarged, spleen slides out and bumps your fingertips -It can grow so large that it extends into lower quadrants

Developmental Competence: Aging Adult

-Nose may appear more prominent on face from a loss of subcutaneous fat. -In edentulous person, mouth and lips fold in, giving a "purse-string" appearance. -Teeth may look slightly yellowed (dentin visible through worn enamel) but color is uniform. -Surface of incisors may show vertical cracks from extreme temperatures.

General Appearance and Measurement

-Note <> Child's ability to amuse while parent speaks <> Parent and child interaction <> Gross and fine motor skills as child plays with toys <> Gradually focus on and involve yourself with child, at first in a "play" period -Evaluate <> Developmental milestones—Denver II <> Posture while child is sitting and standing <> Alignment of legs and feet while walking <> Speech acquisition <> Vision and hearing ability <> Social interaction <> Use age-appropriate techniques to engage child in exam

Developmental Considerations: Children

-Note any extracardiac or cardiac signs that may indicate heart disease <> Poor weight gain, developmental delay, persistent tachycardia, tachypnea, dyspnea on exertion, cyanosis, and clubbing <> Note that clubbing of fingers and toes usually does not appear until late in first year, even with severe cyanotic defects <> Apical impulse sometimes visible in children with thin chest walls <> Note any obvious bulge or any heave; these are not normal

Second Heart Sound (S2)

-Occurs with closure of semilunar valves and signals end of systole -Aortic component of second sound (A2) slightly precedes pulmonic component (P2) <> Although heard over all precordium, S2 loudest at base

Auscultation of the Abdomen: Bowel Sounds

-Note character and frequency of bowel sounds -Bowel sounds originate from movement of air and fluid through small intestine -Depending on time elapsed since eating, a wide range of normal sounds can occur -Bowel sounds are high pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute -Judge if they are normal, hypoactive, or hyperactive -______________ is the sound of hyperperistalsis -Perfectly "silent abdomen" is uncommon; you must listen for 5 minutes by your watch before deciding bowel sounds are completely absent

Developmental Considerations: Infants

-Note if milestones normally expected for each month achieved, and more primitive reflexes eliminated from baby's repertory when expected -Observations of infant's spontaneous waking activity, responses to environmental stimuli, and social interaction with parents and others -Motor system <> Observe spontaneous motor activity for smoothness and symmetry; smoothness of movement suggests proper cerebellar function, as does coordination involved in sucking and swallowing <> Screen gross and fine motor coordination using Denver II test with its age-specific developmental milestones <> Assess muscle tone by first observing resting posture <> Head control is an important milestone in development -Sensory system <> You will perform very little sensory testing with infants and toddlers <> Newborn normally has hypoesthesia and requires strong stimulus to elicit a response <> Baby responds to pain by crying and a general reflex withdrawal of all limbs <> By 7 to 9 months, infant can localize stimulus and shows more specific signs of withdrawal -Reflexes <> Infantile automatisms: reflexes that have predictable timetable of appearance and departure <> For screening examination, check rooting, grasp, tonic neck, and Moro reflexes

Vital Signs and Measurement of Infant

-Note pulse, respirations, and temperature -Weight, length, and head circumference are plotted against growth chart

Skin

-Note skin color, consistent with person's racial heritage -Palpate skin temperature; expect warm and dry -Pinch up a fold of skin under clavicle or on forearm to note mobility and turgor -Note skin integrity, any lesions, and the condition of any dressings -Complete any standardized scales used to quantify risk of skin breakdown -Verify that any air loss or pressure loss surfaces being used are properly applied and operating at correct settings

Deep Palpation of the Abdomen

-Now perform deep palpation using same technique described earlier, but push down about 5 to 8 cm (2 to 3 inches) -Moving clockwise, explore entire abdomen -To overcome resistance of a very large or obese abdomen, use a bimanual technique <> Place your two hands on top of each other <> Top hand does pushing; bottom hand relaxed and can concentrate on sense of palpation

Cardiac Risk Factor Questions

-Nutrition <> Please describe your usual daily diet (Note if this diet is representative of the basic food groups, the amount of calories, cholesterol, and any additives such as salt) <> What is your usual weight? Has there been any recent change? -Smoking <> Do you smoke cigarettes or use other tobacco products? At what age did you start? How many packs per day? For how many years have you smoked this amount? Have you ever tried quitting? If so, how did this go? -Alcohol <> How much alcohol do you usually drink each day or week? When was your last drink? What was the number of drinks that episode? Have you ever been told you had a drinking problem? -Exercise <> What is your usual amount of exercise each day or week? What type of exercise (state type or sport)? If a sport, what is your usual activity level (light, moderate, heavy)? -Drugs <> Do you take any antihypertensives, beta-blockers, calcium channel blockers, digoxin, diuretics, aspirin/anticoagulants, over-the-counter, or street drugs?

Abnormal Findings: Abdominal Distention

-Obesity -Air or gas -Ascites (with peritonitis, cirrhosis, pancreatitis, liver cancer) -Ovarian cyst -Pregnancy -Feces -Tumor

Genetic Considerations

-Obesity is caused by a complex interaction of genetics, dietary consumption, physical activity leading to an obesogenic environment -Globally and within the U.S., the incidence of obesity has increased significantly -Data show significant differences in obesity among racial groups -Obesity across the life cycle leads to development of significant comorbidities -Recommendations: healthy food patterns, decreased consumption of sweetened/processed foods, and increased physical activity

Inspection of Throat I

-Observe oval, rough-surfaced tonsils. <> Color is same pink as oral mucosa, and their surface peppered with indentations, or crypts; there should be no exudate on tonsils. <> Tonsils graded in size as follows: 1+ Visible 2+ Halfway between tonsillar pillars and uvula 3+ Touching uvula 4+ Touching each other <> You may normally see 1+ or 2+ tonsils in healthy people, especially in children, because lymphoid tissue is proportionately enlarged until puberty.

Culture and Genetics: Otitis Media

-Obstruction of eustachian tube or passage of nasopharyngeal secretions into middle ear <> One of most common illnesses in children <> Incidence and severity increased in children of North America, New Zealand, and northern Europe <> Most important cause is environmental: multiple pathogens -In the supine position effects of gravity and sucking tend to draw nasopharyngeal contents directly into middle ear <> Urge parents to hold baby partly upright while feeding <> Do not prop bottle or let baby take a bottle to bed <> Encouraging breastfeeding helps prevent this problem <> Most important side effect of otitis media is persistence of fluid in middle ear after treatment; this middle ear effusion can impair hearing, placing child at risk for delayed cognitive development

Physical Examination: Equipment

-Occasionally need <> Paper tape measure <> Tourniquet or blood pressure cuff <> Stethoscope <> Doppler

Age-Related Changes in ECG

-Occur as result of histologic changes in conduction system; these changes include <> Prolonged P-R interval (first-degree AV block) and prolonged Q-T interval, but the QRS interval is unchanged <> Left axis deviation from age-related mild LV hypertrophy and fibrosis in left bundle branch <> Increased incidence of bundle branch block -Although hemodynamic changes associated with aging alone do not seem severe or portentous, incidence of cardiovascular disease increases with age

First Heart Sound (S1)

-Occurs with closure of AV valves and thus signals beginning of systole -Mitral component of first sound (M1) slightly precedes tricuspid component (T1) <> Usually hear these two components fused as one sound <> Loudest at apex

Percussion of the Abdomen: Splenic Dullness

-Often spleen is obscured by stomach contents, but you may locate it by percussing for a dull note from 9th to 11th intercostal space just behind left midaxillary line -Area of splenic dullness normally is not wider than 7 cm in adult and should not encroach on normal tympany over gastric air bubble -Percuss in lowest interspace in left anterior axillary line -Tympany should result; ask person to take a deep breath; normally tympany remains through full inspiration

The Older Adult: Assessment Questions

-Older people have spent a lifetime with traditional health care that searches only for pathology and what is wrong with their health

Abnormalities of Elbow

-Olecranon bursitis -Gouty arthritis -Subcutaneous nodules -Epicondylitis, tennis elbow

Prostate Gland

-On anterior wall in male, note elastic, bulging prostate gland <> Palpate entire prostate in a systematic manner; note that only superior and part of lateral surfaces is accessible to examination <> Surface should feel smooth and muscular; search for any distinct nodule or diffuse firmness

Skin Changes Questions

-On arms or legs <> Any skin changes in arms or legs? What color: redness, pallor, blueness, brown discolorations? <> Any change in temperature: excess warmth or coolness? <> Do your leg veins look bulging and crooked? How have you treated these? Do you use support hose? <> Any leg sores or ulcers? Where on leg? Any pain with leg ulcer?

Developmental Considerations: Aging Adult

-On inspection, you may note increased deposits of subcutaneous fat on abdomen and hips because it is redistributed away from extremities -Abdominal musculature is thinner and has less tone than that of younger adult, so if not obese you may note peristalsis -Because of thinner, softer abdominal wall, organs may be easier to palpate, in the absence of obesity -Liver and kidneys are easier to palpate; normally you will feel liver edge at or just below costal margin

Health History Sequence

-On your way into room <> Note and verify that necessary markers or flags are in place at doorway regarding such conditions as isolation precautions, latex allergies, or fall precautions -Once in the room <> Introduce yourself as patient's nurse for next 8 hours <> Make direct eye contact and ask how he or she is feeling, how he or she spent previous shift, and whether he or she is having any pain or discomfort <> Refer to what you have heard from previous shift in process of your own questioning <> Offer water as a courtesy, and note data this gives you [] Person's ability to hear, follow directions, cross the midline, and especially ability to swallow <> Complete your initial overview by verifying that correct name band has been applied to wrist

Other Subjective History Questions

-Orthopnea <> How many pillows do you use when sleeping or lying down? -Cyanosis or pallor <> Have you ever noticed your facial skin turn blue or ashen? -Nocturia <> Do you awaken at night with an urgent need to void? How long has this been occurring?

Developmental Competence: Adults

-Otosclerosis <> Common cause of conductive hearing loss in young adults between ages of 20 and 40 years <> Gradual hardening that causes foot plate of stapes to become fixed in oval window -Presbycusis: type of hearing loss that occurs with aging, even in people living in quiet environment <> Gradual sensorineural loss caused by nerve degeneration in inner ear or auditory nerve <> Onset usually occurs in 50s and slowly progresses <> Impacted cerumen is a common but reversible cause of hearing loss in older people

Respiratory System

-Oxygen by mask, nasal cannula, check fitting FiO2 -Respiratory effort -Auscultate breath sounds comparing side to side -Ask patient to cough and deep breathe; note presence of mucus

Types of Pain: Duration

-Pain can be classified by its duration <> Duration can provide information on possible underlying mechanisms and treatment decisions [] Acute pain: short term; self protective purposes [] Chronic pain: long term (6+ months) -breakthrough pain: transient spike in pain level

Pain: The Fifth Vital Sign Definition

-Pain is a highly complex <> subjective experience <> originates from the central nervous system (CNS), <> the peripheral nervous system (PNS), <> or both

Spinothalamic Tract

-Pain: tested by person's ability to perceive pinprick -Temperature: test temperature sensation only when pain sensation is abnormal; otherwise, you may omit it because the fiber tracts are much the same. -Light touch: apply wisp of cotton to skin in random order of sites and at irregular intervals; include arms, forearms, hands, chest, thighs, and legs; ask person to say "now" or "yes" when touch is felt -Compare symmetric points

Assessment: Palpate for Apical Impulse

-Palpable in about half of adults; is not palpable in obese persons or in persons with thick chest walls -Asking person to "exhale and then hold it" aids examiner in locating pulsation; may need to roll person midway to left to find it; note that this also displaces apical impulse farther to left -With high cardiac output states (anxiety, fever, hyperthyroidism, anemia), apical impulse increases in amplitude and duration

Assessment: Palpate for Extra Pulsations

-Palpate across precordium <> Using palmar aspects of your four fingers, gently palpate apex, left sternal border, and base, searching for any other pulsations <> Normally none occur <> If any are present, note timing <> Use carotid artery pulsation as a guide, or auscultate as you palpate

Lobes of the Lung Posterior Chest

-Posterior chest <> The posterior chest is almost all lower lobe ( no right middle lobe) <> Posteriorly, the location of C7 marks apex of lung tissue, and T10 usually corresponds to base.

Developmental Considerations: Children

-Palpate apical impulse <> Up to age 4: in fourth intercostal space to left of midclavicular line <> Age 4 to 6: at fourth interspace at midclavicular line <> Age 7: in fifth interspace to right of midclavicular line <> Average heart rate slows as child grows older, although it is still variable with rest or activity <> Rhythm remains characterized by sinus arrhythmia <> Physiologic S3 is common in children

Developmental Considerations: Children

-Palpate apical impulse <> Heart murmurs that are innocent (or functional) in origin are very common through childhood <> Some say they have 30% occurrence, and some say nearly all children may demonstrate murmur <> Most innocent murmurs have these characteristics [] Soft, relatively short systolic ejection murmur [] Medium pitch; vibratory [] Best heard at left lower sternal or midsternal border, with no radiation to apex, base, or back <> For child whose murmur has been shown to be innocent, it is very important that parents understand completely <> Otherwise, parents may become overprotective and limit activity for child, which may result in child developing a negative self-concept

Radial Pulses

-Palpate both radial pulses, noting rate, rhythm, elasticity of vessel wall, and equal force -Grade force (amplitude) on a three-point scale 3+, increased, full, bounding 2+, normal 1+, weak 0, absent

Assessment: Palpate Carotid Artery

-Palpate each carotid artery medial to sternomastoid muscle in neck; palpate gently -Palpate only one carotid artery at a time to avoid compromising arterial blood to brain -Normally contour is smooth with a rapid upstroke and slower downstroke, and the normal strength (amplitude) is 2+ or moderate -Findings should be same bilaterally

Elbow

-Palpate either side of olecranon process using varying pressure, with thumb in lateral groove and your index and middle fingers in medial groove <> Normally tissues and fat pads feel fairly solid <> Check for synovial thickening, swelling, nodules, or tenderness <> Palpate the area of the olecranon bursa for heat, swelling, tenderness, consistency, or nodules -Test ROM -While testing muscle strength, stabilize person's arm with one hand <> Have person flex elbow against your resistance applied just proximal to wrist <> Then ask person to extend elbow against your resistance

Wrist and Hand

-Palpate metacarpophalangeal joints with your thumbs <> Use thumb and index finger in pinching motion to palpate sides of interphalangeal joints <> Normally no synovial thickening, tenderness, warmth, or nodules are present -For muscle testing, position person's forearm palm up and resting on a table; stabilize by holding your hand at person's midforearm; ask person to flex wrist against your resistance at palm

Palpation of Anterior Chest

-Palpate symmetric chest expansion. <> Any limitation in thoracic expansion is easier to detect on anterior chest because greater range of motion exists here with breathing. -Palpate tactile (vocal) fremitus. <> Avoid palpating over breast tissue because breast tissue normally dampens sound. -Palpate anterior chest wall. <> Note any tenderness; normally none is present. <> Detect any superficial lumps or masses, again, normally none is present. <> Note skin mobility, turgor, temperature, and moisture

Infants and Children: Palpation and Percussion

-Palpation <> Palpate symmetric chest expansion by encircling infant's thorax with both hands. <> Further palpation should yield no lumps, masses, or crepitus, although you may feel costochondral junctions in some normal infants. -Percussion <> Percussion is of limited usefulness in a newborn, especially in a premature newborn, because the adult's fingers are too large in relation to the tiny chest.

Infants and Children: Special Procedures

-Palpation <> Craniotabes is [] Softening of skull's outer layer [] May be normal, especially with premature infants <> Avoid excessive pressure with palpation -Percussion <> With an infant, you may directly percuss with your plexor finger against head surface; this yields a resonant or "cracked pot" sound, which is normal before closure of fontanels -Auscultation <> Bruits are common in skull of children under 4 or 5 years of age or children with anemia <> Systolic or continuous; heard over temporal area

Palpation

-Palpation applies sense of touch to assess: <> Texture <> Temperature <> Moisture <> Presence of lumps or masses <> Mobility <> Consistency <> Swelling, vibration, or pulsation <> Organ location and size <> Rigidity or spasticity <> Crepitation <> Presence of tenderness or pain

Abnormalities in Muscle Movement

-Paralysis -Fasciculations -Tic -Myoclonus -Seizure disorder -Tremor -Rest tremor -Intention tremor -Chorea -Athetosis

Abnormal Findings: Congenital Heart Defects

-Patent ductus arteriosus -Atrial septal defect -Ventricular septal defect -Tetralogy of Fallot -Coarctation of the aorta

Subjective Data Questions

-Penis <> Have you had any problem with your penis, such as pain or lesions? [] Any discharge? How much? Increased or decreased since start? Color? Odor? Discharge associated with pain or urination? -Scrotum, self-care behaviors <> Any problem with scrotum or testicles? [] Any lumps or swelling on testes? Change in size of scrotum? History of undescended testicle as infant? Any bulge or swelling in scrotum? [] Have you ever been told you have a hernia? Have you had any dragging, heavy feeling in the scrotum?

Assessment: Equipment

-Penlight -Tongue blade -Cotton swab -Cotton ball -Tuning fork: 128 Hz or 256 Hz -Percussion hammer

Percussion of the Abdomen

-Percuss general tympany, liver, and splenic dullness <> Percuss to assess relative density of abdominal contents, to locate organs, and to screen for abnormal fluid or masses <> General tympany [] First, percuss lightly in all four quadrants to determine prevailing amount of tympany and dullness [] Move clockwise; tympany should predominate because air in intestines rises to surface when person is supine

Infants and Children: Percussion

-Percussion note of hyperresonance occurs normally in infant and young child because of relatively thin chest wall. -Anything less than hyperresonance would have same clinical significance as dullness in adult.

Palpate Surface and Deep Areas

-Perform palpation <> Judge size, location, and consistency of organs and screen for an abnormal mass or tenderness <> Because most people are naturally inclined to protect abdomen, you need to use additional measures to enhance complete muscle relaxation

Developmental Considerations: Adolescent

-Perform pelvic examination <> When contraception is desired <> When girl's sexual activity includes intercourse <> At age 18 in virgins -Start periodic Pap smears when intercourse begins <> Although techniques of examination are listed in adult section, you will need to provide additional time and psychologic support for adolescent having her first pelvic examination

The Adolescent

-Perform the sequence noted in the head-to-toe format described in the aging adult section -Major task of adolescence is identity -Adolescent is increasingly self-conscious and introspective -Allow adolescent to keep street clothes on for a well-person examination, and work around them

Measure Leg Length Discrepancy

-Perform this measurement if you need to determine whether one leg is shorter than other -For true leg length, measure between fixed points, from anterior iliac spine to medial malleolus, crossing medial side of knee -Normally these measurements are equal or within 1 cm, indicating no true bone discrepancy

Developmental Considerations: Aging Adult

-Peripheral blood vessels grow more rigid with age: arteriosclerosis -DP and PT pulses may become more difficult to find -Trophic changes associated with arterial insufficiency may be seen <> Thin, shiny skin <> Thick, ridged nails <> Loss of hair on lower legs -Loss of lymphatic tissue leads to <> Fewer numbers of lymph nodes in older people <> Decreased size of remaining nodes

Peripheral Nervous System

-Peripheral nervous system composed of cranial nerves and spinal nerves -Carry fibers divided functionally into two parts: <> Somatic fibers innervate skeletal (voluntary) muscles <> Autonomic fibers innervate smooth (involuntary) muscles, cardiac muscle, and glands -Autonomic system mediates unconscious activity

Common Patterns of Sensory Loss

-Peripheral neuropathy <> Loss of sensation involves all modalities; loss most severe distally at feet and hands -Individual nerves or roots <> Decrease or loss of all sensory modalities; corresponds to distribution of involved nerve -Spinal cord hemisection (Brown-Séquard syndrome) <> Loss of pain and temperature, contralateral side, loss of vibration and position discrimination on ipsilateral side -Complete transection of spinal cord <> Complete loss of all sensory modalities below level of lesion; associated with motor paralysis and loss of sphincter control

Developmental Competence: Infants and Children

-Peripheral vision is intact in newborn infant -Macula, area of keenest vision, is absent at birth but mature by 8 months

Abnormal Findings: Friction Rubs and Vascular Sounds

-Peritoneal friction rub -Arterial bruit of aortic aneurysm -Venous hum of inferior vena cava with portal hypertension

Assessment of Spine

-Person should be standing, draped in gown open at back <> Place yourself far enough back so that you can see entire back -Inspect and note if spine is straight by following imaginary vertical line from head through spinous processes to gluteal cleft, and noting equal horizontal positions for shoulders, scapulae, iliac crests, and gluteal folds <> Knees and feet should be aligned with trunk and should be pointing forward

Inspection of Knees

-Person should remain supine with legs extended -Inspect lower leg alignment; should extend in same axis as thigh -Inspect knee's shape and contour; normally distinct hollows present on either side of patella; check for any sign of fullness or swelling; note other locations for any abnormal swelling -Check quadriceps muscle in anterior thigh for any atrophy; because it is a prime mover of the knee, it is important for joint stability during weight-bearing

Carpal Tunnel Testing

-Phalen's Test <> Ask person to hold both hands back to back while flexing wrists 90 degrees <> Acute flexion of wrist for 60 seconds produces no symptoms in the normal hand <> Test reproduces numbness and burning in person with carpal tunnel syndrome -Tinel's Sign <> Direct percussion of location of median nerve at wrist produces no symptoms in normal hand <> Percussion of median nerve produces burning and tingling along its distribution, which is a positive Tinel's sign for carpal tunnel syndrome

TSE Teaching Points

-Phrase your teaching something like this: <> A good time to examine testicles is during shower or bath, when your hands are warm and soapy and scrotum is warm; cold hands retract scrotal contents <> Procedure is simple; hold scrotum in palm of your hand and gently feel testicles using thumb and first two fingers <> Testicle is egg-shaped and movable; it feels rubbery with a smooth surface <> Abnormal lumps are very rare and usually not worrisome, but if you ever notice a firm, painless lump, a hard area, or an overall enlarged testicle, call your physician for further check

Environmental Assessments

-Physical environment: Observations to determine safety -Falls: Nearly 30% of older adults fall in the community -Older adult drivers: 8% of all traffic injuries and 18% of all pedestrian fatalities -Sleep: Screening tools to measure sleep pattern -Spiritual assessment: Individualized inquiry -Special considerations: May require more time to examine -Cultural considerations: May impact care and influence decision making

Deep Palpation of Liver

-Place your left hand under person's back parallel to 11th and 12th ribs and lift up to support abdominal contents -Place your right hand on RUQ, with fingers parallel to midline -Push deeply down and under right costal margin -Ask person to take a deep breath; it is normal to feel edge of liver bump your fingertips as diaphragm pushes it down during inhalation -It feels like a firm regular ridge; often liver is not palpable

Palpation: Symmetric Expansion

-Place your warmed hands on posterolateral chest wall with thumbs at level of T9 or T10, pinching up a fold of skin. -Ask person to take a deep breath. -Note symmetry of expansion or any lag in expansion.

Equipment

-Platform scale with height attachment -Skinfold calipers -Sphygmomanometer -Stethoscope -Thermometer -Pulse oximeter -Penlight -Otoscope -Ophthalmoscope -Tuning fork -Nasal speculum -Tongue depressor -Cotton balls -Pocket vision screener -Skin-marking pen -Flexible tape measure and ruler -Reflex hammer -Sharp object (split tongue blade) -Bivalve vaginal speculum -Clean gloves -Materials for cytologic study -Lubricant -Fecal occult blood test materials

Structure and Function

-Position and surface landmarks <> Thoracic cage is a bony structure with a conical shape, which is narrower at top. [] Defined by sternum, 12 pairs of ribs, and 12 thoracic vertebrae [] Floor is the diaphragm - separates thoracic cavity from abdomen.

Developmental Competence: Aging Adult

-Postural changes include decrease in height, more apparent in eighth and ninth decades -Kyphosis common, with backward head tilt to compensate -Contour changes include a decrease of fat in body periphery; fat deposition over abdomen and hips -Bony prominences become more marked -ROM testing proceeds as described earlier <> ROM and muscle strength are much like younger adult, provided no musculoskeletal illnesses or arthritic changes are present

Developmental Competence

-Pregnant Woman <> Breast changes start during the second month of pregnancy and are an early sign for most women. <> collostrum may be expressed after fourth month. [[[]]] This thick yellow fluid is precursor for milk, containing same amount of protein and lactose, but practically no fat. [[[]]] It is rich with antibodies that protect newborn against infection, so breastfeeding is important. <> lactation, milk production, begins 1 to 3 days postpartum. <> Fine blue vascular network visible during pregnancy; pale linear striae, or stretch marks, follow pregnancy

Developmental Differences

-Pregnant female <> Thyroid gland enlarges slightly during pregnancy -Aging adult <> Facial bones and orbits appear more prominent, facial skin sags resulting from decreased elasticity, decreased subcutaneous fat, and decreased moisture in skin <> Lower face may look smaller if teeth have been lost

Developmental Variations

-Pregnant woman <> Thoracic cage may appear wider. <> Deeper respirations and an increase in tidal volume by 40% -Aging adult <> Chest cage [] Increased anteroposterior diameter [] Kyphosis <> Chest expansion may be somewhat decreased, although still symmetric. <> Tend to tire easily during auscultation when deep mouth breathing is required

Preload

-Preload: venous return that builds during diastole <> Length to which ventricular muscle stretched at end of diastole just before contraction <> When volume of blood returned to ventricles increased [] Muscle bundles stretched beyond normal resting state [] Force of this switch is preload <> According to Frank-Starling law, greater the stretch, the stronger the heart's contraction <> This increased contractility results in an increased volume of blood ejected, increased stroke volume

Child: Past Health History

-Prenatal status -Labor and delivery -Postnatal status -Childhood illnesses -Serious accidents or injuries -Serious or chronic illnesses -Operations or hospitalizations -Immunizations and allergies -Medications -Developmental history <>Growth <>Milestones <>Current development for children 1 month through preschool age <>School-age child -Nutritional history -Family history

Developmental Considerations: Infants

-Prenatally, testes develop in abdominal cavity near kidneys <> During later months of gestation testes migrate <> Descend along inguinal canal into scrotum before birth -At birth, testis measure 1.5 to 2 cm long and 1 cm wide -Only a slight increase in size occurs during pre-pubertal years

Physical Examination: Preparation and Equipment

-Preparation <> To evaluate carotid arteries, person can be sitting <> To assess jugular veins and precordium, person should be supine with head and chest slightly elevated <> Ensure woman's privacy by keeping her breasts draped -Equipment <> Marking pen <>Small centimeter ruler <>Stethoscope with diaphragm and bell <> Alcohol wipe

The Young Child

-Preschool child displays developing initiative and takes on tasks independently <> Cooperative and easy to involve <> Fearful of body injury -Young school child is developing industry <> Cooperative and interested in learning about the body

Culture and Genetics

-Prevalence is an estimate of how many people in a stated geographic location have a disease at a given time <> In the U.S., more than 1 in 3 have one or more forms of cardiovascular heart disease (CVD) [] Annual rates of first CVD event increase with age [] For women, comparable rates occur 10 years later in life than for men, but this gap narrows with advancing age <> Causes of CVD: interaction of genetic, environmental, and lifestyle factors <> Evidence shows potentially modifiable risk factors contribute to overwhelming majority of cardiac risk -Some groups, defined by race, ethnicity, gender, socioeconomic status, and educational level carry an excess burden of CVD <> Higher percent of men than women have hypertension until 45 years, after which the percentages are similar [] After 64 years, women have much higher percentage than men <> Hypertension is 2 to 3 times more common among women taking oral contraceptives, especially obese and older women <> Hypertension in Blacks is among highest in world and is rising

Culture and Genetics: Hypertension

-Prevalence of hypertension is 41.4% Blacks -28.1% for Whites -25.8% for American Indians or Alaska Natives -22.2% for Hispanics and 18.7% for Asians -Compared with Whites, Blacks develop hypertension earlier in life, and their average BP is much higher <> Thus, Blacks have greater rate of stroke, death due from heart disease and end-stage kidney disease

Pain Assessment Tools

-Printed language should be translated to native language of patient <> Standardized overall pain assessment tools are more useful for chronic pain conditions or particularly problematic acute pain problems <> A few examples include the following: [] Initial Pain Assessment [] Brief Pain Inventory [] McGill Questionnaire -Initial pain assessment <> Clinician asks patient to answer eight questions concerning location, duration, quality, intensity, and aggravating/relieving factors <> Furthermore, clinician adds questions about manner of expressing pain and effects of pain that impairs one's quality of life -Brief pain inventory <> Asks patient to rate pain within past 24 hours on graduated scales (0 to 10) with respect to its impact on areas such as mood, walking ability, and sleep

Developmental Competence: Pregnant Woman-

-Proceed through same examination as for adult -Expected postural changes in pregnancy include <> Progressive lordosis <> Toward third trimester, anterior cervical flexion <> Kyphosis and slumped shoulders <> When pregnancy at term, protuberant abdomen and relaxed mobility in joints create characteristic "waddling" gait

Developmental Competence: Adolescents

-Proceed with same musculoskeletal examination as for adult; pay special note to spinal posture <> ____________common during adolescence because of chronic poor posture <> Screen for scoliosis with forward bend test [] From behind standing child, ask child to stand with feet shoulder width apart and bend forward slowly to touch the toes <> Expect straight vertical spine while standing and also while bending forward; posterior ribs should be symmetric, with equal elevation of shoulders, scapulae, and iliac crests

Culture and Genetics: Prostate and Colorectal Cancer

-Prostate cancer <> Screening recommendations vary for racial groups [] Men at high risk, black men, and men with first-degree relative with disease should begin screening at age 45 -Colorectal cancer also has racial variation <> Incidence in black women and men is almost 20% higher than in white women and men <> Mortality is 50% higher in black men and women than in white men and women

Abnormal Findings: Extra Sounds

-Prosthetic valve sound: Click -Third heart sound: "Kentucky" -Fourth heart sound: "Tennesee" -Pericardial friction rub

Developmental Considerations: Infants and Children

-Pulse force should be normal and symmetric in both upper and lower extremities -Lymphatic system has the same function in children as in adults <> Is well developed at birth <> Grows rapidly until age 10 or 11 -Lymph nodes are relatively large in children <> Palpable lymph nodes occur often in healthy infants and children: small, firm (shotty), mobile, and nontender <> Note characteristics of any palpable lymph nodes and whether they are local or generalized <> With infection, excessive swelling and hyperplasia occur <> Vaccinations can produce local lymphadenopathy

Developmental Competence: Aging Adults

-Pupil size decreases -Lens loses elasticity, becoming hard and glasslike, which decreases ability to change shape to accommodate for near vision; this condition is termed presbyopia -By age 70, normally transparent fibers of lens begin to thicken and yellow, the beginning of cataracts -Visual acuity may diminish gradually after age 50, and more so after age 70 -Most common causes of decreased visual functioning in older adults are the following: <> Cataract formation, or lens opacity, resulting from a clumping of proteins in lens <> Glaucoma, or increased intraocular pressure; chronic open-angle glaucoma is most common type <> Macular degeneration, or breakdown of cells in macula of retina <> Loss of central vision is most common cause of blindness; person is unable to read fine print, sew, or do fine work; loss of central vision may cause great distress

Visual Reflexes

-Pupillary light reflex: <> Normal constriction of pupils when bright light shines on retina <> Person has no conscious control over it -Fixation: a reflex direction of eye toward an object attracting person's attention -accommodation : adaptation of eye for near vision

Physical Examination Preparation

-Purposes of musculoskeletal examination <> Assess function for ADLs <> Screen for abnormalities -Note additional ADL data as person goes through motions necessary for examination -Screening musculoskeletal examination suffices for most people -Age-specific screening measures, such as Ortolani's sign for infants or scoliosis screening for adolescents

Culture and Genetics

-Racial/Ethnic Disparity noted relative to strokes <> 4% of African Americans have had a stroke <> 6% of American Indians/Alaska Natives have had a stroke <> 2.5% of Hispanics have had a stroke -Geographic Disparity noted relative to strokes <> Existence of "Stroke Belt" - 8 states in the Southeast with increased stroke mortality -Nationwide Burden of Stroke <> Higher for African Americans and Hispanic populations

Coordination and Skilled Movements

-Rapid Alternating Movements (RAM) <> Ask person to pat knees with both hands, lift up, turn hands over, and pat knees with backs of hands; then ask person to do this faster [] Normally done with equal turning and quick rhythmic pace <> Alternatively, ask person to touch thumb to each finger on same hand, starting with the index finger, then reverse direction

Special Procedures for Advanced Practice

-Rebound tenderness (Blumberg's sign of peritoneal inflammation as with appendicitis) -Inspiratory arrest (Murphy's sign for cholecystitis) -Iliopsoas muscle test (for appendicitis)

Functional Ability

-Refers to one's ability to perform activities necessary to live in modern society <> Includes driving, using telephone, and performing personal tasks, such as bathing and toileting [] Also incorporates older adult's physiologic and psychological status and physical and social environments [] Functional status: individual's actual performance of activities and tasks associated with his or her current life roles and dependent on motivation, vision and hearing, degree of assistance needed to accomplish tasks, and cognition

DTRs 4-Point Scale

-Reflex response graded on 4-point scale 4+= very brisk, hyperactive with clonus, indicative of disease 3+ = brisker than average, may indicate disease 2+ = Average, normal 1+ = diminished, low normal, or occurs with reinforcement 0 = no response Subjective scale

Reflexes

-Reflexes: basic defense mechanisms of nervous system <> Involuntary; below level of conscious control permitting quick reaction to potentially painful or damaging situations -Four types of reflexes: <> Deep tendon reflexes, e.g., knee jerk <> Superficial, e.g., corneal reflex, abdominal reflex <> Visceral, e.g., pupillary response to light <> Pathologic (abnormal), e.g., Babinski's reflex or extensor plantar reflex

Culture and Genetics: Sex Differences

-Regardless of ethnicity, CVD is the leading cause of death in women <> Within the first year following an MI, women age 45 and older are 26% more likely to die than their male counterparts (19%) <> Women may report different symptoms than the typical "chest pain" experienced by men, thus clinical diagnosis may be delayed

HPV Teaching Points

-Remind women that obtaining vaccine does not mean they can forget about routine pelvic examinations and Pap tests <> Vaccine will protect against major types of HPV that cause cervical cancer, but not all types <> Pap tests detect cell changes in cervix before they turn into cancer, at an early, curable stage <> Only other way to prevent HPV is to abstain from all sexual activity [] Condoms may not protect against HPV because areas not covered by condom can be exposed to virus

Internal Anatomy: Inner Layer

-Retina: the visual receptive layer of eye where light waves change into nerve impulses -Optic disc: area in which fibers from retina converge to form optic nerve -Retinal vessels: normally include a paired artery and vein extending to each quadrant -Macula: located on temporal side of fundus <> Slightly darker pigmented region surrounding fovea centralis, area of sharpest and keenest vision <> Receives and transduces light from center of visual field

Abnormalities of Spine

-Scoliosis <> Functional - flexible; disappears with forward bend <> Structural - fixed; rib hump with forward bend

Cardiac Cycle

-Rhythmic flow of blood through heart is cardiac cycle <> Diastole: ventricles relax and fill with blood; this takes up two thirds of cardiac cycle <> Systole: heart's contraction, blood pumped from ventricles fills pulmonary and systemic arteries; this is one third of cardiac cycle

Anatomic Locations of Organs Upper Quadrants

-Right Upper Quadrant (RUQ) <> Liver <> Gallbladder <> Duodenum <> Head of pancreas <> Right kidney and adrenal gland <> Hepatic flexure of colon <> Part of ascending and transverse colon -Left Upper Quadrant (LUQ) <> Stomach <> Spleen <> Left lobe of liver <> Body of pancreas <> Left kidney and adrenal gland <> Splenic flexure of colon <> Part of transverse and descending colon

Anatomic Locations of four Lower Quadrants

-Right lower quadrant (RLQ) Cecum Appendix Right ovary and tube Right spermatic cord Right ureter -Left lower quadrant (LLQ) Part of descending colon Sigmoid colon Left ovary and tube Left spermatic cord Left ureter

Culture and Genetics: Type II Diabetes Mellitus (DM)

-Risk of CVD is twofold greater among persons with DM <> Increased prevalence of DM in U.S. is being followed by an increasing prevalence of CVD morbidity and mortality <> Diabetes causes damage to large blood vessels that nourish brain, heart and extremities; this results in stroke, coronary artery disease, and peripheral vascular disease <> About 12.6% of Blacks over age 20 have DM <> 11.8% of Hispanic Americans have DM, compared to 7.1% of Whites

Test Vestibular Apparatus

-Romberg test: assesses ability of vestibular apparatus in inner ear to help maintain standing balance <> Stand with feet together and arms down, close eyes, and maintain for 20 seconds -Also assesses intactness of cerebellum and proprioception as it is part of the neurologic system

Infant Reflexes

-Rooting reflex: brush the infant's cheek near mouth; note whether infant turns head toward that side and opens mouth <> Appears at birth; disappears at 3 to 4 months -Palmar grasp: place baby's head midline to ensure symmetric response; offer finger from baby's ulnar side, away from thumb; note tight grasp of all baby's fingers <> Present at birth; strongest at 1 to 2 months; disappears at 3 to 4 months -Plantar grasp: touch your thumb at ball of baby's foot; note that toes curl down tightly <> Reflex present at birth; disappears at 8 to 10 months -Babinski reflex: stroke your finger up the lateral edge of the foot and over the ball of the foot; note fanning of toes <> Present at birth; disappears at 2 - 2 ½ years -Tonic neck reflex: with baby supine, turn head to one side with chin over shoulder; note ipsilateral extension of arm and leg, and flexion of opposite arm and leg; the "fencing" position; turning head to opposite side, positions will reverse <> Appears by 2 to 3 months; decreases at 3 to 4 months; disappears by 4 to 6 months -Moro reflex: startle infant by jarring crib, making a loud noise, or supporting head and back in semi-sitting position and quickly lowering infant to 30 degrees <> Baby looks as if he or she is hugging a tree; symmetric abduction and extension of arms and legs, fanning fingers, and curling of index finger and thumb to C position; infant then brings in both arms and legs [] Present at birth; disappears at 1 to 4 months

Male Breast

-Rudimentary structure consisting of a thin disk of undeveloped tissue underlying nipple. -Gynecomastia: during adolescence, it is common for breast tissue to temporarily enlarge.

Developmental Competence: Infants and Children

-Salivation starts at 3 months; baby will drool periodically for a few months before learning to swallow saliva. -Teeth, both sets, begin development in utero -Children have 20 deciduous, or temporary teeth, that erupt between 6 months and 24 months of age; all 20 should appear by 2½ years. -Deciduous teeth lost beginning at age 6 through 12; replaced by permanent, starting with central incisors -Nose develops during adolescence, along with other secondary sex characteristics.

Pitting Edema Scale Classification

-Scale is subjective and qualitative <> The amount of pressure used is arbitrary, as is judgment of depth and rate of pitting <> Many classify the edema by measuring the depth of the pitting in centimeter <> Some measure with a millimeter scale, others by an increase in weight; still others try to quantify rate of time pitting remains after release of pressure <> Check with your institution to determine a consistently used scale

Internal Anatomy: Outer Layer

-Sclera: tough, protective, white covering -Cornea: part of refracting media of eye, bending incoming light rays so that they will be focused on inner retina <> Very sensitive to touch; contact with a wisp of cotton stimulates a blink in both eyes, called corneal reflex <> Trigeminal nerve, cranial nerve V, carries afferent sensation into brain, and facial nerve, cranial nerve VII, carries efferent message that stimulates blink

Liver Span—Scratch Test

-Scratch test: one final technique is scratch test, which may help define liver border when abdomen distended or abdominal muscles are tense -Place your stethoscope over liver -With one fingernail, scratch short strokes over abdomen, starting in RLQ and moving progressively up toward liver -When scratching sound in your stethoscope becomes magnified, you will have crossed border from over a hollow organ to a solid one

Summary Checklist: Neurologic Examination

-Screening and Complete Neuro Exam Mental status Cranial nerves Motor function Sensory function Reflexes

Caregiver Strain Index

-Screening tool that identifies caregivers needing a more comprehensive assessment <> Brief tool with 13 questions addressing potential strain in employment, financial, physical, social, and time domains <> Caregiver stress can lead to mistreatment of older adults <> Thorough assessment may identify opportunities to prevent and stop mistreatment

Palpation of Right Kidney

-Search for right kidney by placing your hands together in a "duck-bill" position at person's right flank -Press your two hands together firmly (you need deeper palpation than that used with the liver or spleen), and ask person to take deep breath -In most people, you will feel no change -Occasionally, you may feel lower pole of right kidney as a round, smooth mass slide between your fingers -Either condition is normal

Functional Assessment: ADLs

-Self-esteem, self-concept, self care ability -Activity and exercise -Sleep and rest -Nutrition and elimination -Interpersonal relationships and resources -Spiritual resources -Coping and stress management -Personal habits -Illicit or street drugs -Environment and work hazards -Intimate partner violence -Occupational health

SL Valves

-Semilunar valves are set between ventricles and arteries <> Each valve has cusps that look like half moons <> Pulmonic valve: in right side of heart <> Aortic valve: in left side of heart <> No valves are present between vena cava and right atrium, or between pulmonary veins and left atrium, for this reason [] Abnormally high pressure in left side of heart gives a person symptoms of pulmonary congestion [] Abnormally high pressure in right side of heart shows in neck veins and abdomen

Physical Examination: Aging Adult - Head and Neck

-Senile tremors not abnormal -Neck may show concave curve to compensate for kyphosis of spine -ROM should be performed slowly -Abnormal Findings: Head Size and Contour -Hydrocephalus <> Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure <> Findings include enlarged head, dilated scalp veins, frontal bossing, and downcast or "setting sun" eyes

Sensory Pathways

-Sensory cortex arranged in corresponding "map" of body -Some organs absent from brain map, such as heart, liver, or spleen <> Pain originating in these organs is referred, e.g., pain in heart referred to chest, shoulder, and left arm; pain originating in spleen felt on left shoulder

Inspection and Palpation: Nails

-Shape and contour <> Profile sign/ Schamroth's window: view index finger at its profile and note angle of nail base; it should be about 160 degrees -Consistency -Color -Capillary refill <> Depress nail edge to blanch and then release, noting return of color; indicates status of peripheral circulation <> Color return is normally instant <> Sluggish color return takes longer than 1 or 2 seconds

Developmental Considerations: Pregnant Women

-Shift in turn creates strain on low back muscles, felt as low back pain during late pregnancy -Anterior flexion of neck and slumping of shoulder girdle are other postural changes that compensate for lordosis -These upper back changes may put pressure on ulnar and median nerves during third trimester

Cornea and Lens

-Shine light from side across cornea, and check for smoothness and clarity -Oblique view highlights any abnormal irregularities in corneal surface -Arcus senilis is normal finding in aging persons

Developmental Considerations: Pregnant Women

-Shortly after first missed menstrual period, genitalia show signs of the growing fetus <> Cervix softens (Goodell's sign) at 4 to 6 weeks of gestation, and vaginal mucosa and cervix look cyanotic (Chadwick's sign) at 8 to 12 weeks of gestation <> Changes occur because of increased vascularity and edema of cervix and hypertrophy and hyperplasia of cervical glands <> Isthmus of uterus softens (Hegar's sign) at 6 to 8 weeks of gestation

Abnormal Findings: Respiratory Patterns

-Sigh -Tachypnea - > 24 breaths per minute -Bradypnea - < 10 breaths per minute -Hyperventilation - Kussmaul's -Hypoventilation -Cheyne-Stokes respiration -Biot's respiration -Chronic obstructive breathing

Abnormal Finding: Hyperthyroidism

-Signs <> Exophthalmos <> Goiter <> Tachycardia <> Sweating <> Weight loss -Symptoms <> Nervousness <> Heat intolerance

Abnormal Finding: Hypothyroidism

-Signs <> Puffy, edematous face <> Coarse hair and brows <> Cool dry skin -Symptoms <> Fatigue <> Cold intolerance -Parotid gland enlargement <> Note swelling anterior to lower ear lobe <> Rapid painful inflammation occurs with mumps <> Parotid swelling also occurs with blockage of duct, abscess, or tumor <> Stensen duct obstruction can occur in aging adults dehydrated from diuretics or anticholinergics

Neurologic Check

-Signs of increasing intracranial pressure signal impending cerebral disaster and death and require early and prompt intervention -Use abbreviation of neurologic examination in following sequence: <> Level of Consciousness(LOC) [] A change in LOC is the single most important factor in this examination <> Motor Function [] Check voluntary responses by giving simple commands as this will also help to validate LOC <> Pupillary Response [] Note size and symmetry of both pupils <> Vital Signs [] Monitor vital signs to establish baseline <> Glasgow Coma Scale [] Accurate and reliable quantitative tool to assess LOC

Developmental Considerations: Adolescents

-Signs of puberty are appearing earlier in boys according to research studies at an average age of 9 years in African Americans & age 10 for Caucasians & Hispanics <> First sign is enlargement of testes <> Next, pubic hair appears, then penis size increases <> Stages of development are documented in Tanner's sexual maturity ratings

Position

-Sitting Up <> Proceed with head, eyes, ears, neck, and thoracic examination <> Sit upright at edge of examination table -Supine <> Conduct cardiac, abdominal, and lower extremity examination next <> Place drape over lower abdomen when examining inguinal area <> Ask adolescent to unzip and lower clothes under drape <> Pant legs can be pulled up to examine lower legs and feet

Extraocular Muscles

-Six muscles attach eyeball to its orbit and direct eye <> Give eye both straight and rotary movement [] Four straight, or rectus, muscles are superior, inferior, lateral, and medial rectus muscles [] Two slanting, or oblique, muscles are superior and inferior muscles <> Each muscle is coordinated, or yoked, with one in other eye ensuring that when two eyes move, their axes always remain parallel (conjugate movement) -Parallel axes are important because human brain has a binocular, single-image visual system Movement of the extraocular muscles stimulated by three cranial nerves <> Cranial nerve VI: abducens nerve, innervates lateral rectus muscle, which abducts eye <> Cranial nerve IV: trochlear nerve, innervates superior oblique muscle <> Cranial nerve III: oculomotor nerve, innervates all the rest: the superior, inferior, and medial rectus and the inferior oblique muscles

Inspect and Palpate Motor System: Muscles

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

Cultivating Your Senses

-Skills performed one at a time, in this order 1. Inspection 2. Palpation 3. Percussion 4. Auscultation

Skin Assessment

-Skin assessment is integrated throughout examination -Scrutinize the outer skin surface first before you concentrate on underlying structures -Separate intertriginous areas (areas with skinfolds) such as under large breasts, obese abdomen, and groins, and inspect them thoroughly -Always inspect feet, toenails, and between toes

Infant Skin Presentations

-Skin color general pigmentation <> Mongolian spot <> Café-au-lait spot -Skin color change <> Beefy red flush <> Harlequin color change <> Erythema toxicum -Temporary cyanotic conditions <> Acrocyanosis <> Cutis marmorata -Physiologic jaundice -Carotenemia -Vascularity or bruising

External Genitalia: Inspection

-Skin color is even; labia minora are darker pink -Hair distribution in usual female pattern of inverted triangle, although it normally may trail up abdomen -Labia majora normally are symmetric, plump, and well formed; in nulliparous woman, labia meet in midline; after a vaginal delivery, labia are gaping and slightly shriveled -No lesions should be present, except for occasional sebaceous cysts

Physical Examination: Posterior Inspection

-Skin color, condition, lesions -Shape and configuration of chest wall <> Anteroposterior diameter should be less than transverse diameter. <> Skin color/ condition/ lesions -Spinous processes <> Scoliosis? <> Kyphosis? -Thorax - symmetrical, elliptical shape, with downward sloping ribs -Scapulae - symmetrical -Neck muscles and trapezius muscles - developed normally for age and occupation.

Inspection & Palpation: Penis

-Skin normally looks wrinkled, hairless, and without lesions; dorsal vein may be apparent -Glans looks smooth and without lesions; ask uncircumcised male to retract foreskin, or you retract it; it should move easily <> Some cheesy smegma may have collected under foreskin; after inspection, slide foreskin back to original position -Urethral meatus positioned just about centrally

Structure and Function: Head

-Skull is rigid box that protects brain and is supported by cervical vertebra <> Closed vault <> Sutures close in infancy/ early childhood -Triangle-shaped posterior fontanel closes by 1 to 2 months, -Diamond-shaped anterior fontanel closes between 9 months and 2 years <> Head size is greater than chest circumference at birth and reaches 90% of final size at 6 years old -Facial expressions formed by facial muscles, which are mediated by cranial nerve 7, the facial nerve -Two pairs of salivary glands are accessible to examination on the face (not normally palpable) <> Parotid glands <> Submandibular glands -Temporal artery lies superior to temporalis muscle, and pulsation is palpable anterior to ear

Test Central Visual Acuity

-Snellen alphabet chart is most commonly used and accurate measure of visual acuity <> It has lines of letters arranged in decreasing size <> Place chart in a well-lit spot at eye level; position person exactly 20 feet from chart; hand person an opaque card with which to shield one eye at a time during test <> If person wears glasses or contact lenses, leave them on; remove only reading glasses <> Ask person to read through chart to smallest line of letters possible; encourage trying next smallest line also -If person unable to see even largest letters, shorten distance to chart until the person sees it, and record that distance (e.g., 10/20) <> Numerator = distance person is standing <> Denominator = distance normal person could stand <> The larger the denominator, the poorer the vision. If visual acuity even lower, assess whether person can count your fingers when they are spread in front of eyes or distinguish light perception from your penlight

Subjective Data: Mouth and Throat

-Sores or lesions -Sore throat -Bleeding gums -Toothache -Hoarseness -Dysphagia -Altered taste -Smoking, alcohol consumption -Self-care behaviors -Dental care pattern -Dentures or appliances

McMurray's Test

-Special test for meniscal tears <> Perform test when person has history of trauma followed by locking, giving way, or local pain in knee <> Position person supine as you stand on affected side <> Hold heel and flex knee and hip; place your other hand on knee with fingers on medial side <> Rotate leg in and out to loosen joint <> Externally rotate leg and push a valgus (inward) stress on knee; then slowly extend knee; normally leg extends smoothly with no pain <> "Click" is + test

Sensory Pathway Routes

-Spinothalamic tracts <> Transmit sensations of: [] pain [] temperature [] crude or light touch -Posterior (dorsal) columns <> Transmit sensations of: [] position [] vibration [] finely localized touch

Structure and Function: Organs related to the Lymphatic System

-Spleen - Located in left upper quadrant of abdomen: <> Destroys old red blood cells <> Produces antibodies <> Stores red blood cells <> Filters microorganisms from blood -Tonsils are located at entrance to respiratory and gastrointestinal tracts and respond to local inflammation -Thymus is flat, pink-gray gland located in superior mediastinum behind sternum and in front of aorta

Palpation Sequence

-Start with light palpation to detect surface characteristics and accustom person to being touched -Then perform deeper palpation when needed -Avoid any situation in which deep palpation could cause internal injury or pain -Bimanual palpation requires use of both hands to envelop or capture certain body parts or organs, such as kidneys, uterus, or adnexa, for more precise delimitation

Objective Data: Body Structure

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

Abnormal Findings: Abnormal Bowel Sounds

-Succussion splash -Hypoactive bowel sounds -Hyperactive bowel sounds

Superficial Reflexes

-Superficial (cutaneous) reflexes <> Sensory receptors in skin rather than in muscles; motor response is localized muscle contraction <> Abdominal reflexes: upper: T8 to T10; lower: T10 to T12 [] Person in supine position, knees slightly bent; use handle end of reflex hammer to stroke skin [] Move from each corner toward midline at both upper and lower abdominal levels [] Normal response is ipsilateral contraction of abdominal muscle with observed deviation of umbilicus toward stroke -Cremasteric reflex, L1 to L2 (not routinely done) <> On male, lightly stroke inner aspect of thigh with reflex hammer or tongue blade [] Note elevation of ipsilateral testicle -Plantar reflex, L4 to S2 <> Position thigh with slight external rotation <> With reflex hammer, draw a light stroke up lateral side of sole of foot and inward across ball of foot, like an upside-down "J" [] Normal response is plantar flexion of toes and inversion and flexion of forefoot [] Abnormal response is extension and fanning of toes

Ankle and Foot

-Support ankle by grasping heel with your fingers while palpating with your thumbs; joint spaces should feel smooth, with no swelling or tenderness -Palpate metatarsophalangeal joints between your thumb on dorsum and fingers on plantar surface -Test ROM -Assess muscle strength by asking person to maintain dorsiflexion and plantar flexion against your resistance

Synovial Joints

-Supported by ligaments <> Fibrous bands running bone to bone <> Strengthen joint <> Prevent movement in some directions -Move freely because <> Bones enclosed in cavity filled with lubricant, or synovial fluid, which allows sliding/ movement <> Bursae (sacs of synovial fluid like joint cavities) cushion areas of friction <> Layer of resilient cartilage covers surface of opposing bones - Is nourished by synovial fluid - Cushions bones

Anterior Thoracic Landmarks

-Surface landmarks on thorax are sign posts for underlying respiratory structures. <> Suprasternal notch: hollow U-shaped depression just above sternum between clavicles. <> Sternum: "breastbone" has three parts; manubrium, body, and xiphoid process. <> "Angel of Louis" (manubriosternal angle): [] Distinct bony ridge [] Marks site of tracheal bifurcation into right and left main bronchi [] Corresponds with upper border of atria of the heart <> Each intercostal space is numbered by rib above it <> Costal angle: usually 90 degrees or less, increases when rib cage is chronically overinflated as in emphysema

Inspection and Palpation of the Neck

-Symmetry -Range of motion -Lymph nodes -Trachea -Thyroid gland <> Posterior approach <> Anterior approach <> Auscultate thyroid for bruit, if enlarged

Inspection of the Abdomen

-Symmetry <> Shine a light across abdomen toward you, or shine it lengthwise across the person <> Abdomen should be symmetric bilaterally -Contour <> Stand on person's side and look down on abdomen <> Stoop or sit to gaze across abdomen <> Determine profile from rib margin to pubic bone; contour describes nutritional state and normally ranges from flat to rounded [] Flat, rounded, scaphoid, protuberant -Umbilicus <> Normally it is midline and inverted, with no sign of discoloration, inflammation, or hernia <> Becomes everted and pushed upward with pregnancy <> Umbilicus is common site for piercings in young women; site should not be red or crusted -Skin <> Surface normally smooth and even, with homogeneous color (good area to judge pigment because often protected from sun) <> Fine venous network may be visible in thin persons <> Good skin turgor reflects healthy nutrition; gently pinch up a fold of skin; then release to note skin's immediate return to original position <> One common pigment change is striae, silvery white, linear, jagged marks [] About 1 to 6 cm long [] Occur when elastic fibers in reticular layer of skin are broken after rapid or prolonged stretching, as in pregnancy or excessive weight gain; [] Recent striae are pink or blue, then they turn silvery white <> Pigmented nevi (moles), circumscribed brown macular or papular areas, common on abdomen <> Normally no lesions are present, although you may note well-healed surgical scars -Hair distribution <> Normal pattern of pubic hair growth is [] Diamond shape in men [] Inverted triangle shape in women -Demeanor <> Comfortable person is relaxed quietly on examining table and has a benign facial expression and slow, even respirations

Straight Leg Raising or Lasègue's Test

-These maneuvers reproduce back and leg pain and may confirm presence of herniated nucleus pulposus -Straight leg raising while keeping the knee extended normally produces no pain -Raise affected leg just short of point where it produces pain; then dorsiflex foot -Test positive if it reproduces sciatic pain; if lifting affected leg reproduces sciatic pain, it confirms presence of herniated nucleus pulposus -Raise unaffected leg leaving other leg flat; inquire about involved side

Events in Right and Left Side of Heart

-Systole <> Consider left side of heart <> When pressure in ventricle finally exceeds pressure in aorta, aortic valve opens and blood is ejected rapidly [] After ventricle's contents are ejected, its pressure falls <> When pressure falls below pressure in aorta, some blood flows backward toward ventricle, causing aortic valve to close <> This closure of semilunar valves causes second heart sound (S2) and signals end of systole -Diastole again <> Now all four valves are closed and ventricles relax [] Isometric or isovolumetric relaxation <> Atria have been filling <> Atrial pressure now higher than relaxed ventricular pressure <> Mitral valve opens and diastolic filling begins again -Same events happening in right side of heart <> But pressures in right side of heart are much lower than those of left side because less energy needed to pump blood to its destination, pulmonary circulation <> Events occur just slightly later in right side of heart because of route of myocardial depolarization -Results in two components to each of the heart sounds <> In first heart sound (S1), mitral component (M1) closes just before tricuspid component (T1) <> With S2, aortic closure (A2) occurs slightly before pulmonic closure (P2)

Percussion

-Tapping person's skin with short, sharp strokes to assess underlying structures -Percussion has following uses: <> Mapping location and size of organs <> Signaling density of a structure <> Detecting a superficial abnormal mass <> Eliciting pain if underlying structure is inflamed <> Eliciting deep tendon reflex using percussion hammer

Examination of Skin, Hair, Nails

-Techniques - Inspection and palpation -Equipment - eyes, hands, gloves, measuring device, penlight, magnifying glass -Lighting -Exposure -Thoroughness -Comparisons -Documentation

Measurement

-Temperature -Pulse -Respiration -Blood pressure -Pulse oximetry -Rate pain level on 1 to 10 scale, pain tolerance -If pain medication is given, note response in 15 minutes for IV administration to 1 hour for oral administration

Range of Motion (ROM) of Neck

-Test muscle strength and status of cranial nerve XI as person shrugs shoulders and turns head to each side -Note any thyroid gland enlargement -Note any obvious pulsations

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 and 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 to 60 cm (1 to 2 ft) from person's ear, exhale and whisper slowly some two-syllable words -Normally, person repeats each word correctly after you say it

Knee: Ballottement of Patella

-Test reliability when larger amounts of fluid are present -Use left hand to compress suprapatellar pouch to move any fluid into knee joint -With right hand, push patella sharply against femur; if no fluid is present, patella is already snug against femur -Palpate infrapatellar fat pad and patella; check for crepitus by holding hand on patella as knee is flexed and extended; some crepitus in knee is not uncommon -Check ROM -Check muscle strength by asking person to maintain knee flexion while you oppose by trying to pull the leg forward

Muscle Testing

-Test strength of prime mover muscle groups for each joint; repeat motions for active ROM -Ask person to flex and hold as you apply opposing force -Muscle strength should be equal bilaterally and should fully resist opposing force and gravity Grade Description Assessment 5 Full ROM, full resistance Normal 4 Full ROM, some resistance Good 3 Full ROM with gravity Fair 2 Full ROM with gravity elim. Poor 1 Slight contraction Trace 0 No contraction Zero

Breast Self-examination: Keep Teaching Simple

-The best time to conduct BSE is: <> Right after menstrual period, when breasts are smallest and least congested. <> sometimes monthly, for a postmenopausal woman. 1) Look at breasts in front of a mirror while disrobed to waist. 2) Start palpation while standing. 3) Then palpation should be performed while lying supine.

Structure and Function: Lymphatics

-The lymphatics form a completely separate vessel system, which retrieves excess fluid from the tissue spaces and returns it to the bloodstream <> Conserve fluid and plasma proteins that leak out of capillaries <> Form a major part of immune system that defends body against disease - not fully understood <> Absorb lipids from intestinal tract -Vessels drain into two main trunks, which empty into the venous system at the subclavian veins -Lymph nodes are small oval clumps of lymphatic tissue located at intervals along vessels -Superficial groups of nodes are accessible to inspection and palpation giving clues to status of lymphatic system

Pleurae

-The thin, slippery pleurae form an envelope between lungs and chest wall. <> Visceral pleura lines outside of lungs, dipping down into fissures. <> Parietal pleura lines inside of chest wall and diaphragm. -Pleural cavity is potential space filled only with few milliliters of lubricating fluid. <> Pleural cavity normally has a vacuum, or negative pressure, which holds lungs tightly against chest wall. <> Air ("pneumothorax") or fluid ("pleural effusion") in the pleural cavity compromises lung expansion.

Structure of the Skin

-skin has 2 layers 1. Epidermis <> outer highly differentiated layer [] basal cell layers form new skin cells [] Outer horny cell layer is dead keratinized cells which is desquamated every 4 weeks 2. Dermis <> inner supportive layer [] Connective tissue or collagen [] Elastic tissue -Beneath these layers is a subcutaneous layer containing adipose tissue

Developmental Considerations: Infant Murmurs

-These murmurs are usually grade I or II <> They are systolic and accompany no other signs of cardiac disease, and they disappear in 2 to 3 days <> Murmur of patent ductus arteriosis is continuous machinery murmur, which disappears by 2 to 3 days <> On other hand, absence of a murmur in immediate newborn period does not ensure a perfect heart <> Congenital defects can be present that are not signaled by an early murmur <> Best to listen frequently and to note and describe any murmur according to characteristics

Structure and Function: Neck

-Think of neck as conduit of many structures <> Vessels, muscles, nerves, lymphatics, trachea, esophagus <> Major neck muscles sternomastoid and trapezius are innervated by cranial nerve XI

Extra Heart Sounds (S3)

-Third heart sound (S3) <> Normally diastole is silent event <> S3 occurs when ventricles resistant to filling during early rapid filling phase <> Normal in children, young adults, and pregnant women <> Occurs immediately after S2, when AV valves open and atrial blood first pours into ventricles

Abnormal Findings: Abnormal Palpable Pulsations

-Thrill at the base -Lift (heave) at the sternal border -Volume overload at the apex

Structure of Neck: Thyroid

-Thyroid gland: an important endocrine gland straddles trachea in middle of the neck -Synthesizes and secretes thyroxine (T4) and triiodothyronine (T3), which are hormones that stimulate rate of cellular metabolism -The gland has two lobes, connected in middle by a thin isthmus and above that by the cricoid cartilage or upper tracheal ring -Thyroid cartilage above that, with small palpable notch in upper edge, the "Adam's apple" in males

Abnormal Findings: Swellings of Head and Neck

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

Developmental Competence: Infants and Children

-Timing is best toward end with ear examination -Essential to determine patency of nares in immediate newborn period -Normal finding in infants is sucking tubercle, a small pad in middle of upper lip from friction of breastfeeding or bottle-feeding. -Epstein pearls on palate are normal finding in newborns and infants. -Note number of teeth and, if appropriate, for child's age. <> Child's age in months minus number 6 should equal expected number of deciduous teeth.

Structure and Function: Middle Ear

-Tiny air-filled cavity inside temporal bone <> Contains tiny ear bones (auditory ossicles): the malleus, incus, and stapes -Several openings are present <> Opening to the outer ear is covered by the tympanic membrane <> Eustachian tube: opening that connects middle ear with nasopharynx and allows passage of air Normally closed, but opens with swallowing or yawning

Palpation of Neck: Trachea and Thyroid

-Trachea - Normally, trachea is midline -Thyroid gland - <> Check for enlargement, consistency, symmetry, and presence of nodules <> If enlarged, auscultate thyroid for presence of bruit, which occurs with accelerated or turbulent blood flow

Trachea and Bronchial Tree

-Trachea lies anterior to esophagus and is 10 to 11 cm long in the adult. -Bifurcates just below sternal angle anteriorly or at T4 or T5 posteriorly into right and left main bronchi. -Constitutes dead space, or space that is filled with air (about 150 ml in an adult) but is not available for gaseous exchange.

Developmental Considerations: Infants

-Transition from fetal to pulmonic circulation occurs in immediate newborn period -Normally the liver is not enlarged, and respirations are not labored -Heart rate may range from 100 to 180 beats per minute (bpm) immediately after birth -Rapid rates make it more challenging to evaluate heart sounds

Wound Types (6)

-Traumatic -Surgical -Burn -Diabetic/ neuropathic -Pressure -Vascular <> Arterial <> Venous <> Mixed

AV Valves

-Two AV valves separate atria and ventricles <> Tricuspid valve: right AV valve <> Bicuspid, or mitral valve: left AV valve <> AV valves open during heart's filling phase, or diastole, to allow ventricles to fill with blood <> During pumping phase, or systole, AV valves close to prevent regurgitation of blood back up into atria

Approaches to Functional Assessment

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

Neck Vessels: Jugular Venous Pulse and Pressure

-Two jugular veins present in each side of neck <> Larger internal jugular lies deep and medial to sternomastoid muscle <> External jugular vein is more superficial; lies lateral to sternomastoid muscle, above clavicle -Jugular venous distention can indicate volume overload

Percussion Methods

-Two methods of percussion can be used <> Direct, sometimes called immediate, the striking hand directly contacts body wall <> Indirect, or mediate, using both hands, the striking hand contacts stationary hand fixed on person's skin

Structure and Function: Sinuses

-Two pairs of sinuses are accessible to examine. <> Frontal sinuses above and medial to orbits <> Maxillary sinuses in maxilla (cheekbone) <> Other two sets are smaller and deeper. [] Ethmoid sinuses between the orbits [] Sphenoid sinuses deep within skull in the sphenoid bone -Only maxillary and ethmoid sinuses are present at birth

Abnormal Findings: Abnormalities on Inspection

-Umbilical hernia -Epigastric hernia -Incisional hernia -Diastasis recti

Inspect and Palpate the Legs

-Uncover the legs while keeping genitalia draped -If lower legs look asymmetric, measure leg at widest point, taking care to measure other leg in exactly same place, same number of centimeters down from patella or other landmark -In presence of skin discoloration, skin ulcers, or gangrene, note size and exact location -Palpate for temperature along legs down to feet, comparing symmetric spots

Developmental Considerations: Child

-Under age 4 years, abdomen looks protuberant when child is both supine and standing -After age 4 years, potbelly remains when standing because of lumbar lordosis, but abdomen looks flat when supine <> Normal movement on abdomen includes respirations, which remain abdominal until 7 years <> To palpate abdomen, position young child on parent's lap as you sit knee-to-knee with parent <> Flex knees up, and elevate head slightly -Child can "pant like a dog" to further relax abdominal muscles <> Hold your entire palm flat on abdominal surface for a moment before starting palpation to accustom the child to being touched <> If the child is very ticklish, hold his or her hand under your own as you palpate; or apply stethoscope and palpate around it <> In assessing abdominal tenderness, remember that young child often answers this question affirmatively no matter how abdomen actually feels -Use objective signs to aid assessment, such as a cry changing in pitch as you palpate, facial grimacing, moving away from you, and guarding -School-age child has a slim abdominal shape as he or she loses potbelly -This slimming trend continues into adolescence -Adolescent easily embarrassed with exposure of abdomen, and adequate draping is necessary -Physical findings are same as those listed for adult

Extremities

-Upper <> Inspect and manipulate ROM, muscle tone, and absence of scarf sign <> Count fingers, palmar creases, and note color of hands and nail beds <> Place your thumbs in the infant's palm to note grasp reflex <> Wrap your hands around infant's hands to pull up, and note head lag -Lower <>Inspect and manipulate legs and feet, noting ROM, muscle tone, and skin condition <> Note alignment of feet and toes, look for flat soles, and count toes <> Perform Ortolani sign for hip stability <> Check plantar grasp reflex (present 8 to 10 months) <> Check Babinski reflex (fanning of toes until 24 months)

Ankle-Brachial Index (ABI)

-Use Doppler stethoscope <> Highly specific, noninvasive, and readily available way to determine extent of peripheral vascular disease <> Specific criteria for procedure with patient lying flat and heels fully supported along with correct choice of cuff size <> No smoking within 2 hours with 5- to 10-minute rest period prior to measurement <> Two measurements taken and then the average is used as the recorded pressure <> Formula calculation required

Palpation: Tactile Fremitus

-Use either palmar base (ball) of fingers or ulnar edge of one hand to touch person's chest while he or she repeats words, "ninety-nine." -Start over lung apices and palpate from one side to another, noting symmetry of sounds. -Note any areas of abnormal fremitus. <> Conditions that increase density of lung tissue make a better conducting medium for sound vibrations and increase tactile fremitus (as with compression or consolidation that extends to the lung surface). -Using fingers, gently palpate entire chest wall. <> Enables noting any areas of tenderness, skin temperature and moisture, detecting any superficial lumps or masses, and exploring any skin lesions noted on inspection

Developmental Considerations: Aging Adult

-Use same examination as with younger adults -Cranial nerves mediating taste and smell not usually tested, may show some decline in function -Decrease in muscle bulk most apparent in hand; dorsal hand muscles often look wasted, even with no apparent arthropathy; grip strength remains relatively good -Senile tremors occasionally occur; these benign tremors include an intention tremor of hands, head nodding, and tongue protrusion -Dyskinesias: repetitive stereotyped movements in jaw, lips, or tongue may accompany senile tremors; no associated rigidity present -Gait may be slower and more deliberate than in younger person; may deviate from midline path -Rapid alternating movements may be difficult to perform -After 65 years of age, loss of sensation of vibration at ankle malleolus common; loss of ankle jerk; tactile sensation may be impaired; may need stronger stimuli for light touch; and especially for pain -DTRs less brisk; those in upper extremities usually present, but ankle jerk commonly lost; knee jerks may be lost; because aging people find it difficult to relax limbs, always use reinforcement when eliciting DTRs -Plantar reflex may be absent or difficult to interpret; often, you will not see a definite normal flexor response; still should consider definite extensor response abnormal -Superficial abdominal reflexes may be absent

Doppler Ultrasonic Probe

-Use this device to detect a weak peripheral pulse, to measure low blood pressure or blood pressure in lower extremity <>Doppler probe magnifies pulsatile sounds from heart and blood vessels <> Position person supine, with legs externally rotated so you can reach medial ankles easily <> Place drop of coupling gel on end of handheld transducer <> Place transducer over pulse site, swiveled at a 90-degree angle; apply very light pressure; locate pulse site by the distinctive puff-of-air sound

Modified Allen Test

-Used to evaluate collateral circulation prior to cannulating radial artery <> Firmly occlude both ulnar and radial arteries of one hand while person makes a fist several times; this causes hand to blanch <> Ask person to open hand without hyperextending it; then release pressure on ulnar artery while maintaining pressure on radial artery <> Adequate circulation is suggested by a return to hand's normal color in approximately 2 to 5 seconds <> Although test is simple and useful, it is relatively crude and subject to error

Assessment: Percuss Cardiac Borders

-Used to outline heart's borders (e.g., LBCD) -Chest x-ray or echocardiogram much more accurate in detecting heart enlargement -Place your stationary finger in person's fifth intercostal space over on left side of chest near anterior axillary line -Slide your stationary hand toward yourself, percussing as you go, noting change in percussion note

Palpation of Sinus Areas

-Using thumbs, press frontal sinuses by pressing up and under the eyebrows and over maxillary sinuses below cheekbones.

Palpation of the Aorta

-Using your opposing thumb and fingers, palpate aortic pulsation in upper abdomen slightly to left of midline -Normally it is 2.5 to 4 cm wide in adult and pulsates in an anterior direction

Developmental Considerations: Aging Woman

-Uterus shrinks in size because of decreased myometrium -Ovaries atrophy to 1 to 2 cm and are not palpable after menopause <> Ovulation still may occur sporadically after menopause -Uterus droops as sacral ligaments relax and pelvic musculature weakens <> Sometimes it may protrude, or prolapse, into vagina <> Cervix shrinks, looks paler, thick, glistening epithelium

Peripheral Vascular System and Lymphatics

-Vascular system consists of vessels <> Vessels are tubes for transporting fluid, such as blood or lymph [] For blood [[[]]] Arteries - deliver oxygen and nutrients to tissues [[[]]] Veins - eliminate waste products from cellular metabolism [] For lymph - retrieve excess fluid from tissue spaces and return it to the blood

Structure and Function: Venous Flow

-Veins drain deoxygenated blood and its waste products from tissues and return it to heart <> Veins are called capacitance vessels because of their ability to stretch <> In the legs, this mechanism is called calf pump or peripheral heart -Hypercoagulable states and vein wall trauma lead to increased risk for venous disease -Varicose veins <> Dilated and tortuous <> Have incompetent valves leading to increased venous pressure, which further dilates the vein

Conditions Resulting in Murmur

-Velocity of blood increases (flow murmur), for example, in exercise, thyrotoxicosis -Viscosity of blood decreases, for example, in anemia -Structural defects in valves, narrowed valve, incompetent valve -Unusual openings occur in chambers, dilated chamber, wall defect

Cardiac Cycle: Diastole

-Ventricles relaxed, and AV valves, tricuspid and mitral, are open; opening of normal valve is silent -Pressure in atria higher than that in ventricles, so blood pours rapidly into ventricles -Toward end of diastole, atria contract and push last amount of blood into ventricles <> This active filling phase or atrial systole -Note that atrial systole occurs during ventricular diastole, a confusing but important point

Cardiac Cycle: Systole

-Ventricular pressure becomes higher than that in atria, so mitral and tricuspid valves close -Closure of AV valves contributes to first heart sound (S1) and signals beginning of systole <> AV valves close to prevent any regurgitation of blood back up into atria during contraction -For a very brief moment, all four valves are closed and ventricular walls contract <> Isometric contraction: this contraction against closed system works to build high level pressure in ventricles

Posterior Thoracic Landmarks

-Vertebra prominens: flex your head and feel for most prominent bony spur protruding at base of neck. <> This is spinous process of C7. <> If two bumps seem equally prominent, upper one is C7 and lower one is T1. -Spinous processes: stack together to form spinal column.

Spine and Vertebrae

-Vertebrae are 33 connecting bones stacked in a vertical column <> 7 cervical <> 12 thoracic <> 5 lumbar <> 5 sacral <> 3 to 4 coccygeal -Can feel spinous processes in furrow down midline of back

Posterior Column Tract

-Vibration: test person's ability to feel vibrations of tuning fork over bony prominences <> Compare right side with left side; if you find a deficit, note whether gradual or abrupt <> Position (kinesthesia): test person's ability to perceive passive movements of extremities -Tactile discrimination (fine touch): tests also measure discrimination ability of sensory cortex <> Stereognosis: test person's ability to recognize objects by feeling their forms, sizes, and weights <> Graphesthesia: ability to "read" a number by having it traced on skin <> Two-point discrimination: test ability to distinguish separation of two simultaneous pin points on skin <> Extinction: simultaneously touch both sides of body at same point; normally both sensations are felt <> Point location: touch skin and withdraw stimulus promptly; ask person to put finger where you touched

Visceral Sources of Pain

-Visceral pain originates from larger interior organs (i.e., kidney, stomach, intestine, gallbladder, pancreas) <> dull, deep, squeezing pain -Pain can stem from direct injury to organ or from stretching of organ from tumor, ischemia, distention, or severe contraction -Pain impulse transmitted by ascending nerve fibers along with nerve fibers of autonomic nervous system -That is why visceral pain often presents with autonomic responses such as vomiting, nausea, pallor, and diaphoresis -Pain sources based on their origin <> Pain that is felt at a particular site but originates from another location is termed referred pain <> For example, an inflamed appendix in right lower quadrant of abdomen may have referred pain in periumbilical area

Developmental Considerations: Pregnant Woman

-Vital signs usually yield an increase in resting pulse rate of 10 to 15 bpm and drop in BP from normal prepregnancy level -Palpation of apical impulse is higher and lateral compared with normal position <> Heart sounds [] Exaggerated splitting of S1 and increased loudness of S1 [] A loud, easily heard S3

Effect of Respiration

-Volume of right and left ventricular systole is just about equal but can be affected by respiration <> To learn this, consider the phrase: More to the right heart, less to the left -That means that during inspiration, intrathoracic pressure is decreased -This pushes more blood into vena cava, increasing venous return to right side of heart, which increases right ventricular stroke volume -Increased volume prolongs right ventricular systole and delays pulmonic valve closure -Meanwhile, on left side, greater amount of blood sequestered in lungs during inspiration -This momentarily decreases amount returned to left side of heart, decreasing left ventricular stroke volume -Decreased volume shortens left ventricular systole and allows aortic valve to close a bit earlier -When aortic valve closes significantly earlier than pulmonic valve, you can hear two components separately; this is a split S2

Additional History Questions: Infants and Children

-Was there any trauma to infant during labor and delivery? Did infant come head first? Was there any need for forceps? -Did infant need resuscitation? -Were infant's motor milestones achieved at about same time as siblings or age-mates? -Has child ever broken any bones? Had dislocations? How were these treated? -Have you noticed any bone deformity? Spinal curvature? Unusual shape of toes or feet?

A Safer Environment: Hand Hygiene

-Wash your hands—This is the single most important step to decrease microorganism transmission <> Before and after physical contact with each patient <> After inadvertent contact with blood, body fluids, secretions, and excretions <> After contact with any equipment contaminated with body fluids <> After removing gloves

Abnormal Findings: Variations in Arterial Pulse

-Weak, "thready" pulse, 1+ -Full, bounding pulse, 3+ -Pulsus bigeminus -Pulsus alternans -Pulsus paradoxus

A Safer Environment: Gloves

-Wear gloves <> When potential exists for contact with any body fluids, for example, blood, mucous membranes, body fluids, drainage, and open skin lesions <> Wearing gloves is not a protective substitute to washing hands <> Wear a gown, mask, and protective eyewear when potential exists for any blood or body fluid spattering

Skin Function

-skin is waterproof, adaptive, and protective <> Protection from environment <> Protection from penetration <> Temperature regulation <> Absorption and excretion <> Production of vitamin D <> Identification <> Perception <> Communication <> Wound repair

Additional History for Adolescents

-What do you eat at regular meals? Do you eat breakfast? What do you eat for snacks? <> How many calories do you consume per day? <> What is your exercise pattern? <> If weight is less than body requirements: How much have you lost? By diet, exercise, or other means? [] How do you feel? Tired? Hungry? How do you think your body looks? [] What is your activity pattern? [] Is weight loss associated with any other body change, such as menstrual irregularity? [] What do your parents and friends say about your eating?

Light and Deep Palpation of Abdomen

-With either technique, note location, size, consistency, and mobility of any palpable organs and presence of any abnormal enlargement, tenderness, or masses -Making sense of what you are feeling is more difficult than it looks -Inexperienced examiners complain that abdomen "all feels same," as if they are pushing their hand into a soft sofa cushion -Helps to memorize anatomy and visualize what is under each quadrant as you palpate -Also remember that some structures are normally palpable -Mild tenderness is normally present when palpating sigmoid colon -Any other tenderness should be investigated -If you identify a mass, first distinguish it from a normally palpable structure or an enlarged organ -If you identify a mass, then note the following: <> Location, Size, Shape <> Consistency: soft, firm, hard <> Surface: smooth, nodular <> Mobility, including movement with respirations <>Pulsatility, Tenderness

Popliteal Pulse

-With leg extended but relaxed, anchor your thumbs on knee, and curl your fingers around into popliteal fossa -Press your fingers forward hard to compress artery against bone (lower edge of femur or upper edge of tibia); often it is just lateral to the medial tendon -If you have difficulty, turn person prone and lift up lower leg; let leg relax against your arm and press in deeply with your two thumbs -Often normal popliteal pulse is impossible to palpate

Assessment of TMJ

-With person seated, inspect area just anterior to ear -Place tips of first two fingers in front of each ear and ask person to open and close mouth -Drop fingers into depressed area over joint, and note smooth motion of mandible -Audible and palpable snap or click occurs in many healthy people as mouth opens -Palpate contracted temporalis and masseter muscles as person clenches teeth -Compare right and left sides for size, firmness, and strength -Ask person to move jaw forward and laterally against your resistance, and to open mouth against your resistance <> This tests integrity of cranial nerve V (trigeminal nerve)

Physical Examination: Capillary Refill

-With person's hands near level of the heart, check capillary refill <> An index of peripheral perfusion and cardiac output <> Depress and blanch nail beds; release and note time for color return <> Usually vessels refill within a fraction of a second <> Normal if color returns in less than 1 or 2 seconds <> Note conditions that can skew your findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia

Breast Cancer Risk Factors

-Women who inherit mutations of BRCA1 and BRACA2 on one or both sides are at an increased risk for developing breast or ovarian cancer. -Screening mammography annual screening is recommended starting at age 40. -Lifestyle risk factors relate to risk. <> Alcohol has dose-dependent effect. <> Continuation of physical exercise during aging helps reduce risk. <> Postmenopausal weight gain negates effects of physical exercise.

Wrists and Carpals

-Wrist, or radiocarpal joint: articulation of radius on thumb side and row of carpal bones <> Condyloid action permits movement in two planes at right angles: flexion and extension, and side-to-side deviation -Midcarpal joint: articulation allows flexion, extension, and some rotation -Metacarpophalangeal and interphalangeal joints permit finger flexion and extension -Flexor tendons of wrist and hand enclosed in synovial sheaths

The Health History Sequence (8)

-biographical data -source of history -reason for seeking care -present health or history of present illness -past health -family history -review of systems -functional assessment including activities of daily livings

Successful Interview Characteristics

-gather complete and accurate data about person's health state, including description and chronology of any symptoms of illness -establish rapport and trust so person feels accepted and free to share all relevant data -teach person about health state so that he or she may participate in identifying problems -build rapport to continue therapeutic relationship and to facilitate future diagnosis, planning and treatment -begin teaching for health promotion and disease prevention

Nursing Process-- Assessment

-collection of data from multiple sources <> interview, health history, physical examination, functional assessment, cultural and spiritual assessment, review of clinical record, consultation, review of the literature -evidenced based assessment <> current and best clinical practice based on research standards focused on systematic reviews of randomized clinical trials (RCTs) <> utilizing evidenced based practice (EBP) in conjunction with provider experience will lead to better health outcomes for patients -expanding the concept of health <> assessment: collection of data about an individuals health state <> a clear idea of health is important because it determines assessment data to be collected -holistic model of health <> mind, body, spirit are interdependent and function as a whole <> multifaceted basis of disease <> individual and human environment are open systems <> expanded assessment factors such as life lifestyle, behavior, culture and values, family and social roles, self care behaviors, job related stress, developmental tasks, failures and frustrations of life <> health promotion and disease prevention form the core of nursing -assessment: ongoing process <> subjective data: what patient say about himself or herself <> objective data: observed when inspecting, percussing, palpating, and auscultating patient during physical examination <> database: formed from these elements (subjective and objective data), plus patients record and laboratory studies

Collecting Types of Data

-complete total health <> includes complete health history and full physical examination <> describes current and past health state and forms baseline to measure all future changes <> yields first diagnosis -episodic/problem centered/focused <> for limited or short term problems <> collect "mini" database, smaller scope and more focused than complete database <> concerns mainly one problem, one cue complex, one body system <> history and examination follow direction of presenting concern -follow up <> status of all identified problems should be evaluated at regular and appropriate intervals <> note changes that have occurred <> evaluate whether problem is getting better or worse <> identify coping strategies being used -emergency <> diagnosis must be rapid and comprehensive in nature <> rapid collection of data, often compiled concurrently with lifesaving measures -also shift assessments and screening assessments -EXP: patient comes in overdosed, ask "what did you take?" "how much?" "when?"

Nociceptive Pain

-develops when functioning and intact nerve fibers in the periphery and the CNS are stimulated -can develop into neuropathic pain over time if not treated properly

Nursing Process-- Planning

-establish priorities -develop outcomes and set time frames -identify relative interventions and utilize interdisciplinary health care team members -document a plan of care

General Survey Characteristics

-general survey is a study of the whole person <> Covers general health state and any obvious physical characteristics [] An introduction for physical examination that will follow; should give an overall impression, a "gestalt," of person [] Objective parameters are used to form general survey, but these apply to whole person, not just to one body system -launch a general survey as soon as you encounter a person

Structure: Epidermal Appendages

-hair follicles and hair -sebaceous gland -sweat glands: important for fluid balance and thermoregulation <> eccrine: produce saline sweat <> apocrine: produce perspiration

Nursing Process-- Outcome Identification

-identify expected outcomes related to patient individualization -ensure outcomes are realistic and measurable -specify short term and long term goal measurement criteria

Interview Goal Identification

-identify health strengths and problems as a bridge to physical examination <> first and most important part of data collection <> collects subjective data: what patients say about his or her own perceived health state <> individual knows everything about his or her own health state, nurse knows nothing

Nursing Process-- Diagnosis

-interpretation of data by identifying clusters of cues to make inferences -cues: a piece of information, sign or symptom or a piece of lab data -hypothesis: a tentative explanation for a cue or set of cue that can be used as a basis for further investigation - diagnostic reasoning: is the process of analyzing health data and drawing conclusions to identify diagnosis -compare clusters of cues with definitions and defining characters -validation of inferences based on findings -identify related factors -document the diagnosis -priority problem level <> *first level priority*: emergent, life threatening, and immediate <> *second level priority*: next in urgency, requiring attention so as to avoid further deterioration <> *third level priority*: important to patients health but can be addressed after more urgent problems are addressed <> collaborative problems: approach to treatment involves multiple disciplines

The Interview Contract Terms

-introduction of and explanation of health care provider's role -purpose of interview -how long will it take -time and place of interview and physical examination -expectation of participation for each person -presence of others (family) -confidentiality and to what extent it may be limited -any caption that the patient must pay

Skin Changes with Pregnancy

-linea nigra: Increased pigmentation midline of abdomen -Chloasma <> Discoloration changes on face representing the "mask of pregnancy" -Striae gravidarum <> Stretch marks, which can develop over the abdomen, breast, and thighs

Nociceptors Fibers

-located primarily within the skin, joints, connective tissue, muscle, thoracic, abdominal, and pelvic viscera -Aδ fibers are myelinated and larger in diameter, and they transmit pain signal rapidly to CNS; localized, short-term, and sharp sensations result from Aδ fiber stimulation -In contrast, C fibers are unmyelinated and smaller, and transmit signal more slowly; sensations are diffuse and aching, and they persist after initial injury -Peripheral sensory Aδ and C fibers enter spinal cord by posterior nerve roots within dorsal horn by tract of Lissauer -Fibers synapse with interneurons located within a specified area of cord called substantia gelatinous

Primary Skin Lesions

-macules (flat) -papules (raised) -patches (larger raised area) -nodules (raised, little bumps) -plaques -wheals (around allergic response) -tumors (large lump) -vesicles (blisters) -urticarcia (hives; large area; raised) -bullas (large blisters >1cm; possibly fluid filled) -pustules (full of pus) -cysts (lump, closed fluid filled)

Bones of the Head

-occipital bone -zygomatic bone -frontal bone -maxilla and mandible -parietal -temporal

Somatic Sources of Pain

-pain source based on their origin <> Deep somatic pain comes from sources such as blood vessels, joints, tendons, muscles, and bone [] aching or throbbing <> Injury may result from pressure, trauma, or ischemia <> Cutaneous pain derived from skin surface and subcutaneous tissues; injury is superficial, with a sharp, burning sensation <> Linking pain to a mental disorder (psychogenic pain) negates person's pain report -referred pain: pain that is felt at a particular site but originates in a different location

Reason for Seeking Care

-person's own words describing reason for visit -symptom: subjective sensation person feels from disorder -Sign: objective abnormality that can be detected on physical examination or in laboratory reports

Process of Communicating: Receiving

-receiver attaches meaning determined by his or her past experiences, culture, self concept, and current physical and emotional state -successful communication requires mutual understanding by sender and receiver -patients health problems intensify communication because patients depend on you to get better

Source of History

-record who furnishes information, usually the person -judge reliability of informant and how willing he or she is to communicate -note any special circumstances, such as use of interpreter

Nursing Process-- Evaluation

-refer to established outcomes -evaluate individuals condition and compare actual outcomes with expected outcomes -summarize results of evaluation -identify reasons for failure to achieve expected outcomes -take corrected action to modify plan of care -document evaluation in plan of care -continuously evaluate whether you are on the right track and correct any missteps or misinterpretation of data

Increased Intracranial Pressure

-signs & symptoms of increase ICP <> diminished level of consciousness <> headache, vomiting, seizure -cushing's triad <> bradycardia <> hypertension <> abnormal respiration -pupillary changes -papilledema

The Interview

-subjective data collection; most important part of data collection -patient's perception of health -first step in therapeutic relationship -succesful interviews: 1. allow you to gather complete and accurate data about the person's health state 2. establish trust 3. educate person about his/her health state 4. build report for a continuing therapeutic relationship 5. discuss health promo and disease prevention

Synovial Joints- 6 types

1. plane/gliding 2. saddle 3. hinge 4. pivot 5. ball & socket 6. ellipsoid

Other Assessments of Interest

Assessing those in pain Alleviating pain should be a priority Premedication may be required Positioning for comfort Using age appropriate pain scale-"gold standard"-patient self report Altered cognition Difficulty in obtaining accurate information from patient Involve the caregiver in the assessment dialogue Split assessments into smaller categories to perhaps get a better understanding of how patient is understanding questions Assessment at end of life

Abnormal Findings: Rectum

Abscess Rectal polyp Fecal impaction Carcinoma

Wells Score for Leg DVT

Active cancer (treatment ongoing, within 6 months or palliative): 1 Paralysis, paresis, or recent plaster immobilization of LE: 1 Recently bedridden >3d or major surgery within 12 weeks requiring general or regional anesthetic: 1 Localized tenderness along the distribution of the deep venous system: 1 Swelling of entire leg: 1 Calf swelling >3cm larger than asymptomatic side (measured 10cm below tibial tuberosity): 1 Pitting edema confined to the symptomatic leg: 1 Collateral superficial veins (non-varicose): 1 Previously documented DVT: 1 Alternative diagnosis at least as likely as DVT: -2

Subjective Questions

Any earache or other pain in ears? Infections? Discharge? Tinnitus? Vertigo? Ever had any trouble hearing? Do you have any hearing aid or other device? How does loss affect your daily life? Any loud noises at home or on the job? Do you take any steps to protect your ears, such as headphones or ear plugs?

Subjective Data

Appetite Dysphagia Food intolerance Abdominal pain Nausea and vomiting Bowel habits Past abdominal history Medications Nutritional assessment

Additional History Questions: Adolescents

Are you involved in any sports at school or after school? How frequently? Do you use any special equipment? Does any training program exist for your sport? What is the nature of your daily warm-up? What do you do if you get hurt? How does your sport fit in with other school demands and other activities?

History Taking: Subjective Data

Chest pain Dyspnea Orthopnea Cough Fatigue Cyanosis or pallor Edema Nocturia Past cardiac history Family cardiac history Personal habits (cardiac risk factors)

Additional History: Preadolescents & Adolescents

Do you and your boyfriend have intercourse? Are you using condoms? What kind of protection did you use the last time you had sex? Has anyone ever talked to you about sexually transmitted infections, such as chlamydia, herpes, gonorrhea, or AIDS? Have you and your parents discussed the human papillomavirus vaccine? It is recommended before girls become sexually active. Sometimes a person touches a girl in a way that she does not want them to. If that happens, the girl should remember it is not her fault. She should tell another adult about it. Has that ever happened to you?

Health Promotion

Foot care: Check your feet daily. If you are unable to see the bottoms of your feet, use a mirror or ask someone to help you. Dry feet carefully after a shower or bath. Examine each foot for red spots or sensitive areas, discoloration of skin or nails, ingrown nails, pain, cuts, swelling, or blisters. Keep toenails trimmed, straight across, and filed at the edges with an emery board or nail file. Chipped nail polish may support the growth of larger numbers of organisms on nails. This is especially important for those already at risk for infection. Do not use nail polish to cover up discolored nails. Nail polish locks out moisture and keeps the nail bed from being able to 'breathe'. Walking is a great way to exercise your feet or try foot exercises such as: Sitting down and rotating your ankles in one direction, then the other, or try writing the alphabet from A to Z! In bare feet curl your toes and spread them out. When an individual is not able to walk, putting the feet up when sitting or lying down, stretching, wiggling toes, or having a gentle foot massage or warm foot bath is a great alternative. Wearing shoes that fit and are comfortable. The best time to measure feet is toward the end of the day, when feet tend to be the largest. Individuals often have one foot that is larger than the other. They should fit their shoes to the larger foot. Select shoes that are shaped like one's feet. The ball of the foot should fit comfortably into the widest part of the shoe. Toes should not be crowded. For women, low-heeled shoes are safer and less damaging than high-heeled shoes. Use mild soap. Be careful about adding oils to bath water. They can make your feet and the bathtub both very slippery. A thin coat of skin lotion over the tops and bottoms of one's feet help to keep skin soft and smooth.

Palpation of Neck: Lymph Nodes

Normal nodes feel movable, discrete, soft, and nontender If any nodes are palpable, note

PQRSTU Mnemonic

P = Provocative or palliative <> what brings it on? what were you doing when you first noticed it? what makes it better? worse? Q = Quality or quantity <> how does it look, feel, sound? how intense or severe is it? R = Region or radiation <> where is it? does it spread anywhere? S = Severity scale: 1 to 10 <> how bad is it from 1-10? is it getting better, worse, or the same? T = Timing or onset <> when did it first occur? how long did it last? U = Understand patient's perception of problem <> what do you think it means?

Subjective Data Health History Questions

Past history of skin disease, allergies, hives, psoriasis, or eczema? Change in pigmentation or color, size, shape, tenderness? Excessive dryness or moisture? Pruritus or skin itching? Excessive bruising? Rash or lesions? Medications: prescription and over-the-counter? Hair loss? Change in nails' shape, color, or brittleness? Environmental or occupational hazards? Self-care behaviors?

Abnormalities of External Genitalia

Pediculosis pubis, crab lice Herpes simplex virus, type 2 herpes genitalis HPV warts (condylomata) Urethritis Uterine prolapse Candidiasis

Abnormal Findings: Anus and Perianal Region

Pilonidal cyst or sinus Anorectal fistula Fissure Hemorrhoids Rectal prolapse Pruritus ani

Additional History Questions: Aging Adult

Use functional assessment history questions to elicit any loss of function, self-care deficit, or safety risk Have you had any change in weakness over past months? Have you had any increase in falls or stumbling in past months? Do you use any mobility aids to help you get around such as a cane or walker?

Subjective Data Questions

Usual bowel routine Change in bowel habits Rectal bleeding, blood in stool Medications: laxatives, stool softeners, iron Rectal conditions: pruritus, hemorrhoids, fissure, fistula Family history Self-care behaviors: diet of high-fiber foods, most recent examinations

Subjective Data

Vaginal discharge Past history Sexual activity Contraceptive use Sexually transmitted infection (STI) contact STI risk reduction Menstrual history Obstetric history Menopause Self-care behaviors Acute pelvic pain Urinary symptoms