Study guide - Physical Assessment Midterm Week 9 Chap 1-11 (Jarvis)

why you use a different side of the stethoscope to hear low pitched or high pitched sounds

!! • Use the stethoscope's diaphragm for high-pitched sounds, such as breath, bowel, and normal heart sounds. Use the stethoscope's bell for soft, low-pitched sounds, such as extra heart sounds or murmurs. !!

Nutritional assessment tools/questionnaires

(● 24 hour dietary recall (Easiest and most used) ● 3 day food record +++not used for culturally diverse backgrounds) ● Food frequency Questionnaire ● Food Diary ● Nutrition Screening ● 1st step ● Identify those at nutrition risk ● Weight and weight history ● Conditions associated with increased nutritional risk ● Diet information ● Routine lab data ● Those at nutritional risk: ● Comprehensive nutritional assessment o Dietary history o Clinical info o Physical examination o Anthropometric measures o Lab tests ● Direct Observation ● Ø Malnutritution Screening Tool...validated for use in adult acute-care patients ● Ø Mini Nutritional Assessment (MNA)...designed and validated for use in older adults in long-term care and community settings ● Ø Admission Nutrition Screening Tool...validated use by nurses I hospital settings ● Ø Nutrition Screening Initiative...designed and validated in outpatient, geriatric population ● Ø Comprehensive Nutritional Assessment...Dietary history and clinical information, Physical examination for clinical signs, Anthropometric measures, Laboratory Tests ● Ø Various methods for collecting current dietary intake information: ● · 24-hour recall ● · food frequency questionnaire ● · food diaries ● · direct observation

Health promotion and disease prevention concept and goals

*Self-responsibility *Control communicable disease *Protect the environment *Modify personal behavior *Prevent severity of chronic *noncommunicable conditions ● Round out our concept of health ● Guidelines to prevention emphasize the link between health and personal behavior ● Prevention can be achieved through: ● counseling from primary care providers designed to change people's unhealthy behaviors related to smoking, alcohol, and other drug use, lack of exercise, poor nutrition, injuries, and STD. ● Health promotion is: ● a set of positive acts that we can take ● (Teaching and helping the patient choose a healthier lifestyle)

Subjective Findings

1) History (subjective data) "patient states." what the person says about him/herself during the history taking

Health history components and what each component tells us about the patient (Second Version)

1. Biographic data ● Name ● Address ● Phone # ● Age ● Birthdate ● Birth place ● Martial status ● Race ● Ethnic origin ● Occupation o (Record who furnishes the info and the reliability) 2. Reason for seeking care ● Subjective statement that describes why they are there use " " when documenting ● States a symptom or sign and their duration ● Symptom o A subjective sensation that the person feels from the disorder ● Sign o Objective abnormality that you as the examiner could detect on phys examination or in lab reports. 3. Present health or history of present illness (PQRSTU)-( Also # 23) ● Location o Localized or radiating o Superficial or deep ● Character or quality o Burning, sharp, dull, aching, knowing, throbbing, shooting o Use similes : "look like" ● Quantity or severity o Pain scale ● Timing o Onset o Duration o Frequency ● Setting o Where did it happen or what were they doing when pain occurred ● Aggravating or relieving factors o What makes pain worse/ better ● Associated factors ● Patients perception o How has it affected the pt

CIWA - Clinical Institute Withdrawal Assessment for Alcohol

1.Nausea and vomiting 2.Tremor 3.Paroxysmal sweats 4.Anxiety 5.Agitation 6.Tactile disturbances 7.Auditory disturbances 8.Visual disturbances 9.Headache 10.Orientation and clouded sensorium The Clinical Institute Withdrawal Assessment for Alcohol, commonly abbreviated as CIWA or CIWA-Ar (revised version), is a ten item scale used in the assessment and management of alcohol withdrawal.[1][2] Each item on the scale is scored independently, and the summation of the scores yields an aggregate value that correlates to the severity of alcohol withdrawal, with ranges of scores designed to prompt specific management decisions such as the administration of benzodiazepines. The maximum score is 67; Mild alcohol withdrawal is defined with a score less than or equal to 15, moderate with scores of 16 to 20, and severe with any score greater than 20. The ten items evaluated on the scale are common symptoms and signs of alcohol withdrawal, and are as follows:

BMI ranges and definitions

17. BMI ranges and definitions ● A practical marker of optimal health weight for height and an indicator of obesity or malnutrition. ● Underweight o <18.5 kg/m2 ● Normal o 18.5 - 24.9 kg/m2 ● Overweight o 25- 29.9 kg/m2 ● Obesity Class 1 o 30- 34.9 kg/m2 ● Obesity Class 2 o 34- 39.9 kg/m2 ● Extreme Obesity Class 3 o > 40

Objective Findings

2) Examination (objective data) what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical exam (WB p2)

PQRST (Second Version)

23. PQRST pain assessment (what each of the letters means and what you would ask) ● Refer to #11 sub # 3 ● 1. PQRST pain assessment (what each of the letters means and what you would ask) ● Ø P= Provokes/Palliation...What where you doing when the pain started? What causes pain? What makes it better? Worse? What trigger it? Stress? Position? Certain activity? What relieves it? Medication, massage, position, resting? What aggravates it? Walking, standing, lying down, bending, movement? ● Ø Q= Quality/Quantity... What does it feel like? Is it sharp? Dull? Stabbing? Burning? Throbbing? Nauseating? Shooting? Crushing? ● Ø R= Radiates/Region... Where does the pain radiate? Is it in one place? Does it go anywhere else? Did it start elsewhere and now localized to one spot? ● Ø S= Severity... How sever is the pain on a scale of 1-10? Does it interfere with acitivies? How bad is it at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last? ● Ø T= Time... Time pain started? How long did it last? How often does it occur: hourly? Daily? Weekly? Monthly? Is it sudden or gradual? Are you ever awakened by it?

4 functions of percussing:

4 functions of percussing: 1. location & size of an organ 2. density of a structure 3. detecting an abnormal mass 4. eliciting a deep tendon reflex using percussion hammer.

?? Table 6-7 - Clinical signs of substance abuse disorders (pp.98-99) Look in book- Alot of info

?? Table 6-7 - Clinical signs of substance abuse disorders (pp.98-99) Look in book- Alot of info

What evidence based practice means

A systematic approach emphasizing the best research evidence, the clinician's experience, patient preferences and values, physical examination, and assessment ● A systematic approach to practice that emphasizes the use of 4 aspects o (1) physical examination and assessment of patient o (2) evidence based from research and evidence-based theories o (3) clinician's experience o (4) patient preferences and values to make decisions about care and treatment

Steps of the nursing process (ADPIE) and what is included in each Including "O"

A= assessment data D= nursing diagnosis (O = Outcome Identification) P= plan I= implementation of care E= evaluation of care

Normal Respirations

Adult: 12-20 Newborn: 30-60 Children: 20-30

What is associated with tympany?

Air-filled viscus, such as the stomach and intestines

Anthropometric measures, most commonly used (those that we did in lab)

Anthropometric measures, most commonly used (those that we did in lab) ● Percent usual body weight ● = Current weight x100 Usual weight ● BMI ● Weight (#) height (in.) ● Waist to hip ratio ● Waist circumference Hip Circumference ● Waist : Measured just above the iliac crests of the hips (in.) ● Hip: Measured at largest portion of butt (in.) ● Skin fold thickness - didn't do in class ● Arm Span or total arm length ● Equivalent to height ● distance from sternal notch to longest finger on the dominant hand and multiply the number by 2.8

A (ADPIE)

Assessment - A the collection of data about an individual's health state 1.Collect data: *Review the clinical record *Health History *Physical Examination *Functional Assessment *Risk Assessment *Review of the literature 2.Use Evidence-based assessment techniques 3.Document relevant data (Book p1) Use evidence based assessment technique o Document relevant data

Two end pieces of the stethoscope and when their used:

Bell: used for low-pitched sounds - extra heart sounds and heart murmurs; light pressure needed. Diaphragm: used for high-pitched sounds - breathing, bowels, and heart; firm pressure needed.

Alcohol use screening questions (like CAGE, AUDIT)

CAGE Test -Have you ever thought you should (C)ut down your drinking? -Have you ever been (A)nnoyed by criticism of your drinking? -Have you ever felt (G)uilty about your drinking? -Do you drink in the morning, an (E)ye opener? If answer 2 or more then suspect alcohol abuse and continue with a more complete substance abuse assessment (Book pg58) The AUDIT questionnaire is a quantitative form with 10 questions that cover alcohol consumption, drinking behavior or dependence, and adverse consequences of alcohol. 1 AUDIT questionnaire: screen for alcohol misuse1 Please circle the answer that is correct for you 1. How often do you have a drink containing alcohol? · Never · Monthly or less · 2-4 times a month · 2-3 times a week · 4 or more times a week 2. How many standard drinks containing alcohol do you have on a typical day when drinking? · 1 or 2 · 3 or 4 · 5 or 6 · 7 to 9 · 10 or more 3. How often do you have six or more drinks on one occasion? · Never · Less than monthly · Monthly · Weekly · Daily or almost daily 4. During the past year, how often have you found that you were not able to stop drinking once you had started? · Never · Less than monthly · Monthly · Weekly · Daily or almost daily 5. During the past year, how often have you failed to do what was normally expected of you because of drinking? · Never · Less than monthly · Monthly · Weekly · Daily or almost daily 6. During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session? 2 · Never · Less than monthly · Monthly · Weekly · Daily or almost daily 7. During the past year, how often have you had a feeling of guilt or remorse after drinking? · Never · Less than monthly · Monthly · Weekly · Daily or almost daily 8. During the past year, have you been unable to remember what happened the night before because you had been drinking? · Never · Less than monthly · Monthly · Weekly · Daily or almost daily 9. Have you or someone else been injured as a result of your drinking? · No · Yes, but not in the past year · Yes, during the past year 10. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down? · No · Yes, but not in the past year · Yes, during the past year Scoring the audit--- Scores for each question range from 0 to 4, with the first response for each question (eg never) scoring 0, the second (eg less than monthly) scoring 1, the third (eg monthly) scoring 2, the fourth (eg weekly) scoring 3, and the last response (eg. daily or almost daily) scoring 4. For questions 9 and 10, which only have three responses, the scoring is 0, 2 and 4 (from left to right). A score of 8 or more is associated with harmful or hazardous drinking, a score of 13or more in women, and 15 or more in men, is likely to indicate alcohol dependence. 1Saunders JB, Aasland OG, Babor TF et al. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption — II. Addiction 1993, 88: 791-803.

PQRST pain assessment (what each of the letters means and what you would ask)

Chief Complaint Mnemonics (PQRST) P-Provocative or palliative-what provokes or relieves the symptom Q-Quality or Quantity-what does the symptom feel like, look like, or sound like R-Region or radiation, where in the body does the symptom occur S-Severity-rate the symptom T-Timing-when did the symptom begin

Child abuse evaluation - type of injury vs. developmental level of child

Child abuse evaluation - type of injury vs. developmental level of child ● Babies- Those who cant walk (cruising) : ● Should have no bruises ● Infants younger than 9 months who can not cruise yet should have NO BRUISING o Alert you to ask about the injury or underlying medical illness ● Children who walk: ● Common ● Concerning: o Buttocks o Hands o Feet o Abdomen ● Children younger than 4, bruising on torso, ears , and neck or any bruising on infant is correlated with abuse ● Bruise that resembles a shape is a flag ● Mongolian Spots: ● Common in Asian, African, or Mediteranean ● Blue-gray appearance ● Found on buttocks and lower back ● Fade after time, do not cause pain ● Henoch Scholen Purpura ● A vasculitis of the small blood vessels ● Present a rash that starts on lower part of body and mimic a bruise ● Malaise, abdominal pain, and arthralgias may be present ● Drug eruptions may mimic burns, bruises, and blisters

E (ADPIE)

Evaluation - E 1. Progress toward outcomes 2. Conduct systematic, ongoing, criterion-based evaluation 3. Include patient and significant others 4. Use ongoing assessment to revise diagnoses, outcomes, plan 5. Disseminate results to patient and family

Health history components and what each component tells us about the patient Shorter version

HH is to collect subjective data, which is what the person says about himself or herself. By combining this subjective data with objective data from the physical examination and diagnostic tests, *you create a database to make a judgment about the person's health status. (B p49) History Components and Sequence -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 living (ADLs)Biographical data What each component tells us about the Patient 1. Source of history - how reliable the information may be 2.Reason for seeking care - Help determine the most pressing concern 3.Present health or history of present illness -Determine symptoms ---PQRST (any symptoms) ---U (understanding) (B pg 51) 4.Past health - May residual effects on current health 5. Family history - highlights diseases and conditions Pt may be at increased risk for 6. Review of systems - evaluate the past and present health state of each body system -double check in case any significant data were omitted in the Present Illness section -evaluate health promotion practices 7. Functional assessment including activities of daily living (ADLs)measures a person's self-care ability in the areas of general physical health or absence of illness (ADL's)

I (ADPIE)

Implementation -I 1. Implement in a safe and timely manner 2. Collaborate with colleagues 3. Use community resources 4. Coordinate care delivery 5. Provide health teaching and promotion 6. Document implementation and any modification

Interview process, sequence, distance

Interview process ● Gather complete and accurate data about the person's health state, including the description and chronology of any symptoms of illness ● Establish trust so the person feels accepted thus free to share all relevant data ● Teach the person about his or her health state ● Build rapport for continuing therapeutic relationships; this rapport facilitates future diagnoses, planning and treatments ● Discuss health promotion and disease prevention ● Elements of interview process: o Nonverbal skills o Physical app o Gestures o Facial expression o Eye contact o Voice o Touch o Closing the interview Sequence ● 3 phases: introduction - introduce yourself, your role, and give reason for interview. a. Working phase - gather data first with open-ended questions then closed or direct questions. b. Closing phase - signal that the interview is ending and summarize what you learned Distance ● 4-5 feet is ideal 8. Communication skills used in the interview (Refer to Paul's Quizlet answer) ● Communication is based on behavior, conscious and unconscious and all behavior has meaning. ● Includes sending and receiving information by verbal and nonverbal communication. -Nonverbal is your body language and is under less conscious control than verbal and may be more reflective of true feelings. -Internal factors are those specific to you as the examiner

Signs of IPV

Intimate Partner Violence (IPV) Physical: *neurologic, *gynecologic, *obstetric, *GI, *musculoskeletal, *poor hygiene, *missed/changed appointments, *psychiatric, *constitutional, *obvious trauma, *and other signs *Suspect IPV when she says no to (abuse assement screen) AAS, but there are other indicators associated with IPV In addition, providers need to be alert for conditions associated with IPV including the following: Gynecologic problems, especially STIs, pelvic pain, and complaints of sexual dysfunction Chronic irritable bowel syndrome, back pain, depression, symptoms of PTSD, problems sleeping, panic attacks, or nerves -------------------------------------------------- CUES of abuse (not necessarily signs) *Hesitation in providing detailed information about injury *Inappropriate affect *Defensive injuries *Delayed reporting of symptoms *Pattern of injury consistent with abuse *Inappropriate explanation for injuries *Vague complaints without accompanying pathology *Lack of eye contact *Signs of increased anxiety in presence of possible batterer

Tympany

Loud amplitude, high pitch, musical and drumlike quality, longest duration

Hyperresonant

Louder amplitude, lower pitch, booming quality, longer duration

Resonant

Medium-low amplitude, low pitch, clear and hollow quality, moderate duration

What is associated with a resonant sound?

Normal lung tissue

What is associated with hyperresonant?

Normal over child's lungs. Abnormal in adults, over lungs with increased amount of air, as in emphysema

Determinants of health and health disparities

Note that- Poverty is the greatest influence on health. Collectively known as the Determinants Of Health -Influenced by a constellation of *personal, *social, *economic, and *environmental factors, collectively known as the Determinants Of Health. (Book Pg12) The determinants of health comprise -political action & legislation *health care services -social factors *such as poverty *occupational status *the quality of neighborhood -environment -lifestyle factors -individual behaviors -biology -genetics +++++++++++++++++++ ● Health Disparities ● A particular type of health difference that is closely linked with social, economic and/or environmental disadvantage ● Affect groups of people who have systematically experienced greater obstacles to health based on: o their racial or ethnic group o Relgion o Socioeconomic status o Gender o Age o Mental health o Cognitive disability o Sensory disability o Physical disability o Sexual orientation or gender identity o Geographic location o Or other characteristics historically linked to discrimination or exclusion

15. Assessment techniques - know inspection, palpation, palpation, and auscultation; what the normal sequence is, and what sounds in percussion and auscultation are associated with location and if there are specifics for certain age groups (developmental competence), and why you use a different side of the stethoscope to hear low pitched or high pitched sounds

Order of assessment 1. inspection, 2. palpation, 3. percussion, 4. auscultation (B. p115) 1. inspection: visual exam -naked eye: bumps, bruises, scars, moisture, shape, size, symmetry instruments used: otoscope ( ear canals ), penlight Inspection is close, careful observation of the individual as a whole and then of each body system. Use the patient's body as the control and compare the right and left sides of the body to determine symmetry. Inspection requires good lighting, adequate exposure, and sometimes the use of certain instruments, such as an otoscope or penlight. 2. palpation: sense of touch -using pads of fingers DETERMINS: texture, temperature, position, size, vibration, mobility, distention ** a. light - superficial ( always use prior to deep) b. requires skill, not done routinely Palpation is the use of touch to assess texture, temperature, moisture, and organ location and size. This technique also helps identify swelling, vibration or pulsation, rigidity or spasticity, crepitation, lumps or masses, and tenderness or pain. • The fingertips are best for fine tactile discrimination. Grasping with the fingers and thumb is ideal for detecting position, shape, and consistency of an organ or mass. The backs of the hands and fingers are good for determining temperature. The base of the fingers or ulnar surface of the hand is best for assessing vibration. • Light palpation detects surface characteristics and accustoms the person to being touched. Deep palpation assesses an organ or mass deeper in a body cavity. Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs. 3. percussion: striking of body surface to elicit sound - direct/indirect Percussion is tapping the patient's skin with short, sharp strokes to assess underlying structures. This technique is used to assess the location, size, and density of an organ; detect a fairly superficial abnormal mass; or elicit a deep tendon reflex. • To perform percussion, hyperextend the middle finger of your nondominant hand and place its distal joint and tip firmly against the person's skin. Then use the middle finger of your dominant hand to strike the stationary finger at a right angle. Deliver two even, staccato blows, using a quick wrist action. • Each percussion sound has four components. Amplitude is the sound's intensity, which may be loud or soft. Pitch or frequency describes the number of vibrations per second. Quality (or timbre) is the subjective difference resulting from a sound's distinctive overtones. Duration is the length of time the note lingers. 4. auscultation: listening - direct, unaided ear - indirect, use of the stethoscope diaphragm - high pitched sounds bell- low pitched sounds Auscultation is listening to sounds produced by the body, usually using a stethoscope. The heart, blood vessels, lungs, and abdomen are commonly auscultated areas. !! • Use the stethoscope's diaphragm for high-pitched sounds, such as breath, bowel, and normal heart sounds. Use the stethoscope's bell for soft, low-pitched sounds, such as extra heart sounds or murmurs. !! • To ensure accurate auscultation, eliminate confusing artifacts, for example, by making sure the room is quiet and warm and not listening through clothing.

P (ADPIE)

Planning-P 1. Establish Priorities 2. Develop outcomes 3. Set timelines for outcomes 4. ID outcomes 5. Integrative, evidence-based trends and research 6. Document Plan of Care

What is associated with a dull note?

Relatively dense organs, such as liver or spleen

Communication skills used in the interview

Sending (Book p 27/8) *Verbal-words, vocalization, tone *nonverbal- body language to include: posture, gesture, facial expression, eye contact, foot tapping, touch -Appearance -Demeanor -Facial expressions -Attitude -Silence -eye contact Receiving *Interpretation- Be aware of the influence personal Interpretation by the receiver, be it self/other, has on communication Internal Factors- specific to you, the examiner 1. Liking others 2. Empathy 3. The ability to listen 4. Self-awareness External Factors (B.p 29/30) The setting (room etc) 1. Ensure Privacy may be "psychological privacy" 2. Refuse interruptions 3. Physical environment *Comfort Temp *Lighting *Secure and Quiet *Avoid clutter, may have tools of trade out *Distance from client 4-5 feet *Equal status setting

What critical thinking means

Simultaneously problem-solving while self-improving one's own thinking ability. Workbook pg 1 ● How we learn to assess and modify, if indicated, before acting, required to make sound diagnostic reasoning

Dull

Soft amplitude, high pitch, muffled thud, short duration

Normal Vital Sign Ranges

Temperature: 96.4 to 100.4 F (35.8 C - 97.5 C) Pulse: 60-100 bpm Respirations: 12-20 /min Blood Pressure: >120/80 SpO2: <90%

The difference in practice between novice and expert nurses

The difference in practice between novice and expert nurses o novice nurse has no experience with a specified patient population and uses rules to guide performance. o expert nurse vaults over the steps and arrive at a clinical judgment in one leap, has an intuitive grasp of a clinical situation and zeroes in on the accurate solution Restated========== Novice No experience of the situation in which they are expected to perform. Novice needs what? Recipes or rules for action. Novices lack what? Lack situational context with which to correlate rule application Novices lack situational context, which results in what? Resulting in an inflexible, universal approach to practice. What kind of understanding of concepts being taught do novices have? Contextual Understanding of theories and concepts being taught. ___________________________________ The expert performer no longer relies on an analytic principle to connect their understanding of the situation to an appropriate action. The expert nurse, with an enormous background of experience, now has an intuitive grasp of each situation. --5+ Years Experience *May never happen The expert performs their duties without... Without thinking; they react automatically to situations and are often 'thinking ahead' during a situation. *Intuition or second nature Expert nurses are often formal or informal what? Leaders and are called upon to provide clinical expertise to other staff members. *************************************************** The Dreyfus model posits that in the acquisition and development of a skill, a learner passes through five levels of proficiency: Novice Advanced beginner Competent Proficient Expert

Flat

Very soft amplitude, high pitch, quality described as a dead stop of sound; absolute dullness, very short duration

Heritage assessment

What does a heritage assessment do? Set of questions that determine the depth to which you and the given patient identify with a traditional heritage; that is, the cultural beliefs and practices of the family, the extended family, and an ethnoreligious community Heritage Assessment questions - Where were you born? -What kind of school did you go to? - Have you visited neighborhoods where your family originated? - Do you participate in ethnic celebrations? - Who lived in your home? - Do you maintain ties to family? - Was your family name changed when you came to the United States? - Did you go to public or private school? - Who are your friends? How often do you spend time with them? - Do you speak or read the language of your parents/grandparents? - Do you identify as an Ethnic American or American? Heritage Assessment Tool - Ask questions slowly over time !!! Additional questions: If the person answers 2 - 4 of theses four additional questions positively, probably use health practices relevant to their traditional heritage. - Do you mostly participate in social activities with members of your family? - Do you mostly have friends from a similar cultural background as you? - Do you mostly eat the foods of your family tradition? - Do you mostly participate in the religious traditions of your family?

Hypertension

above 140/90 in at least two separate readings associated with thickening and loss of elasticity in artery walls stages: pre-hypertension: 120-140/80-90 stage 1: 140-160/90-99 stage 2: >160/>100

the 4 components of the percussion note

amplitude - intensity pitch - frequency quality - timbre duration - length

Define light, deep, and bimanual palpation:

light - to detect surface characteristics and to accustom the person to being touched. deep - as for abdominal contents, intermittent pressure is better than one, long palpation. bimanual - when two hands are needed to envelope or capture an organ; for example, kidneys, uterus, or adnexa of uterus.

D (ADPIE)

nursing Diagnosis (O = Outcome Identification) 1. Compare clinical findings with normal and abnormal variation and developmental events 2. Interpret data *ID clusters of clues *Make Hypotheses *Test Hypotheses *Derive Diagnoses 3. Validate diagnoses 4. Document diagnoses O = Outcome Identification 1. ID expected outcomes 2. Individualize to the person 3. Culturally appropriate 4. Realistic and measurable 5. includes a timeline (Book page 3)

Five Characteristics of Percussion Notes, define their components:

resonant - medium loud, low pitch; clear, hollow quality; moderate duration; normal lung tissue. hyper-resonant - louder, lower pitch, booming quality, longer duration, normal in child's lung. tympany - loud, high pitch, drumlike, sustained longest; stomach, intestines. dull - soft, high pitch, muffled, short duration, dense organ like liver or spleen. flat - very soft, high pitch, dead stop of sound, vbery short duration, where no air is present (thigh muscles, bone, tumor)

Table 7-1, Forensic terminology p. 109

● Abrasion ● Wound caused by rubbing the skin or mucous membrane ● Avulsion ● The tearing away of a structure or part ● Bruise (Contusion) ● Superficial Discoloration caused by hemorrhage into the tissues from ruptured blood vessels beneath the skin surface, without the skin being broken ● Contusion ● A bruise; injury to the tissues without breakage of skin ● Blood from blood vessels accumulate ● Causes pain, swelling, tenderness ● Cut ● "Incision" ● Ecchymosis ● A hemorrhagic spot or blotch, larger than petechia, in the skin or mucous membrane ● Forms a nonelevated, rounded or regular blue or purplish patch ● Hematoma ● A localized collection of extravasated blood ● Usually clotted in organ, space or tissue ● Hemorrhage ● The escape of blood from a ruptured vessel ● Can be external, internal, or into the skin or organ ● Incision ● A cut or wound made by sharp instrument ● Laceration ● Act of tearing or splitting of body tissue ● Usually from impact over a bony tissue ● Patterned Injury ● An injury caused by an object that leaves a distinct pattern on the skin and/or organ.. ● Being whipped by belt ● Burns to the hands / feet ● Pattern of injuries ● Bruises and fractures in various stages of healing ● Petechiae ● Minute, pinpoint ● Nonraised and round ● Purplish-red spots ● Caused by intradermal or submucous hemorrhage- later turn blue/yellow ● Puncture ● Act of piercing or penetrating with pointed object/ instrument ● Stab wound ● A penetrating, sharp cutting injury ● Deeper than it is wide ● Traumatic Alopecia ● Loss of hair from pulling, yanking ● Wound ● General term referring to bodily injury by physical means

Pain assessment

● Allows clinicians to more accurately select effective pharmacologic and non pharmacologic strategies to interrupt the pain processing along multiple points within the pain message system and ultimately provide improved pain relief.

Components of mental status assessment (ABCT), and any developmental competence and age-related change to take into account when performing

● Appearance ● Posture ● Body Movements ● Dress ● Grooming and hygiene ● Behavior ● Level of consciousness ● Facial expression ● Speech (quality, pace, articulation, word choice) ● Mood and affect ● Cognitive functions ● Orientation ● Attention span ● Recent and remote memory ● New learning - the 4-unrelated word test ● Judgement ● Thought process ● Thought process ● Thought content ● Perceptions ● Screen for suicidal thoughts (when indicated) ● Perform the mini-mental state examination or the mini-cog Refresh memory on mini cog: Administering Mini-Cog: Instruct patient to remember 3 words you tell them Have patient draw face of clock on paper Have patient write numbers on clock drawing Ask patient to draw hands on clock at a certain time Ask patient to repeat 3 words again

What pain assessment tool you would use for infants and children

● Depends on behavioral and physiologic cues. ● Oucher Scale ● 6 different expressions of pain for a pain scale of 0-5 ● Ø Faces Pain Scale- Revised (FPS-R)...introduced at 4 to 5 yrs of age & has 6 drawings of faces that show pain intensity, from "no pain"(score of 0) on the left to "very much pain" on the right (score of 10) ● Ø Oucher Scale... has 6 photographs of young boys' faces with different expressions of pain, ranked on a 0-5 scale of increasing intensity. You may use Oucher Scale variations for girls and diverse ethnic groups ● Ø CRIES score...is one tool for postoperative pain in preterm and neonates. It measures physiologic and behavioral indicators on a three-point scale ● Ø FLACC scale...nonverbal assessment tool for infants and young children under 3 years. Five behaviors of pain: facial expression, leg movement, activity level, cry, and consolability (FLACC Behavioral Pain Scale)

HEEADSSS psychosocial interview for adolescents

● Home environment ● Education and employment ● Eating ● Activates ● Drugs ● Sexuality ● Suicide/ depression ● Safety from injury and violence ● 3 diff colors: ● Green : Essential to explore with every adolescent ● Blue: Important for you to ask if time permits ● Red: Delve more deeply if situation demands it ● Interview youth alone with parents out of room ● Sample questions for all these steps above are listed on p.65 Ch.4

Prevention of infection

● PPE- Should know by now ● PAGE 120 if need review Ø Standard Precautions... Hand hygiene, use of gloves, gown, mask, eye protection, or face shield, Respiratory hygiene/cough etiquette

Definition of referred pain

● Pain that is felt at a particular site but originates from another location ● May originate in visceral or somatic structures ● Ex: Inflamed appendix in right lower quadrant of abdomen may have referred pain in the periumbilical area ● Ex: Pain from acute coronary syndrome may be felt in left arm or neck

What is a sign vs. a symptom

● Symptom ● A subjective sensation that the person feels from the disorder. ● Enclose what patient says in " ". And record the time fram ● Ex: "Chest pain for 2 days" ● Sign ● Objective abnormality that you as the examiner could detect on physical examination or in lab reports.