Assessment Remediation

DECREASED CARDIAC OUTPUT (left side heart failure)

• Fatigue • Weakness • Oliguria during the day (nocturia at night) • Angina • Confusion, restlessness • Dizziness • Tachycardia, palpitations • Pallor • Weak peripheral pulses • Cool extremities

Pulse: Planning

• Patient will exhibit increased perfusion as indicated by less than 1+ edema in lower extremities within 48 hours of beginning medication interventions. • Patient will exhibit respirations, pulse, and blood pressure within patient's usual range during activity before discharge. • Patient will demonstrate decreased episodes of shortness of breath, edema, and tachycardia after initiation of treatment plan. • Patient will maintain adequate fluid volume as evidenced by stable vital signs, adequate urinary output, and moist mucous membranes within 12 hours.

Patient and Family Education: Preparing for Self-Management Postoperative Instructions for Patients Having Stretta Procedure

• Remain on clear liquids for 24 hours after the procedure. • After the first day, consume a soft diet, such as custard, pureed vegetables, mashed potatoes, and applesauce. • Avoid nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin for 10 days. • Continue drug therapy as prescribed, usually proton pump inhibitors. • Use liquid medications whenever possible. • Do not allow nasogastric tubes for at least 1 month because the esophagus could be perforated. • Contact the health care provider immediately if these problems occur: ▪ Chest or abdominal pain ▪ Bleeding ▪ Dysphagia ▪ Shortness of breath ▪ Nausea or vomiting

BP

Blood pressure (BP) is the force of the blood pushing against the side of its container, the vessel wall. The strength of the push changes with the event in the cardiac cycle. The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood exerts constantly between each contraction. The pulse pressure is the difference between the systolic and diastolic pressures and reflects the stroke volume (Fig. 9-5). The mean arterial pressure (MAP) is the pressure forcing blood into the tissues averaged over the cardiac cycle. This is not an arithmetic average of systolic and diastolic pressures because diastole lasts longer. Rather it is a value closer to diastolic pressure plus one third the pulse pressure.

BMI

Body mass index (BMI) is a practical marker of optimal healthy weight for height and an indicator of obesity or malnutrition. Evidence supports the use of BMI in obesity risk assessment because it provides a more accurate measure of total body fat compared with the measure of body weight alone.[26]The cause of weight gain is usually excess caloric intake; occasionally it is endocrine disorders, drug therapy (e.g., corticosteroids), or depression. BMI classifications for adults[26]: Underweight < 18.5 kg/m2 Normal weight 18.5 to 24.9 kg/m2 Overweight 25 to 29.9 kg/m2 Obesity (class 1) 30 to 34.9 kg/m2 Obesity (class 2) 35 to 39.9 kg/m2 Extreme obesity (class 3) ≥ 40

Abnormal heart sounds

Both heart sounds are diminished with increased air or tissue between the heart and your stethoscope, such as emphysema (hyperinflated lungs), obesity, and pericardial fluid. A fixed split is unaffected by respiration; the split is always there. A paradoxical split is the opposite of what you would expect: the sounds fuse on inspiration and split on expiration Murmurs may be caused by congenital defects and acquired valvular defects.

Palpating the spleen

. A, Press upward with the left hand at the patient's left costovertebral angle. Feel for the spleen with the right hand below the left costal margin. B, Palpating the spleen with the patient lying on the side. Press inward with the left hand and tips of the right fingers.

Cyanosis

Cyanosis is a blue discoloration of the skin, nail beds, or mucous membranes that results from vasoconstriction or deoxygenated hemoglobin in blood vessels near the skin's surface. Central cyanosis is often due to cardiac or respiratory conditions that lead to poor blood oxygenation. Peripheral cyanosis, causing blue discoloration in the fingers or extremities, is most often due to local vasoconstriction or inadequate peripheral circulation. All factors contributing to central cyanosis also can lead to peripheral symptoms; however, peripheral cyanosis is most often observed in the absence of heart or lung conditions, such as exposure to cold for an extended period of time.

Auscultate the Carotid Artery

For patients older than middle age or who show symptoms or signs of cardiovascular disease, auscultate each carotid artery for the presence of a bruit. This is a blowing, swishing sound indicating blood flow turbulence; normally, there is none.Keep the neck in a neutral position. Lightly apply the bell of the stethoscope over the carotid artery at three levels: (1) the angle of the jaw, (2) the midcervical area, and (3) the base of the neck. Avoid compressing the artery because this could create an artificial bruit. Ask the patient to hold his or her breath while you listen.

The level of BP is determined by five factors

1. Cardiac output. If the heart pumps more blood into the container (i.e., the blood vessels), the pressure on the container walls increases. 2. Peripheral vascular resistance. Peripheral vascular resistance is the opposition to blood flow through the arteries. When the container becomes smaller (e.g., with constricted vessels), the pressure needed to push the contents becomes greater. Conversely, if the container becomes larger (e.g., vasodilation), less pressure is needed. 3. Volume of circulating blood. Volume of circulating blood refers to how tightly the blood is packed into the arteries. Increasing the contents in the container increases the pressure. 4. Viscosity. The "thickness" of blood is determined by its formed elements, the blood cells. When the contents are thicker, the pressure increases. 5. Elasticity of vessel walls. When the container walls are stiff and rigid, the pressure needed to push the contents increases.

Drug therapy in older adults

1. Obtain an accurate history. The older patient should carry a list of current medications or preferably should bring all medicine bottles to each visit; this should include any OTC drugs the patient uses. The health care provider may discover that similar or interacting drugs have been prescribed by different physicians, or the patient may still be taking a drug that is no longer necessary. 2. Dosages may need to be adjusted. The usual adult dosage is based on the amount of drug needed for a healthy man weighing 150 lb. Age-related disorders may require a dosage that is 25% to 50% less than the usual adult dosage. The gastrointestinal tract may not have the "average" pH because of deficient acid production, the gastric emptying time may be slowed, and the gastric blood flow may be deficient. The distribution of a drug depends on body composition (amounts of lipid, water, and lean body mass), and these amounts change with age. Decreased levels of albumin resulting from suboptimal nutrition affect the binding and distribution of drugs. Drug metabolism (i.e., the sum of chemical changes that occurs as a drug is processed) in the liver depends on blood flow and the enzyme system; both may be altered. An age-related decline in renal function affects drug elimination from the body. 3. Be vigilant about drug interactions. Although it is impossible to remember every drug interaction and new interactions are frequently discovered, drug interactions should be checked for every drug combination. Drugs that have frequent interactions and are commonly used in older adults include warfarin, sedatives, antibiotics, and nonsteroidal anti-inflammatory drugs (NSAIDs) (see Box 24-1 for more interactions).

Pulse Sites

1. Temporal: Where the temporal artery passes over the temporal bone of the head, above and lateral to the eye; used when the radial pulse is not accessible 2. Carotid: At the side of the neck where the carotid artery runs between the trachea and the sternocleidomastoid muscle; used in cases of cardiac arrest and for determining circulation to the brain 3. Apical or PMI: Apical, at the apex of the heart, and PMI, at the fifth intercostal space, midclavicular line; used for infants and children up to 3 years of age, placed in the supine position, to determine discrepancies with radial pulse, and used in adults in conjunction with some diseases and medications and during a head-to-toe assessment 4. Brachial: At the inner aspect of the arm; used to assess pulse in pediatric emergencies and to measure blood pressure 5. Radial*: On the thumb side of the inner aspect of the wrist where the radial artery runs along the radial bone 6. Femoral: Where the femoral artery passes alongside the inguinal ligament; used in cases of cardiac arrest and for assessing circulation to the leg 7. Popliteal: Behind the knee where the popliteal artery passes; used to determine circulation to the lower leg 8. Posterior tibial: Medial surface of the ankle; used to determine circulation to the foot 9. Pedal (dorsalis pedis): Where the dorsalis pedis artery passes across the top of the foot; used to determine circulation to the foot

Nursing Assessment Sleep

1. What time do you normally go to bed at night? What time do you normally wake up in the morning? 2. Do you often have trouble falling asleep at night? 3. About how many times do you wake up at night? 4. If you do wake up during the night, do you usually have trouble falling back asleep? 5. Does your bed partner say or are you aware that you frequently snore, gasp for air, or stop breathing? 6. Does your bed partner say or are you aware that you kick or thrash about while asleep? 7. Are you aware that you ever walk, eat, punch, kick, or scream during sleep? 8. Are you sleepy or tired during much of the day? 9. Do you usually take one or more naps during the day? 10. Do you usually doze off without planning to during the day? 11. How much sleep do you need to feel alert and function well? 12. Are you currently taking any type of medication or other preparation to help you sleep?

Nervous Assessment of Sensory Function (touch discriminations)

For testing touch discrimination, the patient closes his or her eyes. The practitioner touches the patient with a finger and asks that he or she point to the area touched. This procedure is repeated on each extremity at random rather than at sequential points. Next, the practitioner touches the patient on each side of the body on corresponding sites at the same time. The patient should be able to point to both sites. The clinician then touches the patient in two places on the same extremity with two objects, such as cotton-tipped applicators. A person can normally identify two points fairly close together depending on the location of the stimuli. When an area is heavily innervated, the two-point discrimination will feel closer.

Auscultation- General

Auscultation with a stethoscope provides important clues to the condition of the lungs and pleura. All sounds can be characterized in the same manner as the percussion notes: intensity, pitch, quality, and duration. Have the patient sit upright, if possible, and breathe slowly and deeply through the mouth, exaggerating normal respiration. Demonstrate this yourself. Caution the patient to keep a pace consistent with comfort; hyperventilation, which occurs more easily than one might think, may cause faintness, and exaggerated breathing can be tiring, especially for frail patients. Because most pulmonary pathologic conditions patients occur at the lung bases, it is a good idea to examine these first, before fatigue sets in. The diaphragm of the stethoscope is usually preferable to the bell for listening to the lungs because it transmits the ordinarily high-pitched sounds better and because it provides a broader area of sound

Posterior Thorax

Begin examination of the posterior thorax by observing for any signs or symptoms in other body systems that indicate pulmonary problems. Reduced mental alertness, nasal flaring, somnolence, and cyanosis are examples of assessed signs that indicate oxygenation problems. Inspect the posterior thorax by observing the shape and symmetry of the chest from the patient's back and front. Note the anteroposterior diameter. Body shape or posture significantly impairs ventilatory movement. Normally the chest contour is symmetrical, with the anteroposterior diameter one third to one half of the transverse, or side-to-side, diameter. A barrel-shaped chest (anteroposterior diameter equals transverse diameter) characterizes aging and chronic lung disease. Infants have an almost round shape. Congenital and postural alterations cause abnormal contours. Some patients lean over a table or splint the side of the chest because of a breathing problem. Splinting or holding the chest wall because of pain causes a patient to bend toward the side affected. Such a posture impairs ventilatory movement.

Abnormal findings: A bruit indicates turbulence due to a local vascular cause, e.g., atherosclerotic narrowing.

A carotid bruit is audible when the lumen is occluded by 1/2 to 2/3. Bruit loudness increases as the atherosclerosis worsens until the lumen is occluded by 2/3. When the lumen is completely occluded, the bruit disappears. Thus, absence of a bruit is not a sure indication of absence of a carotid lesion. A murmur sounds much the same, but is caused by a cardiac disorder. Some aortic valve murmurs radiate to the neck and must be distinguished from a local bruit.

The Procedure: Arm Pressure

A comfortable, relaxed person yields a valid BP. Many people are anxious at the beginning of an examination; allow at least a 5-minute rest before measuring the BP. Then take two or more BP measurements separated by 2 minutes. For each person, verify BP in both arms once, either on admission or for the first complete physical examination. It is not necessary to continue to check both arms for screening or monitoring. Occasionally a 5- to 10-mm Hg difference may occur in BP in the two arms (if values are different, use the higher value), which is caused by artifact or subtle differences in technique.A reproducible difference in the two arms of more than 10 to 15 mm Hg may indicate arterial obstruction on the side with the lower reading. This warrants referral.The person may be sitting or lying, with the bare arm supported at heart level. When sitting, the patient's feet should be flat on the floor because BP has a false-high measurement when legs are crossed versus uncrossed.[18] Palpate the brachial artery, which is located just above the antecubital fossa, medial to the biceps tendon. With the cuff deflated, center it about 2.5 cm (1 in) above the brachial artery and wrap it evenly. Now palpate the brachial or radial artery (Fig. 9-8). Inflate the cuff until the artery pulsation is obliterated and then 20 to 30 mm Hg beyond. This helps you to avoid missing an auscultatory gap, which is a period when Korotkoff sounds disappear during auscultation (Table 9-3).An auscultatory gap occurs in about 5% of people, most often in hypertension caused by a noncompliant arterial system.Deflate the cuff quickly and completely; then wait 15 to 30 seconds before reinflating so the blood trapped in the veins can dissipate. Place the bell or diaphragm of the stethoscope over the site of the brachial artery, making a light but airtight seal (Fig. 9-9). The diaphragm endpiece is usually adequate, but the bell is designed to pick up low-pitched sounds such as the sounds of a BP reading. Most novice practitioners find it easier to use the diaphragm than the bell. You can use either side to obtain an accurate reading.[17]

Gastric: Diagnostic Assessment

A definitive diagnostic test for GERD does not exist; however, health care providers may use one or more options to attempt to establish a diagnosis when GERD is suspected ( The Ohio State University Wexner Medical Center [OSUWMC], 2014). Patients may drink a solution and then have x-rays performed as part of a barium swallow, which shows hiatal hernias, strictures, and other structural or anatomic esophageal problems. Although this test, when conducted by itself, does not confirm GERD, it can be helpful when used in combination with other diagnostic procedures. Upper endoscopy (also called esophagogastroduodenoscopy [EGD]) involves insertion of an endoscope (a flexible plastic tube equipped with a light and lens) down the throat, which allows the health care provider to see the esophagus and look for abnormalities. A biopsy can be taken while the patient undergoes endoscopy (see Chapter 52) (OSUWMC, 2013). This test requires the use of moderate sedation during the procedure, and patients must have someone accompany them home after recovery.

pH monitoring exam

A pH monitoring examination is the most accurate method of diagnosing GERD. This involves either (1) placing a small catheter through the nose into the distal esophagus or (2) temporarily attaching a small capsule to the wall of the esophagus during an upper endoscopy (the 48-hour Bravo esophageal ph test). The patient is asked to keep a diary of activities and symptoms over 24 to 48 hours (depending on diagnostic method), and the pH is continuously monitored and recorded. Ambulatory pH monitoring is especially useful in diagnosing patients with atypical symptoms. A wireless monitoring device may be used to promote patient comfort. Although not as common, esophageal manometry, or motility testing, may be performed when the diagnosis is uncertain. Water-filled catheters are inserted in the patient's nose or mouth and slowly withdrawn while measurements of LES pressure and peristalsis are recorded. When used alone, manometry is not sensitive or specific enough to establish a diagnosis of GERD. A Gastric Emptying Study can also be done while a patient is in the radiology/nuclear medicine department. He or she is given a meal mixed with radiolucent dye, and imaging is performed to determine how well the stomach empties over the next few hours. If food stays too long in the stomach, it can reflux back into the esophagus, causing symptoms. Imaging of the lungs can also be conducted 24 hours later to visualize whether the patient has aspirated stomach contents.

water brash

A reflex salivary hypersecretion known as water brash occurs in response to reflux. Water brash is different from regurgitation. The patient reports a sensation of fluid in the throat, but unlike with regurgitation, there is no bitter or sour taste.

Sample of drug-nutrient interactions*

Acetaminophen Decreased drug absorption with food; overdose associated with liver failure AspirinAbsorbed directly through stomach; decreased drug absorption with food; decreased folic acid, vitamins C and K, and iron absorption Antacid Aluminum hydroxideDecreased phosphate absorption Sodium bicarbonateDecreased folic acid absorption

Categories of Consciousness

AlertPatient responds immediately to minimal external stimuli. ConfusedPatient is disoriented to time or place but usually oriented to person, with impaired judgment and decision making and decreased attention span. DeliriousPatient is disoriented to time, place, and person, with loss of contact with reality, and often has auditory or visual hallucinations. LethargicPatient displays a state of drowsiness or inaction, in which the patient needs an increased stimulus to be awakened. ObtundedPatient displays dull indifference to external stimuli, and response is minimally maintained. Questions are answered with a minimal response. StuporousPatient can be aroused only by vigorous and continuous external stimuli. Motor response is often withdrawal or localizing to stimulus. ComatoseVigorous stimulation fails to produce any voluntary neural response.

Nervous: nursing assessment

As a nurse, you are in a key position to assess sleep problems in patients and their caregivers. Sleep assessment is important in helping patients identify personal habits and environmental factors that contribute to poor sleep. Family caregivers may experience sleep disruptions due to the necessity of providing care to patients in the home. These sleep disruptions can increase the burden of caregiving. Self-report and objective data are used to assess sleep duration and quality. Many patients do not tell their HCP about their sleep problems. Make sure to ask patients about their sleep and problems with sleep. A sleep history includes characteristics of sleep such as sleep duration, the pattern of sleep, and daytime alertness (Table 7-5). Before using any questionnaire, assess the patient's cognitive function, reading level (if a paper form is used), and language ability. Also assess the diet. Question the patient about the intake of caffeine. Ask about alcohol consumption and whether it is used as a sleep aid. Although the sedative effects of alcohol hasten sleep onset, it suppresses REM sleep and increases awakenings later in the night.

eructation (belching), flatulence (gas)

Ask the patient if he or she experiences eructation (belching), flatulence (gas), and bloating after eating; these are other common manifestations. Nausea and vomiting rarely occur; unplanned weight loss is not common. Assess for crackles in the lung, which can be an indication of associated aspiration. Patients who have had long-term regurgitation may experience coughing, hoarseness, or wheezing at night, which may be associated with bronchitis.

Nervous Nursing Assessment

Assess the patient's level of consciousness, orientation, memory, and ability to follow commands. Determine the size, reactivity, and equality of the pupils. Also assess the patient's sleep/wake cycle and sensory and motor status. If the neurologic status is altered, try to determine possible causes. If the patient was mentally alert before surgery and becomes cognitively impaired postoperatively, you should suspect delirium or POCD.

Medications.

Assess the patient's past and current use of medications. Ask about the reason for taking the medication, its name, the dose and frequency, length of time taken, its effect, and any side effects. Include information about over-the-counter (OTC) medications, prescription drugs, herbal products, vitamins, probiotics, and nutritional supplements. This is a critical aspect of history taking. Many medications not only affect the GI system, but they are also affected by abnormalities of the GI system. Many chemicals and drugs are potentially hepatotoxic (see livertox.nih.gov) and result in significant harm unless monitored closely. For example, chronic high doses of acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) may be hepatotoxic. NSAIDs may predispose a patient to upper GI bleeding, with an increasing risk as the person ages. Other medications, such as antibiotics, may change the normal bacterial composition in the GI tract, resulting in diarrhea. Antacids and laxatives may affect the absorption of certain medications. Ask the patient about laxative or antacid use, including the kind and frequency.

Assessment of Pulse

Assessing the pulse includes measuring the rate, rhythm, and volume and comparing the findings on both sides of the body. The pulse is assessed by palpation (feeling with the middle three fingertips), auscultation (listening with a stethoscope) (Evidence-Based Practice and Informatics box), or electronic monitoring through specifically placed sensors. Too much pressure of the fingertips can obliterate the pulse, and pressure that is too light may not capture the pulsations. A Doppler ultrasound unit is used to assess pulses that are otherwise difficult to detect, especially pedal pulses (Nursing Care Guideline box). Skill 19-2 reviews the steps for measuring a pulse.

Patient-Centered Collaborative Care: assessment

Assessment Ask the patient about a history of heartburn or atypical chest pain associated with the reflux of GI contents. Ask whether he or she has been newly diagnosed with asthma or has experienced morning hoarseness or pneumonia, because these symptoms may indicate severe reflux reaching the pharynx or mouth or pulmonary aspiration. Physical Assessment/Clinical Manifestations. Dyspepsia, also known as "indigestion," and regurgitation are the main symptoms of GERD, although symptoms may vary in severity (Chart 54-1). Symptoms associated with "indigestion" may include abdominal discomfort, feeling uncomfortably full, nausea, and burping. Because indigestion might not be viewed as a serious concern, patients may delay seeking treatment. The symptoms typically worsen when the patient bends over, strains, or lies down. If the indigestion is severe, the pain may radiate to the neck or jaw or may be referred to the back, mimicking cardiac pain. Patients may come to the emergency department (ED) fearing that they are having a myocardial infarction ("heart attack").

Linguistic Competence.

Linguistic competence is the ability of an organization and its staff to communicate effectively and convey information in a manner that is easily understood by diverse audiences. These audiences include people of limited English proficiency, those who have low literacy skills or are not literate, individuals with disabilities, and those who are deaf or hard of hearing. Linguistic competency requires organizational resources (e.g., instructional resources designed at a 6th-grade reading level or lower, interpreters) and providers who are able to respond effectively to the health and mental health literacy needs of the populations served. One important service that health care organizations must provide is an interpretive service.

Temp

Cellular metabolism requires a stable core, or "deep body," temperature of a mean of 37.2° C (99° F). The body maintains a steady temperature through a thermostat, or feedback mechanism, regulated in the hypothalamus of the brain. The thermostat balances heat production (from metabolism, exercise, food digestion, external factors) with heat loss (through radiation, evaporation of sweat, convection, conduction). The various routes of temperature measurement reflect the core temperature of the body. The normal oral temperature in a resting person is 37° C (98.6° F), with a range of 35.8° to 37.3° C (96.4° to 99.1° F). The rectal temperature measures 0.4° to 0.5° C (0.7° to 1° F) higher.The thermostatic function of the hypothalamus may become scrambled during illness or central nervous system (CNS) disorders.The normal temperature is influenced by: • A diurnal cycle of 1° to 1.5° F, with the trough occurring in the early morning hours and the peak occurring in late afternoon to early evening. • The menstruation cycle in women. Progesterone secretion, occurring with ovulation at midcycle, causes a 0.5° to 1° F rise in temperature that continues until menses. • Exercise. Moderate-to-hard exercise increases body temperature. • Age. Wider normal variations occur in the infant and young child because of less effective heat control mechanisms. In older adults temperature is usually lower than in other age-groups, with a mean of 36.2° C (97.2° F) via the oral route. Rectal temperatures remain 0.5° C higher than oral temperatures in older adults. Hyperthermia, or fever, is caused by pyrogens secreted by toxic bacteria during infections or from tissue breakdown such as that following myocardial infarction, trauma, surgery, or malignancy. Neurologic disorders (e.g., a stroke, cerebral edema, brain trauma, tumor, or surgery) also can reset the thermostat of the brain at a higher level, resulting in heat production and conservation.

dysphagia (difficulty swallowing)

Chronic GERD can cause dysphagia (difficulty swallowing). Dysphagia usually indicates a narrowing of the esophagus because of stricture or inflammation. Assess the patient for degree of dysphagia, whether ingesting solids and/or liquids induces dysphagia, and whether dysphagia occurs intermittently or with each swallowing effort.

Posture and Gait.

Common spinal deformities. Most patients with musculoskeletal problems eventually have a problem with gait. The nurse or therapist evaluates the patient's balance, steadiness, and ease and length of stride. Any limp or other asymmetric leg movement or deformity is noted. An abnormality in the stance phase of gait is called an antalgic gait. When part of one leg is painful, the patient shortens the stance phase on the affected side. An abnormality in the swing phase is called a lurch. This abnormal gait occurs when the muscles in the buttocks and/or legs are too weak to allow the person to change weight from one foot to the other. In this case, the shoulders are moved either side-to-side or front-to-back for help in shifting the weight from one leg to the other. Some patients, such as those with chronic hip pain and muscle atrophy from arthritic disorders, have a combination of an antalgic gait and lurch.

Arterial Blood Gases.

Determination of a patient's acid-base status requires obtaining a sample of arterial blood for laboratory testing. ABG analysis reveals acid-base status and the adequacy of ventilation and oxygenation. A qualified RN or other health care provider draws arterial blood from a peripheral artery (usually the radial) or from an existing arterial line (see agency policy and procedures). Before an arterial blood draw, perform an Allen test, which assesses arterial circulation in the hand. When performing the Allen test, apply pressure to both the ulnar and radial arteries in the selected hand. The fingers to the hand should be pale and blanched, indicating a lack of arterial blood flow. Release the pressure on the ulnar artery and observe for color to return to the fingers and hand, which indicates that there is adequate circulation to the hand and fingers via the ulnar artery. The Allen test ensures that a patient will have adequate blood flow to the hand if the radial artery is damaged. If color does not return, do not perform radial artery puncture on that arm. After the ABG puncture, apply pressure to the puncture site for at least 5 minutes to reduce the risk of hematoma formation. A longer time is necessary if the patient takes anticoagulant medications. Reassess the radial pulse after removing the pressure. After obtaining the specimen, take care to prevent air from entering the syringe because this alters the blood gas values. To reduce oxygen usage by blood cells, submerge the syringe in crushed ice and transport it immediately to the laboratory.

Gastric Drug Therapy

Drug therapy for GERD management includes three major types—antacids, histamine blockers, and proton pump inhibitors. These drugs, which are also used for peptic ulcer disease, have one or more of these functions • Inhibit gastric acid secretion • Accelerate gastric emptying • Protect the gastric mucosa In uncomplicated cases of GERD, antacids may be effective for occasional episodes of heartburn. Antacids act by elevating the pH level of the gastric contents, thereby deactivating pepsin. They are not helpful in controlling frequent symptoms because their length of action is too short and their nighttime effectiveness is minimal. These drugs also increase LES pressure and therefore are not given for long-term use. Antacids containing aluminum hydroxide or magnesium hydroxide may be used. Maalox and Mylanta consist of a combination of these two agents. Patients often tolerate them better because they produce fewer side effects, such as constipation and diarrhea. Liquid forms of these medications are preferred, since they coat the esophagus to provide pain relief and to buffer acid. Teach the patient to take the antacid 1 hour before and 2 to 3 hours after each meal.

Interprofessional Care

Evaluation and management of a patient with renal calculi consist of two concurrent approaches. The first approach is directed toward management of the acute attack by treating the pain, infection, and/or obstruction. Administer opioids to relieve renal colic pain. Most stones are 4 mm or less in size and will probably pass spontaneously. However, it may take weeks for a stone to pass. Tamsulosin (Flomax) or terazosin, α-adrenergic blockers that relax the smooth muscle in the ureter, can be used to facilitate stone passage. These drugs are also used to relax the muscle tissue in the prostate in men with BPH. The second approach is directed toward evaluation of the cause of the stone formation and prevention of further stone development. Obtain information from the patient, including a family history of stone formation; geographic residence; nutritional assessment, including the intake of vitamins A and D; activity pattern (active or sedentary); history of prolonged illness with immobilization or dehydration; and any history of disease or surgery involving the GI or genitourinary tract. Therapy for active stone formers requires a comprehensive management approach, with the primary emphasis on teaching. Adequate hydration, dietary sodium restrictions, dietary changes, and drugs are used to minimize urinary stone formation (Table 45-11). Depending on the specific problem underlying the stone formation, various drugs are prescribed. These drugs prevent stone formation in various ways, including altering urine pH, preventing excessive urinary excretion of a substance, or correcting a primary disease (e.g., hyperparathyroidism).

Behavior

Facial expression—The person maintains eye contact (if culturally appropriate); expressions are appropriate to the situation (e.g., thoughtful, serious, or smiling). (Note expressions both while the face is at rest and while the person is talking.)Flat, depressed, angry, sad, anxious. However, note that anxiety is common in ill people. Also, some people smile when they are anxious. Mood and affect—The person is comfortable and cooperative with the examiner and interacts pleasantly.Hostile, distrustful, suspicious, crying. Speech—Articulation (the ability to form words) is clear and understandable.Dysarthria and dysphagia (see Table 5-2, Speech Disorders, p. 80). Speech defect, monotone, garbled speech. Speech pattern—The stream of talking is fluent, with an even pace. The person conveys ideas clearly. Word choice is appropriate for culture and education. Communicates in prevailing language easily by himself or herself or with an interpreter.Extremes of few words or constant talking. Dress—Clothing is appropriate to the climate, looks clean and fits the body, and is appropriate to the person's culture and age-group (e.g., normally Amish women wear clothing from the 19th century; Indian women may wear saris). Culturally determined dress should not be labeled as inappropriate by Western standards or adult expectations.Clothing too large and held up by belt suggests weight loss, as does the addition of new holes in belt. Clothing too tight may indicate obesity or ascites.Consistent wear of certain clothing may provide clues: long sleeves may conceal needle marks of drug abuse or thin arms of anorexia;

Sequence for palpation of the precordium. A, Apex. B, Left sternal border. C, Base.

Feel for the apical impulse and identify its location by the intercostal space and the distance from the midsternal line. The point at which the apical impulse is most readily seen or felt should be described as the point of maximal impulse (PMI). The PMI is typically noted at the left 5th intercostal space, midclavicular line in adults and 4th intercostal space medial to the nipple in children. Determine the diameter of the area in which it is felt. Usually it is palpable within a small diameter—no more than 1 cm. The impulse is usually gentle and brief, not lasting as long as systole. In some adults, the apical impulse is not felt because of the thickness of the chest wall

Adventitious Breath Sounds

Fine crackles: high-pitched, discrete, discontinuous crackling sounds heard during the end of inspiration; not cleared by a cough Medium crackles: lower, more moist sound heard during the midstage of inspiration; not cleared by a cough Coarse crackles: loud, bubbly noise heard during inspiration; not cleared by a cough Rhonchi (sonorous wheeze): loud, low, coarse sounds like a snore most often heard continuously during inspiration or expiration; coughing may clear sound (usually means mucus accumulation in trachea or large bronchi) Wheeze (sibilant wheeze): musical noise sounding like a squeak; most often heard continuously during inspiration or expiration; usually louder during expiration Pleural friction rub: dry, rubbing, or grating sound, usually caused by inflammation of pleural surfaces; heard during inspiration or expiration; loudest over lower lateral anterior surface

Odynophagia

Odynophagia (painful swallowing) can also occur with chronic GERD, but it is rare in people with uncomplicated reflux disease. Severe and long-lasting chest pain may be present if esophageal spasms cause the muscle to contract with excess force. The resulting pain can be agonizing and may last for hours. Other manifestations include atypical chest pain, symptoms of asthma, and chronic cough that occurs mostly at night or when the patient is lying down. Cough and symptoms of asthma occur when refluxed acid is spilled over into the tracheobronchial tree. Atypical chest pain is thought to be caused by stimulation of pain receptors in the esophageal wall and by esophageal spasm. This type of chest pain can mimic angina and needs to be carefully distinguished from cardiac pain.

Mobilty

Gait—Feet approximately shoulder width apart; foot placement is accurate; walk is smooth and even, and person can maintain balance without assistance. Associated movements such as symmetric arm swing are present.Exceptionally wide base. Staggering, stumbling.Shuffling, dragging, nonfunctional leg. Limping with injury.Propulsion—Difficulty stopping Range of motion—Note full mobility for each joint and that movement is deliberate, accurate, smooth, and coordinated. (See Chapter 22 for information on more detailed testing of joint range of motion.)Limited joint range of motion.Paralysis—Absent movement.Jerky, uncoordinated movement.No involuntary movement.Tics, tremors, seizures

Palpate the Carotid Artery

Gently palpate only one carotid artery at a time to avoid compromising arterial blood to the brain. Feel the contour and amplitude of the pulse. Normally, the contour is smooth, with a rapid upstroke and slower downstroke, and the normal strength is 2+ or moderate and equal bilaterally. Abnormal findings: Diminished pulse feels small and weak and occurs with decreased stroke volume. Increased pulse feels full and strong and occurs with hyperkinetic states

Heart Sound Descriptors

Grade i—Barely audible, heard only in a quiet room and then with difficulty Grade ii—Clearly audible, but faint Grade iii—Moderately loud Grade iv—Loud, associated with a thrill palpable on the chest wall Grade v—Very loud, heard with one edge of the stethoscope lifted off the chest wall Grade vi—Loudest, still heard with entire stethoscope lifted just off the chest wall Pitch. High, medium, or low. Pattern. Growing louder (crescendo), tapering off (decrescendo), or increasing to a peak and then decreasing (crescendo-decrescendo, or diamond-shaped). Since the entire murmur is just milliseconds long, it takes practice to diagnose pattern. Quality. Musical, blowing, harsh, or rumbling. Location. Area of maximum intensity of the murmur (where it is best heard) as noted by the valve area or intercostal spaces. Radiation. Heard in another place on the precordium, the neck, the back, or the axilla. Posture. Murmurs may disappear or be enhanced by a change in position.

Pulse: Implementation and Evaluation

Hand hygiene is performed before caring for a patient. After selection of the appropriate site and method, the pulse rate is measured. An irregular pulse of new onset should be reported to the PCP. Interventions for an increased pulse rate include identification and treatment of the cause. Fluid replacement is used for tachycardia caused by hypovolemia. Measures to decrease anxiety are implemented for tachycardia related to emotional stress. By contrast, fluid removal by use of diuretic medications would be an appropriate intervention for tachycardia from fluid overload. Oxygenation status often is closely linked to pulse rates and should be stabilized for the patient who experiences deviations in pulse rate. Evaluation is accomplished by comparing the pulse rate with baseline data or to the normal range for the age of the patient. The pulse rate and volume are related to other vital signs, assessment data, and health status.

Heart Failure.

Heart failure (HF) is a complication that occurs when the right or left heart's pumping action is reduced. Depending on the severity and extent of the injury, left-sided HF occurs initially with subtle signs such as mild dyspnea, restlessness, agitation, or slight tachycardia. Other signs indicating the onset of left-sided HF include pulmonary congestion on chest x-ray, S3 or S4 heart sounds on auscultation of the heart, crackles on auscultation of the lungs, paroxysmal nocturnal dyspnea (PND), and orthopnea. Signs of right-sided HF include jugular venous distention, hepatic congestion, or lower extremity edema.

Hypoxia

Hypoxia is inadequate tissue oxygenation at the cellular level. It results from a deficiency in oxygen delivery or oxygen use at the cellular level. It is a life-threatening condition. Untreated it produces possibly fatal cardiac dysrhythmias. Causes of hypoxia include (1) a decreased hemoglobin level and lowered oxygen-carrying capacity of the blood; (2) a diminished concentration of inspired oxygen, which occurs at high altitudes; (3) the inability of the tissues to extract oxygen from the blood, as with cyanide poisoning; (4) decreased diffusion of oxygen from the alveoli to the blood, as in pneumonia; (5) poor tissue perfusion with oxygenated blood, as with shock; and (6) impaired ventilation, as with multiple rib fractures or chest trauma. The clinical signs and symptoms of hypoxia include apprehension, restlessness, inability to concentrate, decreased level of consciousness, dizziness, and behavioral changes. The patient with hypoxia is unable to lie flat and appears both fatigued and agitated. Vital sign changes include an increased pulse rate and increased rate and depth of respiration. During early stages of hypoxia the blood pressure is elevated unless the condition is caused by shock. As the hypoxia worsens, the respiratory rate declines as a result of respiratory muscle fatigue.

Auscultate the Heart Sounds

Identify the auscultatory areas where you will listen. The four traditional valve "areas" (Fig. 12-5) are not over the actual anatomical locations of the valves, but are the sites on the chest wall where sounds produced by the valves are best heard: • Second right interspace—Aortic valve area • Second left interspace—Pulmonic valve area • Fifth intercostal space at left lower sternal border—Tricuspid valve area • Fifth interspace at around left midclavicular line—Mitral valve area Do not limit your auscultation to only four locations because sounds produced by the valves may be heard all over the precordium. Learn to inch your stethoscope in a Z-pattern, from the base of the heart across and down, then over to the apex; or, start at the apex and work your way up. Include the sites shown in Fig. 12-5. Begin with the diaphragm endpiece and clean it using an alcohol wipe. Use the following routine: (1) note the rate and rhythm; (2) identify S1 and S2; (3) assess S1 and S2 separately; (4) listen for extra heart sounds; and (5) listen for murmurs. Note the Rate and Rhythm. The rate changes normally from 60 to 100 beats per minute. The rhythm should be regular, although sinus arrhythmia occurs normally in young adults and children. With sinus arrhythmia, the rhythm varies with the patient's breathing, increasing at the peak of inspiration, and slowing with expiration. Note any other irregular rhythm.

Palpation of the apical pulse.

If the apical impulse is more vigorous than expected, characterize it as a heave or lift. An apical impulse that is more forceful and widely distributed, fills systole, or is displaced laterally and downward may indicate increased cardiac output or left ventricular hypertrophy. A lift along the left sternal border may be caused by right ventricular hypertrophy. A loss of thrust may be related to overlying fluid or air or to displacement beneath the sternum. Displacement of the apical impulse to the right without a loss or gain in thrust suggests dextrocardia, diaphragmatic hernia, distended stomach, or a pulmonary abnormality. Feel for a thrill—a fine, palpable, rushing vibration, a palpable murmur, often, but not always, over the base of the heart in the area of the right or left second intercostal space. It generally indicates turbulence or a disruption of the expected blood flow related to some defect in the closure of the aortic or pulmonic valve (generally aortic or pulmonic stenosis), pulmonary hypertension, or atrial septal defect (Box 14-4). Locate each sensation in terms of its intercostal space and relationship to the midsternal, midclavicular, or axillary lines. Chapter 13 describes the method for counting ribs and intercostal spaces.

Pulse rate

In the adult at physical and mental rest, recent clinical evidence shows the normal resting heart range of 95% of healthy persons at 50 to 95 beats/min.[24] Traditional resting heart rate limits established in the 1950s are 60 to100 beats/min. This range is still used; however, no research evidence supports it.The rate normally varies with age, being more rapid in infancy and childhood and more moderate during adult and older years. The rate also varies with gender; after puberty females have a slightly faster rate than males.Many medications also affect heart rate, with nearly all heart disease patients taking at least one medication that slows the heart rate.In the adult a resting heart rate less than 50 beats/min is bradycardia. Heart rates in the 50s/min occur normally in the well-trained athlete whose heart muscle develops along with the skeletal muscles. The stronger, more efficient heart muscle pushes out a larger stroke volume with each beat, thus requiring fewer beats per minute to maintain a stable cardiac output.For descriptions of abnormal rates and rhythms, see Table 20-1, Variations in Pulse Contour on p. 530).A more rapid heart rate, variably defined as over 95 beats/min or over 100 beats/min, is tachycardia. Rapid rates occur normally with anxiety or with increased exercise to match the body's demand for increased metabolism.Tachycardia occurs with fever and also with sepsis, pneumonia, myocardial infarction, and pancreatitis. This evidence predicts complications and worse survival rates in the latter conditions.[24]

Assessment Techniques

Inspection: By visual or auditory observation. Auscultation: By listening to sounds with a stethoscope. Palpation: By touching Fingertips: Best for texture, moisture, shape. Palmar surface of fingers: Best for vibration. Dorsum of hand: Best for temperature. Percussion: By striking the body and assessing the sound. Light percussion: Best for tenderness, density. Sharp percussion: Best for reflexes.

Palpate the Apical Impulse (This used to be called the point of maximal impulse, or PMI.) Localize the apical impulse precisely using one finger pad.

Location—The apical impulse should occupy only one interspace, the fourth or fifth, and be at or medial to the midclavicular line • Size—Normally 1 cm × 2 cm • Amplitude—Normally a short, gentle tap • Duration—Short, normally occupies only first half of systole The apical impulse is palpable in about half of adults. It is not palpable in obese patients or patients with thick chest walls. With high cardiac output states (anxiety, fever, hyperthyroidism, anemia), the apical impulse increases in amplitude and duration. Abnormal: Cardiac enlargement:Left ventricular dilation (volume overload) displaces apical impulse down and to the left and increases size more than one space. Increased force and duration but no change in location occurs with left ventricular hypertrophy and no dilation (pressure overload). Apical impulse is not palpable with pulmonary emphysema due to hyperinflated lungs, which override the heart.

Cardiovascular Palpation

Make sure that your hands are warm, and with the patient supine, palpate the precordium. Use the proximal halves of the four fingers held gently together or use the whole hand. Touch lightly and let the cardiac movements rise to your hand because sensation decreases as you increase pressure. As always, be methodical. One suggested sequence is to begin at the apex, move to the inferior left sternal border, then move up the sternum to the base and down the right sternal border and into the epigastrium or axillae if the circumstance dictates

Neurovascular Assessment.

Musculoskeletal injuries may cause changes in the neurovascular status of an injured extremity. Application of a cast or constrictive dressing, poor positioning, and physiologic responses to the traumatic injury can cause nerve or vascular damage, usually distal to the injury. The neurovascular assessment should consist of peripheral vascular assessment (color, temperature, capillary refill, peripheral pulses, edema) and peripheral neurologic assessment (sensation, motor function, pain). Throughout the neurovascular assessment, compare both extremities to obtain an accurate assessment. Assess an extremity's color (pink, pale, cyanotic) and temperature (hot, warm, cool, cold) in the area of the injury. Pallor or a cool-to-cold extremity below the injury could indicate arterial insufficiency. A warm, cyanotic extremity could indicate poor venous return. Next assess capillary refill (blanching of the nail bed). A compressed nail bed should return to its original color within 3 seconds. Compare pulses on the unaffected and injured extremity to identify differences in rate or quality. This contralateral evaluation is critical. Pulses are described as strong, diminished, audible by Doppler, or absent. A diminished or absent pulse distal to the injury can indicate vascular dysfunction and insufficiency. Also assess peripheral edema. Pitting edema may be present with severe injury. Assess ulnar, median, and radial nerve function to evaluate sensation and motor innervation in the upper extremity. Assess motor function by asking the patient to (1) abduct the fingers (ulnar nerve), (2) oppose the thumb and small finger (median nerve), and (3) flex and extend the wrist (or the fingers, if in a cast) (radial nerve). In the lower extremity, assess the patient's ability to perform dorsiflexion (peroneal nerve) and plantar flexion (tibial nerve). Evaluate sensory function of the peroneal nerve by touching the web space between the great and second toes. Stroke the plantar surface (sole) of the foot to assess sensory function of the tibial nerve. Paresthesia (abnormal sensation [e.g., numbness, tingling]) and hypersensation or hyperesthesia may be reported by the patient. Partial or full loss of sensation (paresis or paralysis) may be a late sign of neurovascular damage. Instruct patients to immediately report any changes in sensation or the ability to move the digits in the affected extremity.

Inspect the Jugular Venous Pulse: abnormal findings

NOTE: This inspection is considered by many authorities to be an advanced skill for practitioners in the cardiopulmonary environment, in particular. It is not considered part of the basic cardiac assessment when no other abnormal cardiac findings are evident. Unilateral distension of external jugular veins is due to local cause, e.g., kinking or aneurysm. Fully distended external jugular veins above 45 degrees signify increased central venous pressure (CVP).

Anus

The anal surface is more darkly pigmented, and the skin may appear coarse. It should be free of scarring, lesions, inflammation, fissures, lumps, skin tags, or excoriation. If you touch the anus or perianal skin, be sure to change your gloves so that you do not introduce bacteria into the vagina during the internal examination. Spread the patient's buttocks apart and inspect the anus. Use a penlight or lamp to assist in visualization. The skin around the anus will appear coarser and more darkly pigmented. Look for skin lesions, skin tags or warts, external hemorrhoids, fissures, and fistulae. Ask the patient to bear down. This will make fistulae, fissures, rectal prolapse, polyps, and internal hemorrhoids more readily apparent.

Cardiovascular Syncope and Common Causes

Neurologic: Vertebrobasilar transient ischemic attacks, subclavian steal syndrome, hydrocephalus. Metabolic: Hypoxia, hyperventilation, hypoglycemia. Cardiac: Orthostatic hypotension, vasovagal reaction or syncope. Vasomotor: Obstructive lesions, arrhythmias. Assess for dizziness, light-headedness, visual blurring or any visual or hearing changes, weakness, apprehension, nausea, sweating, blood pressure, and pulse. Prevention or intervention: Stay with the patient. Help the patient sit or lower to the chair, bed, or floor. Protect the patient's head at all times. Call for help. Elevate the legs, assess vital signs, use ammonia (if needed), help the patient sit up slowly when he or she is ready, and document per organizational policy.

Gastric Interventions

Nonsurgical Management. The purpose of treatment for GERD is to relieve symptoms, treat esophagitis, and prevent complications such as strictures or Barrett's esophagus. For most patients, GERD can be controlled by nutrition therapy, lifestyle changes, and drug therapy. The most important role of the nurse is patient and family education. Teach the patient that GERD is a chronic disorder that requires ongoing management. The disease should be treated more aggressively in older adults

Respirations

Normally a person's breathing is relaxed, regular, automatic, and silent. Because most people are unaware of their breathing, do not mention that you will be counting the respirations, because sudden awareness may alter the normal pattern. Maintain your position of counting the radial pulse and unobtrusively count the respirations. Count for 30 seconds, but count for a full minute if you suspect an abnormality. Avoid the 15-second interval. The result can vary by a factor of +4 or −4, which is significant with such a small number. If you are having difficulty seeing the chest rise, which can be especially difficult in obese individuals and children, you can place a hand on the upper chest or abdomen to help you "feel" the respiratory rate. Report the number of breaths per minute.Report additional objective data (e.g., labored, shallow, or deep breathing; retractions in infants and children; and accessory muscle use in adults).

Tactile Fremitus

Note the quality of the tactile fremitus, the palpable vibration of the chest wall that results from speech or other verbalizations. Fremitus is best felt posteriorly and laterally at the level of the bifurcation of the bronchi. There is great variability depending on the intensity and pitch of the voice and the structure and thickness of the chest wall. In addition, the scapulae obscure fremitus.

Gastric Nonpharmacologic Interventions.

Nutrition therapy is used to relieve symptoms in patients with relatively mild GERD. Ask about the patient's basic meal patterns and food preferences. Coordinate with the dietitian, patient, and family about how to adapt to changes in eating that may decrease reflux symptoms. Teach the patient to limit or eliminate foods that decrease LES pressure and that irritate inflamed tissue, causing heartburn, such as peppermint, chocolate, alcohol, fatty foods (especially fried), caffeine, and carbonated beverages. The patient should also restrict spicy and acidic foods (e.g., orange juice, tomatoes) until esophageal healing can occur. Patients who are smartphone users may find different types of applications ("apps") that can help them follow a healthier diet, such as MyFitnessPal. In keeping with The Joint Commission Core Measures, teach patients that smoking and alcohol use should also be avoided, because these can also decrease LES pressure. Explore the possibility and methods for smoking cessation, and make appropriate referrals. Ask the patient about his or her use of alcoholic beverages, and if appropriate, assist the patient in finding alcohol-cessation programs.

Enlarged Organs or Masses.

Observe the contour of the abdomen while asking the patient to take a deep breath and hold it. Normally the contour remains smooth and symmetrical. This maneuver forces the diaphragm downward and reduces the size of the abdominal cavity. Any enlarged organs in the upper abdominal cavity (e.g., liver or spleen) descend below the rib cage to cause a bulge. Perform a closer examination with palpation. To evaluate the abdominal musculature have the patient raise the head. This position causes superficial abdominal wall masses, hernias, and muscle separations to become more apparent.

GAIT

Observe the patient walk without shoes around the examining room or down a hallway, first with the eyes open. Observe the expected gait sequence, noting simultaneous arm movements and upright posture: 1. The first heel strikes the floor and then moves to full contact with the floor. 2. The second heel pushes off, leaving the ground. 3. Body weight is transferred from the first heel to the ball of its foot. 4. The leg swing is accelerated as weight is removed from the second foot. 5. The second foot is lifted and travels ahead of the weight-bearing first foot, swinging through. 6. The second foot slows in preparation for heel strike.

Palpation

Palpate the thoracic muscles and skeleton, feeling for pulsations, areas of tenderness, bulges, depressions, masses, and unusual movement. Expect bilateral symmetry and some elasticity of the rib cage, but the sternum and xiphoid should be relatively inflexible and the thoracic spine rigid. Crepitus, a crackly or crinkly sensation, can be both palpated and heard—a gentle, bubbly feeling. It indicates air in the subcutaneous tissue from a rupture somewhere in the respiratory system or by infection with a gas-producing organism. It may be localized (e.g., over the suprasternal notch and base of the neck) or cover a wider area, potentially involving the arms and face with the associated swelling mimicking an allergic reaction. Crepitus always results from an underlying pathologic process. A palpable, coarse, grating vibration, usually on inspiration, suggests a pleural friction rub caused by inflammation of the pleural surfaces. Think of it as the feel of leather rubbing on leather.

Cardiovascular Lab Assessment

Patients with atherosclerosis often have elevated lipids, including cholesterol and triglycerides. Total serum cholesterol levels should be below 200 mg/dL. Elevated cholesterol levels are confirmed by HDL and LDL measurements. Increased low-density lipoprotein cholesterol (LDL-C) ("bad" cholesterol) levels indicate that a person is at an increased risk for atherosclerosis. Low high-density lipoprotein cholesterol (HDL-C) ("good" cholesterol) levels also indicate an increased risk. In general, a desirable LDL-C level is one below 130 mg/dL for healthy people and below 70 mg/dL for those diagnosed with CVD or who are diabetic. A desirable HDL-C level is 45 mg/dL or above for men and 55 mg/dL for women. These values differ based on age and comorbidities. Triglyceride level may also be elevated with atherosclerosis and is an emerging lipid risk factor by the classic Adult Treatment Panel Report No. 3 (ATP III) released by the National Heart, Lung, and Blood Institute ( National Cholesterol Education Program, 2002). A level of 160 mg/dL or above indicates hypertriglyceridemia in men. Women should have a level below 135 mg/dL. Elevated triglycerides are considered a marker for other lipoproteins. They also suggest metabolic syndrome, which increases the risk for coronary heart disease

General Survey

Physical Appearance Age—The person appears his or her stated age.Appears older than stated age, as with chronic illness or chronic alcoholism. Sex—Sexual development is appropriate for sex and age. If the individual is transgender, note the stage of transformation.Delayed or precocious puberty. Level of consciousness—The person is alert and oriented to person, place, time, and situation. Attends to and responds appropriately to your questions.Confused, drowsy, lethargic Skin color—Color tone is even, pigmentation varying with genetic background; skin is intact with no obvious lesions. Make note of tattoos and piercings and stage of healing.Pallor, cyanosis, jaundice, erythema, any lesions Facial features—Facial features are symmetric with movement. Immobile, masklike, asymmetric, drooping Overall appearance—No signs of acute distress are present.Cardiac or respiratory signs— Diaphoresis, clutching the chest, shortness of breath, wheezing.Pain, indicated by facial grimace, holding body part.

Physical Dependence, Tolerance, and Addiction.

Physical dependence is a normal response that occurs with repeated administration of an opioid for several days. Tolerance is also a normal response that occurs with regular administration of an opioid and consists of a decrease in one or more effects of the opioid Opioid addiction is a chronic neurologic and biologic disease. The development and characteristics of addiction are influenced by genetic, psychosocial, and environmental factors. Pseudoaddiction is a mistaken diagnosis of addictive disease. When a patient's pain is not well controlled, the patient may begin to manifest symptoms suggestive of addictive disease.

Polypharmacy

Polypharmacy is "giving medications without a clear indication, giving two similar medications for the same indication, giving medications that are contraindicated, and/or giving medications where the dosage is either too high or too low" (Alexander-Magalee, 2013) (see Evidence-Based Practice box). Older adults are vulnerable to polypharmacy because many have one or more chronic conditions requiring multiple medications. To complicate matters, patients may see more than one provider and may have prescriptions filled at more than one pharmacy (Emmons, 2008). Additional contributors to polypharmacy include the use of OTC and alternative medicines or supplements in the treatment of conditions (Qato et al., 2008). As a result, the patient may end up taking duplicate drugs, similar drugs from the same drug class, and drugs that are contraindicated when taken together.

Inspect the Jugular Venous Pulse

Position the patient supine with the torso elevated anywhere from a 30- to a 45-degree angle. Remove the pillow to avoid flexing the neck. Stand on the patient's right, turn the head slightly away from the examined side, and direct a strong light tangentially onto the neck to highlight pulsations and shadows. Note the external jugular veins overlying the sternomastoid muscle. In some patients, the veins are not visible at all; in others, they are full in the supine position. As the patient is raised to a sitting position, these external jugulars flatten and disappear, usually at 45 degrees.

Nervous Pupil function and intraocular pressure.

Pupil function is determined by inspecting the pupils and their reactions to light. The normal finding is commonly abbreviated as PERRL (pupils are equal [in size], round, and reactive to light). To test for accommodation, ask the person to focus on a distant object. This process dilates the eyes. Then have the person shift the focus to a near object (e.g., your finger held about 3 inches from the person's nose). A normal response is constriction of the eyes and convergence (inward movement of both eyes toward each other). When accommodation is assessed in addition to the pupillary light reflex, a normal response is PERRLA (pupils are equal, round, and reactive to light and accommodation). In a small percentage of the population, the pupils are unequal in size (anisocoria). The pupils should react to light directly (pupil constricts when a light shines into the eye) and consensually (pupil constricts when a light shines into the opposite eye). Intraocular pressure can be measured by a variety of methods, including tonometry. Normal intraocular pressure ranges from 10 to 21 mm Hg.

Pupillary Reflexes and Accommodation

Pupillary reflexes are evaluated in a darkened environment using a penlight. To check for light reflexes, approach the patient's eyes from one side while asking the patient to focus straight ahead into the distance. Ask the patient to avoid looking directly into the light. The pupil closer to the light should constrict immediately in response to exposure to the indirect light, followed by constriction of the opposite pupil (consensual constriction) more distant from the light. Repeat the procedure on the opposite eye. Assessing pupillary light reflex. A, Begin by approaching one eye with a penlight from the side. B, Observe the closest pupil for immediate constriction followed by consensual constriction of the opposite pupil. Testing pupillary reflexes for accommodation evaluates the ability of the eyes to focus on near objects. Assessment of accommodation is necessary only if pupillary reflexes are sluggish, absent, or abnormal in any way (Jun, 2014). Accommodation is facilitated by movement of ciliary muscles and increased curvature of the lens, neither of which is visible. It is assessed by observing whether the pupils converge and constrict when focused on an object at close range. Have the patient focus on a distant object, and then on a pen or unlit penlight held just a few inches in front of the patient's nose. Slowly move the pen or penlight closer to the patient's nose, observing for bilateral convergence and constriction of the pupils. Documentation of a normal pupillary reflex examination is recorded as PERRLA (pupils equal, round, reactive to light and accommodation).

The Procedure: Rectal Temperature

Rectal temperatures are the most accurate route, and the result is as close to core temperature as possible without using more invasive measures reserved for the operating room and critical care environments. Although the rectal temperature provides the closest approximation to core temperature, it is more invasive than other measures; therefore you must weigh the risks and benefits. In children the temporal artery route misses fever in as many as 30% of children 6 to 36 months old[14]; therefore it may be advantageous to use rectal temperature in children with a suspected fever or infection.The rectal temperature is the preferred route when the other routes are not practical (e.g., for the comatose or confused person; people in shock; or those who cannot close the mouth because of breathing or oxygen tubes, wired mandible, or other facial dysfunction). Wear gloves and insert a lubricated rectal probe cover on an electronic thermometer only 2 to 3 cm (1 in) into the adult rectum, directed toward the umbilicus. (For a glass thermometer, leave in place forminutes.) Do not let go of the temperature probe while it is inserted into the rectum. Disadvantages to the rectal route are patient discomfort and the invasive nature of the procedure.

Pain History and Assessment

S: Site (Where is the pain located?) O: Onset (When did the pain start? Was it gradual or sudden?) C: Character (What is the quality of the pain? Is it stabbing, burning, or aching?) R: Radiation (Does the pain radiate anywhere?) A: Associations (What signs and symptoms are associated with the pain?) T: Time course (Is there a pattern to when the pain occurs?) E: Exacerbating or relieving factors (Does anything make the pain worse or lessen it?) S: Severity (On a scale of 0 to 10, what is the intensity of the pain?)

Pulse-Volume Scale

SCALEDESCRIPTION OF PULSE 0Absent pulse 1+Weak and thready pulse, difficult to palpate 2+Normal pulse, able to palpate with normal pressure 3+Bounding pulse, may be able to see pulsation

The Procedure: Oral Temperature

Shake a glass thermometer down to 35.5° C (96° F) and place it at the base of the tongue in either of the posterior sublingual pockets—not in front of the tongue. Instruct the person to keep his or her lips closed. Leave in place 3 to 4 minutes if the person is afebrile and up to 8 minutes if febrile. (Take other vital signs during this time.) Wait 15 minutes if the person has just taken hot or iced liquids and 2 minutes if he or she has just smoked.

General body structure

Stature—The height appears within normal range for age, genetic heritage (see Measurement, p. 130).Excessively short or tall Nutrition—The weight appears within normal range for height and body build; body fat distribution is even.Cachectic, emaciated.Simple obesity, with even fat distribution.Centripetal (truncal) obesity—Fat concentrated in face, neck, trunk, with thin extremities, as in Cushing syndrome Symmetry—Body parts look equal bilaterally and are in relative proportion to each other.Unilateral atrophy or hypertrophy.Asymmetric location of a body part Posture—The person stands comfortably erect as appropriate for age. Note the normal "plumb line" through anterior ear, shoulder, hip, patella, ankle. Exceptions are the standing toddler, who has a normally protuberant abdomen ("toddler lordosis"), and the aging person, who may be stooped with kyphosis.Rigid spine and neck; moves as one unit (e.g., arthritis).Stiff and tense, ready to spring from chair, fidgety movements.Shoulders slumped; looks deflated (e.g., depression). Position—The person sits comfortably with arms relaxed at sides and head turned to examiner.Tripod—Leaning forward with arms braced on chair arms; occurs with chronic pulmonary disease.Sits straight up and resists lying down (e.g., heart failure).

Anatomy of the anus and rectum.

The anal canal is normally kept securely closed by concentric rings of muscle, the internal and external sphincters. The internal ring of smooth muscle is under involuntary autonomic control. The urge to defecate occurs when the rectum fills with feces, which causes reflexive stimulation that relaxes the internal sphincter. Defecation is controlled by the striated external sphincter, which is under voluntary control. The lower half of the canal is supplied with somatic sensory nerves, making it sensitive to painful stimuli, whereas the upper half is under autonomic control and is relatively insensitive. Therefore conditions of the lower anus cause pain, whereas those of the upper anus may not. Internally the anal canal is lined by columns of mucosal tissue (columns of Morgagni) that fuse to form the anorectal junction. The spaces between the columns are called crypts, into which anal glands empty. Inflammation of the crypts can result in fistula or fissure formation. Anastomosing veins cross the columns, forming a ring called the zona hemorrhoidalis. Internal hemorrhoids result from dilation of these veins. The lower segment of the anal canal contains a venous plexus that drains into the inferior rectal veins. Dilation of this plexus results in external hemorrhoids. The rectum lies superior to the anus and is approximately 12 cm long. Its proximal end is continuous with the sigmoid colon. The distal end, the anorectal junction, is visible on proctoscopic examination as a sawtooth-like edge but is not palpable. Above the anorectal junction, the rectum dilates and turns posteriorly into the hollow of the coccyx and sacrum, forming the rectal ampulla, which stores flatus and feces. The rectal wall contains three semilunar transverse folds (Houston valves). The lowest of these folds can be palpated by the examiner. In males, the prostate gland is located at the base of the bladder and surrounds the urethra. It is composed of muscular and glandular tissue and is approximately 4 × 3 × 2 cm. The posterior surface of the prostate gland is in close contact with the anterior rectal wall and is accessible by digital examination. It is convex and is divided by a shallow median sulcus into right and left lateral lobes. A third or median lobe, not palpable on examination, is composed of glandular tissue and lies between the ejaculatory duct and the urethra. It contains active secretory alveoli that contribute to ejaculatory fluid. The seminal vesicles extend outward from the prostate

Cardiovascular assessment

The assessment of a patient with atherosclerosis includes a complete cardiovascular assessment because associated heart disease is often present. Because of the high incidence of hypertension in patients with atherosclerosis, assess the blood pressure in both arms. Palpate pulses at all of the major sites on the body, and note any differences. Palpate each carotid artery separately to prevent blocking blood flow to the brain! Also feel for temperature differences in the lower extremities, and check capillary filling. Prolonged capillary filling (>3 seconds in young to middle-aged adults; >5 seconds in older adults) generally indicates poor circulation, although this indicator is not the most reliable indicator of perfusion. An extremity in a person with severe atherosclerotic disease may be cool or cold with a diminished or absent pulse. Many patients with vascular disease have a bruit in the larger arteries, which can be heard with a stethoscope or Doppler probe. A bruit is a turbulent, swishing sound, which can be soft or loud in pitch. It is heard as a result of blood trying to pass through a narrowed artery. A bruit is considered abnormal, but it does not indicate the severity of disease. Bruits often occur in the carotid, aortic, femoral, and popliteal arteries.

Nervous Assessment of Sensory Function.

The assessment of sensory function is done for patients with problems affecting the spinal cord or spinal nerves, such as trauma, intervertebral disk disease, Guillain-Barré syndrome (GBS), tumor, infection, stenosis, or transverse myelitis. The sensory assessment includes pain, superficial and deep sensation, light touch, and proprioception. Pain and light touch are the most commonly assessed. The acuity level of the patient determines how often the sensory assessment is done. For example, patients with acute spinal cord trauma or ascending GBS are assessed every hour until stable and then every 4 hours. As the condition improves, sensory assessment may be needed only once each shift. Findings are documented according to agency protocol. A special spinal cord assessment flow sheet may be used to document sensory and/or motor findings for the patient with a spinal cord injury. Pain and temperature sensation are transmitted by the same nerve endings. Therefore if one sensation is tested and found to be intact, it can safely be assumed that the other is intact. Testing temperature sensation can usually be accomplished using a cold reflex hammer and the warm touch of the hand for patients with known or suspected spinal problems.

Tissue Perfusion.

The condition of the skin, mucosa, and nail beds offers useful data about the status of circulatory blood flow. Examine the face and upper extremities, looking at the color of the skin, mucosa, and nail beds. The presence of cyanosis requires special attention. Heart disease sometimes causes central cyanosis, which indicates poor arterial oxygenation. Some characteristics of this are a bluish discoloration of the lips, mouth, and conjunctivae. Blue lips, earlobes, and nail beds are signs of peripheral cyanosis, which indicates peripheral vasoconstriction. When cyanosis is present, consult with a health care provider to request laboratory testing of oxygen saturation to determine the severity of the problem. Examination of the nails involves inspection for clubbing, a bulging of the tissues at the nail base. Clubbing is caused by insufficient oxygenation at the periphery resulting from conditions such as chronic emphysema and congenital heart disease. Inspect the lower extremities for changes in color, temperature, and condition of the skin, indicating either arterial or venous alterations (Table 31-25). This is a good time to ask the patient about any history of pain in the legs. If an arterial occlusion is present, the patient has signs resulting from an absence of blood flow. Pain is distal to the occlusion. The five Ps—pain, pallor, pulselessness, paresthesias, and paralysis—characterize an occlusion. Venous congestion causes tissue changes that indicate an inadequate circulatory flow back to the heart.

Pulse Force

The force of the pulse shows the strength of the heart's stroke volume. A "full, bounding" pulse denotes an increased stroke volume (e.g., as with anxiety, exercise, and some abnormal conditions). The pulse force is recorded using a three-point scale: 3+—Full, bounding 2+—Normal 1+—Weak, thready 0—Absent Some agencies use a four-point scale; make sure that your system is consistent with that used by the rest of your staff. Either scale is somewhat subjective. Experience will increase your clinical judgment. Most healthy adults have a force of 2+.Force shows the strength of the heart's stroke volume. "weak thready" pulse reflects a decreased SV (i.e. occurs with hemorrhagic shock) "full, bounding" pulse denotes increased SV: anxiety, exercise, and some abnormal conditions. Recorded using a three-point scale: 3+ full, bounding 2+ normal 1+ weak, thready 0 absent Scale is somewhat subjective

Nervous Change in Level of Consciousness.

The level of consciousness (LOC) is the most sensitive and reliable indicator of the patient's neurologic status. Changes in LOC are a result of impaired CBF, which causes O2 deprivation to the cells of the cerebral cortex and reticular activating system (RAS). The RAS is located in the brainstem, with neural connections to many parts of the nervous system. An intact RAS can maintain a state of wakefulness even in the absence of a functioning cerebral cortex. Interruptions of impulses from the RAS or alterations in functioning of the cerebral hemispheres can cause unconsciousness (abnormal state of complete or partial unawareness of self or environment). The patient's state of consciousness is defined by the patient's clinical responses and pattern of brain activity (recorded by an electroencephalogram [EEG]). A change in consciousness may be dramatic (as in coma) or subtle (such as a flattening of affect, change in orientation, or decrease in level of attention). In the deepest state of unconsciousness (i.e., coma), the patient does not respond to painful stimuli. Corneal and pupillary reflexes are absent. The patient cannot swallow or cough and is incontinent of urine and feces. The EEG pattern demonstrates suppressed or absent neuronal activity.

Lobes of the Lungs

The lungs are paired but not precisely symmetric structures (Fig. 18-6). The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The right lung has three lobes, and the left lung has two lobes. These lobes are not arranged in horizontal bands like dessert layers in a parfait glass. Rather they stack in diagonal sloping segments and are separated by fissures that run obliquely through the chest. Anterior. On the anterior chest the oblique (the major or diagonal) fissure crosses the 5th rib in the midaxillary line and terminates at the 6th rib in the midclavicular line. The right lung also contains the horizontal (minor) fissure, which divides the right upper and middle lobes. This fissure extends from the 5th rib in the right midaxillary line to the 3rd intercostal space or 4th rib at the right sternal border. Posterior. The most remarkable point about the posterior chest is that it is almost all lower lobe (Fig. 18-7). The upper lobes occupy a smaller band of tissue from their apices at T1 down to T3 or T4. At this level the lower lobes begin, and their inferior border reaches down to the level of T10 on expiration and T12 on inspiration. Note that the right middle lobe does not project onto the posterior chest at all. If the person abducts the arms and places the hands on the back of the head, the division between the upper and lower lobes corresponds to the medial border of the scapulae.

Neurologic and Musculoskeletal Assessment.

The neurologic assessment includes motor function (mobility), sensation, and cognition. Assess the patient's pre-existing problems, general physical condition, and communication abilities. Patients may have dysphasia (slurred speech) because of facial muscle weakness or may have aphasia (inability to speak or comprehend), usually the result of a cerebral stroke or traumatic brain injury (TBI). These communication problems are discussed in detail in the chapters on problems of the nervous system. Determine if the patient has paresis (weakness) or paralysis (absence of movement). Observe the patient's gait. Identify sensory-perceptual changes, such as visual acuity, that could contribute to the patient's risk for injury. Assess his or her response to light touch, hot or cold temperature, and position change in each extremity and on the trunk. Identify levels of decreased sensation. For a perceptual assessment, the nurse evaluates the patient's ability to receive and understand what is heard and seen and the ability to express appropriate motor and verbal responses. During this portion of the assessment, begin to assess short-term and long-term memory.

The Procedure: Temporal Artery Thermometer

The newest noninvasive temperature measurement method uses infrared emissions from the temporal artery. The temporal artery thermometer (TAT) is used by sliding the probe across the forehead and behind the ear. The thermometer works by taking multiple readings and providing an average. The reading takes approximately 6 seconds. This approach is well tolerated and is more accurate than TMTs; however, there are conflicting reports about its accuracy.[3,14,33] Report the temperature in degrees Celsius unless your agency uses the Fahrenheit scale. Familiarize yourself with both scales. Note that it is far easier to learn to think in the centigrade scale than to take the time for paper-and-pencil conversions. Begin by memorizing these convenient equivalents:104°=40° C; 98.6° F=37° C; 95° F=35° C36727Along with your results, make sure to note the route used to obtain the temperature reading.

Nervous Mental Status Assessment

The patient's mental status indicates the level of cerebral function. Obtaining a baseline appraisal of the patient's abilities helps the nurse plan patient education, assess understanding of instruction, and determine the patient's capacity to make decisions. Assessment of mental status evaluates brain function related to intellect, behavior, language, memory, knowledge, judgment, association, attention, level of consciousness, decision making, and abstract thinking. The Glasgow Coma Scale is an objective assessment tool used to define a person's level of consciousness by assigning a numeric value to the person's level of arousal. The scale is divided into three areas: eye opening, verbal response, and motor response. Each area is scored separately, and a number is assigned to the person's best response. The three numbers are added, and the total score reflects the patient's level of consciousness. A fully alert, normally responsive patient will have a score of 15. Scores from multiple assessments can be plotted on a graph to provide a visual illustration indicating that the patient is stable, improving, or deteriorating. A score of less than 7 reflects a patient who is comatose

Pulse

The pulse is the palpable, bounding blood flow created by the contraction of the left ventricle of the heart. It can be assessed at various points on the body. The pulse is an indicator of circulatory status. Electrical impulses originating in the sinoatrial (SA) node of the heart stimulate cardiac muscle contraction, which sends a pulse wave. The number of pulsing sensations occurring in 1 minute is the pulse rate. Mechanical, neural, and chemical factors regulate the strength of ventricular contraction and the subsequent cardiac output. As the heart rate increases, less time is available for the heart to fill. An abnormally slow, rapid, or irregular pulse reflects an alteration in cardiac output, which may result in an inability to meet the physiologic demands of the body. The apical pulse is a central pulse that can be auscultated over the apex of the heart at the point of maximal impulse (PMI). Peripheral pulses are those that can be palpated over arteries located away from the heart—at the wrist or foot, for example. Normal pulse rates are listed in Factors Affecting Pulse Rate As noted earlier, pulse rate is expressed in bpm. The pulse rate is variable and is dependent on physiologic and emotional factors. The nurse should consider several patient-specific factors when assessing the pulse, including age, gender, exercise, presence of fever, medications, fluid volume status, stress, and underlying disease processes

Pulse rhythm

The pulse normally has a regular, even tempo. One irregularity that is commonly found in children and young adults is sinus arrhythmia. In sinus arrhythmia the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. Inspiration momentarily causes a decreased stroke volume from the left side of the heart; to compensate the heart rate increases. (See Chapter 19 for a full discussion on sinus arrhythmia.) If any other irregularities are felt, auscultate heart sounds for a more complete assessment (see Chapter 19).

Radial Pulses

The radial artery is palpated on the inner aspect of the wrist in the groove closer to the thumb. On the opposite side of the wrist, the ulnar artery can be felt. The ulnar pulse is less prominent than the radial pulse and is assessed only in circumstances in which the radial pulse is not palpable. The hand normally is supplied by blood from the ulnar and radial arteries. Assessment of the radial pulse is performed on the thumb side of the wrist. The Allen test is used to evaluate for collateral circulation to determine the patency of the arteries of the hand before arterial blood tests. The Allen test is performed by having the patient elevate the extremity and make a fist. The examiner occludes the radial and ulnar arteries, using pressure. The patient's hand should lose color. The patient then opens the fist, and the pressure is released from the ulnar artery. The normal pink color should return to the hand within 10 seconds, showing good circulation. Conducting the Allen test. A, Occlude both the radial and ulnar arteries simultaneously. B, Release pressure on the ulnar artery and observe for return of color to the hand.

Anatomy and Physiology GI

The rectum and anus form the terminal portions of the gastrointestinal (GI) tract (Fig. 20-1). The anal canal is approximately 2.5 to 4 cm long and opens onto the perineum. The tissue visible at the external margin of the anus is moist, hairless mucosa. Juncture with the perianal skin is characterized by increased pigmentation and, in the adult, the presence of hair.

Nervous Spinal Cord and Spinal Tracts

The spinal cord, 40 to 50 cm long, begins at the foramen magnum as a continuation of the medulla oblongata and terminates at L1 or L2 of the vertebral column. Fibers, grouped into tracts, run through the spinal cord carrying sensory, motor, and autonomic impulses between higher centers in the brain and the body. The gray matter, arranged in a butterfly shape with anterior and posterior horns, contains the nerve cell bodies associated with sensory pathways and the autonomic nervous system. The white matter of the spinal cord contains the ascending and descending spinal tracts

Abdomen/ GI Clinical Manifestations

The symptoms of GERD vary from person to person. The persistence of mild symptoms (i.e., more than twice a week) or moderate to severe symptoms once a week is considered GERD. Heartburn (pyrosis) is the most common manifestation. Heartburn is a burning, tight sensation felt intermittently beneath the lower sternum and spreading upward to the throat or jaw. It may occur after ingesting food or drugs that decrease the LES pressure or directly irritate the esophageal mucosa. An HCP should evaluate heartburn that occurs more than twice a week, is severe, is associated with dysphagia, or occurs at night and wakes a person from sleep. Older adults who complain of recent onset of heartburn should receive medical evaluation. Patients may complain of dyspepsia or regurgitation. Dyspepsia is pain or discomfort centered in the upper abdomen (mainly in or around the midline as opposed to the right or left hypochondrium). Regurgitation is often described as hot, bitter, or sour liquid coming into the throat or mouth. A person with GERD may report respiratory symptoms, including wheezing, coughing, and dyspnea. Nocturnal discomfort and coughing can awaken the person, resulting in disturbed sleep patterns. Otolaryngologic symptoms include hoarseness, sore throat, a globus sensation (sense of a lump in the throat), hypersalivation, and choking. GERD-related chest pain can mimic angina. It is described as burning; squeezing; or radiating to the back, neck, jaw, or arms. Complaints of chest pain are more common in older adults with GERD. Unlike angina, GERD-related chest pain is relieved with antacids.

The Procedure: Tympanic Membrane Temperature

The tympanic membrane thermometer (TMT) senses infrared emissions of the tympanic membrane (eardrum). The tympanic membrane shares the same vascular supply that perfuses the hypothalamus (the internal carotid artery); thus it is an accurate measurement of core temperature. The TMT is a noninvasive, nontraumatic device that is extremely quick and efficient. The probe tip has the shape of an otoscope, the instrument used to inspect the ear. Gently place the covered probe tip in the person's ear canal and aim the infrared beam at the tympanic membrane (see Fig. 9-17 on p. 148). Do not occlude the canal. Activate the device and read the temperature in 2 to 3 seconds.

Assessment of Motor Function.

Throughout the physical assessment, observe the patient for involuntary tremors or movements. Describe these movements as accurately as possible, such as "pill-rolling with the thumbs and fingers at rest" or "intention tremors of both hands" (tremors that occur when the patient tries to do something). These abnormalities can indicate certain diseases, such as multiple sclerosis, or the effects of selected psychotropic drugs. In addition, assess the patient for motor movements that indicate irritability, hyperactivity, or slowed movements. Measure the patient's hand strength by asking him or her to grasp and squeeze two fingers of each of your hands. Then compare the grasps for equality of strength. As another means of evaluating strength, try to withdraw the fingers from the patient's grasp and compare the ease or difficulty. He or she should release the grasps on command—another assessment of consciousness and the ability to follow commands. Collaborate with the physical therapist to test the patient's strength. To test strength against resistance, ask the patient to resist the examiner's bending or straightening of the arm, hand, leg, or foot being tested (Fig. 41-7). A five-point rating scale is commonly used (see Chapter 49, Table 49-2). Always evaluate and compare strength on each side. Compare previous results with current findings, and report all decreases to the health care providers.

Characteristics of Pain.

Timing (Onset, Duration, and Pattern). Ask questions to determine the start, duration, and time sequence of pain. When did it begin? How long has it lasted? Does it occur at the same time each day? How often does it recur? It is sometimes easier to diagnose the nature of pain by identifying time factors. The onset of sudden and severe pain is easier to assess than gradual, mild discomfort. Knowing the time cycle of a patient's pain helps you intervene before the pain occurs or worsens. Precipitating Factors. Determine the specific events or conditions that precipitate or aggravate pain. Ask the patient to describe activities that cause pain such as sitting, bending over, drinking coffee or alcohol, urination, swallowing, or emotional stress. Ask the patient to demonstrate actions that cause painful responses such as coughing or turning in a certain manner. After identifying specific factors, it is easier to plan interventions to avoid worsening the pain. Quality. There is no common pain vocabulary in general use. Patients describe pain in their own way. Patients of American descent often use hurt and ache to describe their pain, reserving the word pain for severe discomfort. Knowing the quality of pain helps to select appropriate therapies to treat it. When assessing the quality of pain, do not provide descriptive words for a patient. Assessment is more accurate if a patient describes the sensation in his or her own words after open-ended questions. For example, say, "Tell me what your pain feels like." The only time you offer to list descriptive terms is when the patient is unable to describe pain. There is some consistency in the way patients describe certain types of pain. People often describe the pain of a myocardial infarction (heart attack) as crushing or viselike. Some people describe the pain of a surgical incision as sharp and stabbing. Neuropathic pain is burning or electric-like. When a patient's descriptions fit the pattern forming in your assessment, you are able to make a clearer analysis of the nature and type of pain. This leads to more appropriate pain management (e.g., you treat nociceptive and neuropathic pain differently). Relief Measures. Make sure that you know if a patient has an effective way of relieving pain such as changing position, using ritualistic behavior (pacing, rocking, or rubbing), eating, praying, or applying heat or cold to a painful site. A patient's methods are often ones that you can use for treatment. Determine if patients use relief measures safely in their home. Patients gain trust when they know you are willing to try their relief measures. They also gain a sense of control over the pain instead of the pain controlling them. Assessment also includes identification of all health care providers (e.g., physician, acupuncturist). Patients with chronic pain are more likely to try alternative health care methods. Region/Location. To assess pain location, ask a patient to point to all areas of discomfort. To localize the pain more specifically, have the patient trace the area from the most severe point outward. This is difficult to do if pain is diffuse, involves several sites, or involves large parts of the body. Use a drawing showing the location of pain as the baseline if the pain changes. Use anatomical landmarks and descriptive terminology to record the pain location (e.g., "Pain is in the right upper abdominal quadrant"). Pain classified by location is superficial or cutaneous, deep or visceral, localized or diffuse, or referred or radiating. Severity. One of the most subjective and therefore most useful characteristics for reporting pain is its severity or intensity. Nurses use a variety of pain scales to help patients communicate pain intensity. Many are available in foreign languages. Examples of pain intensity scales include the verbal descriptor scale (VDS), the numerical rating scale (NRS), and the visual analog scale (VAS) (Figure 32-4). Use a scale to measure the current severity of a patient's pain. In addition, ask patients to rate their average pain and the worst pain they have had over the past 24 hours. This helps to determine an average pain intensity that allows you to see trends.

Auscultation

Unlike the usual sequence, always perform auscultation of the abdomen prior to percussion and palpation because these maneuvers may alter the frequency and intensity of bowel sounds. Bowel Sounds Lightly place the diaphragm of a warmed stethoscope on the abdomen. Some health care providers say they prefer to use the bell; in reality, they tend to pull the skin tight with the bell and, in effect, make a diaphragm. A cold stethoscope, like cold hands, may initiate contraction of the abdominal muscles. Listen for bowel sounds and note frequency and character. They are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. Bowel sounds are generalized so most often they can be assessed adequately by listening in one place. Loud prolonged gurgles are called borborygmi (stomach growling). Increased bowel sounds may occur with gastroenteritis, early intestinal obstruction, or hunger. High-pitched tinkling sounds suggest intestinal fluid and air under pressure, as in early obstruction. Decreased bowel sounds occur with peritonitis and paralytic ileus. Auscultate in all four quadrants if you have a concern. Absent bowel sounds, referring to an inability to hear any bowel sounds after 5 minutes of continuous listening, is typically associated with abdominal pain and rigidity and is a surgical emergency. Additional Sounds and Bruits Listen with the diaphragm for friction rubs over the liver and spleen. Friction rubs are high pitched and are heard in association with respiration. Although friction rubs in the abdomen are rare, they indicate inflammation of the peritoneal surface of the organ from tumor, infection, or infarct. A bruit is a harsh or musical intermittent auscultatory sound, which may reflect blood flow turbulence and indicate vascular disease. Listen with the bell of the stethoscope in the epigastric region and for bruits in the aortic, renal, iliac, and femoral arteries. Vascular sounds are usually well localized. Keep their specific locations in mind as you listen at those sites . Auscultate with the bell of the stethoscope in the epigastric region and around the umbilicus for a venous hum, which is soft, low pitched, and continuous. A venous hum occurs with increased collateral circulation between the portal and systemic venous systems.

Abdomen/ GI Inspection

Using the nondominant hand, gently retract the buttocks to view the perianal and sacrococcygeal areas. Perianal skin is smooth, more pigmented, and coarser than skin over the buttocks. Inspect anal tissue for skin characteristics, lesions, external hemorrhoids (dilated veins that appear as reddened protrusions), ulcers, fissures and fistulas, inflammation, rashes, or excoriation. Anal tissues are moist and hairless, and the voluntary external muscle sphincter holds the anus closed. Next ask a patient to bear down as though having a bowel movement. Any internal hemorrhoids or fissures appear at this time. Use clock reference (e.g., 3 o'clock or 8 o'clock) to describe location of findings. Normally there is no protrusion of tissue.

Palpate Across the Precordium

Using the palmar aspects of your four fingers, gently palpate the apex, the left sternal border, and the base, searching for any other pulsations: normally there are none. If any are present, note the timing. Use the carotid artery pulsation as a guide or auscultate as you palpate. Abnormal: A thrill is a palpable vibration. It feels like the throat of a purring cat. The thrill signifies turbulent blood flow and accompanies loud murmurs. Absence of a thrill, however, does not necessarily rule out the presence of a murmur

Measurement

Weight Use a standardized balance or electronic standing scale (Fig. 9-2). Instruct the person to remove his or her shoes and heavy outer clothing before standing on the scale. When a sequence of repeated weights is necessary, aim for approximately the same time of day and the same type of clothing worn each time. Record the weight in kilograms and in pounds.An unexplained weight loss may be a sign of a short-term illness (e.g., fever, infection, disease of the mouth or throat) or a chronic illness (e.g., endocrine disease, malignancy, depression, anorexia nervosa, bulimia). Unexplained weight gain may indicate fluid retention (e.g., heart failure). Height Use a wall-mounted device or the measuring pole on the balance scale. Align the extended headpiece with the top of the head. The person should be shoeless, standing straight with gentle traction under the jaw, and looking straight ahead. Feet, shoulders, and buttocks should be in contact with the hard surface.

An Enlarged Spleen or an Enlarged Left Kidney?

When an organ is palpable below the left costal margin, it may be difficult to differentiate an enlarged spleen from an enlarged left kidney. Percussion should help distinguish between the organs. The percussion note over an enlarged spleen is dull because the spleen displaces the bowel. The usual area of splenic dullness will be increased downward and toward the midline. The percussion note over an enlarged kidney is resonant because the kidney is deeply situated behind the bowel. In addition, the edge of the spleen is sharper than that of the kidney. A palpable notch along the medial border suggests an enlarged spleen rather than an enlarged kidney.

Abdomen/ GI Spleen.

While still standing on the patient's right side, reach across with your left hand and place it beneath the patient over the left costovertebral angle. Press upward with that hand to lift the spleen anteriorly toward the abdominal wall. Place the palmar surface of your right hand with fingers extended on the patient's abdomen below the left costal margin. Use findings from percussion as a guide. Press your fingertips inward toward the spleen as you ask the patient to take a deep breath. Try to feel the edge of the spleen moving downward toward your fingers. The spleen is not usually palpable in an adult; if you can feel it, it is probably enlarged (). Be sure to palpate with your fingers below the costal margin so that you will not miss the lower edge of an enlarged spleen. Be gentle in palpation. Patients with splenomegaly from infectious mononucleosis have a small risk for spontaneous splenic rupture

Pulse: general

With every beat the heart pumps an amount of blood—the stroke volume—into the aorta. This is about 70 mL in the adult. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse. Palpating the peripheral pulse gives the rate and rhythm of the heartbeat and local data on the condition of the artery. Using the pads of your first three fingers, palpate the radial pulse at the flexor aspect of the wrist laterally along the radius bone (Fig. 9-4). If the rhythm is regular, count the number of beats in 30 seconds and multiply by 2. Although the 15-second interval is frequently practiced, any one-beat error in counting results in a recorded error of 4 beats/min. The 30-second interval is most accurate and efficient when heart rates are normal or rapid and when rhythms are regular. However, if the rhythm is irregular, count for a full minute. As you begin the counting interval, start your count with "zero" for the first pulse felt. The second pulse felt is "one," and so on. Assess the pulse, including (1) rate, (2) rhythm, and (3) force.

Regurgitation

With severe GERD, pain generally occurs after each meal and lasts for 20 minutes to 2 hours. Discomfort may worsen when the patient lies down. Drinking fluids, taking antacids, or maintaining an upright posture usually provides prompt relief. Regurgitation (backward flow into the throat) of food particles or fluids is common. Risk for aspiration is increased if regurgitation occurs when the patient is lying down. Even if the patient is in an upright position, he or she may experience warm fluid traveling up the throat without nausea. If the fluid reaches the level of the pharynx, he or she notes a sour or bitter taste in the mouth.

The precordium: Inspect the Anterior Chest

You may or may not see the apical impulse. When visible, it occupies the fourth or fifth intercostal space, at or inside the midclavicular line. It is easier to see in children or those with thin chest walls. Abnormal: A heave or lift is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy and is seen at the sternal border or the apex.

Nervous Disturbed Sleep Pattern

elated to environmental changes, illness, therapeutic regimen, pain, immobility, psychologic stress, altered mental status, or hypoxia Desired Outcomes: After discussion, the patient identifies factors that promote sleep. Within 8 hr of intervention, the patient attains 90-min periods of uninterrupted sleep and verbalizes satisfaction with the ability to rest.

To evaluate the carotid arteries, the patient may be _____. To assess the jugular veins and the precordium, the patient should be _______ with the head and chest slightly elevated. Stand on the patient's ______ side.

sitting up Supine right

Using a Doppler Ultrasound Unit to Obtain a Pulse Background

• A Doppler ultrasound unit may be used to assess peripheral circulation when a pulse cannot be palpated. • Each pulse wave makes a sound that the Doppler ultrasound unit amplifies. • Pulses may be difficult to palpate for many reasons, including poor circulation, edema, obesity, and other obstructive issues. Procedural Concerns • Apply a small amount of special gel to the skin or the tip of the ultrasound probe. The gel helps to further transmit and amplify the sound waves. • Turn on the machine, and adjust the volume control. • Hold the tip of the ultrasound unit (also called the transducer) at a 45- to 90-degree angle against the skin and directed toward the site of the pulse. • Slide the transducer until the pulse (similar to a "whoosh" sound) can be heard. The pressure used to hold the unit against the skin may need to be varied to obtain the strongest signal. • Ensure presence of a consistent sound at the point where the pulse wave is heard before documenting that a pulse was obtained via Doppler technique. • The transducer should be cleaned with a water-based solution.

Factors Affecting Pulse Rate

• Age: As age increases from infancy to adulthood, the pulse rate decreases. • Gender: After puberty, the average-male pulse is lower than that of the average female. • Fever: Pulse increases with fever due to the increased metabolic rate and peripheral vasodilation that occurs. • Medications: Various medications may either increase or decrease the pulse rate. • Hypovolemia: Loss of blood normally increases the pulse rate from sympathetic nervous system stimulation. • Hypoxia and hypoxemia: When oxygen levels decrease, cardiac output increases to attempt to compensate, resulting in an increased pulse rate. • Stress: Sympathetic nervous system stimulation from stress (e.g., fear, anxiety, and the perception of pain) increases the heart rate. • Pathology: Heart conditions or illnesses that impair oxygenation can alter the pulse rate as cardiac output attempts to compensate for low oxygen levels. Head injuries can cause a drop in pulse to compensate for increased intracranial pressure. • Electrolyte balance: Changes in potassium and calcium affect pulse rate and rhythm.

Use of Interpreters

• Collaboration with the institutional department responsible for obtaining interpreters for deaf or limited English proficiency (LEP) patients should be initiated by the nurse as soon as the need is identified. • Interpretation may be provided by a professional interpreter face-to-face with patients and families or by phone or video medical interpretation (VMI). • Family members should not be used as interpreters of specific medical information to maintain the patient's right to privacy and to avoid possible misinterpretation of medical terminology. • Access to interpretation or translation for deaf and LEP patients is required by Title VI of the Civil Rights Act of 1964, which mandates equal rights for people regardless of race, color, or national origin.

Gastroesophageal Reflux Disease

• Dyspepsia (indigestion) • Regurgitation (may lead to aspiration or bronchitis) • Coughing, hoarseness, or wheezing at night • Water brash (hypersalivation) • Dysphagia • Odynophagia (painful swallowing) • Epigastric pain • Generalized abdominal pain • Belching • Flatulence • Nausea • Pyrosis (heartburn) • Globus (feeling of something in back of throat) • Pharyngitis • Dental caries (severe cases)

Patient and Family Education: Preparing for Self-Management Health Promotion and Lifestyle Changes to Control Reflux

• Eat four to six small meals a day. • Limit or eliminate fatty foods, coffee, tea, cola, and chocolate. • Reduce or eliminate from your diet any food or spice that increases gastric acid and causes pain. • Limit or eliminate alcohol and tobacco, and reduce exposure to secondhand smoke. • Do not snack in the evening, and do not eat for 2 to 3 hours before you go to bed. • Eat slowly and chew your food thoroughly to reduce belching. • Remain upright for 1 to 2 hours after meals, if possible. • Elevate the head of your bed 6 to 12 inches using wooden blocks, or elevate your head using a foam wedge. Never sleep flat in bed. • If you are overweight, lose weight. • Do not wear constrictive clothing. • Avoid heavy lifting, straining, and working in a bent-over position. • Chew "chewable" antacids thoroughly, and follow with a glass of water.

PULMONARY CONGESTION (left side heart failure)

• Hacking cough, worse at night • Dyspnea/breathlessness • Crackles or wheezes in lungs • Frothy, pink-tinged sputum • Tachypnea • S3/S4 summation gallop

Pulse: Nursing Diagnosis

• Ineffective Peripheral Tissue Perfusion related to decreased peripheral circulation, as evidenced by pedal edema and need to use Doppler ultrasound to detect pedal pulses • Activity Intolerance related to immobility, as evidenced by shortness of breath with ambulation and increased pulse with activity • Decreased Cardiac Output related to altered contractility of the heart, as evidenced by shortness of breath, peripheral edema, and tachycardia • Deficient Fluid Volume related to fluid volume loss, as evidenced by increased temperature, decreased blood pressure, thirst, and change in mental status

Systemic Congestion (Right-Sided Heart Failure)

• Jugular (neck vein) distention • Enlarged liver and spleen • Anorexia and nausea • Dependent edema (legs and sacrum) • Distended abdomen • Swollen hands and fingers • Polyuria at night • Weight gain • Increased blood pressure (from excess volume) or decreased blood pressure (from failure)

Abdomen/ GI Nursing Interventions

♦ Assess patient's bowel history to determine normal bowel habits and interventions that are used successfully at home. ♦ Monitor and document patient's bowel movements, diet, and I&O. Be alert to the following indications of constipation: fewer than usual number of bowel movements, abdominal discomfort or distention, straining at stool, and complaints of rectal pressure or fullness. Fecal impaction may be manifested by oozing of liquid stool and confirmed via digital examination. ♦ Auscultate each abdominal quadrant for at least 1 min to determine presence of bowel sounds. Normal sounds are gurgles occurring at a rate of 5-34/min. Bowel sounds are decreased or absent with paralytic ileus. High-pitched rushing sounds or "tinkles" may be heard during abdominal cramping, and they indicate intestinal obstruction. ♦ If rectal impaction is suspected, use a gloved, lubricated finger to remove stool from the rectum. This stimulation may be adequate to cause bowel movement. Oil retention enemas may soften impacted stool. ♦ Teach patient importance of a high-fiber diet and fluid intake of at least 2-3 L/day (unless this is contraindicated by a renal, hepatic, or cardiac disorder). High-fiber foods include bran, whole grains, nuts, and raw and coarse vegetables and fruits with skins. ♦ Maintain patient's normal bowel habits whenever possible by offering bedpan; ensuring privacy; and timing medications, enemas, or suppositories so that they take effect at the time of day patient normally has a bowel movement. Provide warm fluids before breakfast, and encourage toileting to take advantage of gastrocolic or duodenocolic reflexes. ♦ Maximize patient's activity level within limitations of endurance, therapy, and pain to promote peristalsis. ♦ Request pharmacologic interventions from health care provider when necessary. Make a priority list of interventions to ensure minimal disruption of patient's normal bowel habits and to help prevent rebound constipation. The following is a suggested hierarchy of interventions: