HA Final
early clubbing nail contour
180 degrees
breath sounds are faint or absent when
air flow is decreased; fluid or tissue obstruct air passage; emphysema r/t lost elasticity and hyperventilation
major risk factors for heart disease
obesity (BMI > 30); smoking history; diabetes mellitus; HTN; high cholesterol levels; all of them together feel like a ticking time bomb
the patient has a blood pressure of 150/88, is this subjective or objective data?
objective
PERRLA
objective data of the eye via inspection; stands for pupils, equal, round, active to light, and accommodation
signs
objective data; things that you are seeing; examples include: diaphoresis, a bloody nose, and a rash.
physical examination of hip joint
observe gait (smooth motion means functional hips and equal leg strength); palpate (as best able) all joint articulations and muscles; flexion/extension with knee straight (90 degrees) or flexion/extension with knee bent (0-120 degrees); internal/external rotation with knee bent (40-45 degrees); abduction (45 degrees)/adduction (30 degrees); test strength when sitting or laying down only!
lowest body core temp and lowest blood pressure reading
obtained between 3-4 am
highest temp and blood pressure readings
obtained between 3-4 pm
pneumothorax
occurs when air leaks into the pleural space
weight gain
occurs when caloric intake exceeds caloric expenditure over time and typically appears as increased body fat; may be caused by hypothyroidism and abnormal accumulation of body fluids that usually result in edema.
fremitus increased
occurs with consolidation or compression of lung tissue as seen in pneumonia, tumors, atelectasis
CN III
oculomotor; works together with CN IV and CN VI; responsible for motion/movement of the eye; tested by EOM function (tracing H in all 6 fields) and PERRLA; moves eye down and out
CN 1
olfactory; sense of smell; assessed by using different scents
relieving/exacerbating factors
one of the 7 attributes of a symptom; include: is there anything that makes it better or worse? does it hurt worse when you stand up and walk? does the symptom get worse when you're in the heat or cold? etc
adduction of wrists
rotation of wrists and fingers together towards ulna
physical exam of anterior chest
same as the posterior!; palpate ribs and ICS feeling for crepitus or pain and assess for tactile fremitus; percuss using 8 pt method; auscultate quality and quantity of breath sounds and identify adventitious or abnormal breath sounds
inspection of the anterior chest
same thing as posterior; shape; width of costal angle; retraction; use of accessory muscles; rate and rhythm of breathing
tanner scale
scale used for external inspection of a females maturity during a reproductive system assessment; inspects the breast and pubic hair to determine the stage; important to determine if sexual maturation has started-we get concerned if it starts too soon (6-7) and is delayed (>12); typical
locations of jaundice skin color
sclera, skin, hard palate, conjunctiva, lips
important health promotion topics to address during an abdominal assessment
screening for alcohol abuse using CAGE; recognizing classical findings of alcohol abuse; patient teaching to help prevent the development of urinary incontinence
positive Psoas muscle test
special maneuver tests available for the physical exam of an abdominal assessment; Pt lays supine and examiner pushes down on pt's R thigh and asks pt to raise R leg; if patient has pain in RLQ, indicates appendicitis
ileus
type of functional intestinal obstruction; loss of peristaltic motor activity
Biot's respiration
aka ataxic respiration; characterized by periodic breathing: hyperpnoea (or normopnoea) and apnoea, poor prognosis, and neuron damage
possible descriptors of LOC assessment for an awake patient during a neuro exam
alert; inattention; confusion; delirium; hallucination; delusions
past history
component of a comprehensive adult health history; include allergies, medications, childhood illnesses, adult illnesses, and health maintenance
treatment
one of the 7 attributes of a symptom; include: what have you done to treat this? was it effective? did it work?
urgency
important topic to address when obtaining health history of the urinary tract; the patient feels like they just emptied there bladder and have to go again
polyuria
important topic to address when obtaining health history of the urinary tract; think diabetes mellitus; large volumes of diluted urine
birth control use + smoking
important topic to address while gathering subjective data for patient medication use of neuro exam; in combination, increases a high risk for strokes
cogwheel rigidity muscle tone assessment finding during an MSK assessment
may indicate presence of parkinsonsim
flaccid muscle tone assessment finding during an MSK assessment
may indicate presence of polio or Guillian-Barre
rigid muscle tone assessment finding during an MSK assessment
may indicate presence of tetanus
associated manifestations
one of the 7 attributes of a symptom; includes: have you noticed anything else that accompanies it?
duration
one of the 7 attributes of a symptom; includes: how long does it last?; is it constant?
CN II
optic; only responsible for vision, not pupil movement; assessed by using the snellen chart and confrontation test for peripheral vision
best location to assess central cyanosis with very dark skin
oral mucosa (inside of the mouth and tongue), not the lips
albuterol
short-term control medication; a vasodilator; if used more than 2x a week, probably means they need a more long-term control medication
orthopnea
shortness of breath that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair
routes of temperature measurement
oral, temporal, axillary, rectal, tympanic membrane; never add or subtract a degree from a reading; type should be documented
possible causes of hearing loss in the middle ear
otitis media; serous otitis; otosclerosis
dysphasia
part of subjective patient history data for abdominal assessment; difficulty speaking
dysphagia
part of subjective patient history data for abdominal assessment; difficulty swallowing
mobility of the skin
tells us about dehydration or edema; "tenting" of pinched skin on the chest is suggestive of dehydration
hypothalamus
temperature regulation, pituitary gland regulation, sleep, and emotions
elevating a patients heels to prevent pressure ulcers is which type of prevention?
tertiary preventative care
superficial reflexes
tested by the corneal reflex (putting a cotton swab in the eye and see if pt blinks) and the abdominal reflex
travel to and from US
part of subjective patient history data for abdominal assessment; important because viruses and parasites can be brought back depending on destination
important topics for family history of peripheral vascular assessment
presence of heart disease, diabetes, HTN, and high cholesterol
normal cerebellar functions of coordination of the hands and legs during a neuro exam
presence of rapid, smooth, and accurate motions
patient description of food intolerances
"If I eat I am not going to die, however I might feel like I'm going to die"; may present with peptic upset, diarrhea, or GERD
best way to ask an adolescent about drug abuse
"do your friend drink and do drugs?"; "what do you do with your friends when you hang out?"
Normal cholesterol ranges for adults should be
120-200 mg/dL
stage 1 hypertension classification
140-159/90-99
normal nail contour
160 degrees
curved nail contour
160 degrees or less
abnormal S3 (pathologic)
present in adults, HTN, volume overload (CHF), mitral regurgitation, high output states (thyroid, anemia)
circumstances that may delay the completion of a health assessment
a critically ill patient coming into the ER (wait until patient is stable to complete); a nurse is caring for the same patient as she did yesterday (just need updates); a patient with dementia may require supplementation from family
normal S3 (physiologic)
present in young adults, children; increased heart rate; late pregnancy
otitis media TM
presents with cone of light having ripples in it when inspected with an otoscope; can sick thick white behind it
assessing cerebellar function during a neuro exam
1. must test coordination of hands and legs by assessing rapid rhythmic alternating movements (back of the hands and palms to thighs or fingers to thumb) and coordination (finger to nose to examiner's finger or finger to nose with eyes closed) 2. testing gait and posture- done by asking patient to walk casually, then heal to toe in straight line (tandem), and the walking on toes and heels 3. balance- done by Romber and Pronator drift tests
your patient has smoked 10 cigarettes daily since 10 years ago; how many pack years is that?
1/2 pack x 10 = 5
PNS components
12 pairs of cranial nerves and 31 pairs of spinal nerves
normal rate for adult respirations
12-20 bpm; assessing depth and rhythm
prehypertension classification
120-139/80-89
pleural effusion
presents with dull percussion notes and decreased tactile fremitus
1+ pitting edema
2 mm depression
the amount of cigarettes in a pack
20
dorsiflexion
20 degrees
normal adult heart position and surface landmarks
2nd to 5th intercostal space, right border of sternum to left MCL; apex is the point (inferior to base of heart); apical impulse (PMI): 5th intercostal space, MCL; if difficult to find, roll the pt to the left (note: this may displace the pulse further to the left);
nutrition of adolescents
rapid growth development requires increased iron and calcium intake, menstruating females may become anemic
acute illness
rapid onset with short duration; < 6 months; happening now; new onset of a symptom
2+ pitting edema
4 mm depression
normal measurement of the liver at MSL
4-8 cm
plantar flexion
45 degrees
4+ pitting edema
8 mm depression
tricuspid area
4th or 5th left ICS along sternum border
risk factors of developing prostate cancer
55-69 yo; African American race; + family history
3+ pitting edema
6 mm depression
normal span of the liver at the MCL
6-12 cm; two ways to measure: percussion technique (difficult way) and scratch test (easy way)
normal pulse rate for adult at rest
60-100
flexion of fingers
90 degrees
normal temp
98.6 F or 37 C
A normal glucose level for an adult would be:
<100 mg/dL
normal BP
<120/<80
Normal Triglyceride levels for adults would be:
<150 mg/dL
breast cancer prevalence in men
> 1000 men affected each year (< 1% of all cancers in men)
abnormal palpation assessment findings of the prostate
> 2.5 cm; irregular; "boggy"/very mushy; nodule; very hard; tender
stage 2 hypertension classification
>160/>100
health beliefs
A person's ideas and attitudes about health; these choices will influence a person's health status; directly influence health practice whether evidence exists to support the practice; this may say that your healthy but practice might say otherwise
order of neuro deterioration
A&O alters: time and/or place, then familiar persons (if applicable), last to self; lose ability to obey simple commands; then responses deteriorate from purposeful to purposeless responses to pain; then absence of response to pain; then loss of corneal and gag reflexes
topics for health promotion in women
A&P of the reproductive system and associated age related changes; cervical cancer screenings (Pap and HPV testing); vaccine information if patient desires (HPV is for male patients too); early prenatal care; options for family planning; STI and HIV prevention
inspection and palpation of texture in regards to physical examination of skin
we often think about thyroid problems
emergency assessment
ABC's (airway, breathing, circulation); pertinent info only; name, allergies, current medications
mild intercostal retractions
alone may be normal; however accompanied by subcostal and substernal retractions may indicate mineral respiratory distress
Pectus carinatum
also called pigeon chest, is a malformation of the chest characterized by a protrusion of the sternum and ribs.
vital signs
BP, pulse, respiratory rate, and temp; establishes a baseline for the patient and all of our interventions; essential that they are measured correctly; measurements need to be understood, interpreted, and communicated; changes in these, either positive or negative, will provide you with valuable information regarding a patient's health status; it will be important to establish a baseline; you will want to make sure the equipment is in good working order and that you have selected the correct BP cuff size and the appropriate device to measure temp; communicated to pt, MD, peer in report
noting width of gait-widens for balance or the inability to walk straight when assessing cerebellar functions of gait and posture during a neuro exam
may indicate vestibular or cerebral disease (MS); or patient is drunk
Rinne test results in conductive hearing loss
Bone conduction > air conduction
two major divisions of the nervous system
CNS and PNS
positive Romberg
means loss of balance; may indicate (cerebellar/vestibular disorder, or drunk) altered proprioception
Gynoid obesity
Excess body fat that is placed predominantly within the hips and thighs
Android Obesity
Excess body fat that is placed predominately within the abdomen and upper body, as opposed to the hips and thighs.
obesity
Excessive accumulation of fat that exceeds the body's skeletal and physical standards, usually an increase of 20 percent or more above ideal body weight
Pain assessment tools
FLACC, numeric, and faces
CN VII
Facial; tested by facial motor expressions: raising the eyebrows, smiling, frowning, puffing the cheeks out
related structures (examined at other times) during lymphatic assessment
HEENT (neck lymph nodes, tonsils); trunk (spleen and Peyer's patches); extremities (inguinal nodes, popliteal nodes, epitrochlear nodes)
confidentiality
HIPPA; keep in mind that it is absolutely paramount that nurse and patient relationship is protected; only appropriate health care members are shared information with
gardasil
HPV vaccine; unlike cervarix, it is a quadrivalent; meaning it protects against 4 strains of HPV (2 that commonly cause genital warts, and 2 that commonly cause cervical cancer); used more often
risk factors of stroke
HTN, smoking, hyperlipidemia, diabetes, obesity, diet high in Na and saturated fats, sedentary lifestyle, heavy alcohol use, atrial fibrillation, CAD, and sleep apnea
CN XII
Hypoglossal; innervates muscles of the tongue; tested by asking patient to protrude the tongue; patient must protrude tongue out and be mid-lined; tested by tongue strength (pressing against resistance when hand on cheek), and speaking that is being done all the time
micturition
Important topic to address when assessing urine during a reproductive assessment; symptoms of urination include: frequency (how often they go); urgency (have to find a bathroom right away); nocturia (urinating at night); hesitancy (start and stop); straining (trying hard to get it out); dribbling (starts and stop); dysuria (difficulty/pain); incontinence; oliguria
important topics of family history in regards to lung and thorax assessments
TB; allergies; asthma; genetic disorders like cystic fibrosis; more accurate than anything; if you get a good history of all of this, you're going to know so much about your patient
chief complaint (s)
component of a comprehensive adult health history; include information like why did your patient come in, why are they here; make every attempt to quit the patient's own words (sx versus sign); doesn't include a medical diagnosis; if there is none, report the patients goals.
nursing patient teaching techniques to prevent urinary incontinence
Include: pelvic muscle training, pelvic muscle exercises, and teaching patients that incontinence is NOT normal, old age is not a cause
nutrition for aging adult
Loss of appetite, due to taste depletion, psychosocial issues (depression), decreased activity levels (this triggers the response for hunger), socioeconomically status (financial concerns or lack of transportation), disease processing if they are in pain don't want to eat if they cant breath they don't want to eat, side effects to meds make you nauseated and don't want to eat.
seven attributes of a symptom
OLD CART; onset, location, duration, characteristic symptoms, associated manifestations, relieving/exacerbating factors, treatment
pneumonic to remember cranial nerves
On occasion our trusty truck acts funny, a good vehicle any how
current cervical cancer screening guidelines for average risk women
PAP smears start at age 21; need to follow MD management protocol if results abnormal
important topics to address when gather subjective data of the breast and lymphatic system
PMH to assess risk for breast cancer (# of pregnancies (none is highest risk); age at birth of 1st baby (after age 30); if they did give birth and no breast feed; breast abnormals (injury; biopsy + atypical hyperplasia; breast cancer-treatment history)); surgical history (mastectomy with or w/o reconstruction; lumpectomy- segmental (partial) or radical; mammoplasty (reduction, argumentation); preventative self care (last clinical breast exam performed by HCP; last mammogram (date and results))
Important topics to address when gathering subjective data for the male reproductive assessment
Past medical history (of undescended testicle, UTI, kidney stones, prostate disorders, sexual abuse, or assault); Surgical history (of hernia repairs, vasectomy); family history (of prostate/testicular cancer (predisposes them at a greater risk)); medication (prescribed and OTC (especially antidepressants)); fertility history (number of children; infertility evaluation); sexual activity (erection and ejaculation history (impotence, dysfunction); partners; practices, protection; past history of STD/STI); sexually transmitted diseases/ health promotion should include recognition and prevention; HPV vaccine (not just for females)
structures in the anterior anatomy of the abdomen
RUQ: liver, gallbladder, ascending colon; RLQ: cecum, appendix, bladder; LUQ: spleen, stomach, small intestine; LLQ: descending colon and sigmoid colon
review of systems
a component of a comprehensive adult health history; address each body system from head to toe; most questions pertain to symptoms (symptoms of the systems); may uncover problems patient has overlooked; when possible, do not use medical terms, use plain english like: "have you ever had shortness of breath, chest pain, wheezing, etc"
special maneuver tests available for the physical exam of an abdominal assessment
Rovsing sign; Psoas muscle test; Murphy's sign
question topics for treatments tried for skin history (subjective)
Rx (steroid creams or pills); OTC (benadryl, calamine, HC 2% cream); home remedies (aloe, meat tenderizer (helps remove venom from jelly fish sting)); baths (cleansing; use of solutions-oatmeal); ointments or lotions (petroleum jelly or OTC antibiotics ointments)
scoliosis
S lateral curve in the spine; asymmetrical waistline
lub
S1; closure of tricuspid and mitral valve (AV valves); start of systole; heard best at the apex and mitral valve
dub
S2; closure of aortic and pulmonic valves (SL valves); end of systole; heard best at the base of the heart
if you have an enlarged organ in the LUQ
STOP palpating because you can rupture the spleen and kill the patient
nutrition of infants
Solids can be introduced at six months of age and breast feeding should be 10 minutes each side on demand
locations to perform musculoskeletal physical examination
TMJ; neck (cervical spine); upper extremities: shoulders, elbows, hands, wrists, fingers; lower extremities: hips, knees, ankles, feet, toes; spine
important topics to address when assessing PMH for female reproductive system
UTI's (over half of all women will have at least 1 in her lifetime due to significantly shorter urethra; very common in sexually active women); STD's; recurrent vaginitis; abnormal paps; uterine fibroids; endometriosis; ovarian cysts; infertility assessment and treatment
CN X
Vagus; "big daddy"; works similarly with CN IX; helps the uvula rise while swallowing; helps rise the soft palate when swallowing; but unlike CN IX, motor innervations include: HR, RR, bronchi, GI, tract and sensory innervation includes: heart, lungs, bronchi, trachea, larynx, pharynx, GI, external ear
Bitot's spots or foamy plaques of the cornea are most likey due to a deficiency of:
Vitamin A
Scorbutic Gums is due to a deficiency in:
Vitamin C
health patterns
a component of a comprehensive adult health history; include: self-perceptions/self-concept, value-belief, activity-excercise, sleep-rest-nutrition, role-relationship, and coping-stress-tolerance
nutritional staus
a key element of overall health; important for every body system
nonpitting edema (brawny edema)
a localized infection or trauma; once issue is resolved it goes away
pulse oximetry
a medical device that indirectly monitors the oxygen saturation of a patient's blood
the crying patient
a signal of strong emotion; sometimes best thing to do is offer a tissue, stand to the side and then be supportive; leaves open the door for those who want to talk about it can, and those that don't want to, gives them some time to process that
acanthuses nigricans
a skin condition characterized by areas of dark, velvety discoloration in body folds and creases; frequently seen in diabetes and obesity
illness
a state in which a person's physical, emotional, intellectual, social, environmental, or spiritual functioning is diminished or impaired; sometimes an experience with this motivates an individual to adopt positive behaviors; doesn't always mean that a disease is present; defined by one or more of the 7 facets are off; include two subsets: acute and chronic
wheeze
a trigger in the airway that causes inflammation and mucus to come to the rescue, which actually makes things worse; results in a narrowing; when two sides get closer, it is hard to take a deep breath in and out
observing natural swaying in response to Romberg test
means that the patient's brain is working to balance in regards to space; if this action is absent, this is abnormal and may indicate something wrong with the cerebellum
oriented x 3
means the patient can state his/her name, what month/day it is, and where they are at the present time
The nurse is testing the function of cranial nerve XI; which of the following best describes the response the nurse would expect if the nerve is intact?
moves the head and shoulders against resistance
normal findings on chest palpation include
normal chest size and shape; warm, dry skin; no tender spots; symmetrical chest expansion, and tactile fremitus over the mainstem bronchi in front and between the scapulae in the back of the chest.
cutaneous reflexes
normal in infants but abnormal in adults (suggest diffuse brain disease); different types include: Babinski, grasp, and sucking
onset
one of the 7 attributes of a symptom; includes: when did (does) it start?; setting in which it occurs, including environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness.
protuberant contour
adipose tissue that is large; may indicate a fetus; the whole idea is that when the patient lays down, it doesn't go away; think about the 6 F's: fat, fluid, flatus, fetus, feces, and fatal growths
nutrition screening
admission nutrition screening tool; 24-hour diet recall; food frequency questionnaire; food diaries; direct observation
location
one of the 7 attributes of a symptom; includes: where is it?; does it radiate?; does it move?
characteristic symptoms
one of the 7 attributes of a symptom; information about what does it feel like; includes: what is it like? how severe is it? (for pain, ask a rating on a scale of 1 to 10); aching, stabbing, dull, etc.
influences on blood pressure
age (lower in babies bc doesn't need much to pump out to all of body) , race, weight, emotions, gender, diurnal rhythm, exercise, stress, white coat HTN, improper positioning of patient, caffeine, smoking, other drugs; poor technique; pain if accute;
menarache
age of onset of menstrual cycle
the lymphatics of testes drain into
abd lymph nodes which aren't accessible to exam
solid viscera
abdominal systems structure; organs that maintain a characteristic shape; include the liver, pancreas, kidney, adrenal glands, and spleen; not going to change unless there is a pathologic reason; shouldn't change shape normally speaking
hollow viscera
abdominal systems structure; organs whose shape depends on their contents; include: the stomach, gallbladder, colon, small intestine, and bladder
CN VI
abducens; works together with CN III and IV; innervates external rectus muscle of the eye; outward motion of eye towards the ears
decorticate
abnormal posturing seen in CNS injuries; results from damage to one or both corticospinal tracts; in this posture, the arms are adducted and flexed, with the writs and fingers flexed on the chest; the legs are stiffly extended and internally rotated, with plantar flexion of the feet
decerebrate
abnormal posturing seen in CNS injuries; results from damage to the upper/brain stem; in this posture, the arms are adducted and extended, with the wrists pronated and the fingers flexed; the legs are stiffly extended with plantar flexion of the feet
absent bowel sounds
abnormal; indicates some sort of obstruction; most listen to a full 5 minutes if this is indicated; if you document this, you better be doing something about it; patient is at risk for constipation and obstruction
otitis externa (swimmer's ear)
abnormality of the external ear
orthostatic or postural hypotension
abrupt peripheral vasodilation without cardiac output compensating for it; lying- rest for 2-3 minutes; standing within 3 minutes; blood working against gravity
apnea
absence of respirations
Babinski response for patients older than 1
absent; causes the pt to slightly plantar flex and the toes curl inward
things that nurses should always be thinking in the back of their minds
abuse on the elderly is real; sex trafficking is real; looking for unexplained injuries (things that don't add up; inconsistent stories); delay of getting treatment (old bruises; non frequent and frequent visits); dominant interviews (red flag when someone refuses to leave patient alone)
possible effects of pain
accompanying symptoms like nausea; sleep; appetite; physical activity; relationship with others; emotions; concentration
CN VIII
acoustic; responsible for hearing; tested by whisper, weber, and Rinne test
resistive exercise
active exercises performed by the patient by pulling or pushing against an opposing force
therapeutic communication techniques
active listening; guided questioning; nonverbal communication; empathic response; validation; reassurance; summarization; transitions; empowering the patient
health practice
activities that individuals do to care for themselves;
auditory fremitus
also called vocal resonance or quality of voice sounds; normally is soft, muffled, indistinct; assessed by placing diaphragm of stethoscope over chest while patient says "99"; assess pattern: apex to base, side-side; if lung density increases as seen in consolidation, sound transmission in enhanced
sternal angle
also known as the angle of louis, where the 2nd rib starts
apex of an organ
always means the point of the organ
A&O x 3
always the same universally; A-being alert, responding to environment, being aware of surroundings; if 1, hope that its to self
split S2
an extra heart sound; SL valves are not synced, one closes before the other, may be prominent or very hard to distinguish; have patient take a big deep breath in and out to hear the difference; presence is abnormal if patient is older than 40 and occurs during exhalation
weight loss
an important symptom with many causes; mechanisms include decreased intake of food for such reasons as anorexia, dysphagia, vomiting, diarrhea, inability to absorb nutrients from GI tract, increased metabolic needs, allergies to foods, problems with chewing, discoing habits, inability to access food stores, or lack of financial resources.
genogram
an important tool in assessing family medical history; can help us figure out how to prevent diseases at risk
important topics to address when gathering objective data for anus and rectum assessment
anal and colorectal exam; inspect anus (for lesions, blood, hemorrhoids, masses); palpation; stool appearance; colorectal cancer symptoms; prostate cancer symptoms
AV valves
anchored by chordae tendinae to papillary muscles in ventricular floor; open during diastole and closed during systole
anxiety or depression in general appearance
anxious face, fidgety movements, poor eye contact, flat affect, psychomotor slowing; looks different in different people; typical profile: fiddling with hand and rapid breathing; flat affect (no facial movement, monotone speech, abnormal)
intestinal obstructions
any condition that prevents the flow of chyme through the intestinal lumen; can be mechanical or functional; major effects: accumulation of gases, abdominal distension, loss of fluids and electrolytes, may lead to strangulation, gangrenous changes, and potentially perforation; they are bridges of scar tissue between the various organs of the peritoneal cavity as a result of a local repair process excessively
DO NOT PERCUSS
anything that has it's own electrical system
physiologic split S2
aortic valve closes earlier than pulmonic valve during inspiration in patients that are less than 40 y.o
where S2 is heard the loudest
aortic valve: right sternum border of 2nd ICS and pulmonic valve: left sternum border of 2nd ICS
organs of the RLQ
appendix; ascending colon; bladder; cecum; rectum; overy, uterus and fallopian tube (female); prostate and spermatic cord (male); small intestine; right ureter
secondary lesions
evolved from primary lesion or external force; ones that are debris and on top of the skin include crust and scales; ones that break the skin surface include fissure and erosion; ones that cause a break in skin continuity: ulcer, scar, lichenification, excoriation, atrophic scar, and keloid
pathologic reflexes
are abnormal; indicated by present Babinski in adults (brushing thumb along bottom of the foot will cause toes to fan out as seen normally in newborns)
poster lower loungs
are at about T10
anthropometric measures
are used to assess the size, shape and composition of the human body; following equipment is needed: balanced beam scale; portable/wall mounted stadiometer with movable head piece, or measuring rod, typically mounted on balanced beam scales; flexible, but non-stretchable measuring tape or insertion tape; full body-length mirror with 10cm ´ 10 cm grid lines; carpenter's level; several calibrated weights (e.g. 10 kg or 20 kg each) that can be combined to give test weights between 50 kg and 100 kg; calibrated length rods of 150 cm and 200 cm; uses derived weight measures: body weight as percent of ideal body weight and percent usual body weight
reflexes
are: involuntary, helps maintain muscle tone, and protects (permits quick response to bad stimuli); include different types: DTR, superficial, visceral, and pathologic
important topics to inspect during the breast and lymphatic assessment
areola (shape, lesions or drainage); nipples (direction, size, shape, color, surface characteristics, and discharge); breasts (size/symmetry, contour, edema, skin, color and texture, venous pattern, skin lesions, dimpling, or retraction)
extension of shoulder
arm back to side
stupor LOC
arouses only to painful stimuli like a sternal rub; may respond with a groan or a brief opening of eyes; little to no awareness of surroundings; if they respond, neuro system is still intact, not always vocal
breast self exam
as of Nov, 2009, the USPSTF no longer recommends teaching this screening exam to patients bc it has been causing more harm than good; there have been a lot of women that have been getting tons of unnecessary testing (still important to educate patients about the exam and allow them to make decisions for themselves) ; but the ACA still recommends this screening test to patients 20 years and older
how to assess the sensory system function for a neuro physical exam
as pt to close eyes, and touch various areas on the body with soft and hard item; ask them to interpret sensation ("is it dull or sharp?") and to discriminate side to side ("tell me where I touch"); examine in detail if: there is a reduced sensation, numbness or pain, or motor/reflex abnormal; should not be tested on the face
organs of the RUQ
ascending colon; duodenum; gallbladder; right kidney; liver; pancreas (head); transverse colon; right ureter
feelings when exploring the patient's perspective in the working phase
ask about things like fears and concerns
expectations when exploring the patients perspective in the working phase
ask about what was their prior experience with other health care providers? helps clear out any misconceptions
function when exploring the patients perspective in the working phase
ask and think about how does it effect function of everyday life
drop arm sign
ask patient to fully abduct the arm to shoulder level; if cannot hold arm fully abducted, test is positive indicating rotator cuff tear because somebody with a tear won't be able to do this, their arm will drop
inspecting and palpating facial motor
ask patient to smile, puff cheeks (and press against them), show teeth, wrinkle brow, squeeze eyes shut against resistance; looking for facial symmetry and ability of the facial muscle and facial nerve VII
rapid screen for dietary intake
ask the patient for a 24-hour dietary recall (or a 2-day diet intake) before completing the form
ideas when exploring the patient's perspective in the working phase
ask them things like why do they think this problem is occurring?
important questions to ask when assessing drug and alcohol use
ask what 1 drink means to them (same thing with drugs); ask the route of consumption like: "how do you do coke, do you snort it?", because the route creates a whole different set of risk factors
Auscultation of posterior chest
assess air flow through traceobronchial tree; assess presence of fluid, mucous, obstruction; assess condition of lung and pleural space; technique: patient breaths deeply through mouth, assess in a patter, listen for symmetry from side to side (8 pt method), and listen to one full breath (both in and out) in each location; listen to upper, middle, lower, and lateral
collecting data on health history
assess validity; asking pertinent questions to gather data (spiritual and cultural beliefs); past medical history; past physical issues; past psychological issues; social history; cultural history; spiritual beliefs
general approach to PE of lungs/thorax
assess whole patient: mental state (confused? agitated?), skin color, finger/toenails, lips (oxygenation status); note respiratory rate and rhythm (even or abnormal?); work from tope down in systematic order; compare side to side; examine thorax in sitting position; have patient breath deeply with mouth open
general appearance
assessed during the general survey; apparent state of health; make general judgements based on data and assessment skills, supported by clinical rationale, look into environmental factors: acute or chronic; frail or fit and robust; looks his or her age; agitated or happy; fatigued or rested; LOC (level of consciousness); facial expression (at rest, during conversation, examination, with others, eye contact, movements symmetric)
collecting data during physical examination
assessing each system; take information and determine what's normal and isn't; when documenting findings we never use the world normal; structured head-to-toe examination; identify changes in patient's body systems; unusual or abnormal findings may support history data or trigger new questions; document all findings in a clear, concise manner- this is a legal and professional responsibility; pull together all information with medical records
posture, gait, motor activity, and speech
assessment of general appearance during general survey; include preferred posture, restless or quiet, changes position often, has fast movements, apparent involuntary motor activity, immobile or stiff joins, speech is either articulate, garbled, rapid, or slow
odors of the body and breath
assessment of general appearance during the general survey; include things like alcohol, acetone, pulmonary infections, uremia, liver failure, fruity; can tell you a lot
physical examination of skin
assessment of overall appearance, hygiene; skin color/tone: fair, medium, dark; abnormal colors: pallor, erythema, cyanosis, jaundice; just palpation (no auscultation and percussion), have to be really good with inspection and vocal
past respiratory history that is important to assess for lung and thorax
asthma; TB or reactive test; pneumonia; pleurisy; bronchitis; emphysema; atelectasis
ABCDE of skin cancer
asymmetry (one half should mirror the other), border irregularity, color, diameter (> 6 cm (the size of a pencil eraser)), and evolving (used to be elevated, have any of your moles changed, has any of them tarted to itch); teach skin self examination
factors that increase a woman's risk of developing breast cancer
at the age of 20 (need to assess FH of any types of cancer; if first degree relative has this, need to find out when they were diagnosed and what age did they die; genetic consoling may be recommended); genetic mutations (BRCA1 and BRCA2 mutations- cause 50% chance of developing); high breast tissue densities on mammograms; hormone/DES exposure; > 50 yo; African american women; if menarche < age 12; late age at menopause > 55; 1st child after age of 30 or never gave birth/breast fed; modifiable factors: high fat diet, low exercise, high weight, and alcohol abuse; # of first degree female relative with history (age of fam member diagnosis, age of fam member at time of death, risk doubles if first degree relative has it); lifetime risk for women is 1 in 8 by old age (men have <1% chance of developing it)
apex of the heart
at the bottom, meaning the base of the heart is at the top
heart valves
atrioventricular (AV) valves: mitral (L) and tricuspid (R); semilunar (SL) valves: aortic (L) and pulmonic (R)
Erb's point
auscultation location for heart sounds and heart murmurs located at the third intercostal space and the left sternal border; here you should be able to hear the SL valves close at the same time.
two subdivisions of the PNS
autonomic and somatic nervous system
mean arterial pressure (MAP)
average pressure forcing blood into tissues (monitoring potent drugs); won't use this unless in critical care situation; forcing pressure into actual tissues
DTR with a rating of 2+
average/normal
ways to treat patients with respect and patience
avoid first names, nicknames, or endearments ("honey", "sweetie"); allow the client to have control (like offering to have someone else in the room privately)
alert LOC
awake or easily woken
lateral
away from the midline
distal
away from the trunk or from the point of origin
posterior tibial pulse
felt for at the crook of the ankle
popliteal pulse
felt for behind the knee, is deep, and difficult to feel
dorsalis pedis pulse
felt for on top of the food
peripheral pulses of the trunk
felt on the abdominal aorta, renal, and iliac
peripheral pulses/ arteries of leg
femoral, popliteal, dorsalis pedis, and posterior tibial
history of present illness (HPI)
component of a comprehensive adult health history; not enough to ask about how you're feeling; have to be systematic: chronologic account of problems, onset of problems; need to know when did it start; asking the right questions; include pertinent positive and negatives; include any treatments the patient is currently taking
cerebral cortex
component of the CNS that dictates mental status; center for highest function including memory, reasoning, sensation, voluntary movement
brainstem
component of the CNS that involves the cranial nerves
cerebral cortex, spinal cord/spinothalamic tract, and posterior columns
components of the CNS involved with the sensory system
cerebellum, cerebral cortex, corticospinal, and extrapyramidal tracts
components of the CNS that are involved with the motor system
mechanisms to integrate neuro during a complete H&P
balance, gait, posture may be assessed while entering room and taking a seat; mental status (alertness, affect, memory, though processes), speech, and language may be assessed during interview; cranial nerves may be assessed at the head and neck; sensory testing and DTR's may be assessed while checking skin and peripheral vascular; motor tone, strength, and size may be assessed while looking at extremities
pain assessment questions
based off OLD CART
strength of pulse
based on a scale of 0-3; 3+ = bounding, 2+ = brisk (normal), 1+= thready, 0 = not palpable
the mental health history
be aware of cultural constructs; be sensitive to mood changes or symptoms of possible depression; ask open-ended questions intially, then move to more specific; if patient seems depressed, ask about thoughts of suicide
organs of the LLQ
bladder; descending colon; ovary, uterus, fallopian tube (female); prostate and spermatic cord (male); small intestine; sigmoid colon; left ureter
second degree burn
blisters, redness, pain, raw surfaces (partial thickness or to dermis layer)
Hep B virus
blood borne pathogen
Hep C virus
blood borne pathogen; transmission through bodily fluids
hematuria
blood in urine
epistaxis
blood nose
weber test results for a kid that puts a marble in their right ear
bone conduction vibrations will lateralize towards the right ear; ear is occluded and getting rid of external sounds
percussion of cardiac and liver regions on anterior chest
both expected to have dullness
genu varum
bow legs
peripheral pulses/ arteries of arm
brachial, radial, and ulnar
chronic pain behaviors
bracing; rubbing; diminished activity; sighing; change in appetite; mild to no change in VS; movement; exercise (to help knee heal but in pain while they are doing it); praying; sleeping; agitation; patient gets used to it, becomes their new norm
CNS components
brain and brainstem; cerebellum; spinal cord
peptic ulcer disease
break or ulceration in the protective mucosal lining of the lower esophagus, stomach, or duodenum; acute versus chronic; superficial (erosions) versus deep; risk factors: genetic predisposition, H. pylori infection, Habitual use of NSAIDs, excessive use of alcohol, smoking, acute pancreatitis, COPD, obesity, cirrhosis, and over 65 years of age;
developmental changes in pregnant women
breast enlargement and milk production; uterine size increases; changes in vaginal secretions, mucosa, and color
hematochezia
bright red blood in the stool; indicates a lower GI bleed
DTR with a rating of 3+
brisker than average
varicose veins
broken valve in the veins; doesn't prevent back flow; more fluid collects; whole are where regurgitation of deoxygenated blood keeps happening and collecting
order of normal breath sounds from largest to smallest
bronchial/tracheal; bronchovesicular; vesicular
characteristics of neuropathic pain
burning; shocking (electric-like); stabbing; "pins and needles" or tingling
the patient with impaired hearing
find out patient's preferred method of communication; eliminate any background noise; turn off TV; speak normal volume at normal rate; if they ask you to speak up then it is okay to
orientation to place
can ask different types of questions and bigger questions like state or county
diarrhea
can be acute or chronic; can be inflammatory (small-volume with presence of fever and bloody diarrhea) versus non-inflammatory (large-volume, water and non bloody with periumbilical cramps); types include: osmotic and secretory
orientation to time
can be broad like season or month
important topics to address when palpating the inguinal area for the male reproductive system
can be done standing or seated; looking for hernias (soft, may be tender); looking at lymph nodes (firm, may also be tender if inflamed)
waist-to-hip ratio
calculated by waist circumference/hip circumference; an important tool that helps you determine your overall health risk. People with more weight around their waist are at greater risk of lifestyle related diseases such as heart disease and diabetes than those with weight around their hips. It is a simple and useful measure of fat distribution; high waist to hip ratio makes patient more susceptible to diabetes and heart disease
important topics to address when assessing objective data for the skull
can be either: normocephalic, microcephalic, or macrocephalic; should have plates that are completely fused; how does the size work for the person?; counter: looking for deformities, lumps, depressions, suture lines, tenderness, protrusions; felling for any lumps and bumps; are any lumps mushy?; facial motor
Rinne test results in sensorineural loss
can be normal; air conduction > bone conduction
3+ tonsils
can be present without the presence of infection, especially in children
EKG and ECG
can be two different things
primary constipation
can either be normal transit (time from mouth to rectum but patient has low-residual diet or low fluid intake), slow-transit (alteration in intestinal innervation), and pelvic floor dysfunction
dried earwax in the auditory canal
can look exactly like dried old blood
sings of distress
cardiac or respiratory distress; pain; anxiety or depression
inspection
cardinal technique of examination; close observation of details; always the first step; getting data by just looking; looking with a critical eye
palpation
cardinal technique of examination; fancy way of saying touch; tactile pressure using hands
percussion
cardinal technique of examination; figuring out density underneath the surface; evoke sound wave or dullness
auscultation
cardinal technique of examination; listening with stethoscope; to listen
passive ROM while palpating
carried out by the nurse without assistance from the patient, used if patient unconscious or debilitated; protect joint if injured and assist in rehab
passive exercise
carried out by the nurse, without assistance from the patient; will not preserve muscle mass or bone mineralization because there is no voluntary contraction, lengthening of muscle, or tension on bones; will encourage joint movement
follicular hyperkeratosis
caused by a vitamin A deficiency
secretory diarrhea
caused by excessive mucosal secretion of Cl or HCO3; causes: large volume stools caused by bacterial endotoxins and neoplasms; small volume stools caused by fecal impaction (which are dangerous events because it can cause back up in the bowel and cause obstruction)
primary skin lesions
caused directly by disease: include macule (patch), papule (plaque), nodule (tumor), wheal (urticaria, hives), vesicle (blister), cyst, and pustule (acne)
brain stem; midbrain; pons; medulla
central core, houses mostly nerve fibers and their tracts connecting the brain and spinal cord
important topics to address when assessing surgical history for female reproductive system
cervical, vaginal, abdominal, or pelvic surgery (tubal ligation); treatment (crytherapy, cautery); circumcision (infundibulation, clitorectomy)
regions and what to assess with speculum for internal inspection of the female reproductive system assessment
cervix and os (color, shape and position, surface lesions (any edema/inflammation, mass or ulcers), secretions (blood or pus)); the vaginal wall (folds or rugae, lesions, discharge); important to note that the RN will not be performing this exam, but it is still important to be aware of the normal anatomy and any deviations that the PCP might find so as to be able to properly educate your patient
abdominal assessment subjective data of patient history: topics of introductory questions
change of appetite, diet; food tolerances, food allergies; 24 hours dietary recall (breakfast, lunch, and dinner); weight changes; difficulty swallowing (dysphagia); exposures; travel to and from US; stressors (ask about IBD; cortisol can do bad things to the GI system and cause symptoms); medications; nausea and or vomiting; elimination; gastroenteritis; pain; GERD; visceral dysfunction; surgery; tests and results; GI cancer; substance abuse (alcohol, opiates, tobacco); family history (GI cancer, colitis, IBS); vaccinations
stage 4 of male Tanner stages
characterized by further penile growth in length and breadth that has occurred; Glans are larger and broader, and hair is adult in type; growth in girth, adult presentation
percussion of most dense tissue
characterized by less air and more compact tissue
proximal obstruction
characterized by mild distension and vomiting of bile-stained fluid
stage 3 of male Tanner stages
characterized by the penis has growing, especially in length, Hair is darker and curlier; described as "pencil penis" - long slender finger like growth; penis grows rapidly during this time
stage 2 of male Tanner stages
characterized by the scrotum and testes have enlarged and have more textured scrotal kin; growth of sightly pigmented downy hair is sparse;
stage 5 of male Tanner stages
characterized by the testes and scrotum are adult in size; pubic hair is adult in quantity and pattern and present along the inner border of the thighs; not a stage where growth is seen just increased hair; done with puberty
if assessing a comatose patient for deterioration
check for Babinski response by doing a smooth stroke of the lateral aspect of the foot from heel to ball ("7" shape); normally absent over age 1
if assessment findings are hyperactive during a neuro physical exam
check for ankle clonus
components of a full neuro physical exam
checks all: mental status (assessing cerebral cortex function); cranial nerves (assessing brainstem); motor system (assessing cerebellar and muscular- cerebellum, cerebral cortex, corticospinal and extrapyramidal tracts); sensory system (assessing cerebral cortex, spinal cord/spinothalamic tract and posterior columns); reflexes
important topics to consider for history of cardiac assessment
chest pain (onset, location, radiation, exertional component); palpitations; dizzy/lightheaded; syncope; dyspnea; orthopnea (how many pillows?); +/- cough; +/- sweats; +/- nausea; peripheral edema; smoking (need to figure out pack years); wheezing; edema (cardiac = swelling is bilateral and worse in evening); "indigestion"; nocturia (recumbency = reabsorption = excretion: HF); obesity; recent viral illness; medications; alcohol or recreational drugs; exercise patterns; PMH; history of heart surgery: (cardiac catheterization, bypass, angioplasty, valve repair, stints) and dental work; heart diagnostic studies
coloboma
chromosomal disorder of the pupil of the eye
IBD
chronic, relapsing inflammatory bowel disorders of unknown origin; influential factors include: genetics, environment (gut flora, smoking), alterations of epithelial barrier functions, immune reactions to intestinal flora, and abnormal T-cell responses; examples include: ulcerative colitis and Crohn disease
palpation methods for a clinical breast exam
circle method; wedge method; lawn mower (strip) method; in all of them, you want to make sure you pay particular attention to the tail of spence along with lymph nodes that follow along with it; make sure we are feeling all the way up into the axially
dress, grooming, and personal hygiene in general appearance
clothing appropriate for weather, clean, properly buttoned, clothing appropriate for age and or social group, tattoos, piercings, hygiene and grooming appropriate for age, lifestyle, occupation
cardiac or respiratory distress in general appearance
clutching chest, pallor (paleness, looks like they have no blood in their face), diaphoresis (sweating) , labored breathing, shortening of breath, tripod position (allows a person to relieve the weight of the chest to expand the lungs more easily)
two steps of assessment
collection and verification of data from multiple sources and analysis of the data
tinnitus
commonly heard as musical ringing in the ear
family medical history (FMH)
component of a comprehensive adult health history; assessment of familial/ genetic risk factors; age, health status or death of parents, spouse, siblings; three or four generation genogram (may also be called a "genetic pedigree"); important to know because risk of disease and allergic are connected by genetics
focused assessment
comprehensive/admission assessment completed; not new to the unit/facility; clinical judgement should be used to decide the extent of the PE; all systems should be addressed, but not all elements will need full I, P, P, A; must address all systems and regulatory assessment tools; focus the assessment of affected and at-risk systems; updates to history as needed; two types: beginning of shift assessment or follow-up or re-evaluation (shift assessment completed) ; subjective: survey, focus on symptom(s) and ask pertinent questions; objective: ABC, focus on affected systems of intervention
types of nursing assessments
comprehensive/admission assessment; focused assessment; emergency assessment
pharyngeal tonsil (adenoids)
compress where everything drains in the posterior oral cavity; usually taken out to relieve back up of drainage
muscle
comprises 40-50% of body's weight; needs intact nerve supply, identified by tone (feeling resistance with passive stretch); bulk of it is related to level of activity, function and innervation and is going to tell us about daily activities and how well the nerves work; have to work for extremities to move; have to have an intact nerve in order for them to work or they will be flaccid and can't contract;
important topics of subjective data in regards to general history, lifestyle, and self care for mouth and throat assessment
conditions of gums and teeth (do they go to a dentist?); painful teeth or gums; bleeding, bad breath (doesn't always mean bacterial infection; could indicate diet difference); sore tongue, lip, mouth; hoarseness, drooling (tells you they aren't swallowing; may indicate that they have dysphagia), difficulty swallowing; sore throat; difficulty speaking or swallowing; fillings (tell you that patient is taking care of their teeth in some way shape or form)
middle ear structure and function
conducts sound, equalizes air pressure and reduces loudness; contains auditory ossicles (malleus, incus, and stapes that transmit vibration from TM to inner ear); the eustachian tube (equalizes air pressure from middle ear to nasopharynx; more horizontal in child; more angled in adults)
Barrett esophagus
consequence of prolonged GERD; when the normal flattened epithelial tissue of the esophageal mucosa becomes columnar (metaplasia) due to esophageal mucosa injury due to refluxate; associated with adenocarcinoma
if you notice a generalized increase in temperature of the skin upon inspection and palpation during a PE
consider fever or other medial problems associated with an increased metabolic rate
if you have a BP of 138/92
considered stage 1 hypertension because value with the largest classification is considered
pericardium
consists of 2 layers: an outer fibrous layer and an inner serous layer that is a double walled sac separated by fluid consisting of an outer parietal layer and an inner visceral layer (the epicardium)
pleural cavity
contain serous fluid when helps reduce friction when the lungs move; location of possible effusion
inner ear structure and function
contains a labyrinth (semicircular canals, vestibule, and cochlea; responsible for balance and transmission of sound; contains crystals that shift on really fine hairs and are responsible for telling us which was is up and down; when they fall off and get lost, you end up with intestinal vertigo); cochlea (converts vibrations and sends them through the cochlear nerve to the brain to be interpreted)
chronic pain
continues for 1 month or longer; continuous or recurring; does not stop when injury heals; source might be unknown; changes from symptom to condition; example includes: phantom limb pain
in a regular/irregular heart rhythm
continuous but don't know whats coming next
percussing all quadrants during the physical exam of an abdominal assessment
could be dull due to feces
a tender lymph node
could suggest multiple things: that it is doing its job; that a patient has been feeling this node over and over gain and they've made it tender from all of the manipulation they've been doing to it; OR a red flag for cancer if it is immobile, swollen over 1.5 cm, and widespread
abnormal (adventitious) breath sounds
crackles (rales); wheezes; rhonchi; and pleural friction rub
factors that result in false low BP readings
cuff too large (bladder > 100%) because air bladder double layered on itself, doesn't need much air to inflate; repeating BP too quickly (must wait at least a full 2 minutes); inaccurate level of inflation or released too quick; pressing stethoscope too tightly; brachial artery above the heart
factors that result in false high BP readings
cuff too small (bladder <80% of arm); cuff too loose or uneven; arm below heart level; inflating or deflating too slow (high diastolic); deflating cuff to quickly (low systolic, high diastolic); brachial artery below heart level; arm not supported
location for cyanosis or pallor skin colors
fingernails, lips, mucous membranes in mouth (normal aging process for individuals that have more melanin in there skin); palms and soles
presbyopia
important objective data to assess for a physical exam of the eye; decreased accommodation with aging; needs to move object farther away to see it because as we age our near vision starts to decrease; nothing you can do about it
heaves
important to consider during palpation of cardiac assessment; pulsation where you can see your hand moving with the pulse; past bounding
muscles of inspiration
diaphragm is the main one- during this process it contracts/moves down; intercostal muscles lift sternum and ribs; accessory neck muscles (forced or heavy)
pulse pressure
difference between systolic and diastolic readings; normal 30-40 mm Hg
paroxysmal nocturnal dyspnea (PND)
difficulty breathing that awaken the patient; usually happens at the same time overtime; need to find out what position causes it to happen more
dysarthria
difficulty forming words; signifies dysfunction of the muscles needed to produce speech like lips, tongue, vocal cords, diaphragm, etc; may be something wrong with the functional aspect of the tongue
ataxia
difficulty walking
when is the health assessment done?
every person needs to have a complete assessment and ideally it is done on introduction/admission; circumstances may delay the completion but should be completed once situation allows
petechia/purpura
deep red or reddish purple; rounded, sometimes irregular, flat; blood outside the vessels; if on dorsal forearms, is usually actinic purport from chronic sun exposure; may indicate a bleeding disorder
weakness
denotes demonstrable loss of muscle power; suggest possible neuropathy or myopathy; do they only use one arm? when they walk are they limping?
organs of the LUQ
descending colon; left kidney; pancreas (body and tail); spleen; stomach; transverse colon; left ureter
The sexual history
determine risk for pregnancy; determine risks for sexually transmitted diseases (STDs), STIs, and AIDS; sexual practices may be related to patient's symptoms; sexual dysfunction may result from use of medication or misinformation; be ammeter-of-fact in questioning; use specific language; make no assumptions about the patient, include questions about gender like: do you identify with a specific gender?; need to make sure we are supporting them and not judging them
2 out of 3 adolescent males
develop gynecomastia, which usually resolves in 1-2 years time
inspection of the using the opthalmoscope
diopter or instrument's lens is used to focus on internal structure; use aperture dial in front for the largest spot of light (start at 0 - without any lines in it); be sure room is darkened; client focuses on distant spot on wall; need to remove client's glasses; hold instrument against your eyebrow when looking at eye; shine light into pupil, start at outer side of patient and move around to front of patient about 15 inches from the clients face; make sure to brace other hand on patient forehead to avoid coming too close
neuropathic pain
direct or indirect injury to peripheral or central nervous system; referred pain; examples include: diabetic neuropathy, carpal tunnel syndrome, and multiple sclerosis pain
lesion patterns of arrangement
discrete (skin cancer); annular or circular (ringworm or tinea corporis); grouped or clustered (herpes simplex or cold sores); linear (contact dermatitis); gyrate or snakelike (scabies); confluent or run together (hives or urticaria); target (lyme), or iris (erythema multiform); nerve root distribution or dermatomal (herpes zoster- also called "zosteriform")
influences on temperature
diurnal cycle (patterns of activity or behavior that follow day-night cycles, like breakfast-lunch-dinner schedules); menstrual cycle (usually runs low 99's, not a fever); exercise; age (lower body temp for older adults; metabolism is slowed down)
breast tissue
divided into quadrants; when documented quadrants should be addressed; referred to in a clockwise manner (the 3 o clock position is the same for left and right breast when documenting any lumps, bumps or lesions); sections include: upper inner quadrant; upper outer quadrant; lower outer quadrant; lower inner quadrant; axillary tail of spence
extensor surfaces
do not touch; skin lesions of psoriasis are seen here
percussion portion of the physical exam of the abdominal assessment
do so in this order: quadrants first, stomach, liver, kidneys, and then bladder
when collecting the history of the nose and sinuses, a patient complains of having rhinorrhea. What question would the nurse ask to determine associated manifestations of the symptoms?
do you have a cough, sore throat, any pain? essential a mini OLD CART
color of mucus
does NOT determine whether patient has an infection or not
routine mammography
does NOT increase risk for cancer
palpation portion of a physical exam of the abdomen
done after last (after inspecting, auscultating, and percussing); two types: light and deep; important to take note of rigidity, guarding, tenderness, and rebound tenderness (does it hurt more when I press down or let go?)
percussing the kidneys during the physical exam of an abdominal assessment
done after the liver; done using the blunt technique (palm of hand placed on back while the other fist is balled into a fist and hit on the dorsal surface of the hand laying on the back) at the costovertebral angle; not going to get a note; checking for costovertebral angle tenderness; looks a lot like respiratory excursion; if I send vibrations to this organ, if tender, patient will be in pain
clinical breast exams
done by a HCP; ACA recommended to be done every 3 years between the age of 20-39, and then annually after that
important objective data topics for physical examination of the neck
done by inspecting and palpating; looking for symmetry, musculature, blood supply (CV/PV system), glands, and lymph nodes
inspection portion of the physical exam of an abdominal assessment
done first; looking for skin lesions or rashes, scars, striae, color; umbilicus (herniation); abdominal contour; distention, symmetry, masses; motion of internal organs on surface (peristalsis); venous patterns, pulsations (aorta)
light palpation of the abdomen during a physical exam
done with one hand and firmly; over 4 quadrants; assessing tone, tenderness, and surface characteristics; assessing for masses and enlarged organs; assessing pulsations of the aorta and femoral arteries; assessing inguinal nodes
palpation for anus and rectum assessment
done with water soluble lubricant and inserting fingers gently; assessing the anus and prostate (abnormal if > 2.5 cm, irregular, "boggy"/ very mushy, nodule, very hard, tender)
posterior
dorsal (in back of)
thrills
important to consider during palpation of cardiac assessment; the feeling of a vibration over a valve; should be thinking about turbulent blood flow (something wrong with the valve and should be present)
micturition issues in the male reproductive system related to an enlarged prostate pushing against the urethra
dribbling; hesitancy; straining
abnormal orthostatic hypotension
drop in systolic value of 20 mm Hg or more; drop in diastolic value of 10 mm Hg or more
if a patient is presenting with a protuberant abdomen due to ascites, when the fluid is percussed it will sound
dull
percussing the liver during the physical exam of an abdominal assessment
dull sounds are expected
what to listen for during auscultation of posterior chest
duration of inspiration and expiration; intensity of expiratory sound; pitch of expiratory sound; for adventitious breath sounds
pylorus obstruction
early; characterized by profuse vomiting of clear gastric fluid; junction between stomach and duodenum
heart diagnostic studies
echocardiogram; exercise stress testing; EKG
abnormal pronator drift test assessment findings
either arm drifts downward; either palm pronates; or if arms unable to find original point; may indicate motor neuron disorder or metabolic disease
turgor
elasticity in our skin; when normal, no tenting is present; can tell you about hydration status; with the elderly, must be tested on sternum.
external variable that influence skin color
emotional states (blushing from vasodilation), temperature, cigarette smoking (pallor because of vasoconstriction), prolonged elevation/dependent position of extremities; prolong inactivity
widespread adenopathy
enlarged lymph nodes in multiple areas in the body; have multiple points of enlargement that do not correlate with one another; very concerning; accompanied with nodes that have been swollen and over 1.5 cm, are all red flags to signs of cancer; start to couple it with patient history; ask questions like how have their energy levels been? any recent weight loss? overall general feelings?
edema
excessive fluid in interstitial spaces; localized = injury; systemic = most often dependent portions of body; skin puffy and feels tight; graded on a 4 point scale; found by assessing mobility of the skin during a physical examination; 1+ = mild pitting, slight indentation; 4+ = very deep pitting, significant indentations, with a very swollen appendage.
purapura
excessive or spontaneous bruising
percussion over the liver
expected to be dull; indication that we've moved too low out of lung tissue
percussion over scapula
expected to be flat
percussion of posterior apices
expected to be resonance
clinical manifestations of parkinson disease
expressionless; mask-like features; eye brows always raised; face that doesn't give you much expression- flat like
S4
extra heart sound; atrial gallop; occurs from resistance in the ventricles when filling at end of diastole; comes before S1; sounds like A Stiff Wall; rarely physiologic(normal); more often times than not, in the hospital setting will be a pathological reason; sound is soft and lower pitched than S1; have to anticipate the sound; could be due to ischemia (aka new MI), aortic stenosis, and pulmonary HTN; should always alarm you
S3
extra heart sound; occurs when ventricles are resistant in early rapid filling phase; doesn't vary with respiration; persists when sitting upright, increases with isotonic exercise (sit ups); comes after S2; too much fluid on board, indicates developing HF; sounds like slosh-ing in; physiologically can happen in kids and pregnant women with increased swelling and volume; abnormal in patient with HTN, CHF, volume overload, too much Iv in a patient; characterized by a softer lower pitched sound that occurs after S2
murmurs
extra heart sounds; big picture: dysfunctional valves cause an increase in turbulence; increased flow through normal structures (exercise, hyperthyroid); back or regurgitation flow (incompetent valve, deformity or irregularity); flow through smaller defects in valve (partial obstruction or irregularity); flow into dilated chamber; blood viscosity decreases (anemia); shunting into abnormal passages (VSD); calcification of aorta (> age 70); graded I-VI, higher the grade, higher the sound
structures of the eye to inspect when collecting objective data
eyelids; eyebrows; eyelashes; conductive; sclera; cornea; lens; iris and pupil; lacrimal apparatus
general considerations during a breast and lymphatic assessment
face patient away from door; open gown up to front; keep cover-up towel available; identify common anxieties
pain in general appearance
facial expression, grimacing, crying
things to inspect and palpate on the head and face
facial structures (eyebrows, palpebral fissures, nasolabial folds, symmetry); facial expression (formed by facial muscles and facial nerve VII; looking for symmetry); TMJ (clench teeth and palpate muscles above and below the join; palpate the joint anteriorly to the triages during opening and closing of the mouth
syncope
fainting; loss of consciousness
6 F's of protuberant abdomen
fat; fluid (ascites); flatus (gas that causes a bloated abdomen); fetus; feces (FOF- full of feces); fatal growths (tumors)
flu-like symptoms
fatigue; malaise; fever; anorexia; sweats; achy; itchy (generalized pruritus); presence suggests infectious disorders when assessing lymphatic system
palpation portion of a physical exam for the assessment of the nose and sinuses
feeling for the frontal and maxillary sinuses (must push on the right spot); assessing nasal patency (having patient occlude one nostril and sniffing); assessing for sense of smell
lithotomy position
feet elevated up in the stirrups and making sure legs arent abducted too far
anatomical stance
feet on the ground; head up; palms facing forward; need to refer to this stance when documenting a lesion or anything on the patient
peripheral pulses of the head and neck
felt at the carotid artery
orchitis
firmness or tenderness felt while palpating the tests
if assessment findings are abnormal for a sensory function test during a neuro physical exam
first check the tool you're using for validity; then further compare symmetric points in these specific categories: pain (sharp, dull), temperature (only if pain sensation is abnormal; test with cold tuning fork or test tube with warm water), touch, vibration (tuning for symmetric sides; start at MTP- first sensation lost with peripheral neuropathies; worse at feet, improves up leg)
comprehensive health history
first part of a health assessment; when patient sits down with health provider and give them all the info about their health
pre-interview
first part of the interview process; sets the stage; going to review medical record before going into room; want to know what you're going to talk about; allow for adequate time; when entering environment, take time to see what it is like, good to be at least 45 degree angle from patient instead of straight on; taking notes is important but to make eye contact is also important
the angry or disruptive patient
first thing: you need to accept the fact that they are angry and if you're the only person available, they may direct it at you; let them say what they need to say and then validate their feelings; keep the door open; if you need to have someone else in the room like a charge nurse, it's always great to have another set of ears and eyes; if it continues to escalate and can't seem to come up with a resolve, politely excuse yourself and then tell them in order to help you, I need to find out from my charge nurse what i can do to help you; always have to protect yourself but protect the patient first
generating and testing diagnostic hypotheses in the working phase of the interview process
first, open-ended questions to hear "the story of the symptom" in the patient's own words; then more specific questions to elicit "the seven features of every symptom"; finally the yes-no questions or "pertinent positives and negatives" from the relevant section of the review of systems
how to assess biceps DTR during a neuro physical exam
flex arm at elbow; black thumb firmly on the biceps tendon in the antecubital fossa; strike thumb with hammer; response: elbow and forearm should flex and muscle should contract
anorexia
flu-like symptom that must be assessed during lymphatic system assessment; symptom that means they have pretty poor eating habits; generally going to see weight loss in these patients; not the eating disorder
pitting edema
fluid has been sitting there for a while; scale of 1+ to 4+ (the higher the worse it is); to scale it we push down, if it leaves a dent in the skin, we measure the dent
crackles (rales)
fluid in small areas like down in the alveoli; small airway moisture; does not clear with cough; at end of inspiration; moist, dry, fine, and coarse; present in pneumonia or CHF
if patient has pleural effusion
fluid is pushing up against lung (say the right side); this shift everything to the left in terms of the pulmonary and system circulation and on to the right side of the heart; the right atrium can no longer fill like its supposed to and increased pressure on the jugular vein is the result (JVD)
TIA
focal neurologic deficit lasting <1 hour without underlying structural defects; highest risk of stroke within next three months
medical assessments
focus is on the diagnoses and treatments of the disease
nursing assessments opposed to a medical assessment
focus on diagnoses and treatment of the actual or potential human responses; identifies many contributing factors to the individual's health and wellness
assessing illicit drug use
focus questions to distinguish use from misuse; adapt CAGE questing by adding "or drugs"; ask about patterns of use; ask about modes of consumption
inspection for cardiovascular assessment
focused on breathlessness or discomfort; pericardium for symmetry, pulsations, structural deformities (pectus carinatum and pectus excavatum); skin: edema, cyanosis, nails (cap refill- skin should blanch when pushed, and when let go, should become red again under 2 seconds; clubbing); looking for signs of distress; any presence of petechiae, JVD, discoloration,
tertiary prevention
focuses on decreasing effects of disease or disability by preventing complications or loss when defect is permanent; when someone has an illness what can they do to prevent other things from happening; examples include: physical therapy and rehab
secondary prevention
focuses on early detection and treatment of disease when curable or has few complications or disabilities; examples of this are medical screenings like mammograms, routine tests that want to catch it early if it does exist
primary prevention
focuses on improving overall wellness and protecting from disease or disability; examples include vaccinations
how to assess achilles DTR during a neuro physical exam
foot at a right angle (slightly dorsiflexed); support foot with your palm; strike the achilles tendon; response: plantar flexion
benign breast disease
formerly known as fibrocystic breast disease; characterized by multiple tender masses, cyclic discomfort, lumpiness, can feel like rope like nodules; no associated risk factors with Breast cancer
topics that healthy people 2020 focuses on in regards to what needs to be fixed
framework that identifies risk factors, health issues, and diseases of concern in the united states; an example might be: Children are becoming more obese
important topics when assessing elimination in patient history of an abdominal assessment
frequency (what is "normal?"; 2-3 times a day to 3 x a week; need to remove bias; need to ask what is normal for that specific patient); color, consistency (ask about diarrhea; 9 x out of 10, usually a loose BM; is it formed? ribbon like? when was your last BM and is that normal for you?); loose stools vs diarrhea (body's way of saying "you don't belong here"); constipation; presence of blood in stools (tarry stools (melena); bright red (hematochezia))
Key topics to address when gathering subjective data on the female reproductive system
frequency, urgency, nocturia; pain (abdominal pain; dysuria); hematuria or pyuria; urinary incontinence; cystocele/rectocele/uterine prolapse may interfere with normal urinary function;
RUQ or epigastric pain
from the biliary tree and liver
hypogastric pain
from the colon, bladder, or uterus; colon pain may be more diffuse though
suprapubic or sacral pain
from the rectum
periumbilical pain
from the small intestine, appendix, or proximal colon
epigastric pain
from the stomach, duodenum, or pancreas
+3 muscle strength
full ROM against gravity
+5 muscle strength
full ROM against resistance
+4 muscle strength
full ROM against some resistance
+2 muscle strength
full ROM with passive motion
things to consider when inspecting muscles and joints
general appearance (at rest and with motion); deformities; erythema; swelling; skin, vascular status; condition of surrounding tissues; muscle size and symmetry: measure as necessary
general survey
general state of health (seeing if someone is tired, do they look angry, their grooming), posture, motor activity, manner of speaking; first impressions; nonverbal cues; include assessing many factors: general appearances, apparent state of health, demeanor, facial affect or expression, posture and gait
two parts of the physical examination
general survey and vital signs
malaise
generalized poor feeling of well-being
location of lesions
generalized vs localized: diffuse- all over (chicken pox) or discrete- in limited number of areas (pityriasis roseca on trunk of body); region of the body: flexor (eczema) or extensor surfaces (psoriasis) or related to clothing lines or jewelry (contact dermatitis, photosensitivity)
review of system components
genre; skin; HEENT; neck; breasts; respiratory; cardiovascular; gastrointestinal; peripheral vascular; urinary; reproductive; musculoskeletal; psychiatric; neurologic; hematologic; endocrine
knee alignment variations
genu valgus and genu varum; note while walking or standing
whole goal of lymphatic system
get lymph fluid up an out; always trying to get it to the center core/ trunk area in order to drain it
vital sign assessment during neuro physical exam
gives clues to functional capacity and status of ANS and brainstem bc the HR is controlled by the vagus nerve; respiratory = medulla,pons; BP = medulla; temp = hypothalamus
CN IX
glossopharyngeal; works similarly with CN X; responsible for the soft palate and uvula; important for swallowing; assessed when palpating the thyroid while patient swallows, taste, the gag reflex, and saying "ahh"
Healthy people 2020: "how do we fix it" defined
goals and objective serve to improve the health of individuals and communities; overall goal is to increase quality of life by creating guidelines for healthy lifestyle; promotes health and prevents disease as it impacts the quality and length of a person's life; an example includes: making recess a requirement to address the increase of child obesity
equipment needed for musculoskeletal physical examination
good light source; plenty of space to move around; measuring tape; only inspection and palpation needed
rhonchi
gook/obstruction in the big airways; like snoring or cleaning mucous; usually clears with cough; low pitch gurgling; thick secretions in upper airways
hematuria
important topic to address when obtaining health history of the urinary tract; sometimes can be seen (microscopic) vs gross
why does orthostatic BP drop
gravity; the further away you are from the heart, the bigger the issue like in tall people; blood from the brain suddenly falls down when someone stands up; a good strong healthy heart will temporarily beat faster to get blood back up; but in a weak heart, it can't keep up to the sudden change and got to keep pumping faster for a longer time; will drop more than 20 mm Hg in systolic BP
transillumination
great diagnostic tool for assessing the scrotum when a mass is noted; great for determining what type of mass is in the scrotum; done by shining a light on the scrotum; if fluid filled mass is present, it will light up; if it is not a fluid filled mass it will NOT light up
acute pain behaviors
guarding; grimacing; vocalization such as moaning, crying; agitation, restlessness; stillness, when someone moves them they scream; diaphoresis; change in vital signs, HR, BP, RR all elevated via sympathetic NS, metabolism is high, anxiety and stress put on the bod, not always seen though; curled up in a fetal position, etc.
medical ethics
guide our professional behavior; stand on the do not harm principle
healthy people 2020
guidelines on what needs to be fixed in and how do we fix it in regards to health
topics of objective data of a head and scalp assessment
hair (quality, quantity, distribution, texture); scalp (lumps, nevi, scaling, dandruff, nits); skull (size and contour)
important topics to inspect when gathering objective data for the male reproductive assessment
hair distribution (using the Tanner scale); penis (presence/absence of foreskin); glans; urethral meatus; urethral discharge; lesions; scrotum (presence of both testes, skin contour, color, lesions, masses or bulges); inguinal region (lumps, masses, or bulges)
2+ tonsils
half way to the uvula
internal rotation of shoulders
hands down toward floor
external rotation of shoulders
hands up toward ceiling
trachea bifurcation
happens at T4; where it splits into branches into the right and left lobes of the lung; when you suction a patient you aren't supposed to go past this
oteosclerosis
hardening of bones in the middle ear; possible cause of hearing loss in this region
prostate cancer screening guidelines
has recently changed; used to be recommended routine screening for all men at certain age; but it was found that elevated PSA could be present without any cancer; realized that anxiety and stress it created outweighed the positive; USPSTF and ACA thus recommended routine screening; instead recommend individualized patient approach
Q-tip users
have put lots of little abrasions in he membrane that are continuously trying to hear; the ear was never meant to have anything inside of it
patients with hypothyroidism
have rough and dry skin
patients with hyperthyroidism
have skin texture that is described as velvety, smooth.
a complete health assessment of the musculoskeletal and neurological include
have the patient stand: assess gait; stand close and protect patient to check balance with romberg's sign then check position sense with pronator drift and tap on palms while client's eyes are still closed; stand behind client and check the spine/musculature as person reaches for toes; test ROM of spine as person flex/extends, rotates, and laterally bends; test hip ROM (strength must be done sitting)
physical examination of the spine
have to be assed while standing; are the shoulders the same height?; are hips the same height?; inspect: lordosis, kyphosis, scoliosis; palpate spinous processes and paravertebral muscles; ROM: flexion (bend forward)/ extension (straighten up)/ hyperextension (bend slightly backward); lateral bending; rotation: twist shoulders, look behind you while hips forward;
important topics to assess when gather subjective data for patient history during a neuro assessment
headache; fever; fainting (syncope); head injuries (vomiting, headache, irritability, LOC); seizures, tremors; coordination changes (altered balance, gait, or coordination); stiff neck?; alterations in sensory function (weakness, paralysis, spasms, vision, hearing, taste, smell, pain, paresthesia, dysphagia, dysphasia, difficulty forming words or language comprehension); Meds (HTN, CV, antidepressants, antianxiety, alternative meds, alcohol, street drugs, tobacco); symptomatic issues with causing neuro deficits PMHx (strokes, seizure dx, DM, hypertension, diabetes; hx trauma (head, neck, back), syphilis, varicella, psych dx, surgical; paresthesias caused by head traumas) FMHx (genetic pieces; neoplasms, strokes, Alzheimer's, psychiatric disorders, HTN, epilepsy, muscular dystrophies, Parkinson's)
topics of subjective data when assessing the head and face
headaches; dizziness; lumps or masses; surgery (trauma); scalp issues; new or old issues with face (lumps, skin, etc); allergies (food, drug, and seasonal); medications and or treatments sued; want to ask about any changes in the skin
routine TSE screening
health promotion topic in men; used to be recommended by the USPSTF and ACA but have revised these guidelines because they found it created more stress and anxiety than good; but still advisable to discuss this with your patient and teach them how to do so with the guidance of they know there body best (like if they were to find something abnormal in testicles, its imperative they get it checked it out)
flat percussion note
heard over bone
dull percussion note
heard over dense tissue like in pleural effusion or lobar pneumonia
hyperresonance
heard when over-hyperinflated lungs are percussed; heard in patients with emphysema or pneumothorax
temporal lobe functions
hearing; taste; smell
understanding how lymph drains
helps you distinguish and anticipate areas in which lymph nodes will be enlarged and tender in order to do their jobs
lab studies in nutritional assessment
hemoglobin, heamtocrit, cholesterol, triglycerides, total lymphocyte count; skin testing; serum proteins: albumin, transferrin, and preablumin; nitrogen balance (protein); creatinine-height index
classic findings of alcohol abuse during an abdominal assessment
hepatosplenogmegaly (HSM); ascites; caput medusa; spider angiomas; peripheral edema; palmar erythema; erythematic or bulbous nose
stridor
high pitched, upper airway blockage; high-pitched sound on inspiration and exhalation, indicating laryngeal obstruction; do not need a stethoscope to hear it
type of synovial joints
hinge; condylar; ball and socket
positive Brudzinski's sign
hips and knees flex as you flex pt's neck; indicative of meningeal signs (irritation, subarachnoid hemorrhage)
important topics to address when assessing subjective data of the eyes
history (cataracts, glaucoma; family history); surgery (acuity correction, glaucoma, cataract repair); trauma; environmental irritants (with sunglasses patient may burn their cornea); occupations hazards; any vision screening done? (last exam: date and results; glasses or contacts prescribed?); visual changes: little floaty things in the eyes, blurring, dark spots, diplopia, photophobia (sensitivity to light; doesn't adjust)?; pain; redness; discharge; excessive tearing?
important topics of child history in regards to lung and thorax assessments
history of prematurity (lungs develop on the last month of gestation, so this might suggest lung issues); vent support; recurrent hospitalization for pulmonary infections (how man times?)
how to assess triceps DTR during a neuro physical exam
hold arm up at inside of elbow (palm down); aim for tendon between epicondyles and olecranon; response: the elbow and the forearm should extend while the muscle contracts
serpiginous
hookworm
important questions to ask following presence of head injuries while gathering subjective data for a neuro assessment
how did it happen, where, what lobes? any accompanied vomting, headache, irritability, LOC?
factors that influence the pulse
how hard you push to feel the pulse; somebody that exercises a lot may have a lower on than the normal; cardiac exercises workout the heart and a lower reading is as efficient as a normal reading because it is stronger; medications; disease; age; gender (females generally run a little big higher); temperature; BP; electrolytes (elevates HR bc brain tells heart not enough oxygen is delivered) ; drugs
good question to ask in regards of nausea and/or vomiting for subjective patient history data in regards to abdominal assessment
how many medicine cups could you fill up with the amount projected? What time of day? only at night/day?
kyphosis
hump back; upper back that curves
risk factors for developing testicular cancer
hx of Ca in other testicle, mumps, inguinal hernia, or hydrocele in childhood, undescended testes
Palpation for PE of posterior chest
identify external areas of pain or tenderness; assess observed abnormalities; evaluate bilateral respiratory excursion (symmetric expansion aka the butterfly test); assess for tactile fremitus
comprehensive adult health history components
identifying data and sources; chief complaint(s); history of present illness; past history; family history; review of systems; health patterns
red flag warning when assessing the head and face
if a patient states "this is the worse headache ever", if they are > 50 years old, present with vomiting, trauma, pregnancy, elevated BP, and rashes; these signs may indicated a bleed, stroke, or aneurysm; stiffness may indicated meningitis (either bacteria or viral)
physical abuse/family violence should be considered in the following situations
if injuries are unexplained, inconsistent with store, concealed, or cause embarrassment; if patient has delayed getting treatment for trauma; if a past history of repeated injuries or "accidents"; if patient or person close to patient has history of alcohol or drug abuse; if partner tried to dominate the interview, will not leave the room, or seems unusually anxious or solicitous
rheumatic fever
if left untreated can damage heart valves permanently
auditory fremitus increases as we auscultate down the chest
if lung density increases as seen in consolidation and pneumonia
Abnormal Babinski
if present in a patient that is older than 1; response to test causes patient to fan toes outward
near syncope
if someone says they feel like they are going to pass out
streptococcus
if untreated in the throat, can infect the lining of the heart and into the valves
chronic illness
illness persists over a period of time; usually > 6 months; after intervention it is still there
worrisome findings upon inspection and palpation of the lymphatic system
immobile/fixed lymph nodes; prolonged sweeping over 1.5 cm; widespread adenopathy; multiple positive history points;
primary prevention examples
immunizations, environmental measures, accident prevention measures, reducing risk factors, occupational measures, health education, provision of adequate housing, periodic selective examinations, diet and exercise
possible causes of hearing loss in the external ear
impacted cerumen; foreign bodies; external otitis
initial pain assessment tool
important because we want to know if pain is getting better or worse; establishes a baseline
leg pain/cramps
important in assessing peripheral vascular history; need to identify if it feels like burning, aching, cramping, stabbing; aggravated by walking or activity (intermittent claudication); note distance walked until pain occurs; less distance is worse! is the pain worse with limb elevation? is the pain increase at night? does the pain increase with cool temperatures?; have to think about lactic acid; think about what is causing it; are we just dealing with electrolyte issues or circulation issues; if it happens during the day during activity = red flag: oxygen isn't getting to lower extremities and this indicates a peripheral arterial issue
palpating the shoulders and the turning of the head against resistance
important in terms of collecting objective data during the physical examination of the neck; assess patients ability to bend neck forward and back, side to side, and rotation
palpating the trachea
important in terms of collecting objective data during the physical examination of the neck; feeling for symmetry; assessing for deviation and obvious masses
palpating the CV/PV system
important in terms of collecting objective data during the physical examination of the neck; includes assessing the carotid pulses (one at a time) and for jugular distention
palpating the glands of the neck
important in terms of collecting objective data during the physical examination; assessing the salivary glands and thyroid at the lower 1/3 of the neck; done by a specific palpation technique
expecting the pinna
important in terms of collecting objective data when assessing the ear; look for any scaling or redness; puling and pushing it shouldn't cause tenderness; if so, may indicate infection
visual fields by confrontation (aka peripheral vision)
important objective data to assess for a physical exam of the eye; done by positioning yourself with 12 inches between you and patient, face to face; instruct patient to look at your eyes; do not move eyes; wiggle two fingers in each outer quadrant at get of visual field; begin outside the range of vision behind patient and then bring two fingers into the rang of vision and tell patient to indicate when fingers are finally seen; test all 6 fields (upper, middle, and lower towards the center)
hyperopia
important objective data to assess for a physical exam of the eye; farsighted; can't see things that are close
myopia
important objective data to assess for a physical exam of the eye; nearsightedness; can't see things far away
EOM functions of the eye
important objective data to assess for a physical exam of the eye; position and alignment; tested by the patients ability to move eyes in the 6 cardinal fields of gaze (around in a counter clockwise and clockwise motion)
corneal light reflex
important objective data to assess for a physical exam of the eye; tests for the position and alignment of the eye; presence of a light shining back at you when tested means nothing is behind it pushing back against it
strabismus
important objective data to assess for a physical exam of the eye; when one eye is weaker than the other (by weakening of one or more muscles that hold the eye) and enables it to deviate; tested for by the cover/uncover test
assessing sense of smell
important part of the physical exam of the nose and sinuses; can be done while check patency; use odiferous scents like spices; if combining patency with sense of smell: have patient close eyes, cover on are then test one side; repeat for other side with different smell
iris and pupil
important structure to inspect when physically examining the eye; assess pupillary light reflex (in mm): direct, consensual; assess accommodation (pupillary constriction when focusing on a near object after looking far away); assess for convergence (eyes inward)
conjuctiva
important structure to inspect when physically examining the eye; the inner lining of the eye; need to pull down on like to see it; should be pink
swollen glands
important subjective data topic for general history, lifestyle, and self care in regards to the neck; if mobile and tender, suggests inflammation and that they are doing their job; if fixed and firm, nodes suggest cancer
hypospadius
important to address when collecting objective data for the male reproductive assessment; characterized as an abnormal location of the urethral opening (it is located lower it's normal location); surgical correction dependent on how severe it is, might be necessary to preserve fertility and adequate elimination
epispadius
important to address when collecting objective data for the male reproductive assessment; characterized as an abnormal location of the urethral opening; sometimes when baby is born it can be more superior to it's normal location; surgical correction dependent on how severe it is, might be necessary to preserve fertility and adequate elimination
fainting (syncope)
important to address when gathering subjective data on patient history during neuro assessment; accompanied with loss of consciousness; when this happens, it is a vasovagal response- ANS reacts causing bradycardia AND allows vasodilation in the lower extremity, if you stand up, gravity will bring all the blood down, meaning no oxygen to the brain, causing the body to end up on the floor
bronchitis
important to asses in terms of past respiratory history; inflammation in upper airways; form of COPD
DTR
important to assess during a neuro physical exam; can be tested on the brachioradialis, biceps, triceps, patellar, and achilles; done by positioning limb so muscle is slightly stretched, reflex hammer should strike tendon briskly to stretch tendon, get patient to relax, and compare side to side; rated on a scale from 0-4+, but as long as the sides are symmetric and not a change from baseline results, results are normal
swelling
important to assess for peripheral vascular; need to note if it is pitting or non pitting; one leg or two; when did it start; doe anything relieve it?
atelectasis
important to assess in terms of past respiratory history; characterized by collapsed alveoli; a good intervention for this is encouragement of IS use
pneumonia
important to assess in terms of past respiratory history; collection of fluid in lung tissue; creates a good breeding ground for bacteria and virus
emphysema
important to assess in terms of past respiratory history; inflammation at alveolar level; form of COPD; where gas exchange occurs, alveoli get so enlarged and aren't able to recoil; a build up of CO2 leads to chronic inflation, barrel chest, and inability to perfuse; once elastin is lost, can never get it back
pleurisy
important to assess in terms of past respiratory history; inflammation between the two pleural linings; very painful; presents with shallow breaths
asthma
important to assess in terms of past respiratory history; triggered by an irritant; airways start to get inflamed, mucus comes, becomes more narrow; need rapid bronchodilators and could be irreversible if not treated
the patient with low literacy
important to assess patients ability to read before asked to sign anything; may ask the patient to read the instructions out loud; try to be sensitive as you can possibly be; usually comes with a response of insult; remember that its your job to educate: go find brochure that has instructions with pictures or decide to draw out pictures to give them
testing cognitive interpretation during a neuro physical exam
important to assess sensory function; include testing stereognosis and graphesthesia
Skene's glands
important to assess when gathering objective data for the female reproductive system; is the urethral opening
Bartholin's glands
important to assess when gathering objective data for the female reproductive system; is the vaginal opening
ear tubes
important to inspect and assess during a physical exam; some adults have them, not just kids; put at the bottom portion of the TM to drain any fluid that build up there; idea is that they hopefully fall out on their own; ones that have fallen out may be indicated by a perfect circular perforation in the TM
peripheral cyanosis
important to inspect during cardiac assessment; if present, seen in the fingers/toes, ear lobes, nails; suggests peripheral vasoconstriction
central cyanosis
important to inspect during cardiac assessment; if present, seen in the lips, gums, tongue, oral mucosa, conjunctivae; suggests poor arterial circulation
petechiae
important to inspect during cardiac assessment; tiny red spots; superficial capillaries that give blood to the skin surface and have too much pressure on them so they rupture; can be anywhere
when assessing skin lesions during a physical examination of the skin
important to note: color, location, elevation or flat (and texture), pattern or shape, size including depth, location and distribution on body, exudate (wet or dry, color, consistency), bleeding, and induration
pulsations
important topic to address during the inspection portion of an abdominal physical exam; abdominal aorta sometimes can be seen without palpating
umbilicus
important topic to address during the inspection portion of an abdominal physical exam; area inspected to assess presence of herniation
striae
important topic to address during the inspection portion of an abdominal physical exam; include stretch marks and atrophic scars; can tell you interesting information: previous pregnancy? purplish in color may indicate addison's disorder; stretching of the skin at a rapid rate.
umbilical hernia
important topic to address during the inspection portion of an abdominal physical exam; intestines pushing through as intestinal walls are flexed; can happen in multiple pregnancies and obese people; the harder a baby cries, the bigger it gets, as they calm down, should be able to push them back in (if not, can lead to necrotic bowel)
contour
important topic to address during the inspection portion of an abdominal physical exam; is it flat, rounded, scaphoid, or protuberant?
peristalsis
important topic to address during the inspection portion of an abdominal physical exam; motion of internal organs on surface; sometimes can be seen in patients in the supine position
incisional hernia
important topic to address during the inspection portion of an abdominal physical exam; someone created a weakened are in the abdominal wall due to a cute; intestine starts to protrude through; can also happen years later
hernias
important topic to address during the inspection portion of an abdominal physical exam; weakened are of the intestinal wall where the stomach starts to push out of it
undescended testicle
important topic to address when gathering subjective data for PMH during a male reproductive assessment; puts them at greater risk as a adult of developing testicular cancer
menstrual history
important topic to address when gathering subjective data for female reproductive assessment; include topics like age of onset (menarche) or cessation (menopause); LMP (day 1 of her last menstrual period; most important); length of cycle (regular and predictable monthly; frequency; asking about sanitary hygiene); vaginal bleeding (not menstrual); any treatments for cramps, excessive bleeding; perimenopausal (irregular cycles, vaginal dryness, hot flashes, mood swings); postmenopausal bleeding needs to be assessed right away
sexual activity
important topic to address when gathering subjective data for female reproductive assessment; remember (similarly to other sensitive topics) need to remind the patient that we need to know this because we need to make sure we know what they are at risk for and helping guide in what we need to educate them for due risk factors they may have (will help get honest answers; include discussion of: # and gender of partners, coital pain (bleeding or discharge after coitus), safer sex (condoms) and BC, and substance abuse
Para
important topic to address when gathering subjective data for obstetric history of the female reproductive system; is the total number of deliveries after 20 weeks gestational age (viable or potentially viable)
gravida
important topic to address when gathering subjective data for obstetric history of the female reproductive system; is the total number of pregancies
abortus
important topic to address when gathering subjective data for obstetric history of the female reproductive system; number of pregnancy losses (elective and spontaneous before 20 weeks gest,. age, induced)
paresthesia
important topic to address when gathering subjective data for patient history during nero assessment; characterized by numbness, tingling, burning, crawling sensation; feels like pins and needles; patient may say "I feel like worms are crawling in my fingers"
dysuria
important topic to address when obtaining health history of the urinary tract; difficulty peeing, pain with urination
UTIs
important topic to address when obtaining health history of the urinary tract; females are most susceptible bc urethra is much shorter in which bacteria can travel to the bladder faster
flank pain
important topic to address when obtaining health history of the urinary tract; located right around the sides of the trunk of the body
kidney pain
important topic to address when obtaining health history of the urinary tract; located towards the back
nocturia
important topic to address when obtaining health history of the urinary tract; night time urination
incontinence
important topic to address when obtaining health history of the urinary tract; not a normal thing no matter the situation; we want to fix it; good intervention is pelvic poor exercises
urine
important topic to asses when gathering subjective data of the reproductive system; should address the many possible colors (blue, dark grey, tea, pink, red, orange, amber, yellow, pale yellow, cloudy); should assess micturition; important to ask about regular appearance, and has it changed; important to ask about symptoms
changes in ability to smell
important topic to assess when gathering subjective data during assessment of the nose; can be a predecessor to Alzheimer's
diarrhea
important topic to discuss when assessing elimination of bowel habits when obtaining subjective data for abdominal patient history; body's way of saying "you don't belong here"; massive flushing that prevents foreign invader from attaching and getting into the system; can happen for a lot of other reasons as well; important to ask, was it all liquid with no formed elements? if they say kind of formed, thats a loose stool, not diarrhea
pain
important topic to discuss when assessing subjective patient history for an abdominal assessment; Do a mini-OLD CART; identify possible causes (food, stress, fatigue, meses, infection); obtain pt description (cramping, sharp, dull, kinfelike, burning, gnawing, use pain scale); ask what relieves the pain (medication: analgesic, antacids?; position?); location and radiation of pain (site characteristics; referred pain (location not always at site of affected organ))
past surgeries
important topic to discuss when assessing subjective patient history for an abdominal assessment; important to note that scar tissue made of fibrin and collagen; as it produces and keeps producing, it starts to adhere on to thing that its not supposed to (like in a C-section having scar tissue adhering to the bladder); causes lysis of adhesions (which leads to obstructions); any patient with a history of abdominal procedures has a high risk of developing obstruction
gastroenteritis
important topic to discuss when assessing subjective patient history for an abdominal assessment; inflammation of the GI tract (mouth, esophagus, stomach, and intestines); multiple causes such as: virus, bacteria, parasite, medications, and food intolerances; aggressive and rapid movement to get foreign invader out of both ends; common symptoms include: nausea and or vomiting, diarrhea, abdominal cramping, and fever
colonoscopy
important topic to discuss when assessing subjective patient history for an abdominal assessment; initial screening should be done at age 50 if there is no presence of family history; important to discuss when the last one was done and what were the results
nocturia
important topic when assessing history for cardiac; patient gets up 3-5 time during the night to pee; think heart or pregnancy (pressure put on kidneys and bladder); interrupted sleep
foreskin
in infant and new borns, it is actually attached to the head of the penis, so not retractable; over the years it will eventually retract on its own; in the adult penis should easily retract over the head; extremely important to inspect when gathering objective data for the male reproductive assessment
observing retractions
in infants and children: not their exact location; an important clue to the cause and severity of respiratory distress
palpate PMI
in left lateral reclining position
interviewing process
in order to be successful in this, you must have effective communication and relational skills; you must have interpersonal skills in order to respond to feeling and concerns
orientation to time place, and self
in someone that is deteriorating, the can't identify one or more of these things; usually the last to go is self; tell us about the neuro system and the brain; if oxygen is getting to the brain that means heart is doing what its supposed to be doing; will always be included in a PE because you don't want to miss something that is deteriorating
peritoneal cavity
incases all of the organs in the peritoneum
PE inspection of peripheral vascular system
include color, hair distribution (hair needs oxygenation and nutrients from capillaries to grow, if patient has sparse hair on legs, indicates lack of oxygen and nutrients from capillaries- PVD), nails, size, skin lesions or ulcerations, edema, obvious venous patterns
objective data of auditory acuity of the ear
include conductive loss, sensorineural loss, and mixed loss; assessed by performing the whisper, weber, and Rinne test
HPV vaccines
include gardasil and cervarix; covers two particular strains that are most commonly known for causing cervical cancer; there are 3 in the series (the adolescent needs to come back and be cooperative); need to make sure patient is looking at valid resources in regards to info and SEs; can be given 11-26 yo (now as early as 9)
abdominal system structures
include solid viscera and hollow viscera
trifecta in family history
include the presence of all 3: diabetes, HTN, and high cholesterol; if all present, risk factor for heart disease is very high
structures of the left eye
include: optic disc; physiologic cup; vein; artery; fovea centralis; macula
localized bulges in the abdominal wall
include: umbilical hernias and incisional hernias
inguinal area of groin of the males RS
includes juncture of lower abd wall and thigh (potential hernia site in which a loop of bowel (colon) protrudes through a weak spot in muscultaure) and inguinal canal that is 4-6 cm long in adults with two openings (internal ring and external ring)
overweight and obesity
increase risk of heart disease, numbers types of cancers, type 2 diabetes, stroke, arthritis, sleep apnea, infertility and depression
large ad tender lymph nodes
indicate a good sign; body is doing what its supposed to be doing
waist circumference
indicates central body fat; when greater than 40 inches in men and greater than 35 inches in women, it is related to an increased risk for cardiovascular disease; must be measured after the patient takes a breath and exhalation; may be a better risk predictor for individuals older than 75 years; ratios greater than .95 in men and greater than .85 in women are considered elevated.
hypoactive bowel sounds
indicates decreased motility; quiet gurgling; characterized by <4 in 1 min; not exciting in post-op patients that haven't eaten, took pain meds, etc.
vomiting of substances that look like coffee grounds
indicates digested blood; indicates lower stomach or SI bleed because acid had time to digest it
hyperactive bowel sounds
indicates increased motility; high pitched and loud; common in patients over 35; sometimes can sound like one long sound that keeps going in many different pitches; expected in diarrhea
when taking an orthostatic BP with a drop of more than or equal to 20 mm Hg systolic and a drop of > or equal to 10 mm Hg diastolic and or/ increase of 20 bpm HR when standing
indicates orthostatic hypotension
Glascow Coma Scale (GCS) score of 3-8
indicates patient is in a coma
meningeal signs
indicative or irritation, subarachnoid hemorrhage; general sx: headache, photophobia, and fever; + Brudzinski's sign: if hips and knees flex as you flex pt's neck (normally would be relaxed and motionless)
expressive dysphasia
individual can understand what others are saying; words are slow and laborious, but meaningful; often gets frustrated; an example is Broca's aphasia; person knows what they wanna say but they can't bc of neuro problems; they know in their head they want to say green but the connection between the brain and mouth is "disconnected"
highest priority nursing diagnosis for swollen glands in the mouth
ineffective airway clearance
nutritional requirements at different ages
infants and children; adolescence; pregnancy and lactation; adulthood; the aging adult
cholecystitis
inflammation of the gallbladder, usually secondary to an obstruction; acute versus chronic; clinical manifestations: fever, leukocytosis, RUQ or epigastric pain, rebound tenderness, and abdominal muscle gaurding
cholecystitis
inflammation of the gallbladder; normally in the RUQ; as it becomes more inflamed, becomes more anterior
pancreatitis
inflammation of the pancreas; full spectrum meaning some can be managed and some may not; not everyone that develops this is a drinker; associated with several clinical disorders (alcohol intake and cholelithiasis); caused by injury or damage to pancreatic cells and ducts, causing a leakage of pancreatic enzymes into the pancreatic tissue. these enzymes cause autodigestion of pancreatic tissue and leak into the bloodstream to cause injury to blood vessels and other organs; types include acute versus chronic
medications
information included in a patent's past history; include prescriptions, OTV, and herbal supplements (considered one because some interact with some medications)
health maintenance
information included in a patient's past history; asking question to know what has the patient done to maintain their health; include: immunizations (past and current, current may tell us about symptoms they are currently experiencing), screening tests, safety measures (wear a helmet, sunscreen, etc), risk factors (tobacco, environment, substance abuse, alcohol, sex- sensitive topics)
allergies
information included in a patient's past history; include specific reactions, medications, food, insects, and environmental factors; when asking about one, the question must be specific to the category of interest; after asking about a specific one, the appropriate follow up question what be: "what happens when you take it?"; important documentation
adult illnesses
information included in a patient's past history; include: medical, surgical, accidents (can explain about whats going on, like in head injuries), and psychiatric (sensitive topic, sometimes patient is reserved, have to know the history, have to determine if patient is a reliable source)
childhood illnesses
information included in a patient's past history; may be grown out of it or it may come back; examples include: measles, rubella, mumps, pertussis, chickenpox, premature baby (may detect lung issues), etc; chronic conditions like asthma;
the lymphatics of penis and scrotal surface drain into
inguinal lymph nodes
gag reflex
initiated to asses CN IX (glossopharyngeal) and X (vagus); looking for the musculature of the posterior nasopharynx; protective mechanism that helps keep you from chocking, and wants you to keep breathing; when doing this, you are aiming for the small palate arch way, if it doesn't initiate it, go back further and further until touching the postpharynx; if touching postpharynx and it doesn't happen, patient may not have one- this is only concerning if they used to have one and now doesn't
sacral nerves
innervate the bowel, bladder, and sexual function
thoracic nerves
innervate the chest muscles and abdominal muscles
cervical nerves
innervate the head and neck, diaphragm, deltoids, biceps, writs extenders, triceps, and hand
lumbar nerves
innervate the leg muscles
peripheral vascular assessment of the upper extremities
inspect for color, size, and lesions; palpate pulses: radial and brachial
peripheral vascular assessment of the lower extremities
inspect for color, size, lesions, skin changes; palpate pulses: femoral, popliteal, posterior tibial, dorsalis pedis; skin temp; presence of edema: bilateral (suggests systemic illness or occlusion in large vessel common to both) and unilateral (suggests localized problem)
carotid artery
inspect for pulsations in the neck; palpate one at a time- assess rhythm, strength, and thrills; auscultate for bruits; if both felt at the same time, syncope will happen; only pulse you are not palpating symmetrically; after palpation, go back and listen for turbulent blood flow that shouldn't be there; in the peripheral vascular system it is called a bruits which is equivalent to a murmur in the PV system
order of the physical exam of an abdominal assessment
inspect, auscultate (done before touching the patient to prevent the moving around of things), percuss, palpate
physical examination techniques for the peripheral vascular system
inspect, palpate, and auscultate the carotid and femoral pulse
tympanic membrane
inspected during the physical examination of the ear; should be a pearly grey, almost translucent, should display cone of light at 4 o clock when inspecting it with an otoscope; if ruptured, heals with scar tissue that is fibrous, non elastic, and causes a difference in hearing
a complete health assessment of the head and face include
inspecting and palpating the scalp, hair, and skull; inspect the face: skin, symmetry, expression, CN VII; palpating the TMJ and not tenderness or crepitus; Test CNV motor strength- both masseter and temporal muscle with clenching; palpate sinuses and lymph nodes
a complete health assessment of the ears include
inspecting external ear: position and alignment, skin condition; inspect/palpate pinna, tragus, and mastoid process; examine internal ear with otoscope: canal, tympanic membrane for color, landmarks, and integrity; test hearing using whisper, weber and Rinne tests, CN VIII
a complete health assessment of the eyes include
inspecting external structures (eyebrows, eyelashes, symmetry); inspecting conjuctiva (pulling lower lids down) and pupils (PERRLA); inspecting sclera, cornea, and iris; testing each pupil size for direct and consensual light reflex and acommodation; testing visual fields by confrontation and acuity of both eyes, CN II; testing EOM with convergence: six cardinal positions of gaze, CN III, IV, VI
a complete health assessment of the nose includes
inspecting external surface for symmetry and lesions; inspecting the nares: nasal mucosa, septume, and turbinates (must use the otoscope); testing the patency of each nostril; testing CN I (using scents); palpating frontal and maxillary sinuses
a complete health assessment of the neck includes
inspecting skin, symmetry, JVD, and carotid pulsations; palpate cervical lymph nodes, carotid pulse (one side at a time); auscultate carotids with bell for bruits; palpate trachea in midline; test ROM through flexion/extension, rotation, lateral motion and muscle strength against resistance and shoulder shrug (CN XI); palpate thyroid from posterior approach
a complete health assessment of the upper extremities include
inspecting skin, symmetry, joints; palpating for temp, tone, crepitus, and edema; palpating pulses: brachial and radial (bilaterally and symmetrically); check cap refill of fingers; test ROM and muscle strength of hands, wrists, elbows, and shoulders; don't forget grip strength
a complete health assessment of the anterior chest/heart includes
inspecting the precordium: skin, presence of heaves; palpating for thrills and apical impulse; auscultating with diaphragm and bell from apex to base or vice versa: aortic, pulmonic, tricuspid, and mitral areas; auscultate apical pulse and rhythm; note where S1 and S2 are heard the loudest and if any extra heart sounds, murmurs, clicks, or rubs were heard
a complete health assessment of the posterior and lateral chest include
inspecting the skin, configuration of thoracic cage, and symmetry of shoulders and muscles; palpating for any lumps or tenderness, tactile fremitus using 8 pts; palpating respiratory excursion; palpating spinous process and paravertebral muscles; percuss costovertebral tenderness; percuss over all lung fields (for resonance); asucultate breath sounds (full breaths using diaphragm)
a complete health assessment of the anterior chest includes
inspecting the skin; palpating chest wall for tactile fremitus, lumps, or tenderness using 8 pth method; percuss anterior lung fields; auscultate breath sounds
cardinal techniques of examination
inspection, palpation, percussion, and auscultation; how we initiate going into systems, need a strategic way of assessing so we don't miss anything; ALWAYS start with inspection (looking with a critical eye, getting data by just looking)
physical examination of lung/thorax components
inspection; palpation; percussion; auscultation
variables that influence health
intellectual, spiritual, emotional; family influences, cultural background, socioeconomic
basal ganglia
involved in automatic movements, like swinging your arms when you walk
serum transferrin
iron-transport protein
things to question when asking about productive coughs
is it yellow, green, clear, pink, thick, or thin?; important to get history
Importance of a good history assessment for lung and thorax
it is key to diagnosis: more accurate than the physical examination portion
importance of encouraging HPV vaccinations in both sexes
it is the leading cause of laryngeal and neck cancers in men; experts predict that because of this virus laryngeal and neck cancers will have higher prevalence than cervical cancer in 2020
question topics for characteristic symptoms for skin history (subjective)
itching, painful, burning, etc; questions to ask: is it tender?; does it itch? does it bleed?
arthraglias
joint pain
genu valgus
knock knees; knees touch
important things to be aware of before starting female reproductive assessment
know the client's concerns: start with their agenda and perspective; cultural/age related considerations; set comfortable environment (collect history while patient is dressed; understand anxieties, discomfort, embarrassments; treat patients with respect and patience )
important topics in patient history for lymphatic assessments
knowing if they have any "swollen glands" (the familiar term for lymph nodes, even though they aren't really glands); if they do, want to know exactly where it is, number, and is it tender? do they have reduced ability to move in that specific area? want to know general overall feeling; want to know of any presence of flu-like symptoms that suggest infectious disorders; any presence of anorexia
dyspnea
known as difficult labored breathing
fatigue
lack of energy
nail clubbing
lack of oxygen in the system; indicated by lack of schamroth's window when nails of opposite hands are put against each other
termination
last phase of the interview process; going to inform patient that you are coming to the end of the interview; don't want to be erupt; want patient to know what you're going to do with the information they gave you; offer patient to add anything else; usually helps guid the ending on mutual terms; summarize important points and discuss plan of care
cou- and contracou head injuries
lead to inflammation and swelling due to the immune system response; this increase ICP which can come in many different forms, some common sxs include: nausea, vomiting, lethargy, irritability, loss of LOC
side of kidney that sits up higher than the other
left
location of kidneys
left higher than right one; use costal vertebral angle; right one starts at the 12 rib (if we need to palpate, this is the one that we would choose to do so)
intermittent claudication
leg pains/cramps aggravated by walking or activity; red flag because this indicates that oxygen isn't getting to lower extremities and this indicates a peripheral arterial issue; lack of healthy oxygen causes a build up of lactic acid; if leg is elevated, pain will get worse, gravity is now working against you because gravity isn't helping more oxygen get to the location
rinne test results for a kid that puts a marble in their right ear
length of time hearing bone conduction will be longer than length of time hearing air conduction on the right ear; air conduction is blocked by the marble
confluent lesions
lesions that run together
important topics to address when palpating the glans and penile shaft during a male reproductive assessment
lesions; discharge; masses; hard areas; compress between thumb and forefinger- if any discharge, collect smear for microscopic examination and culture; if no discharge noted but person gives history of it, ask him to try to produce a drop of discharge (bearing down or gently squeezing)
equipment needed to gather objective data for the female reproductive system assessment
light source; disposable gloves; as needed: urine specimen bottle and wipes (for clean catch), urinalysis lab sticks, urine pregnancy test material, water soluble lubricant, vaginal speculum, cytology kit (thin prep brush and tube or Pap smear slides, ayre aptula, cytobrush, Pap fixative); as a RN you do not perform the internal examination, but may be asked to assist and gather the tools
1+ tonsils
lines with the anterior pillar
buccal mucosa
lining of the cheeks
locations for central cyanosis
lips, oral mucosa, and tongue
auscultation portion of the physical exam of an abdominal assessment
listen for bowel sounds and vascular bruits
the inguinal canal
one of the potential sites for a hernia to develop in the male reproductive system; is 4-6 cm long in adults with two openings (internal ring and external ring); area where bowel and slip and protrude through
auscultation for cardiovascular exam
listen in each area for at least 30 seconds; listen carefully with diaphragm first for 30 seconds, then again with bell for 30 seconds, thus 1 minute at each valve; not rate and rhythm; identify S1 and S2 (S1 loudest in mitral (lub); and S2 lords in aortic/pulmonic (dub)); identify any extras: splitting, S3, S4, murmurs, rubs; not the timing in cycle, location, duration, pitch, quality, intensity, and frequency
pulse deficit
listen to apical pulse and palpate radial; should be identical; if not, possible poor contractions (HF or Afib)
receptive dysphasia
little or no comprehension of words; spoken words are fluent and nonsensical; no idea the words and language are wrong; ex: wernicke's aphasia; associated with word salad and happiness; person has no idea that you are confused about what they are saying and don't know that they don't understand what you're saying; sometimes can get a word out and can find the association of what they are actually trying to say
pressure ulcer
localized injury to the skin and or underlying tissue as a result of pressure or pressure in combination with shear and or friction; stages 1-4; tissue types in wound bed: epithelization, granulation, slough, and eschar; mistake identifications include: skin tears, arterial/venous/diabetic ulcers, and perineal dermatitis; important in evaluation and documentation
anterior lung apices
located 3-4 cm above clavicles
inguinal nodes
located in the groin region; helps fight any kind of infections in the lower extremities
tricuspid valve
located left sternum border of 4th intercostal space
mitral valve
located on left MCL of the 5th intercostal; sits right next to the apex of the heart; if you aren't in breast tissue you aren't in the right place; point of maximal impulse (strong, most accurate, if you can't feel for it, have the patient lay down, if you still can't feel it, have to start thinking why, maybe meed to go down to the the 6th intercostal which might suggest hypertrophy
pulmonic valve
located on left sternum border of 2nd intercostal space
aortic valve
located on right sternum border of 2nd intercostal space
precordium
location of where the heart sits; protected by the rib cage
inspection portion of the physical exam of the nose
looking at internal and external features; use the otoscope with largest speculum piece appropriate for the patient (use for light source only); patient need to tip back so that you can see inside and then tip slightly forward; want light to be focused and shine straight up the nose; want to see the vestibule, color, swelling, bright red or foggy; want to look for ulcerations, polyps, and deviated septum
inspecting the soft and hard palate
looking for completeness where they merge and no holes
palpation of joints with ROM
looking for crepitus; palpate the joint and the nearby muscles during active motions
presbycusis
loss of hearing with age
bronchial/tracheal
loud, high-pitched normal breath sounds heard over the trachea
pleural friction rub
low grating noise in peripheral and lateral chest/all around pleural tissue; cough does no clear; noticed on inspiration/expiration; present in: pleurisy
lordosis
lower back that sways; as fetus enlarges curves lower spine in
developmental consideration for the aging women when gather objective data for the female reproductive assessment
lubricate medication and fingers adequately for anything needing to be done intravaginally; in older women and those that are post-menopausal, you may need to insert only one gloved finger if vaginal stenosis exists.
wheezes
lungs are clamping down; usually occurs in the smaller branches; moisture or debris in larger airway; louder than crackles; inspiratory/expiratory; present in: reactive airway disease and asthma
two important components of the male reproductive system
lymphatic system and hernia sites
the femoral canal
one of the potential sites for a hernia to develop in the male reproductive system; it is at the juncture of lower abd wall and thigh
spinal cord
main highway for ascending and descending tracts between brain and spinal nerves and mediates reflexes
angina
mainly caused by an increase of lactic acid due to decrease of O2 getting to the muscle which causes burning and pain
in preparation of the physical examination of an abdominal assessment
make sure the environment, hands, and stethoscope is warm; short fingernails; client in supine position w/ knees flexed (this position relaxes the natural abdominal muscles); client with empty bladder and bowel (have them go to the bathroom first so it isn't uncomfortable); watch facial expressions for discomfort; examine painful are last (first natural instinct is to push on the location in which the patients chief complaint is about, but always do this area last so that you can collect lots of data and then go to the painful area last)
skin history (subjective) associated symptoms question topics
malaise; fatigue; leathery; arthralgias; myalgias; fever or sweats; N&V, diarrhea, sore throat, cold; edema or swelling (cellulitis)
patient education topics for preventative health measures during a breast assessment
mammography/MRI (ACS and AMA recommend annual mammograms for women ages 40-74; USPSTF recommend biennial tests (Q 2 years) for women 50-74 yo; recommend shared decision making for women >75); regular clinical breast exams (done by HCP, recommended to be done every 3 years between 20-39, then annually >40); BSE (how to do one); patients with familial history of breast cancer may decide to undergo genetic testing to assess BRCA risk; weight management; exercise; smoking and alcohol cessation; general rule, by age 50 should definitely have a mammogram screening
A laboratory finding of serum albumin <2.8 g/dL and Serum transferrin of <100 mg/dL may be indicative of
marasmus/kwashiorkor mix
systolic pressure
maximum pressure on arteries during left ventricular contraction (systole)
nutrition for pregnancy and lactation
may become anemic so increased iron intake needed, folic acid taken to prevent spinal bifida in fetus development
a patient "smelling burnt popcorn"
may indicate patient is having a stroke; may also indicate damage to the temporal lobe
slow and clumsy when assessing cerebellar functions of coordination of the hands and legs during a neuro exam
may indicate possible cerebral/vestibular disease or patient is drunk
Spastic muscle tone assessment finding during an MSK assessment
may indicate presence of cerebral palsy or spinal cord injury
skinfold thickness
measurement provides an estimated size of the subcutaneous fat deposit, which is basically the fat under the skin. By estimating the thickness of this area, researchers are able to obtain an estimation of the total body fat; technique of measurement: repeat three times and then take average
sphygmomanometer
medical instrument used to monitor a patients blood pressure
doppler
medical tool that helps find a difficult pulse
bronchovesicular
medium normal pitched breath sounds heard over the mainstream bronchi, between the scapulae and below the clavicles
possible causes of hearing loss in the inner ear
memeniere's disease; noise exposure; presbycusis; ototoxicity
developmental reproductive changes in the aging woman
menopause- pubic hair gradually decreases; skin is thinner and fat deposits decrease, leaving mons pubis smaller and labia flatter; clitoris size also decreases after age 60; uterus reduces in size; vaginal mucosa things, dries, and becomes less lubricated
materials needed to perform nero physical exam
mental status assessment tool; paper, pencil; familiar object; tongue depressor; reflex hammer; tuning fork, cotton ball, cotton-tipped applicator (for sensory testing); aromatic material (coffee, mint, spices)
Kussmaul breathing
metabolic acidosis (diabetes mellitus); hyperpnoea; characterized by ketones, uremia, sepsis, salicylates, methanol, aldehydes, and lactic acid/lactic acidosis
lateral thoracic reference lines
midaxillary line (MAL)
anterior thoracic reference lines
midsternal line (MSL) and midclavicular line (MCL)
sequence and positioning for the examination
minimize how often you ask the patient to change position; examine the patient from the right side, moving to the opposite side or feet as needed; collect all data that we can possible manner in a time efficient manner and time efficient thought process
where S1 is heard the loudest
mitral area (PMI): 5th left ICS at MCL
physical examination of the skin components
moisture (diaphoresis, dehydration); vascularity, evidence of bruising (new or old); temperature (using the dorsal aspect of your hand); texture (needs to be felt); mobility or turgor (edema or intracellular fluid, dehydration); lesions or bruising; nails (lesions and the texture); hair
distal obstruction
more pronounced distention bc a greater length of intestinal is proximal to the obstruction; vomiting may not occur or may occur later and contain fecal material
endocardium
most inner layer of the heart wall; make up the chambers and valves
breast assessment documentation
most note location of mass using clock face, quadrants, and distance in cm from nipple; size done in cm; address shape (round, regular, or irregular); address consistency (soft, firm, hard, fluctuant); address if mass is well circumscribed (defined borders) or hard to define; is it tender or nontender
physical examination of the frontal sinus
most push on the right spot; palpate by feeling for up and underneath the brow bones for tenderness
physical examination of the maxillary sinus
most push on the right spot; palpate by pushing up and underneath cheek bones; checking for tenderness
acute care neruo assessment (glascow coma scale) components
most sensitive indicator for lapse of neuro function and earliest in acute ICP changes; assessment of: LOC (verbal response assessed for orientation, confusion, inappropriateness, incomprehensibility, or none), motor function (motor response), pupillary response (eye opening assessed for spontaneously, to speech, to pain, or to none), and vital signs; maximum score: 15; a score of 3-8 indicates coma
cerebellum
motor coordination of voluntary movements like piano playing; called the "little brain"; below conscious level
cerebellum lob functions
motor coordination; equilibrium; balance
Broca's area function
motor speech
hyperextension of shoulder
move arm behind
flexion of shoulder
move arm forward, up over head
PE percussion of posterior chest
moves chest wall and tissues to produce audible sounds and palpable vibrations; demonstrates quality of air space below chest wall (air/fluid/solid); most be done in a patter: start at apices, compare side to side, and lateral fields; use middle finger; less density = more air; make sure to do so between intercostal spaces, don't want to do it on the bone
palpation technique used to assess the thyroid
mportant in terms of collecting objective data during the physical examination of the neck; done while the patient is swallowing; feeling for the isthmus, right, and left nodes; feeling for nodules, enlargement, and tenderness; done by using the left hand to slightly deviate the trachea towards the opposite side and the right hand palpates and feels while the patient swallows; done vice-versa for the opposite side; if it isn't smooth, the patient needs to get it checked out
topics to consider when taking MSK history
muscle pain, spasms, cramps; joint pain: at rest, with use- one or many; bone pain (articular (joint) vs. main body of bone); sports, hobbies, job; stiffness; weakness; swelling; if injured: get details of how it occurred, what is it that they can't do because of that injury (want to know every single detail about it); daily dietary intake of calcium and vitamin D; routine exercise/immobility; meds taken (NSAIDS, tylenol, aspirin, muscle relaxants); treatments tried: head, RICE (rest-ice-compression-elevation); ADLs (combing hair, dressing, washing, walking, occupation); PMHx: fractures, bone infections, surgeries, trauma (sprain-ligaments, strain - muscles/tendons), arthritis, gout, backache, scoliosis, fibromyalgia; FHx: autoimmune muscular disorders
myalgias
muscle pains
spasticity or hypertonic muscle tone
muscle that is always contracted; seen in a lot of muscle disorders
fasciculation
muscle twitching most likely due to the muscle being tired; will go away with rest
myocardium
muscular wall; does the pumping; middle layer of the heart wall
for each pregnancy a woman
must be screened for chlamydia, gonorrhea, syphilis, hepatitis B, and HIV
auscultation for vascular bruits in the abdomen
must use bell; listen for aorta, renal arteries, iliac, and femoral arteries; an abnormal finding
identifying data and reliability components
name, address and phone number; age and birth date; sex; marital status; race; ethnic origin; occupation --usual and present; source of information (reliability); cut and dry info
poster lung apices
near C7/T1
proximal
nearest the trunk or from the point of origin
The patient with cognitive disabilities
need to depend on family members or caregivers for patient history; assess sexual history
sexuality in the nurse-patient relationship
need to recognize and bring it to the cognitive level; if patient advances, calmly and clearly state the professional job
palpation of MSK physical examination
needs to be done first without ROM; looking for sings of inflammation: edema (swelling in soft tissue or fluid in joint space), erythema, warmth, and tenderness; looking for nodules (lumps and bumps); when feeling muscles and biceps you shouldn't be feeling lumps and bumps; after done first without ROM, needs to be done again with ROM to look for: crepitus (grating or "cat purr" with motion) and subluxation
comprehensive or admission assessment
new patient to the unit/facility; establishes a baseline subjective: complete health history, general survey, well-being, social/cultural; objective: VS, Ht, Wt, detailed physical exam; head-to-toe system examination; must address all systems and regulatory assessment tools (braden, GCS, etc
key symptoms of TB
night sweats, bloody sputum (hemoptysis), weight loss; a good question to ask patient is if they've recently traveled outside the US; important to assess last TB screen/x-ray and results
abnormal findings when assessing the breast and lymphatic system
nipple changes (discharge other than milk in lactating women, direction it points, lesions); skin characteristics (any lesions; any puckering or edema of the skin; masses felt; edema, erythema, scars) density changes; mobile vs fixed area; engorgement or fullness of glandular tissue
stage 1 of female tanner scale
no breast development // no pubic hair
0 muscle strength
no movement; flaccid; not tone
negative Homan's test
no pain
DTR with a rating of 0
no response; can be normal; should be wondering why though
worrisome assessment findings during a breast exam
nodules (painless); nipple changes; lymph changes
osmotic diarrhea
non-abosorable substances draw water into the lumen; excessive motility decreases transit time, mucosal surface contact and opportunities for fluid absorption; abundance of substances in the GI tract that aren't getting broken down and not absorbing, as a consequence they are pulling water into the lumen of the GI tract which is ultimately the cause; examples include lactase and celiac to those who are intolerant; causes: Mg, sulfates, and phosphates; lactase deficiency; celiac disease; short bowel syndrome
fatigue opposed to lethargy
nonspecific symptom with many causes; refers to sense of weariness or loss of energy, can be normal response to hard work; expressed by someone saying "I'm so tired that I can crawl under this table and sleep"
cremasteric reflex
normal reflex in which the scrotum retracts; causing the right side of the scrotum to retract pull more midline towards the middle of the body is elicited by stroking the right inner thigh and vice versa; scrotum will move up and away from sensation to protect reproductive system components
resonance
normal sound our lungs should make when percussed; indicates the presence of mainly air and little lung tissue in healthy lung or bronchitis
nutrition for adulthood
not as much dairy needed, intake of fat and cholesterol needs to be limited
lethargic LOC
not fully alert, answers questions, goes back to sleep when not stimulated; not just laying on the couch, feeling lazy, thats malaise; seen in a lot of people that take pain medicines; physically cant get out of bed, muscles won't do what you want them to do
Jugular venous distension (JVD)
not measured with a ruler, documented as present or not; measurement of right sided heart activity (volume and pressure and cardiac function); normal: can be seen with supine position because gravity is now working against it and might notice a little bit of definition as patient is laid back but goes away as head goes up, stop at 30-45 degree angle and look for pulsations and fullness; abnormal: will start to get bigger and wider as patient is laid back, can see it extending from the neck; can be bilateral or unilateral
pain fibers in the lung and thorax
not present in lung tissue itself, but is present in the pleural and surrounding tissue
coma LOC
not responsive even to pain stimuli
scaphoid contour
not so normal; indicates malnutrition
important topics to address when inspecting and palpating the mouth and throat
note any slurred speech; assess lips, buccal mucosa, gums, teeth, palate, salivary duct; stick tongue out, grab with gauze, move side to side, test strength; assess dorsum, sides and ventral surface of tongue
important topics of objective data when assessing the ear
note that the external portion collects sound and supports inner structures; inspect pinna; palpate pinna (move/pull and assess for canal tenderness); note that the external auditory canal is S-shaped and about 2.5 cm long in adults; palpate mastoid process and tragus; inspect TM
to calculate pack years
number of packs of cigarettes daily x number of year of smoking
objective data
nurse observed data, lab results, and physical examination; when collecting this type of data always consider cultural influences
roles of nurses
nurses assess the needs of a patient by focusing on the patient's health; include sympathizer, manager, supporter, etc.
two screening tools to identify individuals at risk for nutrition deficits
nutrition screening checklist and rapid screen for dietary intake
deep palpation of the abdomen during a physical exam
one using 2 hands over all 4 quadrants; assessing the spleen (avoid if enlarged or if concern for injury); assessing the kidneys using the sandwich technique (shouldn't be able to feel the left one, the right one is 1-2 cm lower and can only feel lower pole); asses the liver using the hook technique
visceral reflexes
ones that are deep within; tested by the pupillary response to light
inspection and palpation of lymphatic assessment
only physical examination techniques that need to be done; assess superficial nodes (can't feel the deep ones) starting at head and working down the body; lymph nodes should be small mobile nodules with smooth borders
PPD
only used if they've never been exposed to TB
7 attributes of a symptom
onset, location, duration, characteristic symptoms, associated manifestations, relieving/exacerbating factors, and treatment
SL valves
open during systole to allow blood to be ejected and close during diastole
things to assess for smoking patients
pack years; cough (at night? only while laying down? productive? sputum- quality, color, consistency, amount); change in voice; wheeze; shortness of breath (all the time?); chest pain (where, how long?)
Faces Scale
pain assessment tool; good for kids; the right way to use it is by having the patient look at the faces and ask them which one they feel like; the wrong way to use is looking at the chart yourself and not letting the patient see it
FLACC
pain assessment tool; how we turn subjective information into objective; scoring from 0-2; Face, legs, activity, cry, consolability; used a lot in pediatrics and new borns; higher the number, greater the pain; can be used in patients that aren't able to verbalize
positive Homan's sign
pain present; suggests DVT (35% accurate only); false positives with tendonitis, muscle injury, and lumbosacral disease
important subjective data topics when assessing the ears
pain; hearing loss (use of assistive devices; is it on and in place?); discharge, blood (otorrhea); tinnitus (ringing in ears); vertigo (intense spinning can cause the eyes to start bouncing back and forth); trauma, noise overexposure (want to know about use of ear buds and chronic ear plug users when they sleep), medications; URI symptoms (nasal congestion, fever, sore throat, jaw/tooth pain); history of infections, surgery (tubes); family history (presbycusis)
physical examination of ankles
palpate all joint articulations and muscles; ROM: dorsiflexion (20 degrees); plantar flexion (45 degrees); inversion (30 degrees); eversion (20 degrees); test strength by push/pull flex/extend
physical examination of wrists
palpate all joint articulations and muscles; flex (hand forward) 90 degrees; extend (hand backward) 70 degrees; adduction/abduction (rotate wrist, fingers together toward radius and ulna); supination (palm up or "serve soup"); pronation (palm down) 90 degrees each from mid point of 0 with side of hand on table; test strength by push/pull flex/extend
physical examination of the hands
palpate all joint articulations and muscles; flexion (90 degrees) and extension (30 degrees) of all IP joints; abduction and adduction of fingers; strength tests: grip strength, push/pull with add/abduction
physical examination of elbow
palpate all joint articulations and muscles; flexion (bend elbow) and extensions (straiten elbow) 160 degrees to 0; test strength by push/pull against flex/extend
physical examination of shoulder motions
palpate all joint articulations and muscles; flexion (move arm forward, up over head; extensions (arm back to side); hyperextension (move arm behind); internal rotation (hand down toward floor)/ external rotation (hand up toward ceiling; abduction (move arm away (flap wing motion))/ adduction (cross over midline); test strength by push/pull in adduction and shrug against resistance
physical examination of feet and toes
palpate all joint articulations and muscles; inspect MTP (metatarsophalangeal): great toe: need to "push" for ambulation, inspect bunions, and corns at pressure points; ROM: flexion and extension, abduction and adduction
physical examination of knee joint
palpate all joint articulations and muscles; test ROM (normal motion is only extension ( 0 degrees, just standing there)/ flexion(130 degrees); test strength by push/pull on extension and flexion
additional maneuver available for the physical exam of an abdominal assessment
palpate in other positions besides supine; palpate inguinal area for hernia; can localize most painful area by having patient breathe in deep and contract abdomen (coughing motion) and let patient point to most tender spot; assessing whether patient is ticklish or not
physical examination of the cervical spine
palpate spinous processes and muscles; flexion (chin to chest)/ extension (head up)/ hypertension (chin to ceiling); lateral bending or abduction and adduction (put ear to shoulder on each side); rotation (turn head); test strength by turning head against resistance
salivary glands of the HNNT
parotid, sublingual, and submandibular
level of consciousness (LOC)
part of assessing general appearance during the general survey part of the PE; aspects include awake, alert, responsive; orientation to person, place, and time (A&O x 3); awareness of your existence and the environment; include: alert, lethargic, obtunded, stupor, and coma
diopter or instrument's lens
part of ophthalmoscope used to focus on internal structures
making the patient feel comfortable
part of setting the stage for the PE; show concern for privacy and modesty; provide proper draping; visualize one area of the body at a time; tell the patient what you will be doing; be sensitive to patients nonverbal cues; tell the patient your general impression
weight changes
part of subjective patient history data for abdominal assessment; could be eating or not eating; still have to think about anything rapid associated with accumulation of fluid (like in abdominal ascites)
elimination
part of subjective patient history data for abdominal assessment; important topics: urinary and fecal, color (can answer what the problem is; can be altered by different foods), odor, different or not smell?
food allergies
part of subjective patient history data for abdominal assessment; presents with hives, systemic reactions, anyone that uses an epipen
medications
part of subjective patient history data for abdominal assessment; topics of importance include: use of NSAIDS (peptic ulcers developed if taken w/o food), antiemetics, antibiotics, iron tablets (associated with constipation, stool turns very dark, almost black), anticoagulants, antidiarrheals, laxatives, antacids (peptobismal can cause a black tongue, need to know why they are taking it), and intolerances
nausea and or vomiting
part of subjective patient history data for abdominal assessment; topics of importance: frequency and amount (ask how many times? are you able to keep anything down? someone that can keep some water and crackers down is someone that can stay hydrated enough to avoid the ER; what time of day?), color (undigested food looks like vomit; is there blood in it? is it bright round or look like coffee grounds?) and odor (blood in vomit (hematemesis)), relationship to foods, and pregnancy
environmental influences
part of the 7 facets; favorable conditions to promote health; safe space, safe food and water, personal satisfaction of career, build work relationships
cultural influences
part of the 7 facets; favorable connections/conditions to promote health;
developmental level
part of the 7 facets; how one thinks, solve problems, and make decisions; life-long learning, life experiences
physical health
part of the 7 facets; how the body works and adapts; includes eating right and exercise
spiritual influence
part of the 7 facets; living peacefully, morally, and ethically; living with values; connection with religion, but doesn't have to be religious; what directs you with your morals and how you are ethically; early teachings and how you see the world
emotional health
part of the 7 facets; positive outlook and emotions channeled in a healthy manner; express feelings in a nondestructive manner; being able to have a person to be able to talk to and let it all out
social well being
part of the 7 facets; supportive relationships with family and friends; builds sense of community
convergence
part of the inspection portion of the PE of the eye; assessing whether they come in and move smoothly and symmetrically when moving an object towards the center of the face
papillary fissures
part of the inspection portion of the PE of the eye; how wide the eye is open in regards to the eye lids
accommodation
part of the inspection portion of the PE of the eye; pupillary constriction when focusing on a near object after looking far away
lacrimal apparatus
part of the inspection portion of the PE of the eye; the tear ducts
pupillary light reflex
part of the inspection portion of the PE of the eye; when light is put on the eye; pupils should constrict; want to see that it is doing something; that means the thing that is working in the brain is actually working; testing consensually is when you cover one eye, shine a light on one pupil and the other pupil constricts at the same time
negotiate a plan with the patient
part of the working phase of the interview process; that works for the nursing/medical side and the patient; develop a nursing plan; needs to think of any further future evaluations needed; need to look at entire picture of the problem
testing for clonus
passive movements in which the pt's foot will be put in plantar/dorsi-flexion back and fourth, after a few times, is left dorsi-flexed and when let go, will continue to tap (abnormal result)
hyperextension
past anatomical stance
5 components needed to elicit a DTR response
patient must have: intact sensory nerve (afferent), a functional synapse in the cord, an intact motor nerve fiber (efferent), the neuromuscular joint, and a competent muscle; if unable to get a response, have to think which part has a dysfunction
the patient with personal problems
patients that ask you for advice that is out of your clinical expertise; in these situations you need to know where to step but make sure you have clear boundaries for what it is that you are discussing; if you think this isn't outside your boundaries, ask them what they have tried to address the problem and let the patient talk through their problems
topics of inspection for the lungs/thorax
pattern of respirations; symmetry of respirations; shape of chest (slope of ribs; deformities-AP diameter-barrel chest)
topics of health history questions in regards to nutrition
patterns: eating, exercise, and activity; weight: usual, changes; appetite, fast, smell, chewing, swallowing; recent surgery, trauma, burns, infection; chronic illnesses; vomiting, diarrhea, constipation; food allergies or intolerances; medications and or nutritional supplements; self-care behaviors; alcohol or illegal drug use; family history (is there any heart disease, osteoporosis, diabetes, obesity, or GI disorders in the family?)
screening for chlamydia and gonorrhea for women
recommended annually for women under the age 24, and women above 24 with any certain risk factors and pregnant women; evidence is not clear so the TSE have not recommended routine tests
equipment needed for this physical examination of the eyes and ears
penlight or light source; ophthalmoscope; otoscope and ear pieces; snellen chart; 3x5 card; tuning fork
equipment needed to perform the breast and lymphatic system assessment
penlight or light source; small pillow; ruler marked in centimeters; disposable gloves (only for axillary exam); BSE instructional material
equipment needed for the physical examination of the mouth and throat
penlight or light source; tongue blade (to see back to the tonsils); disposable gloves; 4x4 inch nonsterile gauze
musculoskeletal physical examination
percussion and auscultation are not needed for this system; includes: inspect, palpate, ROM, and strength; always compare side to side for symmetry, failing to do so will cause you to miss if one side has weakness or not ; inspection and palpation of the muscles and all the joints; testing strength always comes after ROM
less dense lung tissue
percussion is characterized by more air, less compact tissue, longer sound, and louder sounds;
actions in order to start a complete health assessment of a patient
perform a general survey (physical appearance and signs of distress, body structure, mobility, behavior, speech); complete a health history; obtain measurements and VS
active assistive exercise
performed by the patient with assistance from the nurse; encourages normal muscle function while the nurse supports the distal joint
active exercise
performed by the patient, without assistance, to increase muscle strength
active ROM while palpating
performed by the patient; used for general screening, healthy adults, and to assess joint function
Cheyne-stokes respiration
periodic breathing: gradual hyperpnoea/hypopnoea and apnoea; rapid breathing followed by apnea; sleep/hypoxemia/drugs; hypo perfusion of the brain (respiratory center)
orientation components of a neuro physical exam
person (sever impairment if gone; always the last to go); place; time; 4th-familiar person or situation
personal bias
personal belief based on culture, beliefs, and experiences; in everything we do we must check it at the door; job is to take care of humans regardless of their store; cannot check this at the door if we don't understand it; recognize what you have issues with, do what you need to do to cope with and then check it at the door
frontal lob functions
personality; behavior; emotion; intellectual functions
ways to make talking about the male reproductive system with the pt more comfortable
phrasing it in a way that you emphasize that it is just as important as the cardiac and respiratory system; "these are question I need to ask you to keep you as healthy as possible"; practice and finding the best ways
lethargy
physically can't get up r/t exhaustion
femoral arterial pulse
right where underwear line is; must be found before auscultating (listening for turbulent blood flow (bruits), like in the carotid); listen for low-pitched sounds using the bell; feel for symmetry
auscultating for vascular bruits in the renal arteries
place bell at two points that are lateral and inferior to the point of auscultation of the abdominal aorta
auscultating for vascular bruits in the abdominal aorta
place bell between the xiphoid process and umbilicus
auscultating for vascular bruits in the femoral arteries
place bell on two points shown on graph
respiratory excursion
place hands on each side, near 10th rib; have patient take deep breath; note the distance between thumbs with expiration; want to see thumbs go out symmetrically; if one side doesn't move, may indicate collapsed lung
lung and thorax vaccinations
pneumovax (one dose after 65); flu shot or FluMist annual (bringing it back this fall); DTaP/Tdap (every 5-10 years, given to pregnant women in the last 4 weeks of pregnancy)
auscultating for vascular bruits in the iliac arteries
point where abdominal aorta bifurcates; place bell at bi-lateral/inferior points to the umbilicus
important factors when taking blood pressure measurement in the arm
position of person (sitting up right, feet flat on the floor, legs aren't crossed, arm at heart level); palpate brachia, radial arteries; proper inflation and deflation technique; korotkoff's sounds
factors that increase the likelihood of malnutrition
poverty, old age, social isolation, physical disability, emotional or mental impairment, lack of teeth, ill-fitting dentures, alcoholism, and drug abuse
phases of the interview
pre-interview; introduction; working; termination
lymph nodes of the HNNT
preauricular (in front of the tragus), posterior auricular (behind the ears), occipital (base of the skull), submental (under the anterior portion of the chin), submandibular (under the base of the jaw), jugulodigastric (right behind base of jaw, underneath ear lobe), superficial cervical, deep cervical chain (along neck), posterior cervical, supraclavicular
testicular cancer
predominately occurs in males age 15-35; average age of diagnosis is 34 yo; affects 5 in 100,00 men; have specific risk factors; no early symptoms; signs: unilateral, hard, painless mass; has a high cure rate if identified early, more likely if men know their normal anatomy and report changes
two important developmental stages other than the tanner stages that occur throughout a females lifetime that change the structure and function of the reproductive system
pregnancy and the aging adult
stage 1 of male Tanner stages
prepubertal; no pubic hair yet; no secondary sexual characteristic; seen in infants and young children before puberty
breath sounds are louder (abnormal) when
presence of expiratory wheezes (asthma), consolidation, and compression
main topics of health promotion for the male reproductive system assessment
prevention of HIV/STI's (encouraging HPV vaccination); testicular cancer screening guidelines (USPSTF and ACA have no recommended routine TSE for screening, however, clinicians may teach TSE and should always discuss abnormal findings that need evaluation as part of health and body awareness); prostate cancer screening guidelines (USPSTF and AUA recommend against routine screening using PSA. individualized patient approach/shared decision making based on pt's age and risk factors); important to discuss certain risk factors; but no universal screening guidelines
main topics of health promotion during the female reproductive assessment
prevention of HIV/STI's; HPV testing; encouraging HPV vaccination from late childhood-young adult;
order of descending branches into the lungs from the trachea
primary bronchus, secondary bronchus, tertiary bronchus, bronchiole, terminal bronchiole, alveoli
precentral gyrus functions
primary motor area
postcnetral gyrus functions
primary sensory area
three levels of preventive care
primary, secondary, and tertiary prevention
ethics
principles that are crafted through the reflection of the discussion to define what is right and what is wrong
lacrimal secretions
produced in the lacrimal glands superior and lateral to the eye; drain into the superior lacrimal punctum; which drains in the lacrimal sac, through the nasolacrimal duct, and into the inferior meatus and turbinate
functions of the skin
protection; temperature regulation; vitamin D metabolism; sensation; excretion
kwashiorkor
protein malnutrition; a form of severe protein-energy malnutrition characterized by edema, irritability, ulcerating dermatoses, and an enlarged liver with fatty infiltrates. Sufficient calorie intake, but with insufficient protein consumption, distinguishes it from marasmus.
marasmus
protein-calorie malnutrition; a form of severe malnutrition characterized by protein deficiency. It can occur in anyone with severe malnutrition but usually occurs in children. A child with this malnutrition looks emaciated. Body weight is reduced to less than 62.36% of the normal (expected) body weight for the age.
how to assess patellar DTR during a neuro physical exam
pt sits on edge of table, legs relaxed and hanging down, freely swinging; strike the tendon just below the knee and above the tibial tuberosity; response: quadriceps contract and knee extends
palpating the mouth
pull out the tongue, grab with gauze, move side to side, and test strength; assessing for geographic tongue (not smooth, looks like it has a map on it); feel for abnormalities and symmetry; if you wet the gauze, it's less uncomfortable for the patient
important things to address when assessing CNS injury
pupil size and symmetry (CN III- pressure on brainstem from herniation will cause sudden pupillary dilation and nonreactive pupil (VERY bad); abnormal posturing (decorticate or decerebrate)
ecchymosis
purple or purplish blue, fading to green, yellow and brown with time. variable size; larger than petechiae, > 3 mm; blood outside the vessels, often secondary to bruising or trauma; also seen in bleeding disorders
important topics to address when assessing objective data for hair
quality, quantity, distribution, and texture; can tell us about someone nutritional status, hygiene, people that pull it; can tell you a lot of good information
normal bowel habits
range from 2-3 times a day to 1 x a week
abduction of wrists
rotation of wrists and fingers together towards radius
other things to consider when assessing skin history (subjective)
recreational hazards (sun, camping, yard work, new activities); environmental hazards (tetanus vaccine up to date?); occupational hazards (contact, aerosol); exposure to illnesses; medical problem associated skin symptoms (Rosca= butterfly mask); recent acute illness (allergies, hives, flu-like sx) or chronic skin dx (thyroid, psoriasis, eczema), medications (Rx and OTC)
functions of lymphatic system
recycle and conserve fluids and plasma proteins (leakage into interstitial spaces); part of immune system pathway: lymph nodes (climbs of lymphatic tissue that filter out pathogens and produce antigenic response); absorb lipids from the intestinal tract; major role in fluid homeostasis
first degree burn
red, painful, blanches with pressure, no blistering (epidermal layer only); example: sun burn
rhinorrhea
refers to drainage from the nose
retroperitoneal
refers to the space near the posterior abdominal wall and the peritoneum
tactile fremitus
refers to the vibrations that are transmitted through lung tissues and the chest wall when a low-pitched vocal sound is made; place ball of hand (MCP) or ulnar surface over chest while patient says "99"; assess for pattern and symmetry; is normally found over the mainstem bronchi near the clavicles in the front or between the scapulae in the back. As you move your hands downward and outward, fremitus should decrease.
setting the stage for the PE
reflect on your approach to the patient; be straightforward; have a professional demeanor (call body parts proper names, promoting dignity to patients); make the patient feel comfortable; spend extra time as needed; explain to the patient what is happening; educate, but don't diagnose; use good lighting; bed side manner matters; do not use terms of endearment
GERD
reflux happening all the time; suggesting something is broken; lower esophageal sphincter is weak/incompetent; refluxate leads to esophageal mucosa injury; treated with antacids, H2-receptors antagonists, PPIs; can lead to Barrett esophagus and adenocarcinoma; having really acidic environment touch esophageal mucosa (typically lined with flattened epithelial tissue) becomes columnar (metaplasia)
tertiary prevention examples
rehab programs, provision of hospital and community facilities, promotion of employing rehabilitated individuals in the workplace, sheltered communities, prevention of skin breakdown in immobile patients
symptoms of prostate cancer
related to the prostate enlarging and pushing on urethra; incomplete emptying of bladder; urinary frequency, urgency, dribbling; change in stream; hematuria, nocturia; pelvic bony pain; health promotion for this includes screening
thalamus
relay station; sensory fibers forms synapses here on their way to the cerebral cortex
chronic pancreatitis
repeated exacerbation of acute pancreatitis can lead to chronic changes; destroys acing cells and the islets of langerhans; pancreatic parenchyma is destroyed and replaced by fibrous tissues, strictures, calcification, ductal obstruction, and pancreatic cysts; chronic alcohol abuse is the most common cause; is a risk factor for pancreatic cancer
acute pancreatitis
resolves spontaneously; systemic effects are associated with severe acute types of this disease; clinical manifestations: epigastric or mid abdominal pain, nausea, vomiting, fever, and leukocytosis
percussion over ICS on the anterior chest
resonance is expected
percussion over anterior apices/above clavicles
resonance is expected
the anterior lower lungs
rest on diaphragm at about the 6th rib, MCL
diastolic pressure
resting pressure that blood exerts constantly between each heart contraction
secondary constipation
result of neurologic disorders, drugs, and metabolic disorders
functional intestinal obstruction
results from neurogenic or muscular impairment of peristalsis; example is an ileus
healthy people 2020 goals and objectives are based on:
results of healthy people 2020; current data; new developments; emerging challenges in the united states
assessment topics of past medical history for cardiac
rheumatic fever; prior MI; angina; hypertension; diabetes; high cholesterol; murmurs; CAD; arrhythmia; drug abuse
A magenta tounge would be a sign of:
riboflavin deficiency
side of the lungs which has 3 lobes instead of 2
right
umbo
right in the middle of the pearly grey tympanic membrane
different types of visceral pain
right upper quadrant or epigastric pain; epigastric pain; periumbilical pain; hypogastric pain; suprapubic or sacral pain
CAGE
screening tool that uses 4 important questions to asses alcohol use; have you ever felt the need to cut down on drinking?; have you ever felt annoyed by criticism of your drinking?; have you ever felt guild about drinking?; have you ever taken a drink first thing in the morning (eye-opener/hair of the dog) to stead your nerves or get rid of a hangover?;
secondary prevention examples
screening, early treatment of diseases, and self-examination
important things to palpate when assessing the male reproductive system
scrotum (for any masses, if so transilluminate it); testes (should feel spongy) and testicular size (for lumps, firmness or tenderness (orchitis), and epididymis, spermatic cord abnormalities that can cause male factor infertility; glans and penile shaft (looking for lesions, masses, hard areas); the penis (between your thumb and first two fingers, normally smooth, semi firm, and nontender; inguinal area (standing or seated); cremasteric reflex; hypospadius/epispadius
physical examination
second part of a health assessment; when a nurse starts putting actual hands on the patient and starts to collect data
introduction
second phase of the interview process; establish credibility by introducing yourself and setting the agenda; first impression (depends on how you sit, how you enter the room, how you look and dress; how you greet your patient (always use formal name until asked to do otherwise); need to address other visitors other then the patient is they are in the room; before discussing anything, need to ask if it's okay to disclose information in front of visitor
inspecting use of accessory muscles
seen by tripoding and bulging or retraction of interspaces
efferent peripheral nerves
send motor messages from the CNS out to the muscle, organs, and glands
afferent peripheral nerves
send sensory messages to the CNS from sensory receptors
parietal lobe functions
sensation; damage to this region would hinder a patient's ability to fell pain if their hand was left on a stove top
alcohol and illicit drugs
sensitive topic; misuse of these can contribute to symptoms; avoid letting personal feelings interfere with your role; should routinely ask about current and past use of these, patterns of use, and family history (huge for this topic; specific genes known for that potential)
graphesthesia
sensory function test to assess cognitive interpretation during a neuro physical exam; done by "writing" a number in the palm of the patient and asking the to identify it; remember if you are standing infront of the patient, you must write the number backwards and do NOT use your finger (finger is blunted and can give you false positive, pick something that is pointy); if patient unable to do ID item, this may indicate a sensory cortex lesion
stereognosis
sensory function test to assess cognitive interpretation during a neuro physical exam; while patient's eyes are closed, place a familiar item in their hand, and ask them to identify the item; if unable to, this may indicated a sensory cortex lesion
techniques of examination
sequence and positioning; and cardinal techniques
HPI key elements
seven attributes of each principle symptom (OLD CART); self-treatment by patient or family; past occurrences of the symptom; pertinent positives and or negatives from the review of systems; risk factors or other pertinent information related to the symptom
important topics to address when gathering objective data of the female reproductive system
sexual maturity using the tanner scale; skin (important to know normal color, lesions, masses, discharge); labia and clitoris (scarring); perineum; anus (lesions, blood, hemorrhoids); external palpation (inguinal lymph glands, urethral opening (Skene's glands), vaginal opening (Bartholin's glands), perineum-muscle tone); need to have a good grasp of what is normal and how to describe it
characteristics of nociceptive or idiopathic pain
sharp, twisting, squeezing; dull, boring, annoying; cutting, searing, burning; heavy, pressing, pounding; ache, throbbing, tender, cramping; radiating, spreading
The silent patient
short one word answers; no eye contact; distant; quiet; ways to tack the interview: need to remember silence has a lot of meaning and purposes; sometimes silent because we want to listen and don't want to talk. maybe trying to remember details, maybe deciding if they trust you. not always necessary to disrupt silence; watch for verbal ques; watching for nonverbal ques like anger, unhappiness, uncomfortable with speaking wit you; remember to keep culture in mind; could possible be a sing of depression or dementia; practice taking deep breaths and trying to fill the void
acute pain
short term; self-limiting and predictable r/t injury or illness; dissipate after injury heals
palpating peripheral pulses
should always be down symmetrically; note amplitude or force: +3 for bounding, +2 for a normal brisk one, and +1 for weak or thready (easily obliterated); if you document a 0, you better be doing something about it, you CANNOT document 0 and keep moving on with your day, it means there is no blood flow going to the extremity, think blood clot, not good, and RUN; note rate (normal is 60-100 in adults); note rhythm (regular is normal, if irregular, assess for at least one minute); not; assessing skin temp: equal and warm to toes bilaterally; assess capillary refill (normal = < 2 seconds)
cone of light
should be able to see on every healthy tympanic membrane; nothing pushing or pulling from the back side; seen as a light shining back at you at 4 o'clock when using an otoscope
equipment
should be checked in preparation for the PE; include: satdiometer, scale, opthalmoscope, otoscope, snellen chart, near vision chart, penlight, tongue depressors, ruler and flexible tape measure, thermometer, examination gloves; 2 x 2 gauze pads, watch with second hand, sphygomomanometer, sethoscope; reflex hammer; tuning forks; Q-tips; cotton; paper and pen or computer
tail of spence
should be focused on when performing palpation methods during a breast assessment; where a lot of cancers will show up; follows the curvature up towards the axially
normal male urethral opening
should be midlined at the end of the glands (right in the middle)
if PAP smear results are normal
should be repeated every 3 years until 65; if older than 30 can possibly spread repeated tests to every 5 years instead with HPV testing for women 30-65)
pain with urination, in the back, and have a fever
should be thinking along the lines of a kidney infection
peripheral pulses
should match the apical pulse
cyanosis
signals hypoxia
concerning signs that may indicate breast cancer
signs of retraction; abnormal contours; skin dimpling; nipple retraction/deviation; edema of the skin; paget disease of the nipple
important topics of subjective data when assessing the nose
sinus pain, facial pain, teeth pain; Hx sinusitis, sinus surgeries; nasal stuffiness, discharge, bleeding, postnasal drip; history of previous nose issues/surgery; seasonal allergies; snoring (excessive); changes in ability to smell; assessing for deviated septum (narrowing of one of the passage ways), polyps (any protrusion that shouldn't be there; fleshy growth that may or may not be malignant), broken nose (presence of epistaxis, indications if it is new or old)
kidneys
sit up high because they are trying to get under rib cage for protection
stage 5 of female tanner scale
size may vary in the mature stage; the breast is fully developed; the contours are distinct and the areola has receded into the general contour of the breast // the hair is adult in type, distributed as an inverse triangle; there may be hair on the inside of the thighs
important things to assess when inspecting for presence/absence of foreskin for the male reproductive assessment
skin integrity, color, lesions, masses or bulges; whether it covers the head if uncircumcised
arterial problem findings
skin is cool and pale; very little oxygenated blood; ulcers
venous problem findings
skin is warm and red; lots of oxygenated blood present
third degree burn
skin white or charred, not painful (full thickness; deeper skin elements destroyed into muscle and bone)
systems to be assessed during the PE
skin, HEENT (head, eyes, ears, nose, throat); neck; cardiac; respiratory; abdomen; peripheral vascular; lymphatics; MSK; neuro; GU/breast
equipment to obtain objective data for a nutritional physical exam
skinfold calipers, measurement tape, pen/pencil, nutrition assessment form;
what components contribute to health
sleep, diet and water intake, emotional well being, stress coping mechanisms, exercise, healthy relationships; everyone differs on how they define it; we must understand a patients idea of this topic to assess their needs
obtunded LOC
sleeps most times, difficult to wake (loud noice, vigorous shaking or pain needed), slow to respond and generally confused; may respond in ways that don't make sense to the question asked
+1 muscle strength
slight contraction noted
post-breast augmentation or reconstruction breast assessment
special consideration; palpate breast tissue on top and around edges of implant; palpate along incision lines; palpate axilla carefully; mammography is still indicated
topics to assess lung and thorax history
smoking; cough, change in voice; wheeze; shortness of breath; chest pain; hemoptysis, night sweats, weight loss, last TB screen/x-ray and results; travel outside US; paroxysmal nocturnal dyspnea (PND); current medication use; vaccinations; environmental factors (pets, allergens); exposure history (inhalants, carcinogens); Past respiratory history; child history; family history
important topics to consider when obtain history for peripheral vascular assessment
smoking; leg pain/cramps (burning, aching, cramping, stabbing); skin color changes (red, violet, blue, pale, brown); skin temp changes; skin ulcerations; swelling in extremities; obesity; males: changes in sexual functioning; prolonged stasis: pregnancy, bed rest; trauma; medications (contraceptives (estrogen, BCPs, increase the risk of forming blood clots), anticoagulants, aspirin)
normal palpation findings of the thyroid during the physical examination of the neck
smooth; no lumps and bumps; have patient swallow to allow it to rise and fall along finger tips; shouldn't be tender
7 facets of health
social well-being; physical health; emotional health; environmental influences; cultural influences; spiritual influences; developmental level; all of these pieces come together, we need to make sure all of these aspects are intact
vesicular
soft, breezy, normal, low-pitched vascular breath sounds over most of the peripheral lung fields
symptoms of breast cancer
solid/hard; non-tender, usually; irregular, ill-defined borders; fixed (may be mobile in early stages); lymphadenopathy; 85% >40 yrs; 66% > 50 years; 21% of patients that have this that are 30-54 yo are identified with the classic risk factors
nociceptive pain
somatic pain; tissue damage (thermal, mechanical, chemical); types include: visceral, deep somatic, and cutaneous; responsive to inflammatory mediators; examples include: GSW, sprains, and arthritis
drugs
some people interrupt questions about these as medications; need to ask something like: "are there any street drugs that your on?"
symptoms
something the patient is going to tell you; subjective data; examples include dizziness, headache, and nausea.
the talkative patient
sometimes a patient feels so comfortable with you to tell you everything about their life; a lot of times, nurses don't have 20 min to spare for an interview and don't want to be rude so you can give the patient free reign for 5-10 minutes and in the mean time focus on whats important to patient; interrupt and ask if this is why they came in; set limits where needed; take step back to remember role in patients life, professional boundaries are needed; could say something like "oh thats really sweet you want to know about my life but I want to know more about yours"; if time runs out, explain that you need to have a second appointment; set time limit for the next appointment: difficult at hospital setting, when coming in to a room you could say "I have about 10 minutes, is there anything I need to get you"
DTR with a rating of 1+
somewhat diminished
pleural
sound lung tissue; consists of an inner visceral layer and outer parietal layer with space in-between known as the pleural cavity
post-mastectomy breast assessment
special consideration; inspect scar and axilla carefully; not changes in skin color; palpate gently, especially over scar, upper OQ and axilla; not presence of lymph edema in the adjacent arm, lymph enlargement, inflammation, infection, or chest masses
positive Murphy's sign
special maneuver tests available for the physical exam of an abdominal assessment; indicated by sharp pain upon inspiration when examiner's hand is palpating the liver edge; indicates possible cholecystitis
positive Rovsing Sign
special maneuver tests available for the physical exam of an abdominal assessment; push on LLQ then quickly remove hand; rebound tenderness in RLQ or pain in RLQ during LLQ pressure indicates appendicitis
allen test
special maneuver to test patency of radial or ulnar arteries; done by compressing both arteries, having the patient pump fist, then releasing ulnar artery before radial artery; look for quick return of blood flow (flush of pinkish color to hand and nails); if pallor persists, occlusion possible; repeat for other artery; useful before performing arterial procedures with limited blood supply to hand
bronchophony
special test performed if abnormal breath sounds or abnormal tactile fremitus is found; patient says "99" and sounds are louder and clearer over airless tissue as seen in pleural effusions, thickening, and areas of consolidation
egophony
special test performed if abnormal breath sounds or abnormal tactile fremitus is found; patient says "ee" and when auscultated changes to "aa" over areas of consolidation
whispered pectoriloquy
special test performed if abnormal breath sounds or abnormal tactile fremitus is found; whispered words sound clearer over areas of consolidation ("99" or "1-2-3")
wernicke's area functions
speech comprehension
CN XI
spinal accessory; controls sternocleidomastoid and trapezius muscles; tested by asking the patient to shrug shoulders against resistance and turning head against resistance
extra heart sounds
splitting; S3; S4; murmurs; rubs; need to note the timing in cycle, location, duration, pitch, quality, intensity, and frequency
testing vibration during a specific sensory function tests for a neuro physical exam
start at MTP; ask patient to close their eyes, hit the tuning fork, and instruct patient to verbalize when they now longer feel the vibration; upon stoping the vibration, patient should indicate they no longer feel it within 1-2 seconds
measures to help a client relax and retain a sense of control during an internal female reproductive system assessment
start with an empty bladder; but before they do making sure to assess any symptoms of urinary issues or conditions that require a sample; position table so that pt is not exposed to an inadvertent open door; ask if she would like someone present; position by woman's head; elevate her head and shoulders to semi sitting position to maintain eye contact; place stirrups so that legs are not abducted too far (lithotomy position); offer a mirror so client can see exam; explain each step of exam; making sure that you as a nurse understands all the steps of the procedure
important topics to address when gathering subjective data of the female reproductive system
start with concerns the pt may have today; organize H&P from least invasive to most invasive; cervical cancer screening; menstrual history; obstetric history (GPA (gravida, para, abortus); past pregnancy complications) ; manopause; self-care behaviors; urinary symptoms; vaginal discharge; urinary symptoms; vaginal discharge; history; sexual activity/preferences; contraceptive use; sexually transmitted infection (STI) contact; STI risk reduction; HIV risk and reduction; trauma/abuse; PMH; surgeries; sexual assault or abuse (if present, often have protocols put in place, specially trained nurse that will work with the patient to collect all data to be utilized in a court of law); family history (endometriosis, cancers); abdominal pain or cramps; lesions; itching; vaginal self care
the confusing patient
starts with one line of symptom and ends with a bunch of unrelated ones; guide interview in psychosocial assessment; maybe alcohol and drugs need to be assessed, sleeping patterns; if its a psychiatric or neurological disorders, shift to mental status exam: "remember these 3 words" test; asking where they are; so you can determine if you are dealing with psychiatric or neurological disorder
anterior thoracic landmarks
sternal notch at the base of the throat; clavicle; costal angle margin (>90 degrees if chronic over-inflation)
equipment needed for lung and thorax physical examination
stethoscope and measuring tape
equipment needed for cardiovascular exam
stethoscope with bell and diaphragm functions; blood pressure cuff; and quiet room
important subjective data topics for general history, lifestyle, and self care in regards to the neck
stiffness, pain; presence of masses; swollen glands; swollen thyroid (goiter); surgery
Homan's test
still used; first support the patient's thigh with one hand and his foot with the other; bend his leg slightly at the nee, and then firmly and abruptly dorsiflex the ankle; the gastrocnemius pushes on blood supply and if blood clot is present, pain will be felt ( a positive sign) ; flex knee and compress the calf (gastrocnemius) against tibia or dorsiflex foot towards tibia; only valid 35% of the time bc there are other things that can cause a positive sign (tendonitis, muscle injury, and lumbosacral disease)
objective data findings from musculoskeletal that tie into neuro
strength against gravity and full resistance (5/5 normal); muscle size and symmetry (atrophy, hypertrophy); full ROM of joints; muscle tone: slight resistance with massive motion; +/- involuntary motion: tremor or flaccidity; assess hand grasp, arm, and leg strength bilaterally think: diabetic neuropathies; atrophy from polio; MS; paralysis; involuntary movements like tics and tremors; Pain in ROM, resistance; tone (polio, Guillian-Barre; cerebral palsy; spinal cord injury; tetanus; parkinsonism)
clinical manifestation of intestinal obstructions
stuff isn't moving so I start having gas and fluid build up; pain in the small bowel (colicky pains caused by intestinal distention, followed by nausea and vomiting) and in the large bowel (hypogastric pain and abdominal distention); distention; vomiting: pylorus (early, profuse vomiting of clear gastric fluid), proximal (mild distention and vomiting of bile-stained fluid), and distal (more pronounced distention because a greater length of intestine is proximal to the obstruction. vomiting may not occur or may occur later and contain fecal material)
parasympathetic nervous system
subdivision of the ANS; "Rest and digest"; Conserves body resources and maintain normal bodily functions; Increases gastric secretion, slows heart rate, RR, and normal BP
sympathetic nervous system
subdivision of the ANS; "fight of flight" stress response; increases HR, BP, RR, and pupil size
somatic nervous system functions
subdivision of the PNS; control skeletal muscles and is responsible for voluntary movement
autonomic nervous system
subdivision of the PNS; controls smooth muscle and is responsible for involuntary movement like breathing and the heart breathing; mediates unconscious activity (homeostasis, heart, glands); subdivides into two parts, sympathetic and parasympathetic
a patient is a practicing buddhist and gets along with her parents, is this subjective or objective data?
subjective
skin history
subjective info we need to know; include info like: trauma (burn, cut, sting or bit, crush), excessive or spontaneous bruising (purapura), change in mole (size or color), change in pigmentation, excessive dryness or moisture, pruritus (itching), hair changes or loss (fungus, hormonal, vascular, nutrition based), nail changes, wound healing changes, environmental or occupational hazards, tattoos and piercing, self-care (how often are they bathing)/ protective behaviors, medications, and risk or lesion; PMHx: allergies and skin diagnoses; family history: allergies and skin diagnoses (genetic components like scerlosis)
patient has pain in the left lower quadrant of her abdomen which wakes her at night, is this subjective or objective?
subjective; pain is ALWAYS subjective
important topics to consider for family history for cardiac assessment
sudden death before age 50; heart attacks; strokes; diabetes; hypertension; high cholesterol; genetic testing available
stroke
sudden neurologic deficit caused by ischemia or hemorrhage
warning signs of stroke
sudden numbness or weakness of the face, arm, or leg; sudden confusion or trouble speaking or understanding; sudden trouble walking, dizziness, or loss of balance or coordination, sudden trouble with vision in one or both eyes, sudden severe headache; teaching tool: FAST (facial drooping, arm weakness, speech difficulty, time to call 911)
weight loss with relatively high food intake
suggest diabetes mellitus, hyperthyroidism, or malabsorption.
bilateral JVD
suggests increase of central venous pressure (CVP) and indicates fluid overload; should be thinking systemic problems, fluid overload, high pressure and high volume
unilateral JVD
suggests right-sided heart failure, or obstruction like a nonfunctioning valve
normal neck mobility
supple, touches chin to chest without resistance
how to assess brachioradialis DTR during a neuro physical exam
support the forearm with the palm down; aim 1-2 inches above the wrist on the radial side; response: forearm should flex slightly, and palm should turn up slightly
important questions to address in regards to obtain health history of the urinary tract
suprapubic pain? dysuria? urgency? frequency? polyuria? nocturne? urinary incontinence? hematuria (gross vs microscopic)? kidney or flank pain?
points of retractions to inspect
suprasternal; intercostal; substernal; and subcostal; on adults you might see these based on their disease process; where issue is; more important in clavicle area because that means something is blocking the main airway in which we don't have a back up for
testicular torsion
surgical and medical emergency that is time sensative; occurs predominately in adolescent men
factors that influence respiration?
symbiotic with pulse influences
colorectal cancer
symptoms are important to assess when gather objective data for anus and rectum assessment
reasons as to why women can have abnormal urinary functions
systemic diseases and high susceptibility of UTIs
orthostatic BP
taken while the patient is lying, sitting, and standing; if they are having a heart issue or some sort of regulatory issue- when they are lying flat and then stand up, taking a reading within 3 minutes should give us an idea of how well the heart responds to the change of gravity; shouldn't drop > 20 mm Hg for systolic or > 10 mm Hg diastolic
melena
tarry black stool; indicates digested red blood cells; indicates an upper GI bleed
assessing muscle strength
testing major muscle groups against gravity and with resistance; looking to see if there is weakness; finding muscles that have abnormal tone, feel like fat tissue and can almost feel to the bone (atrophy); flaccidity or hypotonic; spasticity or hypertonic (always contracted, seen in a lot of muscle disorders); scored on a scale of 0-5
a complete health assessment of the neuro system include
testing sensation (sharp/dull sensation, light touch, vibration, graphesthesia, sterognosis); test coordination of arms using finger to nose rapid alternating movements; test deep tendon reflexes
stage 4 of female tanner scale
the breast is further enlarged and there is greater contour distinction; the nipple including the areola forms a secondary mound on the breast // the hair is now adult in type, but the are covered is smaller than in most adults; there is no pubic hair on the inside of the thighs
stage 3 of female tanner scale
the breast is more distinct although there is no separation between contours of the two breasts // the hair is darker, coarser, and curlier and spreads sparsely over the skin around the vaginal lips
measuring the liver using the percussion technique
the difficult way; measure at MCL; start with lung resonance and work down; work up from abdominal sounds until dull; measure the distance between
measuring the liver using the liver scratch test
the easy way; measure at MCL; place stethoscope on the liver; begin scratching fingernail lightly just below where you expect the liver to be; scratch sound will intensify over liver; mark it; then scratch above expected liver border and measure the distance
when inspecting and palpating the conjunctiva and sclera
the eye lids most be pulled down to access the color and lining of the eyes and eye balls; normal values are pink and white respectively
sites for potential hernias in the male reproductive system
the femoral canal and inguinal canal; can cause a loop of bowel (colon) to protrude through a weak spot in musculature; can cause bowel to become strangulated which may potentially lead to necrosis (medical emergency)
blood pressure defined
the force of blood pushing against the artery walls
smoking
the leading cause of preventable death
peritoneum
the membrane lining the walls of the abdominal and pelvic cavities
Pectus excavatum
the most common chest wall deformity where the sternum (breast bone) and ribs develop abnormally. This causes the sternum to drop inward towards the spine producing a caved in or sunken appearance to the chest. It is sometimes referred to as "funnel" chest.
if patient presents with axillary pain and enlarged nodes
the nurse would anticipate an infection int he areas that drain to this region
if patient presents with bicep and breast infections
the nurse would anticipate for the axillary nodes to be enlarged and tender
if the patient has a STI
the nurse would anticipate for the inguinal nodes to be enlarged and tender
if the patient's wrist or hand was infected
the nurse would anticipate for the trochlear nodes to be enlarged and tender
inspection of the ears
the pinna must be pulled back and up to straighten canal; pull ear down and back in children; using an otoscope (make sure both hands are braised), assess the auditory canal's color, for edema, for discharge, and cerumen (can have a lot or little); assess the tympanic membrane's color, for presence of perforation, and bulge (OM)
health assessment defined
the processes used to evaluate the health status of a person; consists of a comprehensive health history and complete physical examination
when a person shifts gaze from a far object to a near one
the pupils constrict
when a person shifts gaze from a close object to a far one
the pupils dilate
in patients with barrel chest
the ratio of anteroposterior to transverse (or lateral) diameter is 1:1 as the anteroposterior diameter enlarges
in a normal adult chest
the ratio of anteroposterior to transverse (or lateral) diameter is 1:2
the nursing process
unique to the nursing profession; overall goals: extrapolate the findings, prioritize the findings, formulate the plan of care, and implement the plan of care; ADPIE (assessment, diagnosis, plan, implement, evaluate); an approach to the identification, diagnosis, and treatment of responses to illness; integrates elements of critical thinking
nutrition
the science of food as it relates to promoting optimal health and preventing chronic disease
guidelines for sensitive topics
the single most important rule is to be nonjudgemental; explain why you need to know certain information, if patient doesn't understand why, you're not going to get the information you're looking for; find opening questions for sensitive topics and learn the specific kinds of information needed for your assessments; consciously acknowledge whatever discomfort you are feeling. Denying your discomfort may lead you to avoid the topic altogether
cochlea
the spiral cavity of the inner ear containing the organ of court, which produces nerve impulses in response to sound vibrations for the middle ear
working phase
third part of the interview process; where subjective data is collected from patient; need to have excellent communication skills; don't interrupt them; use focus approach; identify and respond to emotional ques; expand and clarify patient story; use the patients word and not medical jargon; generating and testing diagnostic hypotheses; explore the patient's perspective through their feelings, ideas, function, and expectations; negotiate a plan
upon assessment, if abnormal breath sounds or abnormal tactile fremitus is found
then check for: broncophony, egophony, and whispered pectoriloquy
validation
therapeutic communication technique; acknowledge legitimacy of emotions
reassurance
therapeutic communication technique; be careful not to provide false ones like "everything is going to be fine"; make sure to convey info in competent manner
nonverbal communication
therapeutic communication technique; can be really intense and subconscious; pay very close attention to eye contact; might mean they are embarrassed; movements like hand dwindling; interpersonal distance if leaning towards you they may be more engaged; placement of arms and legs (crossed infront of chest means I'm closed off to discussing this); match your position to the patient's decision; be sensitive to culture (some cultures aren't allowed to make eye contact with opposite sex)
empowering the patient
therapeutic communication technique; follow patient lead; elicit and validate that persons content; must educate them so where they can take care of themselves; make clinical reasoning transparent; okay to say I don't know but follow it with let me find out
summarization
therapeutic communication technique; giving capsule summary of patient story
active listening
therapeutic communication technique; offers feedback to the speaker based on paraphrasing on what they say; be aware of emotional state; try not to shift topic all together
guided questioning
therapeutic communication technique; use the question to elicit a graded response; encourage with continuers like "go on" "uh huh" or even silence; use reflection: "so what your saying is-"
transitions
therapeutic communication technique; you tell patient when changing direction of the interview like switching topics; orient the patient with brief transitionally statements
if you see a patient really using their abdominal muscles
they are working hard to exhale
if a patient uses an epipen
they must go to the hospital to be monitored due to an immediate reaction of a big plateau of feeling great and then that feel quickly declines; patient actually needs 2 (not a lot of people know this); this is something that isn't just going to go away, patient will continue to digest the allergen and reaction will come back
tympany
think "tight drum" that is heard over organs that stretch when percussed; i.e.: the stomach and bladder
if you notice a localized temperature decrease in the skin upon inspection and palpation during a PE
think about peripheral arterial insufficiency
eschar
think black
hot, red, swollen joints
think inflammation, injury, immune, infected
epithelialization
think pink and dry
granulation tissue
think red and moist
slough
think yellow
if someone has 20/100 vision
this means that at 20 feet the patient can see what normal people can see at 100 feet
factors that influence how an individual experience pain
unique; physical; physiological; social; age, previous pain experiences, cultural norms, unknown expectations, history of drug abuse, perception of pain
erectile dysfunction
topic that must be addressed when assessing for peripheral vascular system in males
question topics for relieving/exacerbating factors of skin history (subjective)
topical substances: lotion, soap, perfume, and jewelry; foods; clothing; other hx of allergies; stressors; illness; environment temperature changes
flexor surfaces
touch; skin lesions of atopic eczema are seen here
4+ tonsils
touching and pushing the uvula; if divots are seen along the tonsils, this is physiologic, if it were to become infected, causes a serious problem; these are the patients we want to surgical remove them from
3+ tonsils presentation
touching the uvula but isn't pushing it
medial
toward the midline
inferior
towards bottom (feet) of body
superior
towards top (head) of body
Hep A virus
transmitted through food and oral fecal route
CN V
trigeminal; sensory (face, sinuses, teeth, etc) and motor (chewing functions; muscles of mastication); assessed by gently touching cheeks with cotton ball while eyes are closed; also assed by making pt clench teeth, opening the jaw, and testing TMJ
CN IV
trochlear; works with CN II and CN VI; innervates superior oblique muscle of the eye; moves eye down and inward
true or false: only 65% of obese US adults report that health care professionals have told them they were overweight. Less than half report being advised to lose weight.
true
if a patient is presenting with a protuberant abdomen due to ascites, when the air pocket is percussed it will sound
tympanic
percussing the stomach during the physical exam of an abdominal assessment
tympanic sounds are expected
percussion notes ordered from least dense to most dense with examples
tympany (stomach), hyperresonance (emphysema), resonance (healthy lung tissue/bronchitis), dull (liver), and flat (scapula)
percussion over stomach on anterior chest
tympany is expected
temporomandibular joint (TMJ)
type articulating condylar joint; the most active joint in the body; only freely movable joint on head; when physically examining this part of the body observe side to side (lateral motion) and protrusion forward (jaw thrust) and palpate while opening and closing jaw, biting dow-extension and flexion
an episodic assessment of the female reproductive system
type of exam not prompted by a sign/symptom; now is the time to get comfortable with talking about the uncomfortable; ask the kind of question that will elicit informative responses
follow-up/re-evaluation assessment
type of focused assessment; shift assessment has been completed; focuses on symptom and asks pertinent questions; focuses on affected systems; evaluation of interventions
Crohns disease
type of inflammatory bowel disease: clinical manifestations: abdominal pain and diarrhea are the most common signs, more than 5 stools per day, anemia may develop as a result of malabsorption of vitamin B12 and folic acid; skip pattern in which it doesn't have to be continuous, presence of granulomas with cobblestone appearance; transmural (goes all the way through and may create a fistula)
Ulcerative colitis
type of inflammatory bowel disease; common in those 20-40 years of age or of jewish descent; clinical manifestations: diarrhea (10 to 20 BM's per day), bloody stools, cramps, remission and exacerbations, and increased risk for colon cancer is demonstrated; starts at the colony and works its way up; affects the mucosal layer with ulcerations; may present with polyps, when active presents with superficial ulceration, and when inactive presents with atrophy
slightly movable
type of joint; cartilaginous; include pivotable (neck) and gliding joints (wrist)
immovable joints
type of joint; fibrous; bone to bone connection; example: skull sutures that form after 2 years of age
freely movable
type of joint; synovial; have the most movement; can do the most things; example: shoulders
marasmus/kwashiorkor mix
type of malnutrition has the highest risk for morbidity and mortality; severely malnourished children that have clinical features of both marasmus and kwashiorkor. They are severely underweight (below 60% of the 50th centile) but also have oedema.
referred pain
type of neuropathic pain; is felt at a particular site but originates from another location. both sites are innervated by the same spinal nerve, and it is difficult for the brain to differentiate the point of origin
deep somatic pain
type of nociceptive pain; comes from blood vessels, joints, tendons, muscles, and bone; injury may result from pressure, trauma, or ischemia.
cutaneous pain
type of nociceptive pain; is derived from skin surface and subcutaneous tissues; the injury is superficial with a sharp, burning sensation.
visceral pain
type of nociceptive pain; originates from larger interior organs; the pain can stem from direct injury or stretching; examples include: arterial colic, acute appendicitis, ulcer pain, and cholecystitis; it is transmitted by ascending nerve fibers along with nerve fibers of the autonomic NS hence presentation is with autonomic responses (vomiting, nausea, pallor, and diaphoresis).
sensorineural loss
type of objective data of auditory acuity; cochlear, auditory nerve damage or auditory area of cerebral cortex damage; may be caused by presbycusis; inner ear disease; can be caused by ototoxic drugs
conductive loss
type of objective data of auditory acuity; mechanical dysfunction in external or middle ear; may be caused by foreign object in canal, perforated TM, or ostosclerosis
condylar joints
type of synovial joint; covex or concave like the knee; articulating (TMJ)-the most active joint
hinge joints
type of synovial joint; flat or planar (moves on one plane like the elbow); flexion and extension only
ball and socket joints
type of synovial joint; have the most movement; include your hip and shoulder; can flex and extend, abduct and adduct, rotate, and circumduction
deep suprasternal retractions
typically indicate severe distress
stage 2 of female tanner scale
typically reached by the age of 12; the first sign of breast development has appeared; this stage is sometimes referred to as the breast budding stage; some palpable breast tissue under the nipple, the areola may be somewhat enlarged // there is small amount of long pubic hair chiefly along the vaginal lips
normal orthostatic hypotension
unchanged or less than a 10 mm Hg drop in systolic value will occur; unchanged or slight rise in diastolic
4th orientation of A&O
unit specific, facility driven, and nonuniversal
phalen's test
upside down praying; put dorsal aspects of the hands together and push; if there is shooting/stabbing pain or numb before 1 minute, patient may have carpal tunnel syndrome
important topics to discuss when gather subjective data for anus, prostate, and rectum assessment
urinary (for prostate); bowel habits (frequency, stool color and consistency); medications; medical history; surgical history; family history; symptoms (pain, bleeding, lesions, discharge, itching)
teaching point for the prevention of UTI in females
urinating after sexual intercourse to help flush out bacteria that may infect the bladder and urethra
techniques to be used to figure out patient's LOC who isn't alert
use acute care exam: LOC-Glasgow coma scale which looks at motor function, responses to pain, VS and pupils; never document patient is sleeping; if patient ends up being dead, and you didn't know it, very bad instead write "patient resting comfortable, doesn't need anything"
auscultation of bowel sounds
use diaphragm in all 4 quadrants and listen for a full minute if you are a new nurse; normal amount is 5-34 times per minute; abnormal amounts include: absent (obstruction), hypoactive, and hyperactive; can be high or low pitched
palpation of cardiac physical exam
use finger tips to find intercostal spaces; locate apical impulse (PMI), feel for pulsations; feel for thrills using MCP joints (vibration; "purring cat"); feel for heaves (lifting from vigorous pulsations); using MCP and ulnar surfaces pick up the best vibrations; do so in symmetric manner and across precordium
the interview across a language barrier
use interpreter that is qualified; keep in mind that you are using a lot of medical words and need people that are trained specifically for this so they can get it right across to their patient; can use the interpreter as a resource to learn about the culture; generally not a good idea to use family members as interpreters; because you aren't really sure if they fully understand medical terminology or how to properly translate it and may purposefully avoid saying things to patient; make quesitons clear, short, and simple; make eye contact with the patient; orient interpreter to any topics you are about to cover; make sure to reinforce questions with nonverbal behavior; verify that the mutual understanding has occurred with the patient by reconfirming what the patient has understood
forced expiration
use of accessory muscles; abdominal muscles contract to push viscera up and squeeze air up
if nail polish is present when checking cap refill
use the underside of the finger
CAGE
used for screening alcohol abuse; health promotion portion of the abdominal assessment
whisper test
used to asses objective data of auditory acuity; tests for high frequency loss and gross hearing
Romberg test
used to assess cerebellar function of balance; done by having patient stand up, you then stand beside the patient with one arm infront and behind them; testing cerebellum's ability to balance; ask the patient to close their eyes, standing, feet shoulder/together width apart; assess what happens when they close their eyes; does the patient lose their balance? should see natural swaying
pronator drift test
used to assess cerebellar function of balance; pt holds "pizza box" at chest level, with supinated palms; pt then closes their eyes and holds this position for 20 secs; after 20 secs, tap downwards on alternating arms and ask pt to bring them back to original position when done so; must always be prepared to protect client from falling!
Rinne Test
used to assess objective data of auditory acuity; compares air conduction to bone conduction; done by first whacking the tuning fork and placing the stem on the mastoid process to transmit through sensory neuro; the patient is instructed to indicate when the noise stops being heard, and then the tuning for is placed next to the ear to test air conduction and asked to indicate when the noise stops being heard; in normal test results, the patient will have a shorter length of time for hearing bone conduction and longer length of time for hearing air conduction
weber test
used to assess objective data of auditory acuity; tests for bone conduction; done by putting the step of a tuning for on the top of the head and assessing whether the vibrations cause a noise and whether it lateralizes or is heard equally in both ears; a normal result is if the sound and vibrations where distributed equally
snellen chart
used to collect objective data of visual acuity; eyes are supposed to be tested separately and then together; the bigger the denominator the worse the vision
Male Tanner stages
used to distinguish sexual maturity in men; done by examining the genital and pubic hair development; 1-5
important topics to assess when gathering objective data of visual acuity
using the snellen vision acuity chart; chart is 20 feet away from the patient; the patient covers one eye during testing, then switches to the other, and then uses both eyes; the larger the denominator, the poorer the vision; does the patient have myopia, hyperopia, or presbyopia?; visual fields by confrontation; corneal light reflex; assess for nystagmus and strabismus
characteristics of cystic masses in breast tissue
usual age: 30-50 with regression after menopause except in estrogen therapy use number: single or multiple shape: round consistency: soft or firm-usually elastic delineation: well delineated mobility: mobile tenderness: often tender retraction signs: absent
characteristics of breast cancer masses
usual age: 30-90, but most common after age 50 number: usually single, but may co-exist with other nodules shape: irregular or stellate consistency: firm or hard delineation: not well delineated from underlying tissues mobility: fixed to skin or underlying tissues tenderness: usually non tender retraction signs: may be present
characteristics of fibroadenoma masses in breast tissue
usual age: usually 15-25 but can occur up to age 55 number: usually single, may be multiple shape: round or lobular consistency: may be soft-usually firm delineation: well delineated mobility: very mobile tenderness: non tender retraction signs: absent
normal expiration
usually a passive (autonomic) process: muscles relax, thorax gets smaller, air gets pressed out
subcostal and substernal retractions
usually result from lower respiratory tract disorders
suptrasternal retractions
usually result from upper respiratory tract disorders
important topics of PMH for peripheral vascular assessment
vascular disorders (thrombophlebitis, varicose veins, hx of claudication); elevated serum cholesterol or lipids (last test results); heart disorders (angina, coronary artery disease, heart attacks, heart surgeries); diabetes; HTN
anterior
ventral (in front of)
posterior thoracic reference lines
vertebral line and mid scapular line (MSL); its almost impossible to count ribs from the back; need to use these as landmarks
posterior thoracic landmarks
vertebral prominences: C7 and T1 at base of neck (apices); T10 (base of lungs); ribs; intercostal spacing; scapula; costal vertebral angle (CVA)
DTR with a rating of 4+
very brisk (clonus present- muscle continuously firing and spazzing)
if leg pain gets worse with cold therapy
vessels vasoconstriction and make things worse
Weber test results in sensorineural loss
vibration will be louder in the ear without hearing deficit
Weber test results in conductive hearing loss
vibrations will be louder in the ear with hearing deficit (less room for noise = vibrations better heard)
nystagmus
vision movement in which the eyes bounce back and forth rapidly; can be caused by intense vertigo; tested by EOMs (6 cardinal fields of gaze); at extremes of gaze, presence of this is normal; in labyrinth disorders (like crystals that have fallen off), presence of this will be present in certain positions
occipital lobe functions
visual reception; injury to this region, you could expect double vision
basics of cardiovascular exam
vital signs: BP/T/P/RR and pain; blood pressure (orthostatic BP-lying, sitting, and standing; technique used influences reading; check orthostatic readings if dizzy; supine: 5-10 min; sitting: 3 minutes: standing: within 3 minutes); weight (taken at the same time everyday to detect fluid overload); height; BMI (rapid weight gain = collection of fluid); pulses: apical, carotids, peripheral (HR and regularity; pulse deficit); peripheral edema; precordium
A beefy red-colored tongue is probably due to:
vitamin B-complex deficiency as in Pernicious Anemia
rickets is due to a deficiency in
vitamin D and calcium
hematemesis
vomiting bright red blood; indicates an upper GI bleed
external female genital structures
vulva, or pudendum; mons pubis; labia majora; labia minora; frenulum or fourchette; clitoris; vestibule; urethral meatus; Skene's glands; Vaginal orifice; Hymen; Bartholin's glands
tandem gait
walking heel to toe in a straight line; used to assess cerebellar function of gait and posture
the patient with altered capacity
want to determine what there decision making capacity is; want to make sure you understand if they can make it themselves; obtain permission for family member to talk for themselves; may need to find surrogate informant and apply same interview process; if family is disconnected to patient, your best informant might be the nurse or aid that takes care of them
examples of male genital lesions
warts and syphilitic chancre
mandatory performance criteria of the H2T
wash hands before starting and at completion of exam; all systems must be addressed; use the following equipment competently: stethoscope, otoscope, reflex hammer, tuning fork, penlight; exam is organized and uses a systematic approach (the student demonstrates clear evidence of practicing); maintain patient safety throughout exam, especially all items marked with an asterisk (*); provides adequate patient privacy and comfort during the exam; observes appropriate contamination precaution throughout exam (cleans hand after touching feet, wears gloves for internal mouth exam) must be completed within 45 minutes; must have a passing score of 161 or better prior to the EC being added
why do we need to perform a health assessment on our patients?
we need to understand the patients health status, risk factors, and educational needs to determine a plan of care
body mass index (BMI)
weight (kg)/ height (m)^2 or weight (lbs)/ Height (in)^2 x 703; the proportion of weigh to thigh can indicate whether the patient is over or underweight; note that individuals with large muscle mass may have a falsely high calculated value. This must be taken into account before assuming the patient is obese or overweight; if the value is 35 or higher, measure the patient waist circumference;, the patient may have excess body fat if the waist measures: >35 inches for women, and >40 inches for men
General survey measurements
weight, height, BMI
hemoptysis
what blood sputum is documented as; important to ask, what does it look like?
Important components of the health history during the male reproductive assessment
what may have brought the patient in; sexual preference and sexual response (different risk factors, erectile function); penile discharge or lesions; scrotal pain or swelling; inguinal pain or swelling; problems with urination; topics that unfortunately make the patients uncomfortable; what they may have put on the form may not be the chief complaint
subjective data
what the client feels, reports, and believes; what the patient says;
pertinent negative
when a patient replies no to a question about a symptom you have asked when trying to gather data for history of present illness (HPI); also very important
pertinent positive
when a patient replies yes to a question about a symptoms you have asked when trying to gather data for history of present illness (HPI)
palpitations
when a patient tells you their heart is racing; when a patient feels or hearts the heart in their ears; can feel the rhythms not being right
fremitus decreases
when anything obstructs transmission of air/vibration to the viscera like an obstructed bronchus, pleural effusion, pneumothorax, or emphysema
questions to ask about swelling when obtaining history for a cardiac assessment
when does it happen?; is it always there?; do you notice it anywhere else?; is it related to cardiac, or peripheral vascular system, or injury?; important to not that the blood works with gravity, with or against it; is it worse in the evening?
assessment of hair during a physical examination of skin
when doing so, maintain your index of suspicion for possible abuse; watch for grimaces as you inspect the scalp that may suggest injury or patches of alopecia from traumatic hair pulling.
mechanical intestinal obstructions
when something is actually blocking it like a tumor, or hernia; number 1 reason for adhesions or hernias (inguinal, femoral, and umbilical)
why nocturia may be related to cardiac issues
when standing up all day; lymph and fluid collect; when an individual lays down, the collecting lymph and blood can work with gravity and carry it back up to the kidney (in which it wasn't able to do against gravity); the patient ends up peeing a lot
protuberant abdomens due to ascites
when standing upright (air pocket up at the top) while fluid is sitting around organs in peritoneum; when patient lays down, fluid is going to shift because of gravity; when percussed at air pocket, will sound tympanic; when percussed on fluid, will sound dull; if you have a patient roll onto different areas and different sounds are percussed, this indicates ascites
lung tissue
where all of the perfusion occurs
costal angle margin
where ribs come together; usually < 90 degrees; if above 90 degrees, may indicate chronic over-inflation like in COPD patients with barrel chest
a good land mark on the back to listen to the base of the lungs
where the scapulae points end
apical impulse (PMI)
where you can feel and listen to the left ventricle doing its job; where pulse should be counted before going cardiac medication; must be document before giving it to them
a complete health assessment of the abdomen includes
while pt in supine with knees flexed; inspect skin (color, scars/striae), contour, umbilicus, bulges, peristalsis, and pulsations; auscultate bowel sounds in 4 Q's; auscultate for bruits: aorta, renal, iliac, femoral (must palpate femoral prior to auscultation; percuss all quadrants; percuss height of liver span and location of spleen; palpate lightly in all quadrants; palpate for liver; palpate each groin for femoral pulse and inguinal nodes; don't forget CVA tenderness (on the posterior chest)
a complete health assessment of the lower extremities include
while pt supine; inspect skin, symmetry, hair, joints, and veins; palpate for temp and edema; test ROM and strength of hips; palpate pulses: popliteal, PT, DP; check cap refill in toes; don't forget hand hygiene after touching a patient's feet
weight measurements
will be repeated, time of day and amount of clothing should be the same each time; takin on a balance scale
over half of all women, at one point of their life
will develop at least 1 UTI
collection of data
will give you information about a patient's current and past health status, functional status, and coping patterns
a complete health assessment of the mouth and throat include
with a penlight, inspect teeth and gums, buccal mucosa, tongue, sublingual area, palpate tonsils and uvula (a lot to verbalize here, so take your time); have person phonate, "ahh", swallow, test gag reflex, CN IX, X; ask the person to stick out tongue and check strength within cheek, CN XII
structures of the posterior anatomy of the abdomen
within the retroperitoneal region; inferior vena cava; abdominal aorta (splits to supply blood to the lower extremities); kidneys; duodenum; pancreas; ureters; common iliac artery and vein; rectum; ovary; bladder; external iliac artery and vein; uterus; sacral promontory
idiopathic pain
without etiology; not sure where it is coming from
normally palpable structures of the abdomen
xiphoid process; normal liver edge; lower pole of the right kidney; pulsatile aorta; rectors muscles; lateral borders; sacral promontory; cecum; ascending colon; sigmoid colon; uterus (gravid); full bladder; but overall not going to feel "much", lots of squish, maybe a pulse, can feel liver
carotenemia
yellowish palms; subtle difference; unlike jaundice, it doesn't affect the sclera, which remains white; the cause is a diet high in carrots and other yellow veggies and fruits; not harmful but indicates the need for assessing dietary intake
things that can cause changes of color in urine
yellows (hydration); certain foods; medications (blue that can look green, oranges, reds); liver disease; bile duct disease (orange and brown); blood (reds and pinks); rare genetic diseases (blue)
admission nutrition screening tool
yes or no checklist; check yes for each condition that applies, then total the nutritional score; for total scores of 3-5 points (moderate risk), or > or = to 6 (high risk), further evaluation is needed, especially for the elderly
if you get a shocked and embarrassed reaction when asking a question to a sensitive topic
you didn't explain why you needed the information well enough; re-explain why you need to know and don't be judgemental
if you retract the male foreskin during a nursing intervention
you must always put it back bc it, if you don't it essentially acts as a rubber band and lead to necrosis; might end up needing a surgery to cut the skin
