physical assessment exam 1 from powerpoints

personal distance

1/2-4 ft (much of px assessment done at this distance)

recent memory

Assess in context of interview by 24-hour diet recall or by asking time person arrived at agency Ask questions you can corroborate to screen for occasional person who confabulates or makes up answers to fill in gaps of memory loss

BMI

Body mass index is practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition Nurse's note: Weigh pt at same time, same scale, same clothes each time for daily weight

brachioradialis reflex

C5 to C6 Hold person's thumbs to suspend forearms in relaxation and strike forearm directly, about 2 to 3 cm above radial styloid process Normal response is flexion and supination of forearm

biceps reflex

C5 to C6 Support the person's forearm on yours; place your thumb on biceps tendon and strike a blow on your thumb Normal response is contraction of biceps muscle and flexion of forearm

triceps reflex

C7 to C8 Tell person to let arm "just go dead" as you strike triceps tendon directly just above the elbow Normal response is extension of forearm

brainstem

Central core of brain consists of nerve fibers: Cranial nerve (CN) III through XII originate from nuclei in brain stem Midbrain: most anterior part of brain stem with tubular structure of spinal cord; merges into thalamus and hypothalamus; contains many motor neurons and tracts Pons: enlarged area containing ascending sensory and descending motor tracts Medulla: continuation of spinal cord in brain; contains all fiber tracts connecting brain and spinal cord Has vital autonomic centers (respiration, heart, gastrointestinal function); nuclei for CN VIII through XII Pyramidal decussation (crossing of motor fibers)

comprehensive adult health history

Chief complaint Past history: medical, surgical, OB, & psych Immunizations Allergies with reactions Family history Personal & social history

cachetic appearance

Chronic wasting diseases Cancer Dehydration Starvation Sunken eyes Hollow cheeks Exhausted Defeated expression

dermatome

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

process of communication

Communication is a tool, as basic to quality health care as are tools of inspection or palpation Communication can be learned and polished when you are a beginning practitioner

sending in communication

Communication is behavior, conscious and unconscious, verbal and nonverbal All behavior has meaning Body language: posture, gestures, facial expression, eye contact, foot tapping, touch, even where you place your chair

flaccid quadriplegia

Complete loss of muscle tone and paralysis of all four extremities, indicating nonfunctional brain stem

the cultural connection

Cultural perspectives on professional interactions Etiquette Space & distance: 0.5-4 ft = Physical Assessment (personal distance) Cultural considerations on gender Cultural considerations on sexual orientation

reflection

Echoes patient's words, repeating what person has just said; focuses further attention on a specific phrase; and helps person continue in his or her own way

pediatric facial abnormalities

Fetal alcohol syndrome (FAS) Down syndrome Atopic (allergic) facies Allergic salute and crease

spinal cord

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

types of assessments

Health history (Interview) Physical assessment Mental health assessment Domestic violence assessment Nutritional assessment Pain assessment

Spinal cord hemisection (Brown-Séquard syndrome)

Loss of pain and temperature, contralateral side, loss of vibration and position discrimination on ipsilateral (same) side

peripheral neuropathy

Loss of sensation involves all modalities; loss most severe distally at feet and hands

linea nigra

Increased pigmentation midline of abdomen

cremasteric reflex

L1 to L2 (not routinely done) On male, lightly stroke inner aspect of thigh with reflex hammer or tongue blade Note elevation of ipsilateral testicle

quadriceps reflex

L2 to L4 ("knee jerk") Let lower legs dangle freely to flex knee and stretch tendons; strike tendon directly just below patella Normal response is extension of lower leg

plantar reflex

L4 to S2 Position thigh with slight external rotation With reflex hammer, draw a light stroke up lateral side of sole of foot and inward across ball of foot, like an upside-down "J" Normal response is plantar flexion of toes and inversion and flexion of forefoot

achilles reflex

L5 to S2 ("ankle jerk") Position person with knee flexed; hold foot in dorsiflexion and strike Achilles tendon directly Normal response is foot plantar flexes against your hand

basal ganglia

Large bands of gray matter in two cerebral hemispheres that form subcortical associated motor system (extrapyramidal system) Initiate and coordinate movement and control automatic associated movements of body

ausculatation

Listening w/stethoscope to sounds w/in the body Expose are to be auscultated while providing privacy and warmth Assess Pitch: ranging from high to low Loudness: ranging from soft to loud Quality: gurgling or swishing Duration: short, medium, or long

present health or history of present illness

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

patient self-report of pain

Location Intensity Quality Onset and duration Alleviating or relieving factors Effect of pain on quality of life and functional status Comfort and function goal

10 traps of interviewing

Providing false assurance or reassurance Giving unwanted advice Using authority Using avoidance language Engaging in distancing Using professional jargon Using leading or biased questions Talking too much Interrupting Using "why" questions

PQRSTU

Provocative or palliative, quality or quantity, region or radiation, severity scale from 1 to 10, timing or onset, understand patient's perception of problem

past health

Provocative or palliative, quality or quantity, region or radiation, severity scale from 1 to 10, timing or onset, understand patient's perception of problem Obstetric history Immunizations Last examination date Allergies Current medications Latex allergy is important to know (gloves, for example) Allergies can be added at any age

clinical reasoning

The thinking process used by a nurse to make a clinical judgment

posterior dorsal columns

These fibers conduct sensations of position, vibration, and finely localized touch

explanation

These statements inform the person; you share factual and objective information offering reasons for requirements or actions

aging skin

Senile lentigines Keratoses Xerosis Skin tags or acrohordons Thin parchment Decreased hair growth Decreased nail growth and brittle nails

sensorineural loss

Sensorineural hearing loss among adolescents is increasing, especially among those with high levels of noise exposure, as from loud music. [Photo is normal right tympanic membrane.]

abdominal reflexes

Sensory receptors in skin rather than in muscles; motor response is localized muscle contraction Abdominal reflexes: upper: T8 to T10;lower: T10 to T12 Person in supine position, knees slightly bent; use handle end of reflex hammer to stroke skin Move from each corner toward midline at both upper and lower abdominal levels Normal response is ipsilateral contraction of abdominal muscle with observed deviation of umbilicus toward stroke

developmental care of older adult

Similar to younger adult, + additional questions Consider if ADLs are affected by normal aging or by chronic illness/disability Not age specific; use when appropriate Recognize positive health measures: What they are doing to help themselves stay well? Old health care model: searching for what is wrong with their health Affirm positive steps to good health Affirm how they are healthy

sources of pain

Somatic - musculoskeletal Deep somatic - blood vessels, joints, tendons, muscles, bone Cutaneous - skin, subcutaneous tissue Referred pain - felt at one site but originates in another

subjective data of eyes

Vision difficulty: decreased acuity, blurring, blind spots Pain Strabismus, diplopia Redness, swelling Watering, discharge History of ocular problems Glaucoma Use of glasses or contact lenses Self-care behaviors

subjective data

What patient says about himself or herself during history taking

thought content

What person says should be consistent and logical

cranial nerve VIII

acoustic nerve (Vestibulocochlear) Test hearing acuity by ability to hear normal conversation and by whispered voice test

where to check for turgor

anterior chest under clavicle

aging adult blood pressure

aorta and major arteries tend to harden with age As heart pumps against a stiffer aorta, systolic pressure increases, leading to widened pulse pressure In many older people, both systolic and diastolic pressures increase, making it difficult to distinguish normal aging values from abnormal hypertension

ABCT

appearance behavior cognition thought processes

aging adult weight

appears sharper in contour with more prominent bony landmarks than younger adult Weight decreases during 80s and 90s; this factor more evident in males, because of greater muscle shrinkage Distribution of fat also changes during 80s and 90s; even with good nutrition, subcutaneous fat lost from face and periphery (especially the forearms), whereas additional fat deposited on abdomen and hips

dress

appropriate to climate, looks clean and fits body, and is appropriate to person's culture and age group; for example, normally: Amish women wear clothing from nineteenth century Indian women may wear saris Culturally determined dress should not be labeled as bizarre by Western standards or by adult expectations

speech

articulation (ability to form words) clear and understandable Stream of talking is fluent, with an even pace Conveys ideas clearly Word choice appropriate to culture and education Person communicates in prevailing language easily by himself or herself or with interpreter

rooting reflex

brush the infant's cheek near mouth; note whether infant turns head toward that side and opens mouth Appears at birth; disappears at 3 to 4 months

exophthalamos

bulging eyeballs

aging adult height

by 80s and 90s, many people are shorter than they were in their 70s Results from shortening in spinal column, thinning of vertebral disks, shortening of individual vertebrae, and postural changes of kyphosis and slight flexion in knees and hips Because long bones do not shorten with age, overall body proportion looks different: shorter trunk with relatively long extremities

aging adult general appearance

by eighth and ninth decades, body contour sharper, with more angular facial features, and body proportions redistributed

lanugo

fine downy hair of newborn infant

down syndrome

flat nasal bridge, small broad flat nose, thick tongue, low-set ears, small hands with single palmar crease.

behavioral checklist

for school-age children, ages 7 to 11, is tool given to parent along with the history Covers five major areas: mood, play, school, friends, and family relations It is easy to administer and lasts about 5 minutes

cataract

formation, or lens opacity, resulting from a clumping of proteins in lens

neuropathic pain

from abnormal processes of sensory input by the nervous system as a result of damage to the brain, SC, or peripheral nerves. Often described as burning, sharp, shooting. Ex are diabetic neuropathy and phantom pain, post herpetic lesions

brocas area

frontal lobe mediates motor speech When injured in dominant hemisphere, expressive aphasia results; person cannot talk; person can understand language and knows what they want to say, but can produce only garbled sound

aging adult posture

general flexion occurs by eighth or ninth decade

personal space

interpersonal transactions and care of belongings

conductive hearing loss

interrupts sound waves traveling from outer ear to cochlea of inner ear d/t sound waves NOT transmitted through the outer and middle ear structures. E.g. Otosclerosis common in 20-40 y/o causing progressive deafness from gradual bone formation causing footplate of stapes to become fixed, impeding transmission of sound. E.g. Cerumen dry impact conduction . After removal of wax, > ½ people pass whisper voice test.

sebum

holding water in the skin producing milia

cranial nerve XII

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

preventive services

immunizations

focused assessment

limited or short-term problem (presents at clinic with rash, flu symptoms, pain)

where to observe cyanosis

lips, nail beds, palpebral conjunctivae, and palms

aphasia

loss of ability to speak or write coherently or to understand speech or writing due to a cerebrovascular accident

most common cause of blindness

loss of central vision. person is unable to read fine print, sew, or do fine work; loss of central vision may cause great distress

tympany

loud, high, musical and drumlike, stomach or air-filled cheek

hyperresonant

louder, lower, booming, abnormal adult lung/normal child lung

wernickes area

in temporal lobe associated with language comprehension When damaged in the person's dominant hemisphere, receptive aphasia results; person hears sound, but it has no meaning, like hearing a foreign language

dysphagia

inability to swallow

functional assessment

including ADLs Are they able to do activities of daily living; getting dressed, showering, brushing teeth, feeding themselves. Self-esteem, self-concept Activity and exercise Sleep and rest Nutrition and elimination Interpersonal relationships and resources Spiritual resources Coping and stress management Personal habits Alcohol CAGE test Illicit or street drugs Environment and work hazards Intimate partner violence Occupational health

functional assessment for children

including ADLs Interpersonal relationships Activity and rest Economic status Home environment Environmental hazards Coping and stress management Habits Health promotion

older adult functioning assessment

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

glaucoma

increased intraocular pressure; chronic open-angle glaucoma is most common type

nociceptive pain

means "normal pain" and comes from the normal functioning of physiologic systems that perceive and interpret noxious stimuli as being painful. Pain from surgery, trauma, burns, tumor growth and described as aching, cramping, throbbing.

head circumference

measure infant's head circumference at birth and at each well visit up to age 2 years and then yearly up to 6 years Circle tape around head at prominent frontal and occipital bones; widest span is correct Plot measurement on standardized growth charts Compare infant's head size with that expected for age Series of measurements more valuable than single figure to show rate of head growth Newborn's head measures about 32 to 38 cm (average around 34 cm) and about 2 cm larger than chest circumference

resonant

medium-loud, low, clear/hollow, normal lung

pain rating scales

one-dimensional and are intended to reflect pain intensity They come in various forms Pain rating scales can indicate a baseline intensity, track changes, and give some degree of evaluation to a treatment modality Numeric rating scales ask patient to choose a number that rates level of pain, with 0 being no pain and highest anchor 10 indicating worst pain In general, older adults find numeric rating scale abstract and have difficulty responding, especially with a fluctuating chronic pain experience An alternative is simple Descriptor Scale that lists words that describe different levels of pain intensity, such as no pain, mild pain, moderate pain, and severe pain Older adults will often to scales in which words are selected It is essential to teach person how to use scale to enhance accuracy video

cranial nerve II

optic nerve Test visual acuity and visual fields by confrontation Using ophthalmoscope, examine ocular fundus to determine color, size, and shape of optic disc

cognitive functions

orientation attention span recent memory remote memory

personal hygiene

person appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group

mood and affect

person comfortable and cooperative with examiner and interacts pleasantly

facial expression

person maintains eye contact (unless a cultural taboo exists), expressions appropriate to situation (e.g., thoughtful, serious, or smiling) Note expressions both while face is at rest and while person is talking

neck assessment

pharynx, neck, lymph nodes, carotid arteries, thyroid gland, and trachea

vocal cues

pitch, tone, and quality of voice, including moaning, crying, and groaning

palmar grasp

place baby's head midline to ensure symmetric response; offer finger from baby's ulnar side, away from thumb; note tight grasp of all baby's fingers Present at birth; strongest at 1 to 2 months; disappears at 3 to 4 months

word comprehension

point to articles in the room or articles from pockets and ask person to name them

parietal lobe

postcentral gyrus is primary center for sensation

action cues

posture, facial expression, and gestures

older adult reason for seeking care

reason for seeking care Allow time to figure out why older person has come for an examination Older person May dismiss symptoms, attributing them to evidence of growing old and be unsure whether it is worth mentioning May have a conservative philosophy toward their health status and come for care only when something is seriously wrong May have many chronic problems (diabetes, hypertension, or constipation) Final statement should be person's reason for seeking care, not your assumption of problem Constipation is common as they become less active or if they are taking pain killers

hyperemia

redness found in pressure areas such as sacrum, heels, and greater trochanter

dyskinesias

repetitive stereotyped movements in jaw, lips, or tongue may accompany senile tremors; no associated rigidity present

dull

soft, high, muffled thud, liver/spleen (dense organ)

cranial nerve XI

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

two point discrimination

test ability to distinguish separation of two simultaneous pin points on skin

stereognosis

test person's ability to recognize objects by feeling their forms, sizes, and weights

clonus

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

Vernix caseosa

thick, cheesy substance

arcus senilis

thin white arc/ring along margin of iris - common with aging d/t lipid deposits but is normal with aging over 40 and has no affect on vision. EOM test cranial nerves III, IV, VI. "H pattern" and then to nose.

why do we assess skin?

to assess oxygenation, circulation, nutrition, local tissue damage, and hydration

point location

touch skin and withdraw stimulus promptly; ask person to put finger where you touched

plantar grasp

touch your thumb at ball of baby's foot; note that toes curl down tightly Reflex present at birth; disappears at 8 to 10 months

cranial nerve V

trigeminal nerve Motor function: assess muscles of mastication by palpating temporal and masseter muscles as person clenches teeth Muscles should feel equally strong on both sides; try to separate jaws by pushing down on chin; normally you cannot Sensory function: with person's eyes closed, test light touch sensation by touching a cotton wisp to designated areas on person's face: forehead, cheeks, and chin Tests all three divisions of CN V: ophthalmic, maxillary, and mandibular Corneal reflex: omit test, unless person has abnormal facial sensation or abnormalities of facial movement Remove any contact lenses; with person looking forward, bring wisp of cotton in from side (to minimize defensive blinking) and lightly touch cornea, not conjunctiva Normally, person will blink bilaterally Corneal reflex may be decreased or absent in those who have worn contact lenses This procedure tests sensory afferent in cranial nerve V and motor efferent in cranial nerve VII (muscles that close eye)

presbyopia

unable to see near w/o "cheaters"

emergency assessment

urgent, rapid collection of info compiled with lifesaving measures

flat

very soft, high, absolute dullness, thigh/bone, tumor (no air present; "dead stop of sound")

cultural assessment

what are the patient's health and illness beliefs and practices?

pain

whatever the experiencing person says it is, existing whenever he says it does

integumentary system

skin, hair, scalp, & nails.

cutaneous pain

skin, subcutaneous tissue

strabismus

"cross-eyed" eyes don't look in exactly same direction

pathologic reflex

(abnormal), e.g., Babinski's reflex or extensor plantar reflex

hirsutism

(male-pattern hair growth)

deep tendon reflexes

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

superficial reflex

, corneal reflex, abdominal reflex

intimate distance

0-1.5 ft

public distance

12+ feet (public distance; subtle facial expressions imperceptible)

hearing acuity

3 main types of hearing loss Conductive Sensorineural Combination

spinal nerves

31 pairs of spinal nerves arise from length of spinal cord and supply rest of body Named for region of spine from which they exit:8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and1 coccygeal "Mixed" nerves, they contain both sensory and motor fibers Each innervates particular segment of body Dermal segmentation is cutaneous distribution of various spinal nerves

social distance

4-12 ft (much of interview at this space; used for impersonal business)

Oucher scale

6 photographs of young boys' faces with different expressions of pain, ranked on a 0 to 5 scale of increasing intensity Child asked to point at face that best matches their hurt or pain Oucher Scale has variations for girls and ethnic groups

environmental and occupational hazards

Are you exposed to insecticides, organic solvents, or lead? Are you taking any medications now? How much alcohol do you drink? Each week? Each day? How about mood-altering drugs, such as marijuana, cocaine, barbiturates, and tranquilizers?

adolescent skin

Acne Open and closed comedones

judgment

Ability to compare and evaluate alternatives, and reach an appropriate course of action Test judgment about daily or long-term goals, likelihood of acting in response to hallucinations or delusions, and capacity for violent or suicidal behavior Note what person says about job plans, social or family obligations, and plans for the future; job and future plans should be realistic, considering person's health situation Ask for rationale for his or her health care, and how he or she decided about compliance with prescribed health regimens; actions and decisions should be realistic

types of pain

Acute Chronic (persistent) Breakthrough

cross-cultural care

Additional questions for new immigrants Biographical data Spiritual resource and religion: assess if certain procedures cannot be done Past health: what immunizations, if any Health perception How does person describe health and illness How does person see problems he or she is now experiencing Nutrition: taboo foods or food combinations Important to know their perception of their own health. For example an elderly person might think that pain is normal with getting old. As a nurse, want to make sure they are making an informed decision about immunizations.

mexican americans

Age 20 and older, 2.6% of men and 1.8% of women have had stroke

family history

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

objective data- appearance

Age: person appears his or her stated age Sex: sexual development appropriate for gender and age Level of consciousness: person alert and oriented, attends to your questions and responds appropriately Skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesion Facial features: symmetric with movement No signs of acute distress present

american indians

Ages 65 to 74, annual rates per 1000 population of new and recurrent strokes are 6.1 for men and 6.6 for women

aging adult and pain

Although pain should not be considered a "normal" part of aging, it is prevalent. When older adult reports osteoarthritis, PVD, cancer, osteoporosis, angina, or chronic constipation, consider a pain problem. Older adults often deny having pain for fear of dependency, further testing, or invasive procedures, cost, and fear of taking pain killers or becoming a drug addict. During interview you must establish an empathic and caring rapport to gain trust.

additional history for aging adult

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

Facial expression

Appropriate to situation and changes appropriately with topic Comfortable eye contact unless precluded by cultural norm

open ended questions

Ask for narrative responses State topic only in general terms Use them: To begin interview To introduce a new section of questions Whenever the patient introduces new topic

closed or direct questions

Ask for specific information Elicit short, one-or-two word answers, a yes or no answer, or a forced choice Use them: After opening narrative to fill in details person may have left out When you need many specific facts about past health problems, or during review of systems To move the interview along

assess sensory system

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

Rapid Alternating Movements (RAM)

Ask person to pat knees with both hands, lift up, turn hands over, and pat knees with backs of hands; then ask person to do this faster Normally done with equal turning and quick rhythmic pace Alternatively, ask person to touch thumb to each finger on same hand, starting with the index finger, then reverse direction Normally done quickly and accurately

romberg test

Ask person to stand up with feet together and arms at sides; when in stable position, ask person to close eyes and to hold position for about 20 seconds Normally, person can maintain posture and balance even with visual orienting information blocked Ask person to perform shallow knee bend or hop in place, first on one leg, then other Demonstrates normal position sense, muscle strength, and cerebellar function Some individuals cannot hop because of aging or obesity

perception of health

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

stroke

Ask the person to ... Smile Upper half of face is not affected Lower facial muscles paralyzed (due to intact nerve from unaffected hemisphere) Wrinkle forehead - unaffected Close eyes - unaffected Acute neurologic deficit caused by blood clot of cerebral vessel (atherosclerosis - ishemic stroke OR rupture of cerebral vessel - hemorrhagic stroke.

general survey of infant

Assess appearance and behavior. Assess vital signs. Assess height and weight. Learn a lot before touching them. •Visually assess: Gender and race, age, signs of distress, body type, posture, gait, body movements, hygiene and grooming, dress, body odor, affect and mood, speech, signs of patient abuse, and signs of substance abuse. Always remember how age, gender, culture, and ethnicity affect your patient. •Height and weight reflect a person's overall level of health. It will be important to obtain a diet history for your patient. Measurement of infant length.

preschool and school age children neuro

Assess the child's general behavior during play activities, reaction to parent, and cooperation with parent and with you Much of motor assessment can be derived from watching child undress and dress and manipulate buttons; indicates muscle strength, symmetry, joint range of motion, and fine motor skills Use Denver II to screen gross and fine motor skills appropriate for child's age Note child's gait both walking and running; allow for normal wide-based gate of toddler and normal knock-kneed walk of preschooler Normally, child can balance on one foot for about 5 seconds by 4 years, for 8 to 10 seconds at 5 years, and can hop at 4 years Observe child as rising from supine position to sitting position, then to a stand; note muscles of neck, arms, legs, and abdomen Normally child curls up midline to sit up, then pushes off with both hands against floor to stand Assess fine coordination using finger-to-nose test Demonstrate procedure first, then ask child to do test with the eyes open, then with eyes closed Fine coordination not fully developed until child is 4 to 6 years; consider it normal if younger child can bring finger to within 2 to 5 cm of nose Testing sensation very unreliable in toddlers and preschoolers May test light touch by asking child to close eyes and point to spot where you touch When you need to test DTRs in young child, use your finger to percuss tendon Use reflex hammer only with an older child; coax child to relax, or distract and percuss discreetly when child not paying attention Knee jerk present at birth; then ankle jerk and brachial reflex appear; and triceps reflex present by 6 months

waist circumference

Assesses body fat distribution as indicator of health risk Excess abdominal fat is an independent risk factor for disease, over and above that of BMI Waist circumference measured in inches at smallest circumference below rib cage and above iliac crest Hip circumference measured in inches at largest circumference of buttocks Note the measurement at end of normal expiration

Nursing Process

Assessment Diagnosis Planning Implementation Evaluation "ADPIE"

aging adult and neuro system

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

ears

Auricles Texture Tenderness Lesions Color Pain Cerumen Ear canals and eardrums Palpate the AURICLES for texture, tenderness, and skin lesions. •Auricles are normally smooth and w/o lesions. •Ear color is usually the same as that of the face, without moles, cysts, deformities, or nodules. Redness is a sign of inflammation or fever. Extreme pallor indicates frostbite. •If palpation causes pain, an external ear infection is likely. If the patient has ear pain, but palpation does not cause additional pain, infection may be present in the middle ear. •A yellow, waxy substance called cerumen is common. Yellow or green, foul-smelling discharge indicates infection or a foreign body.

autonomic nervous system

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

blood pressure

Average BP in young adult is 120/80 mm Hg; varies normally with many factors: Age: gradual rise through childhood and into adult years Gender: after puberty, females show a lower BP than males; after menopause, females higher than males Race: African American adult's BP usually higher than White person's of same age The incidence of hypertension is twice as high in African Americans as in Whites; reasons for difference not understood fully but appear to be due to genetic heritage and environmental factors

receiving in communication

Awareness of messages you send is only part of process Words and gestures must be interpreted in a specific context to have meaning Receiver attaches meaning determined by his or her past experiences, culture, self-concept, and current physical and emotional state Successful communication requires mutual understanding by sender and receiver Patients' health problems intensify communication because patients depend on you to get better

interpretation

Based on your inference or conclusion It links events, makes associations, implies cause, ascribes feelings Helps person understand his or her own feelings in relation to the verbal message If your inference is incorrect, the patient may correct it, and thus prompt further discussion of topic

main components of mental status exam

Basic functions are assessed first First steps must be accurately assessed to ensure validity of steps that follow Appearance Behavior Cognition Thought processes

acute pain behaviors

Because acute pain involves autonomic responses and has protective purpose, individuals experiencing moderate to intense levels of pain may exhibit the following behaviors: Guarding, grimacing, vocalizations such as moaning, agitation, restlessness, stillness, diaphoresis, or change in vital signs This list of behaviors is not exhaustive because they should not be used exclusively to deny or confirm presence of pain

chronic pain behaviors

Because acute pain involves autonomic responses and has protective purpose, individuals experiencing moderate to intense levels of pain may exhibit the following behaviors: Guarding, grimacing, vocalizations such as moaning, agitation, restlessness, stillness, diaphoresis, or change in vital signs This list of behaviors is not exhaustive because they should not be used exclusively to deny or confirm presence of pain Persons with chronic pain typically try to give little indication they are in pain and therefore are at higher risk for underdetection. Behaviors that have been associated with chronic pain include bracing, rubbing, diminished activity, sighing, and change in appetite. Whenever possible it is best to ask person how they act or behave when in pain. Chronic pain coping behaviors (being with other people, movement, exercise, prayer, sleeping, or inactivity) demonstrate less anticipated ways in which persons behave when they are experiencing chronic pain. Sleeping is one way persons behave in response to chronic pain in order to self distract. Clinical staff may interpret this behavior as "comfort" and not follow up with an appropriate pharmacologic intervention.

pain assessment tools for infants and children

Because infants are preverbal and incapable of self report, pain assessment is dependent upon behavioral and physiologic cues It is important to underscore understanding that infants do feel pain Children 2 years of age can report pain and point to its location They cannot rate pain intensity at this developmental level It is helpful to ask parent or caregiver what words their child uses to report pain Rating scales can be introduced at 4 or 5 years Wong-Baker Scale Oucher Scale

religion

Belief in divine or superhuman power, or powers to be obeyed and worshipped as creator/ruler of universe System of beliefs, practices, and ethical values Shared experience of spirituality

reason for seeking care

Brief spontaneous statement in person's own words describing reason for visit Symptom: subjective sensation person feels from disorder What person says is reason for seeking care is recorded and enclosed in quotation marks to indicate person's exact words Sign: objective abnormality that can be detected on physical examination or in laboratory reports

mouth and pharynx

Buccal mucosa Gums Teeth Tongue Floor of mouth Palate Hard Soft Pharynx Clench teeth & smile to observe tooth occlusion. Upper molars normally rest directly on the lower molars, and the upper incisors slightly override the lower incisors. •Inspect the mucosa for color; hydration; texture; and lesions such as ulcers, abrasions, or cysts. Normally, the mucosa is glistening, pink, smooth, and moist. Some common small, yellow-white raised lesions on the buccal mucosa and lips are Fordyce spots, or ectopic sebaceous glands. If lesions are present, palpate them gently with a gloved hand for tenderness, size, and consistency (usually painless & not significant). •Inspect the gums (gingivae) for color, edema, retraction, bleeding, and lesions. •Inspect the teeth to determine the quality of dental hygiene. Note the color of teeth and the presence of dental caries (cavities), tartar, and extraction sites. Inspection of inner oral mucosa of lower lip.] Retraction of buccal mucosa allows for clear visualization.] Using a penlight for illumination, examine the tongue for color, size, position, texture, and coatings or lesions. Inspect for color, swelling, and lesions such as nodules or cysts. [Image is Figure 16-13 (on text p. 365), The undersurface of the tongue is highly vascular.] Observe the palates for color, shape, texture, and extra bony prominences or defects. •Perform an examination of pharyngeal structures to rule out infection, inflammation, or lesions. [Box 30-16 (on text p. 518) provides patient teaching for mouth and pharyngeal assessment.] [Left image is Figure 30-25 (on text p. 519), The hard palate is located anteriorly in the roof of the mouth.] [Right image is Figure 30-26 (on text p. 519), A penlight and tongue depressor allow the visualization of the uvula and posterior soft palate.]

abnormalities in the cranial nerves

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

cerebral cortex

Cerebral cortex is cerebrum's outer layer of nerve cells Cerebral cortex is center of functions governing thought, memory, reasoning, sensation, and voluntary movement Each half of cerebrum is hemisphere Each hemisphere divided into four lobes: frontal, parietal, temporal, and occipital Important to know lobes because you want to know if someone has a stroke where it would be Damage to specific cortical areas produces a corresponding loss of function: Motor weakness Paralysis Loss of sensation Impaired ability to understand and process language Damage occurs when highly specialized neurologic cells are deprived of blood supply, such as when a cerebral artery becomes occluded

motor system dysfunction

Cerebral palsy Muscular dystrophy Hemiplegia Parkinsonism Cerebellar Paraplegia Multiple sclerosis

attention span

Check person's ability to concentrate by noting whether he or she completes a thought without wandering Attention span commonly is impaired in people who are anxious, fatigued, or intoxicated

developmental care of aging adults

Check sensory status, vision, and hearing before any aspect of mental status Confusion is common and is easily misdiagnosed One third to one half of older adults admitted to acute-care medical and surgical services show varying degrees of confusion already present In the community, about 5% of adults over 65 and almost 20% of those over 75 have some degree of clinically detectable impaired cognitive function Check sensory status before assessing any aspect of mental status Vision and hearing changes due to aging may alter alertness and leave the person looking confused When older people cannot hear your questions, they may test worse than they actually are One group of older people with psychiatric mental illness tested significantly better when they wore hearing aids

chest circumference

Chest grows at faster rate than cranium; between 6 months and 2 years, both measurements about same, and after age 2 chest circumference greater than head circumference Measurement of chest circumference is valuable in a comparison with head circumference, but not necessarily by itself Encircle tape around chest at nipple line It should be snug, but not so tight it leaves a mark

cerebellum

Coiled structure located under occipital lobe concerned with coordination of voluntary movements, equilibrium, and muscle tone Does not initiate, but coordinates and smoothes movements Coordinates many different muscles needed in playing piano, swimming, or juggling Adjusts and corrects voluntary movements, but operates entirely below conscious level

lips

Color Texture Hydration Contour Lesions Lips are normally pink, symmetrical, smooth, and moist. Lip color in the dark-skinned patient varies from pink to plum. •Anemia → pallor of the lips, w/cyanosis caused by respiratory or CV problems. Cherry-colored lips indicate carbon monoxide poisoning. •Evaluate any lesion for potential of being an infection, an irritation, or skin cancer.

upper neurons

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

Mini Mental State Exam

Concentrates only on cognitive functioning, not on mood or thought processes Standard set of 11 questions, 5-10 minutes to administer Useful for both initial and serial measurement, so worsening or improvement of cognition over time and with treatment can be assessed Good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illness Normal mental status average 27; Score 24-30 = no cognitive impairment

nails

Condition of nails reflects: General health State of nutrition Occupation Level of self-care Age How do you assess nails? inspection and palpation. •Trauma, cirrhosis, diabetes mellitus, and HTN cause splinter hemorrhages. •Vitamin, protein, and electrolyte changes cause various lines or bands to form on the nail beds. Elderly-grow more slowly, lack luster, longitudinal ridges from trauma at nail matrix Nail clubbing: heart dx, lung ca, pulmonary dx. If dx is treated, clubbing may resolve. Capillary refill - blanch, release. Good circulation = color return<1-2 sec.

spinothomalic tract

Contains sensory fibers that transmit sensations of pain, temperature, and crude or light touch Fibers enter dorsal root of spinal cord and synapse with a second sensory neuron At thalamus, fibers synapse with third sensory neuron, carrying message to sensory cortex for full interpretation

motor pathways

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

infants and children developmental competence

Covers behavioral, cognitive, and psychosocial development and examines how child is coping with his or her environment Follow A-B-C-T guidelines as for adults, with consideration for developmental milestones Abnormalities often problems of omission; child does not achieve expected milestone Parent's health history, especially sections on developmental history and personal history, yields most of mental status data

general survey

Covers general health state and any obvious physical characteristics An introduction for physical examination that will follow; should give an overall impression, a "gestalt," of person Objective parameters are used to form general survey, but these apply to whole person, not just to one body system What leaves an immediate impression? Does person stand promptly as his or her name is called and walk easily to meet you? Consider these 4 areas: physical appearance, body structure, mobility, and behavior

pathways of CNS

Crossed representation is notable feature of nerve tracts Left cerebral cortex receives sensory information from and controls motor function to right side of the body Right cerebral cortex likewise interacts with left side of body Knowledge of where fibers cross midline will help interpret clinical findings

cultural sensitivity

Culture influences a patient's behavior. Consider health beliefs, use of alternative therapies, nutritional habits, relationships with family, and personal comfort zone. Avoid stereotyping. Avoid gender bias Cultural characteristics ≠ physical characteristics. •Learn to recognize common characteristics and disorders among members of ethnic populations in your area. Why do you think it's important to be aware of disorders that are more commonly seen in a particular ethnic group? Discuss: More likely to recognize rare conditions unique to each ethnic group, which will lead to higher-quality care. •Recognition and respect for cultural diversity lead to pt. satisfaction and improved clinical outcomes.

working phase

Data-gathering phase Verbal skills include questions to patient your responses to what is said

Parkinsons disease

Deficiency of neurotransmitter dopamine and degeneration of basal ganglia of brain. Immobility of features ...flat and expressionless face, masklike, elevated eyebrows, staring gaze, oily skin, drooling

inspection

Deliberate and purposeful observation in systematic manner Observer uses his/her vision, sense of smell, and hearing Describe size - position color - symmetry shape

clinical reasoning models

Diagnostic Reasoning Critical Thinking Nursing Process

common skin lesions in children

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

additional history for infants and children

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

edema causes

Direct trauma and impairment of venous return. Inspect edematous areas for location, color, and shape. The formation of edema separates the surface of the skin from pigmented and vascular layers, masking skin color.

orientation

Discern orientation through course of interview, or ask for it directly, using tact: "Some people have trouble keeping up with dates while in the hospital; what is today's date?" Time: day of week, date, year, season Place: where person lives, address, phone number, present location, type of building, name of city and state Person: own name, age, who examiner is, type of worker Many hospitalized people normally have trouble with exact date but are fully oriented on remaining items

chloasma

Discoloration changes on face representing the "mask of pregnancy

dizziness/vertigo questions

Do you ever feel a lightheaded, swimming sensation, like feeling faint? When have you noticed this? How often does it occur? Does it occur with activity or a change in position? Do you ever feel a sensation called vertigo, a rotational spinning sensation? Do you feel as if the room spins, or do you feel you are spinning? Does it come on suddenly or gradually?

significant history

Do you have a history of stroke (cerebrovascular accident), spinal cord injury, meningitis or encephalitis, congenital defect, or alcoholism?

incoordination

Do you have any problem with balance when walking? Any falling? Which way? Do your legs seem to give way? Any clumsy movement? Cerebellum

difficulty speaking

Do you have difficultly forming words or saying what you intend? When did you first notice this? How long did it last?

difficulty swallowing

Do you have difficulty swallowing solids or liquids? Have you experienced excessive saliva or drooling?

numbness or tingling

Does it ever feel like pins and needles? When did this start? Where do you feel it? Does it occur with activity?

the aging adult integumentary system

Elasticity Loses elasticity; skin folds and sags Sweat and sebaceous glands Decrease in number and function, leaving skin dry Senile purpura Discoloration due to increasing capillary fragility Skin breakdown due to multiple factors Cell replacement is slower and wound healing is delayed Hair matrix Functioning melanocytes decrease, leading to gray fine hair

external factors of communication

Ensure privacy Refuse interruptions Physical environment Dress Noise Note-Taking EMR

cranial nerves

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

integumentary system development for children

Epidermis thickens, darkens, and becomes lubricated Hair growth accelerates

seizures

Ever had any convulsions? When did they start? How often do they occur? When seizure starts, do you have warning sign? Motor activity: Where in your body do seizures begin? Do seizures travel through your body? Do they occur on one side or both? Do you have any associated signs, such as color change in face or lips, loss of consciousness, or incontinence? Are there any precipitating factors? Does anything seem to bring on seizures, such as activity, discontinuing medication, fatigue, stress? Postictal phase: After having a seizure, do you sleep? Do you have confusion, weakness, headache, or muscle ache? Are you on any medication? Coping strategies: How have seizures affected daily life and your occupation? Tremors: Any shakes or tremors in hands or face? When did these start? Do they seem to grow worse with anxiety, intention, or rest? Do they affect daily activities?

Cushing syndrome

Excessive ACTH (adrenocorticotropin hormone) & chronic steroid use... rounded "moonlike" face w/prominent jowls red cheeks hirsutism on upper lip, lower cheeks, chin, and chest rash

Nose assessment

Excoriation Polyps When inspecting the external nose, observe for shape, size, skin, color, and the presence of deformity or inflammation. If swelling or deformities exist, gently palpate the ridge and soft tissue of the nose by placing one finger on each side of the nasal arch and gently moving the fingers from the nasal bridge to the tip. How can the color of nasal discharge indicate patient condition? Discuss: Pale mucosa with clear discharge indicates allergy. A mucoid discharge indicates rhinitis. A sinus infection results in yellowish or greenish discharge.] For the patient with a nasogastric tube, routinely check for local skin breakdown (excoriation) of the naris, characterized by redness and skin sloughing. During the examination, note any polyps (tumorlike growths) or purulent drainage.

development of integumentary system for aging adult

Facial bones and orbits appear more prominent, facial skin sags resulting from ↓ elasticity, ↓ subcutaneous fat, and ↓ moisture in skin Lower face may look smaller if teeth have been lost

behavioral signs of pain

Facial expressions Restlessness Change in activity Crying if they are unable to self report

lower motor neurons

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

summary

Final review of what person has said; it condenses facts and presents your view of health problem Is a type of validation that person can agree with or correct; both you and patient should participate Occurring at the end of the interview, it signals that termination of the interview is near

abnormalities in muscle tone

Flaccidity Spasticity Rigidity Cogwheel rigidity

adolescents screening test

Follow same A-B-C-T guidelines as for adults (Appearance - Behavior - Cognition - Thought process)

confrontation

Frame of reference shifts from patient's perspective to yours May focus on discrepancy or inconsistency in person's narrative You have observed a certain action, feeling, or statement and now focus person's attention on it You give honest feedback about what you see or feel "Jane, you've said you don't drink but I see an airline bottle of alcohol in your purse."

components of mental status exam

Full mental status examination is a systematic check of emotional and cognitive functioning Usually, mental status can be assessed in the context of the health history interview Keep in mind the four main headings of mental status assessment (Objective Data): A-B-C-T Appearance Behavior Cognition Thought processes

balance test for cerebellar function

Gait: observe as person walks 10 to 20 feet, turns, and returns to starting point; normally person moves with a sense of freedom; gait is smooth, rhythmic, and effortless; opposing arm swing is coordinated; person turns smooth; step length about 15 inches from heel to heel Ask person to walk straight line in heel-to-toe fashion; this decreases base of support and accentuates any problem with coordination; normally person can walk straight and stay balanced You may also test for balance by asking person to walk on toes, then on heels for a few steps

older adult review of systems

General Skin Eyes Ears Mouth Respiratory system Cardiovascular system Peripheral vascular system Urinary system Sexual health Musculoskeletal system Neurologic system Pay attention to urinary system especially; as people get older, they start to get up in the middle of the night to go to the bathroom, there is a greater risk of falling. Especially with lower visual acuity. Enlarged prostate also makes them have to go to the bathroom in the middle of the night

past health of older adult

General health in past 5 years Accidents or injuries, serious or chronic illnesses, hospitalizations, operations Last examination Obstetric history Current Medications Also consider following issues: Some older persons take large number of drugs prescribed by different physicians Person may not know drug name or purpose Ask person to bring in drug to be identified When person is unable to afford drug, he or she may decrease dosage or not refill immediately Travel to pharmacy may present a problem May use over-the-counter medications for self-treatment Some share medications with neighbors or friends have them bring in bottles so we know exactly what they are taking

review of systems

General overall health state Skin Hair Head Eyes Ears Nose and Sinuses Mouth and Throat Neck Breast Axilla Respiratory system Cardiovascular Peripheral vascular Gastrointestinal Urinary system Male genital system Female genital system Sexual health Musculoskeletal system Neurologic system Hematologic system Endocrine system

culture and genetics

Genetic attributes of dark-skinned individuals afford protection against skin cancer due to melanin Increased likelihood of skin cancer in Whites than in Black and Hispanic populations Most important environmental risk factor for skin cancer is exposure to ultraviolet (UV) radiation both from sun and tanning sources Increased risk for melanoma related to increased number of sunburns during one's lifetime Certain skin presentations associated with different ethnic groups

closing phase

Give the patient a gentle warning the interview is about to end Ask "Is there anything you else you would like to mention?" "Are there any questions you would like to ask?" "Are there any other areas I should have asked about?" "We have covered a number of concerns today, what would you most like to accomplish?" End with a Thank you. ("T" of AIDET)

silent attentiveness

Gives patient time to think and organize what to say without interruption from you Gives you a chance to observe person unobtrusively and note nonverbal cues

hyperthyroidism

Goiter Exophthalmos Nervousness Fatigue Weight loss Muscle cramps Heat intolerance T3, T4, TSH Tachycardia, SOB Fine muscle tremor Thin silky hair Infrequent blinking Staring appearance Excessive sweating Moist skin

hair and scalp

Hair: Color Distribution Quantity Thickness Texture Lubrication Careful inspection of hair follicles on the scalp and pubic areas can reveal lice or other parasites. •Gender & race specific ∆: AfrAm hair: fragile, spiraled/thick/kinky, dry - needing gentle brushing & oil Asians: straight, silky hair •Hair loss (alopecia) or thinning r/t genetic tendencies or endocrine disorders such as diabetes, thyroiditis, and even menopause. •Normal aging - ↓ functioning melanocytes → hair thin, fine, gray/white. Male patterned baldness. ↓axillary/pubic hair Age-related differences will be seen across the life span.

head injury questions

Have you ever had any head injury? What part of head was injured? Describe. Did you have loss of consciousness? For how long?

CAGE test

Have you ever thought you should Cut down your drinking? Have you ever been Annoyed by criticism of your drinking? Have you ever felt Guilty about your drinking? Do you drink in the morning, an Eye opener?

headache questions

Have you had any unusually frequent or severe headaches? When did this start? How often does it occur? Where do you feel headaches? Do headaches seem to be associated with anything?

Children health history

Health history adapted to include information specific for age and developmental stage of child Biographic data Source of history Person providing information and relation to child Your impression of reliability of information Any special circumstances, e.g., use of an interpreter Reason for seeking care history of present Illness Severity of pain: note effect on usual behavior, e.g., does it stop child from playing? Associated factors, such as relation to activity, eating, and body position Parent's intuitive sense of problem often accurate; even if proven otherwise, this gives an idea of parent's area of concern Parent's coping ability and reaction of other family members to child's symptoms or illness Munchausen syndrome by proxy

four unrelated word test

Highly sensitive and valid memory test Requires more effort than recall of personal or historic events, and avoids danger of unverifiable recall Pick four words with semantic and phonetic diversity; ask person to remember the four words To be sure person understood, have him or her repeat the words Ask for the recall of four words at 5, 10, and 30 min Normal response for persons younger than 60 is an accurate 3 or 4 word recall after 5, 10, and 30 min.

Webers Test

Hold fork at base and tap it lightly against heel of palm. Place base of vibrating fork on midline vertex of patient's head or middle of forehead. Ask patient if he or she hears the sound equally in both ears or better in one ear (lateralization). This test is done for lateralization of sound. •Rationale: Patient with normal hearing hears sound equally in both ears. In conduction deafness, sound is heard best in impaired ear. In sensorineural hearing loss, sound is heard better in normal ear. [Image is from Table 15-7 (on text p. 350) , Tuning Fork Tests.]

HEEADSSS psychosocial interview

Home environment Education/employment Eating Activities - peer related Drugs Sexuality Suicide and depression Safety from injury & violence

pain assessment

How does the nurse assess for breakthrough pain? How does the nurse conduct a pain reassessment? What are common challenges with pain assessment? When does the nurse use a surrogate to facilitate pain assessment?

abnormal findings in body height and proportion

Hypopituitary dwarfism Gigantism Acromegaly (hyperpituitarism) Achondroplastic dwarfism Anorexia nervosa Marfan syndrome Endogenous obesity: Cushing syndrome

abnormal findings in blood pressure

Hypotension Hypertension

Graves' Disease

Immune disorder of butterfly-shaped thyroid gland (overproduction of thyroid hormone)

infants and children BP

In children aged 3 and older, and in younger children at risk, measure a routine BP at least annually For accurate measurement in children, make some adjustment in choice of equipment and technique Most common error is to use incorrect size cuff Cuff width must cover two thirds of upper arm, and cuff bladder must completely encircle it Use a pediatric-sized end piece on stethoscope to locate sounds

remote memory

In the context of the interview, ask the person verifiable past events; for example, ask to describe past health, the first job, birthday and anniversary dates, and historical events that are relevant for that person Remote memory is lost when cortical storage area for that memory is damaged, such as in Alzheimer disease, dementia, or any disease that damages cerebral cortex

heritage assessment

Indicators of heritage consistency Childhood occurred in country of origin or immigrant neighborhood of like ethnic group Extended family support of traditional activities Frequent visits to old country or old neighborhood Family home within ethnic community to which they belong Participation in ethnic cultural events Raised in extended family setting Regular contact with extended family Name not anglicized Educated in parochial school Social activities primarily with members of ethnic community Knowledge of language/culture of origin Expresses pride in heritage

preparation for examination

Infection control Environment Equipment Physical preparation of patient Positioning Psychological preparation of patient Assessment of age groups Follow to ensure that your pt is physically & emotionally ready for exam. Wash hands in front of pt. •The environment must provide privacy, good lighting, ↓background noise, and climate control. The patient must be comfortable. •Inform pt what will occur and when. Proper draping is necessary, as is proper positioning. •Encourage the patient to ask questions. If pt/nurse/physician are of opposite gender, 3rd person in the room may be indicated. (1st pelvic exam, testicular exam) Consider cultural and social norms. •When assessing various age groups, you may have to vary your techniques and styles. Children require different handling than do adolescents, adults, and the elderly.

head and neck examination

Inspect and palpate the skin General size and contour Note any deformities Palpate temporal artery and temporomandibular joint (TMJ) Inspect and palpate the face Observe facial expression Cranial nerve VII: symmetry of movement Observe for any abnormal movements Inspect and palpate the neck Active ROM, potential enlargement and position of trachea Auscultate thyroid (if enlarged) for bruit Cranial nerve 7 = facial muscles

summary checklist of skin hair and nails

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

mental status examination

Integrating mental status examination into the health history interview is sufficient for most people You will collect ample data to be able to assess mental health strengths and coping skills and to screen for any dysfunction When any abnormality in affect or behavior is discovered and in certain situations, it is necessary to perform a full mental status examination

skin

Integument Color Pigmentation Cyanosis Jaundice Erythema Moisture Temperature Texture Turgor Localized skin changes e.g. pallor, erythema (red discoloration) indicate circulatory changes. For example, an area of erythema is caused by localized vasodilation resulting from sunburn, inflammation, or fever.

phases of an interview

Introducing the interview Working Phase - gather data Closing - Is there anything else you'd like to mention?

introduction part of interview

Introduction of self "I" Purpose "E" Length of time "D" Expectations from participants "E" Other participants other than patient "E" Confidentiality "E" The "I" "D" and "E" of AIDET.

auscultation of integumentary system

Involves listening to sounds Learn normal sounds first before identifying abnormal sounds or variations. Requires a good stethoscope Requires concentration and practice Some sounds you can hear without assistance; other sounds require the use of a stethoscope. •Becoming proficient in auscultation requires that you recognize the sounds produced by body parts and the best locations for hearing sounds. •Bell: low-pitched sounds Diaphragm: high-pitched sounds

weakness

Is this generalized or local? Does weakness occur with particular movement? Is it hard to get up out of a chair or reach for an object? With distal or small muscle weakness, it is hard to open a jar, write, use scissors, or walk without tripping?

mood and affect

Judge by body language and facial expression and by asking directly, "How do you feel today?" or "How do you usually feel?" Mood should be appropriate to person's place and condition and should change appropriately with topics; person is willing to cooperate

Speech

Judge the quality of speech, noting that person makes sounds effortlessly and shares conversation appropriately Pace of conversation is moderate, and stream is fluent Articulation (the ability to form words) is clear and understandable Word choice is effortless and appropriate to educational level; person completes sentences, occasionally pausing to think

Behavior

Level of consciousness Facial expression Speech Mood and affect

internal factors of communication

Liking others - helping others Empathy - feeling with the person; ability to recognize how another perceives the world Ability to listen - active listening, don't interrupt Self-awareness - aware of personal biases, prejudices, stereotypes

Bell's palsy

Lower motor neuron lesion (peripheral) rapid onset of cranial nerve VII (7) paralysis of facial muscles (reactivation of HSV-1): paralysis of ½ face, cannot wrinkle forehead, smooth forehead, drooling, pain behind ear.

thalamus

Main relay station where sensory pathways of spinal cord, cerebellum, and brain stem form synapses

hypothalamus

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

aging adults: orientation

Many aging persons experience social isolation, loss of structure without a job, change in residence, or some short-term memory loss Consider them oriented to time if year and month are correctly stated Orientation to place is accepted with correct identification of the type of setting (e.g., the hospital and name of town) new learning In people of normal cognitive function, age-related decline occurs in performance in the Four Unrelated Words Test Octogenarians (80+ y/o) average 2 of 4 words recalled over 5 minutes and will improve performance at 10 and 30 minutes after being reminded by verbal cues (< 60 y/o, 3-4 words) The performance of those with Alzheimer disease does not improve on subsequent trials

sensory pathways

Millions of sensory receptors are embroidered into skin, mucous membranes, muscles, tendons, and viscera Monitor conscious sensation, internal organ functions, body position, and reflexes Sensation travels in afferent fibers in peripheral nerve, through posterior (dorsal) root, and into spinal cord There, may take one of two routes: spinothalamic tract or posterior (dorsal) columns Sensory cortex arranged in corresponding "map" of body; pain in right hand perceived at specific spot on left cortex map Some organs absent from brain map, such as heart, liver, or spleen; you know you have one, but have no "felt image" of it Pain originating in these organs is referred, e.g., pain in heart referred to chest, shoulder, and left arm, neighbors in fetal development; pain originating in spleen felt on left shoulder

holistic health

Mind, body, and spirit are interdependent Assessment expanded to include lifestyle behaviors culture and values family and social roles self-care behaviors job-related stress developmental tasks failures/frustrations of life

Supplemental mini status exam

Mini-Cog is a reliable, quick, and easily available instrument to screen for cognitive impairment in healthy adults Consists of 3 item recall test and clock-drawing test Tests person's executive function, including ability to plan, manage time, and organize activities, and working memory Those with no cognitive impairment or dementia can recall the three words and draw a complete, round, closed clock circle with all face numbers in correct position and sequence and hour and minute hands indicating time you requested

african americans

More likely than whites to have high blood pressure Tend to have strokes earlier in life and with more severe results than whites Have almost twice risk of first stroke compared with whites

infants motor system

Motor system Observe spontaneous motor activity for smoothness and symmetry; smoothness of movement suggests proper cerebellar function, as does coordination involved in sucking and swallowing Screen gross and fine motor coordination using Denver II test with its age-specific developmental milestones Assess muscle tone by first observing resting posture Newborn favors flexed position; extremities symmetrically folded inward, hips slightly abducted, and fists tightly flexed

biographical data

Name Address and phone number Age and birth date Birthplace Sex Marital status Race Ethnic origin Occupation: usual and present Where people have lived before could create a difference in our findings. Environmental hazards so we want to know occupation (what they are at a greater risk for)

neck

Neck muscles Anterior triangle Posterior triangle Lymph nodes Malignancy Carotid artery Jugular vein •Inspect the neck in the usual anatomical position, flexed forward, hyperextended backward, and moved laterally and sideways to test the sternocleidomastoid and trapezius muscles. •The sternocleidomastoid and trapezius muscles outline the areas of the neck, dividing each side of the neck into two triangles. The anterior triangle contains the trachea, thyroid gland, carotid artery, and anterior cervical lymph nodes. The posterior triangle contains the posterior lymph nodes. [Image is Figure 13-4 (on text p. 253), Anatomical position of major neck structures. Note triangles formed by the sternocleidomastoid muscle, lower jaw, and anterior neck anteriorly and the sternocleidomastoid muscle, trapezius muscle, and lower neck posteriorly. ] Torticollis (Wryneck) - head tilting to 1 side r/t hematoma in one sternomastoid muscle, requires tx so muscle won't become fibrotic and permanently shortened resulting in permanent ROM impairment. An abnormality of superficial lymph nodes sometimes reveals the presence of an infection or malignancy. [Palpable lymph nodes in the head and neck.] Order of Palpation Occipitital nodes Post auricular Pre aruicular Retropharyngeal (tonsillar) Submandibular Submental Supraclavicular Note direction of drainage to discover where infection might be. To palpate supraclavicular nodes, ask the patient to bend the head forward and relax the shoulders. Palpate these nodes by hooking the index and third fingers over the clavicle lateral to the sternocleidomastoid muscle. •You may postpone examination of the jugular veins and carotid arteries until the vascular system assessment is performed. •Never palpate both of the carotid arteries simultaneously. [Box 13-3 (on text p. 252) provides patient teaching for neck assessment.]

infants and neurological system

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

lymph nodes

Normal nodes feel movable, discrete, soft, and nontender If palpable, note location, size, shape, delimitation (discrete or matted together), mobility, consistency, and tenderness If enlarged or tender, check area they drain for source of the problem; they often relate to inflammation or neoplasm in head and neck Follow up on or refer your findings; an enlarged lymph node, particularly when you cannot find the source of problem, deserves prompt attention!

older adult family history

Not as useful in predicting which familial diseases person may contract, because most of those will have occurred at an earlier age Useful to assess which diseases or causes of death of relatives person has experienced Also describes person's existing social network

reflexes in infants

Note if milestones normally expected for each month achieved, and more primitive reflexes eliminated from baby's repertory when expected Observations of infant's spontaneous waking activity, responses to environmental stimuli, and social interaction with parents and others By 2 months, baby smiles and recognizes parent's face Babbling occurs at 4 months, and one or two words (mama, dada) used nonspecifically after 9 months Reflexes Infantile automatisms: reflexes that have predictable timetable of appearance and departure For screening examination, just check rooting, grasp, tonic neck, and Moro reflexes Rooting reflex Palmar grasp Plantar grasp Tonic neck reflex

ear canals and eardrums

Observe the deeper structures of the external and middle ear with the use of an otoscope. Adult/older child - insert scope while pulling auricle up & backward. This maneuver straightens the ear canal. Infants-pull auricle DOWN and backward.

objective data

Observed during physical exam when inspecting, percussing, palpating, and auscultating patient Laboratory and diagnostic studies

pain subjective data

Pain is always subjective. Pain is whatever the experiencing person says it is, existing whenever he or she says it does. Patient's subjective report is most reliable indicator of pain.

spinothalamic tract sensory assessment

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

infants and children (pulse, HR, respirations)

Palpate or auscultate an apical rate with infants and toddlers In children older than 2, use radial site Count pulse for a full minute to take into account normal irregularities, such as sinus arrhythmia Heart rate normally fluctuates more with infants and children than adults from exercise, emotion, and illness Respirations Watch infant's abdomen for movement, because infant's respirations normally more diaphragmatic than thoracic

sinus assessment

Palpation of Maxillary Sinus Examination of the sinuses involves palpation.

abnormalities in muscle movement

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

abnormal facial appearances associated with chronic illnesses

Parkinson syndrome Cushing syndrome Graves disease/ Hyperthyroidism Myxedema (hypothyroidism) Bell's palsy Brain attack or cerebrovascular accident Cachectic appearance Scleroderma

preparation for neuro assessment

Perform screening neurologic examination on well persons with no significant findings from history Perform complete neurologic examination on persons with neurologic concerns, e.g., headache, weakness, loss of coordination, or who have shown signs of neurologic dysfunction Perform neurologic recheck examination on persons with demonstrated neurologic deficits who require periodic assessments, e.g., hospitalized persons or those in extended care Integrate steps of neurologic examination with examination of particular part of body Test cranial nerves while assessing head and neck; test superficial abdominal reflexes while assessing abdomen Record all neurologic data together as a functional unit Use following sequence for complete neurologic examinatinon Mental status Cranial nerves Motor system Sensory system Reflexes Equipment needed: Penlight Tongue blade Cotton swab Cotton ball Tuning fork: 128 Hz or 256 Hz Percussion hammer

IPPA

Performed in this order except for abdomen need to listen to Bowel sounds first because palpation may stimulate peristalsis. Inspection: looking (eyes, skin, etc), listening, smelling Palpation: touch. Means to feel with fingertips Percussion: listening to the bum bum sound Auscultation: listening through stethosope

common patterns of sensory loss

Peripheral neuropathy Loss of sensation involves all modalities; loss most severe distally at feet and hands Individual nerves or roots Decrease or loss of all sensory modalities; corresponds to distribution of involved nerve Spinal cord hemisection (Brown-Séquard syndrome) Loss of pain and temperature, contralateral side, loss of vibration and position discrimination on ipsilateral (same) side Complete transection of spinal cord Complete loss of all sensory modalities below level of lesion; associated with motor paralysis and loss of sphincter control Thalamus Loss of all sensory modalities on face, arm, and leg; contralateral to lesion Cortex Loss of discrimination on contralateral side; loss of graphesthesia, stereognosis, recognition of shapes and weights, finger finding

Level of consciousness

Person is awake, alert, aware of stimuli from environment and within self Responds appropriately and reasonably soon to stimuli

grooming and hygiene

Person is clean and well groomed; hair is neat and clean Use care in interpreting clothing that is disheveled, bizarre, or in poor repair, as well as piercings and tattoos (may reflect person's economic status or deliberate fashion trend, especially among adolescents) Disheveled appearance in previously well-groomed person is significant

arm blood pressure procedure

Person may be sitting or lying, with bare arm supported at heart level Palpate brachial artery Apply BP cuff center it about 2.5 cm (1 in) above brachial artery and wrap it evenly Again, palpate brachial or radial artery Inflate cuff until artery pulsation obliterated and then 20 to 30 mm Hg beyond Deflate cuff quickly and completely; wait 15 to 30 seconds before reinflating so blood trapped in veins can dissipate Place bell of stethoscope over site of brachial artery, making a light but airtight seal Diaphragm end piece usually adequate, but bell designed to pick up low-pitched sounds of blood pressure reading So if you have a bell, use it Rapidly inflate cuff to maximal inflation level you determined Then deflate the cuff slowly and evenly, about 2 mm Hg per heartbeat Note points at which you first hear sound, then muffling of sound, and finally the disappearance of sound Korotkoff 1= "tapping" (Systolic) Korotkoff 5= silence (Diastolic)

perceptions

Person should be consistently aware of reality; perceptions should be congruent with yours

Racial differences evident in palpebral fissures

Persons of Asian origin often identified by eyes, whereas presence of narrowed palpebral fissures in non-Asian individuals may be diagnostic of congenital anomaly, Down syndrome Culturally based variability exists in color of iris and retinal pigmentation, with darker irises having darker retinas behind them Normal 10mm vertically 30 mm horizontally

nonverbal skills/cues

Physical appearance Posture Gestures Facial expression Eye contact Voice Touch

Rinne test

Place stem of vibrating tuning fork against patient's mastoid process (see illustration B). Begin counting the interval with your watch. Ask patient to tell you when she no longer hears the sound; note number of seconds. Quickly place still-vibrating tines 1 to 2 cm (1/2 to 1 inch) from ear canal, and ask patient to tell you when she no longer hears the sound. Continue counting time the sound is heard by air conduction Compare number of seconds the sound is heard by bone conduction versus air conduction. Patient should hear air-conducted sound twice as long as bone-conducted sound (2:1 ratio). For example, if patient hears bone-conducted sound for 10 seconds, he or she should hear air-conducted sound for an additional 10 seconds. •In conduction deafness, patient hears bone conduction longer than air conduction in affected ear. •In sensorineural loss, patient hears air conduction longer than bone conduction in affected ear, but at less than a 2:1 ratio. This test is done for comparison of air and bone conduction. (Sound heard twice as long by air conduction as by bone conduction.)

external eye structure

Position and alignment Eyebrows Eyelids Lacrimal apparatus Conjunctivae and sclerae Corneas Pupils and irises PERRLA

Appearance

Posture Erect and position relaxed Body movements Body movements voluntary, deliberate, coordinated, and smooth and even Dress Appropriate for setting, season, age, gender, and social group (fashion trend?) Appearance can be affected by fashion trends and economic status, in addition to changes in mental status. Posture; looking for signs of a stroke or something like that Grooming and hygiene

past health for children

Prenatal status Labor and delivery Postnatal status Childhood illnesses Serious accidents or injuries Serious or chronic illnesses Operations or hospitalizations Immunizations and allergies Medications

racial variations in disease

Primary open-angle glaucoma affects African Americans 3-6 times more often than Whites and is 6 times more likely to cause blindness than in Whites; reasons are not known Lose peripheral vision. Prevalence rates are 50% higher for those living below the poverty level than among other adults

socialization

Process of being raised within a culture and acquiring characteristics of that group

clinical judgment

Process of forming an opinion or evaluation The foundation for safe and effective nursing practice

Opisthotonos

Prolonged arching of back, with head and heels bent backward; indicates meningeal irritation

eyes and aging adult

Pupil size decreases Lens loses elasticity, becoming hard and glasslike, which decreases ability to change shape to accommodate for near vision; this condition is termed presbyopia By age 70, normally transparent fibers of lens begin to thicken and yellow, the beginning of cataracts Visual acuity may diminish gradually after age 50, and more so after age 70

RESPECT

Realize you must know heritage of yourself and patient Examine patient within cultural context Select simple questions and speak slowly Pace questioning throughout exam Encourage patient to discuss meaning of health and illness with you Check patient's understanding and acceptance of recommendations Touch patient within boundaries of his or her heritage

empathy

Recognizes a feeling and puts it into words Names the feeling and allows expression of it Patient feels accepted and can deal with feeling openly

source of history

Record who furnishes information, usually the person, although source may be relative or friend Judge reliability of informant and how willing he or she is to communicate A reliable person always gives same answers when questions are rephrased or are repeated later in interview Note any special circumstances, such as use of interpreter

deep tendon reflex scale

Reflex response graded on 4-point scale 4 = very brisk, hyperactive with clonus, indicative of disease 3 = brisker than average, may indicate disease 2 = Average, normal 1 = diminished, low normal, or occurs with reinforcement 0 = no response Subjective scale requires clinical practice; scale not completely reliable; a wide range of normal exists in reflex responses

percussion sounds

Resonant: medium-loud, low, clear/hollow, normal lung Hyperresonant: louder, lower, booming, abnormal adult lung/normal child lung Tympany: loud, high, musical and drumlike, stomach or air-filled cheek Dull: soft, high, muffled thud, liver/spleen (dense organ) Flat: very soft, high, absolute dullness, thigh/bone, tumor (no air present; "dead stop of sound")

internal eye structure

Retina Choroid Optic nerve disc Macula Fovea Centralis Retinal vessels Especially examine pts w/diabetes, HTN, & intracranial disorders. •Exam of internal eye structures w/ophthalmoscope is beyond the scope of practice of new graduate nurses. APNs use ophthalmoscope to inspect the fundus. [Images are Figure 30-15 (on text p. 512), Fundus of (A) white patient and (B) black patient.]

integumentary system development for adolescents

Secretions from apocrine sweat glands increase Subcutaneous fat deposits increase Secondary sex characteristics

muscles

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

complete physical examination

Skin assessment integrated throughout examination Scrutinize the outer skin surface first before you concentrate on underlying structures Separate intertriginous areas (areas with skinfolds) such as under large breasts, obese abdomen, and groin, and inspect them thoroughly These areas are dark, warm, and moist and provide perfect conditions for irritation or infection Always inspect feet, toenails, and between toes

infant skin presentations

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

skin function

Skin is waterproof, protective, and adaptive Protection from environment Prevents penetration Perception Temperature regulation Identification Communication Wound repair Absorption and excretion Production of vitamin D

snellen chart

Snellen chart for distance visual acuity. Numerator is the distance away from the chart. Should be 20. (Visual impairment is not being able to see line 20/50 or lower on chart. Denominator is the distance normal person would be standing to read each line. Larger the denominator, the poorer the vision. 20/30=can read at 20 ft what normal eye can see from 30 ft away.(Must note if test is done w/correction or w/o.) By 40 y/o in 50% of people, lens loses elasticity and ability to accommodate for near vision "presbyopia." Need magnification for reading ("cheaters"). Visual acuity

abnormal gaits

Spastic hemiparesis Cerebellar ataxia Parkinsonian (festinating) Scissors Steppage or footdrop Waddling Short leg

Whisper test

Stand 1-2 ft behind pt (to prevent lip reading) Instruct pt to place 1 finger on tragus of left ear to obscure sound. Whisper word with 2 distinct syllables toward pt's right ear. Ask pt to repeat word back. Repeat test for left ear. Pt should correctly repeat 2 syllable word.

objective data- body structure

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

assessment tools

Stethoscope Sphygmomanometer Penlight Gloves Percussion hammer Tuning fork Wooden tongue blade Cotton balls Metric ruler Snellen visual acuity chart Opthalmoscope Otoscope

Striae gravidarum

Stretch marks, which can develop over the abdomen, breast, and thighs

pregnancy skin

Striae Linea nigra Chloasma Vascular spiders

percussion

Striking an object against another to produce a sound Percussion tones Location Shape Size Tissue density Percussion through middle finger. As sound changes can determine the location or size of something

inspection and palpation of the neck

Symmetry Range of motion Lymph nodes Trachea Thyroid gland Posterior approach Anterior approach If enlarged, auscultate thyroid for bruit, if enlarged

orthostatic bp

Take serial measurements of pulse and blood pressure in the following situations: You suspect volume depletion Person is known to have hypertension or taking antihypertensive medications Person reports fainting or syncope Position changed from supine to standing, normally slight decrease (less than 10 mm Hg) in systolic pressure may occur Have person rest supine for 2 or 3 minutes, take baseline readings of pulse and BP, and then repeat with person sitting and then standing For person who is too weak or dizzy to stand, assess BP supine and then sitting with legs dangling Record BP by using even numbers Also record person's position, arm used, and cuff size, if different from standard adult cuff Record pulse rate and rhythm, noting whether pulse is regular

percussion of integumentary system

Tap body with fingertips to produce a vibration. Sound determines location, size, and density of structures. Dull: dense organ - liver or spleen Tympany: air filled - stomach, intestine Flat: no air - thigh muscle, bone, tumor Resonant: normal lung Hyperresonant: child's lung or abnormal finding for adult lung (emphysema) Know densities of structures to locate organs or masses, to map their boundaries, and to determine their size. •An abnormal size suggests a mass or air or fluid within an organ or cavity. •Developing the skill of percussion requires practice. Jarvis, p 117, Table 8-1 Characteristics of Percussion

aging adult physical exam

Temporal arteries may look twisted and prominent In some aging adults, a mild rhythmic tremor of head may be normal Senile tremors are benign and include head nodding and tongue protrusion If some teeth have been lost, lower face looks unusually small, with mouth sunken in Neck may show concave curve when head and jaw are extended forward to compensate for kyphosis of spine During examination, direct aging person to perform ROM slowly; he or she may experience dizziness with side movements Aging person may have prolapse of submandibular glands, which may be mistaken for a tumor; but drooping submandibular glands will feel soft and be present bilaterally

culture

Thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups Characteristics of culture Learned Shared Adapted Dynamic

pregnant female

Thyroid gland enlarges slightly during pregnancy (due to hyperplasia of tissue and increased vascularity)

the role of data

To be valid practitioners, we must have evidence to practice safely. Nursing care begins with assessment and is an ongoing process. The purpose of the data is to make a judgment about the patient. The nurse plans care based upon data and judgments. The nurse evaluates care based upon the change in data collected.

breakthrough pain

Transitory exacerbation of pain in a patient who has controlled baseline pain. Incident pain is brief and precipitated by a movement. Idiopathic pain has an unknown cause and often lasts longer than incident pain End of dose failure pain

allergic salute

Transverse line on mose.hand to push nose up and back to relive itching and free swollen nasal psgs

purposes of physical examination

Triage for emergency care Routine screening to promote health and wellness To determine eligibility for Starting school/school sports Health insurance Military service A new job To admit a patient to a hospital or long-term care facility Use physical examination to: Gather baseline data about patient's health Support or refute subjective data obtained in the nursing history Identify and confirm nursing diagnoses Make clinical decisions about a patient's changing health status and management Evaluate the outcomes of care •Gathering a health history requires that you communicate with the patient. In Chapter 24, we discussed communication techniques. •We have talked a lot about nursing process and the importance of a nursing diagnosis and a nursing care plan. Physical assessment findings determine the cause of the diagnosis, which enables nurses to individualize a plan of care. While managing patient problems, you will use physical assessment skills to assess the status of your patient's health. Nurses can revise the care plan to ensure that the patient's problems are addressed. •During the evaluation phase, nurses can revise, amend, or discontinue nursing interventions as patients achieve their outcomes and/or goals.

decorticate rigidity

Upper extremities Flexion of arm, wrist, and fingers Adduction of arm: tight against thorax Lower extremities Extension, internal rotation, plantar flexion; indicates hemispheric lesion of cerebral cortex

decerebrete rigidity

Upper extremities: stiffly extended, adducted, internal rotation, palms pronated Lower extremities: stiffly extended, plantar flexion; teeth clenched; hyperextended back More ominous than decorticate rigidity; indicates lesion in brain stem at midbrain or upper pons

inspection for integumentary system

Use adequate lighting. Use direct lighting to inspect body cavities. Inspect: size, shape, color, symmetry, position, and abnormality. Position and expose body parts, as needed, so surfaces can be viewed but privacy & warmth can be maintained. When possible, check for symmetry. Validate findings with the patient. •To inspect, carefully look, listen, and smell to distinguish normal from abnormal findings. •Recognize normal vs abnormal •Bruises - Abuse? Aspirin therapy? Platelet/clotting problem?..ITP [Ask the class: Why is olfaction an important part of your assessment? Discuss: Olfaction helps to detect abnormalities that cannot be recognized by any other means. For example, when a patient's breath has a sweet, fruity odor, assess for signs of diabetes.]

aging adult neuro

Use same examination as with younger adults Cranial nerves mediating taste and smell not usually tested, may show some decline in function Decrease in muscle bulk most apparent in hand; dorsal hand muscles often look wasted, even with no apparent arthropathy; grip strength remains relatively good Senile tremors occasionally occur; these benign tremors include an intention tremor of hands, head nodding, and tongue protrusion Dyskinesias: repetitive stereotyped movements in jaw, lips, or tongue may accompany senile tremors; no associated rigidity present Gait may be slower and more deliberate than in younger person; may deviate from midline path Rapid alternating movements, e.g., pronating and supinating hands on thigh, may be difficult to perform After 65 years of age, loss of sensation of vibration at ankle malleolus common; loss of ankle jerk; tactile sensation may be impaired; may need stronger stimuli for light touch; and especially for pain DTRs less brisk; those in upper extremities usually present, but ankle jerk commonly lost; knee jerks may be lost; because aging people find it difficult to relax limbs, always use reinforcement when eliciting DTRs Plantar reflex may be absent or difficult to interpret; often, you will not see a definite normal flexor response; still should consider definite extensor response abnormal Superficial abdominal reflexes may be absent, probably because of stretching of musculature through pregnancy or obesity Neurologic check Some hospitalized persons have head trauma or a neurologic deficit due to systemic disease process Must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure Signs of increasing intracranial pressure signal impending cerebral disaster and death and require early and prompt intervention Use abbreviation of neurologic examination in following sequence: Level of consciousness Motor function Pupillary response Vital signs

ABCDE

Use the ABCD mnemonic to assess the skin for any type of carcinoma: Asymmetry—look for an uneven shape Border irregularity—look for edges that are blurred, notched, or ragged Color—look for pigmentation that is not uniform; variegated areas of blue, black, and brown and areas of pink, white, gray, blue, or red are abnormal Diameter—>6mm (pencil eraser) Elevation (raised) or Evolution (changing)

height

Use wall-mounted device or measuring pole on scale Align extended headpiece with top of head Person should be shoeless, standing straight, looking straight ahead, with feet and shoulders on hard surface

clarification

Use when person's words are ambiguous or confusing Used to summarize person's words and to simplify them to make them clearer You are asking for agreement, and the person can then confirm or deny your understanding

palpation of integumentary system

Used to gather information Use different parts of hands to detect different characteristics Hands should be warm, fingernails short. Start with light palpation; end with deep palpation. Always tell the patient what you are doing. •Place the patient in a comfortable position, and encourage the patient to relax. •Palpate sensitive areas last. •Use different parts of the hand to detect different characteristics. The palmar surface of the hand and finger pads is more sensitive than the fingertips and should be used to determine position, texture, size, consistency, masses, fluid, and crepitus. Assess body temperature by using the dorsal surface or back of the hand. The palmar surface of the hand and fingers is more sensitive to vibration. Measure position, consistency, and turgor by lightly grasping the body part with the fingertips. [Table 30-5 (on text p. 494) provides examples of characteristics measured by palpation.]

palpation

Uses sense of touch Examiner uses warm hands (short fingernails) Start with light palpation and progress to moderate to deep Palpate areas of tenderness last Temperature Turgor Texture Moisture Shape Want to make sure your hands are warm. Turgor is to check for hydration. If you pinch and it goes back right away, there is no dehydration

assessing edema

Vascularity Edema Lesions

posterior column tract sensory assessment

Vibration: test person's ability to feel vibrations of tuning fork over bony prominences Compare right side with left side; if you find a deficit, note whether gradual or abrupt Position (kinesthesia): test person's ability to perceive passive movements of extremities

eyes

Visual acuity Extraocular movements Nystagmus Visual fields Pupils Assess size, shape, structure, visual acuity, visual fields, conjunctiva, sclera, cornea, pupil, and iris. •Nystagmus-involuntary, rhythmical oscillation of the eyes, d/t local injury to eye muscles & supporting structures, or may follow a disorder of the cranial nerves innervating the muscles. •Redness in conjunctiva...allergic rxn? infectious conjunctivitis? •Arcus senilis - thin white arc/ring along margin of iris - common with aging d/t lipid deposits but is normal with aging over 40 and has no affect on vision. EOM test cranial nerves III, IV, VI. "H pattern" and then to nose. The lacrimal apparatus secretes and drains tears, which moisten and lubricate eye structures. Aging adult lacrimal glands involute → ↓tear production→dry eyes/burning. Often eye drops are prescribed. The lids are close to the eyeball. An abnormal drooping of the lid over the pupil is called ptosis, which is caused by edema or impairment of the third cranial nerve. In the older adult, ptosis results from loss of elasticity that accompanies aging. If impairs visual field, surgery can be done to lift eyelid; initial look after surgery is exopthalamos. The nurse observes for defects in the position of the lid margins. An older adult frequently has lid margins that turn outward (ectropion) or inward (entropion).

EMR during assessment

Watch screen and computer placement Posture and placement of you and the computer Eye-to-eye contact Ask/explain that you will be using the computer as you go along... but talk to your patient first ask questions without the computer directly in front of you. Type after the discussion not during.

thought processes

Way person thinks should be logical, goal directed, coherent, and relevant; should complete thoughts

thigh pressure procedure

When BP measured at arm is excessively high, compare it with thigh pressure to check for coarctation of aorta (congenital form of narrowing) Particularly in adolescents and young adults Normally, thigh pressure higher than that in arm If possible, turn person to prone position on abdomen Wrap large cuff around lower third of thigh, centered over popliteal artery on back of the knee Auscultate popliteal artery for reading Normally, systolic value is 10 to 40 mm Hg higher in thigh than in arm, and diastolic pressure is same

normal behaviors of pain

When individual cannot verbally communicate pain, you can (to a limited extent) identify pain using behavioral cues Reactions to painful stimuli very individual - wide variety of behaviors Behaviors influenced by a wide variety of factors, including nature of pain (acute versus chronic), age, and cultural and gender expectations teenagers tend to be more dramatic, women say that men are more dramatic

developmental competence

When interviewing children, most interaction is with the parent. When taking care of a child we are taking care of a parent. Awareness of the developmental stage of the patient (child) will assist in determining your approach to the child. Address questions to child, if appropriate.

screening for suicidal thoughts

When the person expresses feelings of sadness, hopelessness, despair, or grief, it is important to assess any possible risk of physical harm to himself or herself Begin with more general questions; if you hear affirmative answers, continue with more specific probing questions Have you ever felt so blue you thought of hurting yourself or do you feel like hurting yourself now? Do you have a plan to hurt yourself? How would you do it? What would happen if you were dead? How would other people react if you were dead?

aging adult behavioral clues of pain

When you look for behavioral cues, look at changes in functional status Observe for changes in dressing, walking, toileting, or involvement in activities Slowness and rigidity may develop, and fatigue may occur Look for sudden onset of acute confusion, which may indicate poorly controlled pain However, you will need to rule out other competing explanations such as infection or adverse reaction from medications

initial pain assessment

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

additional testing for persons with aphasia

Word comprehension: point to articles in the room or articles from pockets and ask person to name them Reading: ask person to read available print; be aware that reading is related to educational level Writing: ask person to make up and write a sentence; note coherence, spelling, and parts of speech

overcoming communication barriers

Working with and without interpreters Nonverbal cross-cultural communication Touch Touching patients is a necessary component of comprehensive assessment Physical contact with patients conveys various meanings cross-culturally Patient's significant other may exert pressure on nurses by enforcing culturally meaningful norms in health care setting In some cultures, it is considered an acceptable expression of friendship and affection to openly and publicly hold hands with or embrace members of same gender with no sexual connotation You may find that a patient displays similar behaviors and should feel free to discuss cultural differences and similarities openly with the person

infants sensory system

You will perform very little sensory testing with infants and toddlers Newborn normally has hypoesthesia and requires strong stimulus to elicit a response Baby responds to pain by crying and a general reflex withdrawal of all limbs By 7 to 9 months, infant can localize stimulus and shows more specific signs of withdrawal Other sensory modalities not tested

mixed pain syndromes

a combination of both ex tumor pressing against a nerve plexus.

Munchausen syndrome

a mental illness and a form of child abuse. The caretaker of a child, most often a mother, either makes up fake symptoms or causes real symptoms to make it look like the child is sick. Causes No one is sure what causes Munchausen syndrome by proxy. Sometimes, the person was abused as a child or has Munchausen syndrome (fake illness for themselves). Symptoms The mother can do extreme things to fake symptoms of illness in her child. For example, she may: Add blood to the child's urine or stool Withhold food so the child looks like they can't gain weight Heat up thermometers so it looks like the child has a fever Make up lab results Give the child drugs to make the child throw up or have diarrhea Infect an intravenous line (IV) to make the child sick What are signs in a mother? Most people with this problem are mothers with small children. Some are adult children taking care of an older parent. The mother often works in health care and knows a lot about medical care. She can describe the child's symptoms in great medical detail. She likes to be very involved with the health care team and is liked by the staff for the care she gives her child. These mothers are very involved with their children. They seem devoted to the child. This makes it hard for health professionals to see a diagnosis of Munchausen syndrome by proxy.

pulse oximiter

a noninvasive method to assess arterial oxygen saturation (SpO2) Sensor attached to person's finger or earlobe has diode that emits light and detector measures relative amount of light absorbed by oxyhemoglobin (HbO2) and unoxygenated (reduced) hemoglobin (Hgb) Compares ratio of light emitted to light absorbed and converts this ratio to percentage of oxygen saturation Because it only measures light absorption of pulsatile flow, result arterial oxygen saturation Healthy person with no lung disease and no anemia normally has an SpO2 of 97%-98%. Select appropriate pulse oximeter probe. Finger probe spring loaded and feels like clothespin attached to finger but does not hurt. At lower oxygen saturations, earlobe probe more accurate and less affected by peripheral vasoconstriction.

graphesthesia

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

skin circulation

affects skin color leads to appearance of superficial blood vessels. Vascularity appears reddened, pink, or pale when pts remain in 1 position. With aging, capillaries become fragile and are more easily injured. Petechiae are nonblanching, red/purple pinpoints on skin caused by small hemorrhages in the skin layers.

aging adult respirations

aging causes decrease in vital capacity and decreased inspiratory reserve volume You may note shallower inspiratory phase and an increased respiratory rate

RAM heel to shin test

ask person in supine position to place heel on opposite knee and run it down shin to ankle Normally, person moves heel in straight line down shin

RAM finger to nose test

ask person to close eyes and stretch out arms and touch tip of their nose with each index finger, alternating hands and increasing speed Normally this is done with accurate and smooth movement

reflexes

basic defense mechanisms of nervous system Involuntary; below level of conscious control permitting quick reaction to potentially painful or damaging situations

aggravating and alleviating factors of pain

behavioral, pharmacologic, non-pharmacologic interventions

cultural and linguistic competence

behaviors, attitudes, and policies supporting cross-cultural health care experiences

temporal lobe

behind ear, has primary auditory reception center, taste, and smell

patient's sclera

best site to look for jaundice can be due to cirrhosis from liver failure

capillary refill

blanch, release. Good circulation = color return<1-2 sec.

deep somatic pain

blood vessels, joints, tendons, muscles, bone

macular degeneration

breakdown of cells in macula of retina

mentals status

cannot be scrutinized directly like the characteristics of skin or heart sounds Its functioning is inferred through assessment of an individual's behaviors: Consciousness Language Mood and affect Orientation Attention Memory Abstract reasoning Thought process Thought content Perceptions

culturally appropriate

caregiver applies underlying background knowledge to provide best possible health care to the individual

culturally sensitive

caregiver has basic knowledge and constructive attitude toward diverse population

culturally competent

caregivers understand and provide individualized care based on immigration status, stress factors, other social factors, and cultural similarities and differences

aging adult temperature

changes in body's temperature regulatory mechanism leave aging person less likely to have fever but at greater risk for hypothermia Temperature is less reliable index of older person's true health state; sweat gland activity is also diminished

skin texture

character of skin surface and how the deeper layers feel. Using light palpation w/fingertips, determine skin smooth or rough, thin or thick, tight or supple, and indurated (hardened) or soft.

Wong-Baker scale

child asked to choose face that shows, "how much hurt you have now"

risk assessment

cholesterol, lifestyle behaviors (motorcyle, sexual practices)

object cues

clothing, jewelry, and hair styles

complete assessment

complete history & full physical in primary care office (1st visit)

frontal lobe

concerned with personality, behavior, emotions, and intellectual function Precentral gyrus of frontal lobe initiates voluntary movement

respectful care

considers values, preferences, and expressed patient needs

children developmental history

developmental history Growth Milestones Current development for children 1 month through preschool School-age child Nutritional history Family history

diplopia

double vision

biculturalism

dual pattern of identification and often of divided loyalty

health promotion

encourage pt to choose a healthier lifestyle.

facilitation

encourages patients to say more and shows you are interested and will listen further

goiter

enlarged thyroid gland...neck swelling

referred pain

felt at one site but originates in another

follow-up assessment

evaluation of problem for which tx was given

head assessment

eyes, ears, nose, mouth

cranial nerve VII

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

Denver II screening test

gives a chance to interact directly with child to assess mental status Birth to 6 years of age, helps identify children slow to develop in behavioral, language, cognitive, and psychosocial areas An additional language test is the Denver Articulation Screening Examination 125 items (4 parts): Social/personal (smiling), Fine motor (grasping, drawing), Language (understand and use language/combine words), Gross motor functions (sitting, walking, jumping)

cranial nerves IX and X

glossopharyngeal and vagus nerves Motor function Depress tongue with tongue blade, and note pharyngeal movement as person says "ahhh" or yawns; uvula and soft palate should rise in midline, and tonsillar pillars should move medially Touch posterior pharyngeal wall with tongue blade, and note gag reflex; voice should sound smooth, not strained Sensory function Cranial nerve IX does mediate taste on posterior one third of tongue, but technically too difficult to test

scleroderma

hardening of skin

nail clubbing

heart dx, lung ca, pulmonary dx. If dx is treated, clubbing may resolve.

touch

involves use of personal space and action

age related macular degeneration

is more prevalent among Whites, especially those over the age of 75, and is the leading form of blindness in Whites Lose central vision

otitis media

middle ear infection - 90% of toddlers <2 y/o at least once d/t obstruction in eustachian tube or passage of nasopharyngeal secretions into middle ear...favorable for bacterial growth. Risk factors to OM: absence of breastfdg in first 3 months, exposure to 2nd hand smoke, daycare (↑bacteria), males, pacifier use. Newborns undergo hearing screening prior to leaving hospital.

thyroid gland

midline & fixed to the trachea. •Inspect the lower neck overlying the thyroid gland for obvious masses, symmetry, and any subtle fullness at the base of the neck. Masses in the neck or mediastinum and pulmonary abnormalities cause displacement laterally. Usually unable to palpate normal adult thyroid. Determine the position of the trachea by palpating at the suprasternal notch, slipping the thumb and index fingers to each side. Note whether the finger and the thumb shift laterally. Do not apply forceful pressure because this elicits coughing. -If enlarged, auscultate for bruit. Bruit occurs w/turbulent blood flow indicating hyperplasia of thyroid (eg hyperthyroidism).

evidence based practice

most current and best-practice techniques

somatic pain

musculoskeletal

cranial nerve I

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

aging adult pulse

normal range of heart rate is 60 to 100 bpm, but rhythm may be slightly irregular Radial artery may feel stiff, rigid, and tortuous in older person, although does not necessarily imply vascular disease in heart or brain Increasingly rigid arterial wall needs faster upstroke of blood, so pulse is actually easier to palpate Elderly patients have a greater risk for hypothermia. They get cold a lot faster. Typically run a little bit lower for temperature like 97.2 instead of 98.6 Might manifest an infection through temperature and confusion- if they are usually 97.2 and are suddenly 98.6 could be an infection

gait

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

nystagmus

nvoluntary, rhythmical oscillation of the eyes, d/t local injury to eye muscles & supporting structures, or may follow a disorder of the cranial nerves innervating the muscles.

Cranial Nerves III, IV, and VI

oculomotor, trochlear, and abducens nerves Palpebral fissures usually equal in width Check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation Assess extraocular movements by cardinal positions of gaze Nystagmus is back-and-forth oscillation of eyes Assess nystagmus carefully, noting: Presence of nystagmus in one or both eyes Pendular movement (oscillations move equally left to right); or jerk (a quick phase in one direction, then a slow phase in other) Amplitude: degree of movement: fine, medium, or coarse Frequency: constant, or fades after a few beats Plane of movement: horizontal, vertical, rotary, or combination

allergic facies

often atopic derm, too. Exhausted face, blue shadows below eyes "allergic shiners" from sluggish venous return, double or single crease on lower eyelids, central facial pallor, open-mouth breathing

aging adult gait

older adults often use a wider base to compensate for diminished balance, arms may be held out to help balance, and steps may be shorter or uneven

occipital lobe

primary visual receptor center

acculturation

process of adapting to and acquiring another culture

assimilation

process of developing a new cultural identity and becoming like members of dominant culture

visceral reflex

pupillary response to light

PERRLA

pupils equal, round, reactive to light, and accommodation. A- To check pupillary reflexes the nurse first holds the penlight to the side of the patient's face. B- Illumination of the pupil causes pupillary constriction. Chart depicting pupillary size in millimeters. Pupils are normally 3-7 mm in diameter. Reflex reaction is a function of the 3rd cranial nerve. Pupils (P) should be equal (E), round and regular (R), reacts (R) to light (L) and accomodation (A). Accomodation eyes converge and pupils constrict with object at close vision. Consensual light reflex. Visual acuity ↓ at 50 & 70 → ↓ adaptation to darkness → difficulty night driving, need night light. ↑ risk of falling.

effective care

results in positive outcomes and patient satisfaction

injuries to child; lesions caused by trauma or abuse

scalding injury bite marks belt marks deformity from an untreated fracture cigarette burns hematomas or scalp petechiae

cherry angiomas

senile angiomas (1-5 mm), smooth, slightly raised; appear over 30y/o;↑size and # w/aging normally. Assess for skin lesions or skin cancer, and take the opportunity to educate the patient.

extinction

simultaneously touch both sides of body at same point; normally, both sensations are felt

moro reflex

startle infant by jarring crib, making a loud noise, or supporting head and back in semi-sitting position and quickly lowering infant to 30 degrees Baby looks as if he or she is hugging a tree; symmetric abduction and extension of arms and legs, fanning fingers, and curling of index finger and thumb to C position; infant then brings in both arms and legs Present at birth; disappears at 1 to 4 months

edematous skin

stretched & shiny. Palpate edematous areas to determine mobility, consistency, and tenderness. When pressure from the examiner's fingers leaves an indentation in the edematous area, this is called pitting edema. To assess the degree of pitting edema (shown), press the edematous area firmly with the thumb for several seconds, and release. The depth of pitting, in mm, determines degree of edema. For example, 1+ edema equals a 2-mm depth, 2+ edema equals a 4-mm depth, 3+ equals 6 mm, and 4+ equals 8 mm.

PNS

which includes all nerve fibers outside brain and spinal cord Includes 12 pairs of cranial nerves, 31 pairs of spinal nerves, and all their branches Carries sensory (afferent) messages to CNS from sensory receptors Motor (efferent) messages from CNS to muscles and glands, as well as autonomic messages that govern internal organs and blood vessels

CNS

which includes brain and spinal cord

tonic neck reflex

with baby supine, turn head to one side with chin over shoulder; note ipsilateral extension of arm and leg, and flexion of opposite arm and leg; the "fencing" position; turning head to opposite side, positions will reverse Appears by 2 to 3 months; decreases at 3 to 4 months; disappears by 4 to 6 months

RAM finger to finger test

with eyes open, ask person to use index finger to touch your finger, then their own nose; then move your finger to continue test Person's movement should be smooth and accurate

hypothyroidism

↓ metabolic rate When severe... nonpitting edema/myxedema (Usual cause -"Hashimoto thyroiditis") Fatigue Cold intolerance T3, T4, TSH Puffy face, periorbital edema Puffy hands & feet Coarse facial features Coarse dry hair & eyebrows Cool, dry skin