Health Assessment Final Study Guide

Interviewing Traps

1 Providing False Assurance or Reassurance 2 Giving Unwanted Advice Know when to give advice and when to avoid giving it. Often, people seek health care because they do want your professional advice and information on the management of a health problem: "My child has chickenpox; how should I take care of him?" This is a straightforward request for information that you have that the parent needs. You respond by giving a health prescription, a therapeutic plan based on your knowledge and experience. Although it is quicker just to give advice, take the time to involve the patient in a problem-solving process. When a patient participates, he or she is more likely to learn and to change behavior. 3 Using Authority "Your doctor/nurse knows best" is a response that promotes dependency and inferiority. The communication pathway looks something like this: 4 Using Avoidance Language People use euphemisms such as "passed on" to avoid reality or to hide their feelings. They think if they just say the word "death," it might really happen. So to protect themselves, they evade the issue. Although it seems this will make comfortable potentially fearful topics, it does not. Not talking about the fear does not make it go away; it just suppresses the fear and makes it even more frightening. Using direct language is the best way to deal with frightening topics. 5 Engaging in Distancing Distancing is the use of impersonal speech to put space between a threat and the self: "My friend has a problem; she is afraid she...." or "There is a lump in the left breast." By using "the" instead of "my," the woman can deny any association with her diseased breast and protect herself from it. Health professionals use distancing, too, to soften reality. This does not work because it communicates to the other person that you also are afraid of the procedure. The use of blunt specific terms actually is preferable to defuse anxiety. 6 Using Professional Jargon What is called a myocardial infarction in the health profession is called a heart attack by most laypeople. Use of jargon sounds exclusionary and paternalistic. You need to adjust your vocabulary to the person, but avoid sounding condescending. 7 Using Leading or Biased Questions Asking a man, "You don't smoke, do you?" implies that one answer is "better" than another. If the person wants to please you, either he is forced to answer in a way corresponding to your values or he feels guilty when he must admit the other answer. He risks your disapproval. And if he feels dependent on you for care, the last thing he wants to do is alienate you. 8 Talking Too Much Some examiners positively associate helpfulness with verbal productivity. If the air has been thick with their oratory and advice, these examiners leave thinking they have met the patient's needs. Just the opposite is true. Anxious to please the examiner, the patient lets the professional talk at the expense of his or her need to express himself or herself. A good rule for every interviewer is to listen more than you talk. 9 Interrupting Often, when you think you know what the person will say, you interrupt and cut the person off. This does not show that you are clever. Rather, it signals that you are impatient or bored with the interview. 10 Using "Why" Questions

carcinoma

begins as red, raised, warty growth or as an ulcer, with watery discharge

aging adult

The skin is a mirror that reflects aging changes that proceed in all our organ systems; it just happens to be the one organ we can view directly. The aging process carries a slow atrophy of skin structures. The aging skin loses its elasticity; it folds and sags. By the 70s to 80s, it looks parchment thin, lax, dry, and wrinkled. The epidermis's outer layer thins and flattens. This allows chemicals easier access into the body. Wrinkling occurs because the underlying dermis thins and flattens. A loss of elastin, collagen, and subcutaneous fat occurs as well as a reduction in muscle tone. The loss of collagen increases the risk for shearing, tearing injuries. Sweat glands and sebaceous glands decrease in number and function, leaving dry skin. Decreased response of the sweat glands to thermoregulatory demand also puts the aging person at greater risk for heat stroke. The vascularity of the skin diminishes while the vascular fragility increases; a minor trauma may produce dark red discolored areas, or senile purpura. Sun exposure and cigarette smoking further accentuate aging changes in the skin. Coarse wrinkling, decreased elasticity, atrophy, speckled and uneven coloring, more pigment changes, and a yellowed, leathery texture occur. Chronic sun damage is even more prominent in pale or light-skinned persons. An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, the decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging (e.g., less nutrition, limited financial resources), the increasingly sedentary lifestyle, and the chance of immobility. When skin breakdown does occur, subsequent cell replacement is slower and wound healing is delayed. In the aging hair matrix, the number of functioning melanocytes decreases, so the hair looks gray or white and feels thin and fine. A person's genetic script determines the onset of graying and the number of gray hairs. Hair distribution changes. Males may have a symmetric W-shaped balding in the frontal areas. Some testosterone is present in both males and females; as it decreases with age, axillary and pubic hair decrease. As the female's estrogen also decreases, testosterone is unopposed and the female may have some bristly facial hairs. Nails grow more slowly. Their surface is lusterless and is characterized by longitudinal ridges resulting from local trauma at the nail matrix. Because the aging changes in the skin and hair can be viewed directly, they carry a profound psychological impact. For many people, self-esteem is linked to a youthful appearance. This view is compounded by media advertising in Western society. Although sagging and wrinkling skin and graying and thinning hair are normal processes of aging, they prompt a loss of self-esteem for many adults. (Jarvis 206)

BSE (timing)

"Help each woman establish a regular schedule of self-care. The best time to conduct BSE is right after the menstrual period, or the 4th through 7th day of the menstrual cycle, when the breasts are the smallest and least congested. Advise the pregnant or menopausal woman who is not having menstrual periods to select a familiar date to examine her breasts each month—for example, her birth date or the day the rent is due."(Jarvis)

Normal testes

"No lesions, inflammation, or discharge from penis. Scrotum—testes descended, symmetric, no masses. No inguinal hernia." (Jarvis)

Glascow coma scale

(GCS).Because the terms describing levels of consciousness are ambiguous, the Glasgow Coma Scale was developed as an accurate and reliable quantitative tool (Fig. 23-59). The GCS is a standardized, objective assessment that defines the level of consciousness by giving it a numeric value. The scale is divided into three areas: eye opening, verbal response, and motor response. Each area is rated separately, and a number is given for the person's best response. The three numbers are added; the total score reflects the brain's functional level. A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma. Serial assessments can be plotted on a graph to illustrate visually whether the person is stable, improving, or deteriorating. The GCS assesses the functional state of the brain as a whole, not of any particular site in the brain. The scale is easy to learn and master, has good interrater reliability, and enhances interprofessional communication by providing a common language. (Jarvis 651-663)

sensorineural hearing loss

(or perceptive) loss signifies pathology of the inner ear, cranial nerve VIII, or the auditory areas of the cerebral cortex. A simple increase in amplitude may not enable the person to understand words. Sensorineural hearing loss may be caused by presbycusis, a gradual nerve degeneration that occurs with aging, and by ototoxic drugs, which affect the hair cells in the cochlea. A mixed loss is a combination of conductive and sensorineural types in the same ear (Jarvis 326)

variocele

Subjective: Dull pain; constant pulling or dragging feeling; or may be asymptomatic Objective: Inspection—usually no sign. May show bluish color through light scrotal skin; Palpation—when standing, feel soft, irregular mass posterior to and above testis; collapses when supine, refills when upright. Feels distinctive, like a "bag of worms" The testis on the side of the varicocele may be smaller owing to impaired circulation Assessment: Soft mass on spermatic cord (Jarvis 706)

Objective

what you see (examination findings)

Subjective

your perception, or what the patient says

Priority levels

1 Assign high priority to First-level priority problems (immediate priorities): Remember the "ABCs plus V": • Airway problems • Breathing problems • Cardiac/circulation problems • Vital sign concerns (e.g., high fever) Exception: With cardiopulmonary resuscitation (CPR) for cardiac arrest, begin chest compressions immediately. Go online to www.americanheart.org for the most current CPR guidelines. 2 Next, attend to Second-level priority problems: • Mental status change (e.g., confusion, decreased alertness) • Untreated medical problems requiring immediate attention (e.g., a diabetic who has not had insulin) • Acute pain • Acute urinary elimination problems • Abnormal laboratory values • Risks of infection, safety, or security (for the patient or for others) 3 Address Third-level priority problems (later priorities): • Health problems that do not fit into the above categories (e.g., problems with lack of knowledge, activity, rest, family coping)

Inspection of chest

1 Inspection Thoracic cage Respirations Skin color and condition Person's position Facial expression Level of consciousness 2 Palpation Confirm symmetric expansion Tactile fremitus Detect any lumps, masses, tenderness 3 Percussion Percuss over lung fields Estimate diaphragmatic excursion 4 Auscultation Assess normal breath sounds Note any abnormal breath sounds, If abnormal breath sounds present, perform bronchophony, whispered pectoriloquy, egophony Note any adventitious sounds (Jarvis 453)

abnormalities

1 Pain. Any pain or tenderness in the breasts? When did you first notice it? • Where is the pain? Localized or all over? • Is the painful spot sore to touch? Do you feel a burning or pulling sensation? Mastalgia occurs with trauma, inflammation, infection, and benign breast disease. • Is the pain cyclic? Any relation to your menstrual period? Cyclic pain is common with normal breasts, oral contraceptives, and benign breast (fibrocystic) disease. • Is the pain brought on by strenuous activity, especially involving one arm; a change in activity; manipulation during sex; part of underwire bra; exercise? Is pain related to specific cause? 2 Lump. Ever noticed a lump or thickening in the breast? Where? • When did you first notice it? Changed at all since then? • Does the lump have any relation to your menstrual period? • Noticed any change in the overlying skin: redness, warmth, dimpling, swelling? Carefully explore the presence of any lump. A lump present for many years and exhibiting no change may not be serious but still should be explored. Approach any recent change or new lump with suspicion. 3 Discharge. Any discharge from the nipple? • When did you first notice this? • What color is the discharge? • Consistency—thick or runny? • Odor? Galactorrhea. Note medications that may cause clear nipple discharge: oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, calcium channel blockers. Bloody or blood-tinged discharge always is significant. Any discharge with a lump is significant. 4 Rash. Any rash on the breast? • When did you first notice this? • Where did it start? On the nipple, areola, or surrounding skin? Paget's disease starts with a small crust on the nipple apex and then spreads to areola (see Table 17-6, Abnormal Nipple Discharge, p. 407). Eczema or other dermatitis rarely starts at the nipple unless it is due to breastfeeding. It usually starts on the areola or surrounding skin and then spreads to the nipple. 5 Swelling. Any swelling in the breasts? In one spot or all over? • Related to your menstrual period, pregnancy, or breastfeeding? • Any change in bra size? 6 Trauma. Any trauma or injury to the breasts? • Did it result in any swelling, lump, or break in skin? A lump from an injury is due to local hematoma or edema and resolves shortly. Or, trauma may cause a woman to feel the breast and find a lump that really was there before. 7 History of breast disease. Any history of breast disease yourself? • What type? How was this diagnosed? • When did this occur? • How is it being treated? (Jarvis 391)

venous stasis ulcer

After acute deep vein thrombosis or chronic incompetent valves in deep veins. S:Aching pain in calf or lower leg, worse at end of the day, worse with prolonged standing or sitting. O:Firm, brawny edema; coarse, thickened skin; pulses normal; brown pigment discoloration; petechiae; dermatitis. Venous stasis causes increased venous pressure, which then causes red blood cells (RBCs) to leak out of veins and into the skin. The RBCs break down and leave hemosiderin (iron deposits) behind, which are the brown pigment deposits. A weepy, pruritic stasis dermatitis may be present. Ulcers occur at medial malleolus and are characterized by bleeding, uneven edges. (Jarvis 522)

Aphthous Ulcer

A "canker sore" is a vesicle at first and then a small, round, "punched-out" ulcer with a white base surrounded by a red halo. It is quite painful and lasts for 1 to 2 weeks. The cause is unknown, although it is associated with stress, fatigue, and food allergy. It is common, affecting 20% to 60% of the population. (Jarvis 379)

deep vein thrombophlebitus

A deep vein is occluded by a thrombus, causing inflammation, blocked venous return, cyanosis, and edema. Virchow's triad is the classic 3 factors that promote thrombogenesis: stasis, hypercoagulability, and endothelial dysfunction.16 Cause may be prolonged bedrest; history of varicose veins; trauma; infection; cancer; and, in younger women, the use of oral estrogenic contraceptives. Requires emergency referral because of risk for pulmonary embolism. Note that upper-extremity DVT is increasingly common due to frequent use of invasive lines such as central venous catheters.10 S:Sudden onset of intense, sharp, deep muscle pain; may increase with sharp dorsiflexion of foot. O:Increased warmth; swelling (to compare swelling, observe the usual shoe size as in above photo); redness; dependent cyanosis is mild or may be absent; tender to palpation; Homan sign is present only in few cases. (Jarvis 523-524)

Candidiasis

A white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that bleeds easily. Termed "thrush" in the newborn. It is an opportunistic infection that occurs after the use of antibiotics and corticosteroids and in immunosuppressed persons. (Jarvis 379)

Family History

As with the adult, diagram a family tree for the child, including siblings, parents, and grandparents go back 3 generations(see p. 53). Ask specifically for the family history of heart disease, high blood pressure, diabetes, blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity, cystic fibrosis, alcoholism, mental illness, seizure disorder, kidney disease, mental retardation, learning disabilities, birth defects, and sudden infant death.

Range of motion (ROM)

Ask for active (voluntary) ROM while stabilizing the body area proximal to that being moved. Familiarize yourself with the type of each joint and its normal ROM so that you can recognize limitations. If you see a limitation, gently attempt passive motion with the person's muscles relaxed and with you moving the body part. Anchor the joint with one hand while your other hand slowly moves it to its limit. The normal ranges of active and passive motion should be the same. Limitation in ROM is the most sensitive sign of joint disease.15a The amount of limitation may alert you to the cause of disease. Articular disease (inside the joint capsule [e.g., arthritis]) produces swelling and tenderness around the whole joint, and it limits all planes of ROM in both active and passive motion. Extra-articular disease (injury to a specific tendon, ligament, nerve) produces swelling and tenderness to that one spot in the joint and affects only certain planes of ROM, especially during active (voluntary) motion. Joint motion normally causes no tenderness, pain, or crepitation. Do not confuse crepitation with the normal discrete "crack" heard as a tendon or ligament slips over bone during motion, such as when you do a knee bend. Crepitation is an audible and palpable crunching or grating that accompanies movement. It occurs when the articular surfaces in the joints are roughened, as with rheumatoid arthritis (see Table 22-1, Abnormalities Affecting Multiple Joints, p. 608). (Jarvis 605)

bronchophony

Ask the person to repeat "ninety-nine" while you listen with the stethoscope over the chest wall; listen especially if you suspect pathology Normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but cannot distinguish exactly what is being said Pathology that increases lung density will enhance transmission of voice sounds; you auscultate a clear "ninety-nine" The words are more distinct than normal and sound close to your ear (Jarvis 446)

Testicular torsion

Subjective: Excruciating pain in testicle of sudden onset, often during sleep or following trauma. May also have lower abdominal pain, nausea and vomiting, no fever Objective: Inspection—red, swollen scrotum, one testis (usually left) higher owing to rotation and shortening; Palpation—cord feels thick, swollen, tender; epididymis may be anterior; cremasteric reflex is absent on side of torsion (Jarvis 706)

Spermatocele

Subjective: Painless, usually found on examination Objective: Inspection—does transilluminate higher in the scrotum than a hydrocele, and the sperm may fluoresce; Palpation—round, freely movable mass lying above and behind testis. If large, feels like a third testis Assessment: Free cystic mass on epididymis (Jarvis 706)

syphilitic cancre

Begins within 2 to 4 weeks of infection, as a small, solitary, silvery papule that erodes to a red, round or oval, superficial ulcer with a yellowish serous discharge. Palpation reveals a nontender indurated base that can be lifted like a button between the thumb and the finger. Lymph nodes enlarge early but are nontender. This is an STI easily treated with penicillin G, but untreated leads to cardiac and neurologic problems, blindness. Almost eradicated in the United States in 1957; epidemics recur cyclically every 7 to 10 years (Jarvis 703)

Deep tendon reflexs (DTR's)

Biceps reflex Triceps reflex Brachioradialis reflex Patellar reflex (Quadriceps/Knee jerk) Achilles reflex Plantar reflex 4+ Very brisk, hyperactive with clonus, indicative of disease 3+ Brisker than average, may indicate disease, probably normal 2+ Average, normal 1+ Diminished, low normal, or occurs only with reinforcement 0 No response This is a subjective scale and requires some clinical practice. Even then, the scale is not completely reliable because no standard exists to say how brisk a reflex should be to warrant a grade of 3+. Also, a wide range of normal exists in reflex responses. Healthy people may have diminished reflexes, or they may have brisk ones. Your best plan is to interpret the DTRs only within the context of the rest of the neurologic examination. Clonus is a set of rapid, rhythmic contractions of the same muscle. Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the usually inhibiting influence of higher cortical levels. This occurs with upper motor neuron lesions (e.g., a brain attack). Hyporeflexia, which is the absence of a reflex, is a lower motor neuron problem. It occurs with interruption of sensory afferents or destruction of motor efferents and anterior horn cells (e.g., spinal cord injury). (Jarvis 651)

Arterial ischemic ulcer

Buildup of fatty plaques on intima (atherosclerosis) plus hardening and calcification of arterial wall (arteriosclerosis). S:Deep muscle pain in calf or foot, claudication (pain with walking), pain at rest indicates worsening of condition. O:Coolness, pallor, elevational pallor, and dependent rubor; diminished pulses; systolic bruits; signs of malnutrition (thin, shiny skin; thick-ridged nails; atrophy of muscles); distal gangrene. Ulcers occur at toes, metatarsal heads, heels, lateral ankle, and are characterized by pale ischemic base, well-defined edges, and no bleeding. (Jarvis 522)

leukoplakia

Chalky white, thick, raised patch with well-defined borders. The lesion is firmly attached and does not scrape off. It may occur on the lateral edges of tongue. It is due to chronic irritation and occurs more frequently with heavy smoking and heavy alcohol use. Lesions are precancerous, and the person should be referred. (Here, the lesion is associated with squamous carcinoma.) (Jarvis 379)

Increased intracranial pressure

Can cause: Palpebral edema (cranial nerve II) Dilated pupil, ptosis, eye turns out and slightly down & absent light reflex; caused by paralysis of Cranial nerve III (III: Oculomotor)(Jarvis 668)

Cranial Nerve I

Transmits sense of smell from the nasal cavity

lesions

Common Shapes and Configurations of Lesions ANNULAR, or circular, begins in center and spreads to periphery (e.g., tinea corporis or ringworm, tinea versicolor, pityriasis rosea). CONFLUENT, lesions run together (e.g., urticaria [hives]). DISCRETE, distinct, individual lesions that remain separate (e.g., acrochordon or skin tags, acne). GROUPED, clusters of lesions (e.g., vesicles of contact dermatitis). GYRATE, twisted, coiled spiral, snakelike. TARGET, or iris, resembles iris of eye, concentric rings of color in the lesions (e.g., erythema multiforme). LINEAR, a scratch, streak, line, or stripe. POLYCYCLIC, annular lesions grow together (e.g., lichen planus, psoriasis). ZOSTERIFORM, linear arrangement along a unilateral nerve route (e.g., herpes zoster). Primary Skin Lesions* Macule Solely a color change, flat and circumscribed, of less than 1 cm. Examples: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever. Patch Macules that are larger than 1 cm. Examples: mongolian spot, vitiligo, café au lait spot, chloasma, measles rash. Papule Something you can feel (i.e., solid, elevated, circumscribed, less than 1 cm diameter) caused by superficial thickening in the epidermis. Examples: elevated nevus (mole), lichen planus, molluscum, wart (verruca). Plaque Papules coalesce to form surface elevation wider than 1 cm. A plateau-like, disk-shaped lesion. Examples: psoriasis, lichen planus. Nodule Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule. Examples: xanthoma, fibroma, intradermal nevi. Tumor Larger than a few centimeters in diameter, firm or soft, deeper into dermis; may be benign or malignant, although "tumor" implies "cancer" to most people. Examples: lipoma, hemangioma. Wheal Superficial, raised, transient, and erythematous; slightly irregular shape due to edema (fluid held diffusely in the tissues). Examples: mosquito bite, allergic reaction, dermographism. Urticaria (Hives) Wheals coalesce to form extensive reaction, intensely pruritic. Vesicle Elevated cavity containing free fluid, up to 1 cm; a "blister." Clear serum flows if wall is ruptured. Examples: herpes simplex, early varicella (chickenpox), herpes zoster (shingles), contact dermatitis. Bulla Larger than 1 cm diameter; usually single chambered (unilocular); superficial in epidermis; it is thin walled, so it ruptures easily. Examples: friction blister, pemphigus, burns, contact dermatitis. Cyst Encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin. Examples: sebaceous cyst, wen. Pustule Turbid fluid (pus) in the cavity. Circumscribed and elevated. Examples: impetigo, acne. * The immediate result of a specific causative factor; primary lesions develop on previously unaltered skin. Secondary Skin Lesions* DEBRIS ON SKIN SURFACE Crust Scale The thickened, dried-out exudate left when vesicles/pustules burst or dry up. Color can be red-brown, honey, or yellow, depending on the fluid's ingredients (blood, serum, pus). Examples: impetigo (dry, honey-colored), weeping eczematous dermatitis, scab after abrasion. Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells. Examples: after scarlet fever or drug reaction (laminated sheets), psoriasis (silver, mica-like), seborrheic dermatitis (yellow, greasy), eczema, ichthyosis (large, adherent, laminated), dry skin. BREAK IN CONTINUITY OF SURFACE Fissure Erosion Linear crack with abrupt edges, extends into dermis, dry or moist. Examples: cheilosis—at corners of mouth due to excess moisture; athlete's foot. Scooped out but shallow depression. Superficial; epidermis lost; moist but no bleeding; heals without scar because erosion does not extend into dermis. Ulcer Excoriation Deeper depression extending into dermis, irregular shape; may bleed; leaves scar when heals. Examples: stasis ulcer, pressure sore, chancre. Self-inflicted abrasion; superficial; sometimes crusted; scratches from intense itching. Examples: insect bites, scabies, dermatitis, varicella. Scar Atrophic Scar After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). This is a permanent fibrotic change. Examples: healed area of surgery or injury, acne. The resulting skin level is depressed with loss of tissue; a thinning of the epidermis. Example: striae. Lichenification Keloid Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen). A hypertrophic scar. The resulting skin level is elevated by excess scar tissue, which is invasive beyond the site of original injury. May increase long after healing occurs. Looks smooth, rubbery, and "clawlike" and has a higher incidence among Blacks. Note: Combinations of primary and secondary lesions may coexist in the same person. Such combined designations may be termed papulosquamous, maculopapular, vesiculopustular, or papulovesicular. (Jarvis 230-235)

Cranial Nerve XI

Controls the sternocleidomastoid and trapezius muscles, and overlaps with functions of the vagus nerve (CN X).

Olfactory nerve

Cranial Nerve 1

Trigeminal nerve

Cranial Nerve 5

Facial nerve

Cranial Nerve 7

Glossopharyangeal nerve

Cranial Nerve IX

Vagus nerve

Cranial Nerve X

Spinal accessory nerve

Cranial Nerve XI

Hypoglossal

Cranial Nerve XII

Cranial nerves

Cranial nerves enter and exit the brain rather than the spinal cord (Fig. 23-7). Cranial nerves I and II extend from the cerebrum; cranial nerves III through XII extend from the lower diencephalon and brainstem. The 12 pairs of cranial nerves supply primarily the head and neck, except the vagus nerve (Lat. vagus, or wanderer, as in "vagabond"), which travels to the heart, respiratory muscles, stomach, and gallbladder. (Jarvis 627-628)

retraction

Direct the woman to change position while you check the breasts for skin retraction signs. First ask her to lift her arms slowly over her head. Both breasts should move up symmetrically (Fig. 17-9). Retraction signs are due to fibrosis in the breast tissue, usually caused by growing neoplasms. The fibrosis shortens with time, causing contrasting signs with the normally loose breast tissue. Note a lag in the movement of one breast. Retraction maneuver. Next ask her to push her hands onto her hips (Fig. 17-10) and to push her two palms together (Fig. 17-11). These maneuvers contract the pectoralis major muscle. A slight lifting of both breasts will occur. Note a dimpling or a pucker, which indicates skin retraction (see Table 17-3). Ask the woman with large pendulous breasts to lean forward while you support her forearms. Note the symmetric free-forward movement of both breasts (Fig. 17-12). Note fixation to chest wall or skin retraction (see Table 17-3). (Jarvis 391)

spread of infection

Do not let your stethoscope become a staph-oscope! Stethoscopes and other equipment that are frequently used on many patients are a common vehicle for transmission of infection. Clean your stethoscope endpiece with an alcohol wipe before and after every patient contact. The best routine is to combine stethoscope rubbing with every hand hygiene. The single most important step to decrease risk of microorganism transmission is to wash your hands promptly and thoroughly: (1) before and after every physical patient encounter; (2) after contact with blood, body fluids, secretions, and excretions; (3) after contact with any equipment contaminated with body fluids; and (4) after removing gloves (see Table 8-2). Using alcohol-based hand rubs takes less time than soap-and-water handwashing; it also kills more organisms more quickly and is less damaging to the skin because of emollients added to the product. Alcohol is highly effective against both gram-positive and gram-negative bacteria, Mycobacterium tuberculosis, and most viruses, including hepatitis B and C viruses, HIV, and enteroviruses.5 Use the mechanical action of soap-and-water handwashing when hands are visibly soiled and when patients are infected with spore-forming organisms (e.g., Clostridium difficile or Bacillus anthracis). (Jarvis 120-121) Wear gloves when the potential exists for contact with any body fluids (e.g., blood, mucous membranes, body fluids, drainage, open skin lesions). Wearing gloves is not a protective substitute for washing hands, however, because gloves may have undetectable holes or may become torn during use or hands may become contaminated as gloves are removed. Wear a gown, mask, and protective eyewear when the potential exists for any blood or body fluid spattering (e.g., suctioning, arterial puncture). (Jarvis 121)

Heart disease risk factors

Family cardiac history. Any family history of: Hypertension, obesity, diabetes, coronary artery disease (CAD), sudden death at younger age? Personal habits (cardiac risk factors). •Nutrition: Please describe your usual daily diet. (Note if this diet is representative of the basic food groups, the amount of calories, cholesterol,and any additives such as salt.) What is your usual weight? Has there been any recent change? •Smoking: •Alcohol: Risk factors for CAD—Collect data regarding elevated cholesterol, elevated blood pressure, blood sugar levels above 130 mg/dL or known diabetes mellitus, obesity, cigarette smoking, low activity level, and length of any hormone replacement therapy for postmenopausal women. (Jarvis 472)

Adult and child Pinna

Pull the pinna up and back on an adult or older child; this helps straighten the S-shape of the canal (Fig. 15-7). (Pull the pinna down on an infant and a child younger than 3 years [see Fig. 15-13]). Hold the pinna gently but firmly. Do not release traction on the ear until you have finished the examination and the otoscope is removed. (Jarvis 337)

Examples of Prevention

Guidelines to prevention emphasize the link between health and personal behavior. The report of the U.S. Preventive Services Task Force19 asserts that the great majority of deaths among Americans younger than 65 years are preventable. Prevention can be achieved through counseling from primary care providers designed to change people's unhealthy behaviors related to smoking, alcohol and other drug use, lack of exercise, poor nutrition, injuries, and sexually transmitted infections.(Jarvis 8)

varicosities

Hormonal changes cause vasodilation and the resulting drop in blood pressure described in Chapter 19. The growing uterus obstructs drainage of the iliac veins and the inferior vena cava. This condition causes low blood flow and increases venous pressure. This, in turn, causes dependent edema,in the legs and vulva, and hemorrhoids. (Jarvis 504)

S1 & S2

Identify S1 and S2. This is important because S1 is the start of systole and thus serves as the reference point for the timing of all other cardiac sounds. Usually, you can identify S1 instantly because you hear a pair of sounds close together (lub-dup), and S1 is the first of the pair. This guideline works, except in the cases of the tachydysrhythmias (rates >100 per minute). Then the diastolic filling time is shortened, and the beats are too close together to distinguish. Other guidelines to distinguish S1 from S2 are: • S1 is louder than S2 at the apex; S2 is louder than S1 at the base. • S1 coincides with the carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1 (Fig. 19-23). • S1 coincides with the R wave (the upstroke of the QRS complex) if the person is on an ECG monitor. Listen to S1 and S2 Separately. Note whether each heart sound is normal, accentuated, diminished, or split. Inch your diaphragm across the chest as you do this. First Heart Sound (S1). Caused by closure of the AV valves, S1 signals the beginning of systole. You can hear it over the entire precordium, although it is loudest at the apex (Fig. 19-24). (Sometimes the two sounds are equally loud at the apex, because S1 is lower pitched than S2.) Causes of accentuated or diminished S1 (see Table 19-3, Variations in S1, on p. 487). Both heart sounds are diminished with conditions that place an increased amount of tissue between the heart and your stethoscope: emphysema (hyperinflated lungs), obesity, pericardial fluid. You can hear S1 with the diaphragm with the person in any position and equally well in inspiration and expiration. A split S1 is normal, but it occurs rarely. A split S1 means you are hearing the mitral and tricuspid components separately. It is audible in the tricuspid valve area, the left lower sternal border. The split is very rapid, with the two components only 0.03 second apart. Second Heart Sound (S2). The S2 is associated with closure of the semilunar valves. You can hear it with the diaphragm, over the entire precordium, although S2 is loudest at the base (Fig. 19-25). Accentuated or diminished S2 (see Table 19-4, Variations in S2, on p. 488). (Jarvis 472)

teething

In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does. The teeth, both sets, begin development in utero. Children have 20 deciduous, or temporary, teeth. These erupt between 6 months and 24 months of age. All 20 teeth should appear by 2 1/2 leukyears of age. The deciduous teeth are lost beginning at age 6 years through age 12 years. They are replaced by the permanent teeth, starting with the central incisors (Fig. 16-6). The permanent teeth appear earlier in girls than in boys, and they erupt earlier in Black children than in white children. (Jarvis 355)

CVA tenderness

Indirect fist percussion causes the tissues to vibrate instead of producing a sound. To assess the kidney, place one hand over the twelfth rib at the costovertebral angle on the back (Fig. 21-17). Thump that hand with the ulnar edge of your other fist. The person normally feels a thud but no pain. (Although this step is explained here with percussion techniques, its usual sequence in a complete examination is with thoracic assessment, when the person is sitting up and you are standing behind.) Sharp pain occurs with inflammation of the kidney or paranephric area. (Jarvis 554)

Coping and Stress Management

Kinds of stresses in life, especially in the past year, any change in lifestyle or any current stress, methods tried to relieve stress, and whether these have been helpful. Personal Habits Tobacco, alcohol, street drugs: "Do you smoke cigarettes (pipe, use chewing tobacco)?" "At what age did you start?" "How many packs do you smoke per day?" "How many years have you smoked?" Record the number of packs smoked per day (PPD) and duration (e.g., 1 PPD × 5 years). Then ask, "Have you ever tried to quit?" and "How did it go?" to introduce plans about smoking cessation. Alcohol Health care professionals often fail to question about alcohol unless problems are obvious. However, alcohol interacts adversely with all medications; is a factor in many social problems such as assaults, rapes, high-risk sexual behavior, and child abuse; contributes to half of all fatal traffic accidents; and accounts for 5% of all deaths in the United States. The latter figure is actually an underestimate because alcohol-related conditions are underreported on death certificates. Be alert, then, to early signs of hazardous alcohol use. Ask whether the person drinks alcohol. If yes, ask specific questions about the amount and frequency of alcohol use: "When was your last drink of alcohol?" "How much did you drink that time?" "Out of the past 30 days, about how many days would you say that you drank alcohol?" Has anyone ever said you had a drinking problem?" You may wish to use a screening questionnaire to identify excessive or uncontrolled drinking, such as the Cut down, Annoyed, Guilty, and Eye-opener (CAGE) test.4 • 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? (i.e., an Eye opener?) If the person answers "yes" to two or more CAGE questions, you should suspect alcohol abuse and continue with a more complete substance abuse assessment (see Chapter 6, p. 93). If the person answers "no" to drinking alcohol, ask the reason for this decision (psychosocial, legal, health). Any history of alcohol treatment? Involvement in recovery activities? History of family member with problem drinking? Illicit or Street Drugs Ask specifically about marijuana, cocaine, crack cocaine, amphetamines, heroin, pain killers like OxyContin or Vicodin, and barbiturates. Indicate frequency of use and how usage has affected work or family. Environment/Hazards Housing and neighborhood (living alone, knowledge of neighbors), safety of area, adequate heat and utilities, access to transportation, and involvement in community services. Note environmental health, including hazards in workplace, hazards at home, use of seatbelts, geographic or occupational exposures, and travel or residence in other countries, including time spent abroad during military service. Intimate Partner Violence Begin with open-ended questions: "How are things at home?" and "Do you feel safe?" These are valuable initial screening questions, because some people may not recognize that they are in abusive situations or may be reluctant to admit it due to guilt, fear, shame, or denial. If the person responds to feeling unsafe, follow up with closed-ended questions: "Have you ever been emotionally or physically abused by your partner or someone important to you?" "Within the past year, have you been hit, slapped, kicked, pushed, or shoved or otherwise physically hurt by your partner or ex-partner?" "If yes, by whom?" "Number of times?" "Does your partner ever force you into having sex?" "Are you afraid of your partner or ex-partner?" see Chapter 7 for more information. Occupational Health Ask the person to describe his or her job. Ever worked with any health hazard, such as asbestos, inhalants, chemicals, repetitive motion? Wear any protective equipment? Any work programs in place that monitor exposure? Aware of any health problems now that may be related to work exposure? Note the timing of the reason for seeking care and whether it may be related to change in work or home activities, job titles, or exposure history. Take a careful smoking history, which may contribute to occupational hazards. Finally, ask the person what he or she likes or dislikes about the job. Perception of Health Ask the person 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)?" (Jarvis 58-59)

peau d'Orange

Lymphatic obstruction produces edema. This thickens the skin and exaggerates the hair follicles, giving a pigskin or orange-peel look. This condition suggests cancer. Edema usually begins in the skin around and beneath the areola, the most dependent area of the breast. Also note nipple infiltration here. (Jarvis 404)

aortic aneurysm

Most aortic aneurysms (>95%) are located below the renal arteries and extend to the umbilicus. A focal bulging >5 cm is palpable in about 80% of cases during routine physical examination and feels like a pulsating mass in the upper abdomen just to the left of midline. You will hear a bruit. Femoral pulses are present but decreased. Aortic aneurysm—murmur is harsh, systolic, or continuous and accentuated with systole. Note in person with hypertension. (Jarvis 563)

Corticospinal tract

Motor nerve fibers originate in the motor cortex and travel to the brainstem, where they cross to the opposite or contralateral side (pyramidal decussation) and then pass down in the lateral column of the spinal cord. Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, purposeful movements, such as writing. The corticospinal tract is a newer, "higher," motor system that permits humans to have very skilled and purposeful movements. (Jarvis 625)

benign breast disease

Multiple tender masses. "Fibrocystic disease" is not accurate because, actually, six diagnostic categories exist, based on symptoms and physical findings: • Swelling and tenderness (cyclic discomfort) • Mastalgia (severe pain, both cyclic and noncyclic) • Nodularity (significant lumpiness, both cyclic and noncyclic) • Dominant lumps (including cysts and fibroadenomas) • Nipple discharge (including intraductal papilloma and duct ectasia) • Infections and inflammations (including subareolar abscess, lactational mastitis, breast abscess, and Mondor's disease) About 50% of all women have some form of benign breast disease. Nodularity occurs bilaterally; regular, firm nodules that are mobile, well demarcated, and feel rubbery, like small water balloons. Pain may be dull, heavy, and cyclic or just before menses as nodules enlarge. Some women have nodularity but no pain, and vice versa. Cysts are discrete, fluid-filled sacs. Dominant lumps and nipple discharge must be investigated carefully and may need biopsy to rule out cancer. Nodularity itself is not premalignant but produces difficulty in detecting other cancerous lumps. (Jarvis 405)

Organs by quadrant

RIGHT UPPER QUADRANT (RUQ) Liver Gallbladder Duodenum Head of pancreas Right kidney and adrenal Hepatic flexure of colon Part of ascending and transverse colon LEFT UPPER QUADRANT (LUQ) Stomach Spleen Left lobe of liver Body of pancreas Left kidney and adrenal Splenic flexure of colon Part of transverse and descending colon RIGHT LOWER QUADRANT (RLQ) Cecum Appendix Right ovary and tube Right ureter Right spermatic cord LEFT LOWER QUADRANT (LLQ) Part of descending colon Sigmoid colon Left ovary and tube Left ureter Left spermatic cord MIDLINE Aorta Uterus (if enlarged) Bladder (if distended) (Jarvis 530-531)

Tracheal Shift

Normally, the trachea is midline; palpate for any tracheal shift. Place your index finger on the trachea in the sternal notch, and slip it off to each side (Fig. 13-13). The space should be symmetric on both sides. Note any deviation from the midline. Conditions of tracheal shift: • The trachea is pushed to the unaffected (or healthy) side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax. • The trachea is pulled toward the affected (diseased) side with large atelectasis, pleural adhesions, or fibrosis. • Tracheal tug is a rhythmic downward pull that is synchronous with systole and that occurs with aortic arch aneurysm. (Jarvis 267)

Cranial Nerve V

Receives sensation from the face and innervates the muscles of mastication.

Cranial Nerve IX

Receives taste from the posterior 1/3 of the tongue, provides secretomotor innervation to the parotid gland, and provides motor innervation to the stylopharyngeus. Some sensation is also relayed to the brain from the palatine tonsils.

pulses

Palpate both radial pulses, noting rate, rhythm, elasticity of vessel wall, and equal force (Fig. 20-8). Grade the force (amplitude) on a 3-point scale: 3+, increased, full, bounding 2+, normal 1+, weak 0, absent Full, bounding pulse (3+) occurs with hyperkinetic states (exercise, anxiety, fever), anemia, and hyperthyroidism. Weak, "thready" pulse (1+) occurs with shock and peripheral arterial disease. See Table 20-1 on p. 519 for illustrations of these and irregular pulse rhythms. (Jarvis 517)

Palpating

Palpation follows and often confirms points you noted during inspection. Palpation applies your sense of touch to assess these factors: texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain. Different parts of the hands are best suited for assessing different factors: • Fingertips—best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps • A grasping action of the fingers and thumb—to detect the position, shape, and consistency of an organ or mass • Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand—best for vibration Your palpation technique should be slow and systematic. A person stiffens when touched suddenly, making it difficult for you to feel very much. Use a calm, gentle approach. Warm your hands by kneading them together or holding them under warm water. Identify any tender areas, and palpate them last. Start with light palpation to detect surface characteristics and to accustom the person to being touched. Then perform deeper palpation, perhaps by helping the person use relaxation techniques such as imagery or deep breathing. Your sense of touch becomes blunted with heavy or continuous pressure. When deep palpation is needed (as for abdominal contents), intermittent pressure is better than one long, continuous palpation. Avoid any situation in which deep palpation could cause internal injury or pain. Bimanual palpation requires the use of both of your hands to envelop or capture certain body parts or organs—such as the kidneys, uterus, or adnexa—for more precise delimitation (Jarvis 116)

percussion

Percussion is tapping the person's skin with short, sharp strokes to assess underlying structures. The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ.Percussion has the following uses: • Mapping out the location and size of an organ by exploring where the percussion note changes between the borders of an organ and its neighbors. • Signaling the density (air, fluid, or solid) of a structure by a characteristic note. • Detecting an abnormal mass if it is fairly superficial; the percussion vibrations penetrate about 5 cm deep—a deeper mass would give no change in percussion. • Eliciting a deep tendon reflex using the percussion hammer. (Jarvis 116)

Eye tests

Position the person standing for vision screening; then sitting up with the head at your eye level. Snellen eye chart Handheld visual screener Opaque card or occluder Penlight Applicator stick Ophthalmoscope Normal Range of Findings Abnormal Findings TEST CENTRAL VISUAL ACUITY Snellen Eye Chart The Snellen alphabet chart is the most commonly used and accurate measure of visual acuity. It has lines of letters arranged in decreasing size. Place the Snellen alphabet chart in a well-lit spot at eye level. Position the person on a mark exactly 20 feet from the chart. Hand over an opaque card with which to shield one eye at a time during the test; inadvertent peeking may result when shielding the eye with the person's own fingers (Fig. 14-9). If the person wears glasses or contact lenses, leave them on. Remove only reading glasses because they will blur distance vision. Ask the person to read through the chart to the smallest line of letters possible. Encourage trying the next smallest line also. (Note: Use a Snellen picture chart for people who cannot read letters. See p. 303.) Note hesitancy, squinting, leaning forward, misreading letters. Record the result using the numeric fraction at the end of the last successful line read. Indicate whether the person missed any letters or if corrective lenses were worn—for example, "Right 20/30 − 1, with glasses." That is, the right eye scored 20/30, missing one letter, Normal visual acuity is 20/20. Contrary to some people's impression, the numeric fraction is not a percentage of normal vision. Instead, the top number (numerator) indicates the distance the person is standing from the chart, and the denominator gives the distance at which a normal eye could have read that particular line. Thus "20/30" means, "You can read at 20 feet what the normal eye can see from 30 feet away." The larger the denominator, the poorer the vision. If vision is poorer than 20/30, refer to an ophthalmologist or optometrist. Impaired vision may be due to refractive error, opacity in the media (cornea, lens, vitreous), or disorder in the retina or optic pathway. If the person is unable to see even the largest letters, shorten the distance to the chart until it is seen and record that distance (e.g., "10/200"). If visual acuity is even lower, assess whether the person can count your fingers when they are spread in front of the eyes or distinguish light perception from your penlight. Near Vision For people older than 40 years or for those who report increasing difficulty reading, test near vision with a handheld vision screener with various sizes of print (e.g., a Jaeger card) (Fig. 14-10). Hold the card in good light about 35 cm (14 inches) from the eye—this distance equals the print size on the 20-foot chart. Test each eye separately, with glasses on. A normal result is "14/14" in each eye, read without hesitancy and without moving the card closer or farther away. When no vision screening card is available, ask the person to read from a magazine or newspaper. Presbyopia, the decrease in power of accommodation with aging, is suggested when the person moves the card farther away. TEST VISUAL FIELDS Confrontation Test This is a gross measure of peripheral vision. It compares the person's peripheral vision with your own, assuming yours is normal. Position yourself at eye level with the person, about 2 feet away. Direct the person to cover one eye with an opaque card, and with the other eye to look straight at you. Cover your own eye opposite to the person's covered one. You are testing the uncovered eye. Hold a pencil or your flicking finger as a target midline between you and slowly advance it in from the periphery in several directions (Fig. 14-11, A and B). Ask the person to say "now" as the target is first seen; this should be just as you see the object also. (This works with all but the temporal visual field, with which you would need a 6-foot arm to avoid being seen initially! With the temporal direction, start the object somewhat behind the person.) Estimate the angle between the anteroposterior axis of the eye and the peripheral axis where the object is first seen. Normal results are about 50 degrees upward, 90 degrees temporally, 70 degrees down, and 60 degrees nasally (Fig. 14-12). If the person is unable to see the object as the examiner does, the test suggests peripheral field loss. In an older adult, this screens for glaucoma. Refer to a specialist for more precise testing (see Table 14-5, Visual Field Loss, on p. 316). Acutely diminished visual fields occur with diseases of the retina and stroke. Range of peripheral vision. INSPECT EXTRAOCULAR MUSCLE FUNCTION Corneal Light Reflex (The Hirschberg Test) Assess the parallel alignment of the eye axes by shining a light toward the person's eyes. Direct the person to stare straight ahead as you hold the light about 30 cm (12 inches) away. Note the reflection of the light on the corneas; it should be in exactly the same spot on each eye. See the bright white dots in Fig. 14-30 for symmetry of the corneal light reflex. Asymmetry of the light reflex indicates deviation in alignment from eye muscle weakness or paralysis. If you see this, perform the cover test. Cover Test This test detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps the two eyes parallel. Ask the person to stare straight ahead at your nose even though the gaze may be interrupted. With an opaque card, cover one eye. As it is covered, note the uncovered eye. A normal response is a steady fixed gaze (Fig. 14-13, A). If the eye jumps to fixate on the designated point, it was out of alignment before. Meanwhile, the macular image has been suppressed on the covered eye. If muscle weakness exists, the covered eye will drift into a relaxed position. Now uncover the eye and observe it for movement. It should stare straight ahead (Fig. 14-13, B). If it jumps to re-establish fixation, eye muscle weakness exists. Repeat with the other eye. A phoria is a mild weakness noted only when fusion is blocked. Tropia is more severe—a constant malalignment of the eyes (see Table 14-1, Extraocular Muscle Dysfunction, on p. 311). Diagnostic Positions Test Leading the eyes through the six cardinal positions of gaze will elicit any muscle weakness during movement (Fig. 14-14). Ask the person to hold the head steady and to follow the movement of your finger, pen, or penlight only with the eyes. Hold the target back about 12 inches so the person can focus on it comfortably, and move it to each of the six positions, hold it momentarily, then back to center. Progress clockwise. A normal response is parallel tracking of the object with both eyes. Eye movement is not parallel. Failure to follow in a certain direction indicates weakness of an extraocular muscle (EOM) or dysfunction of cranial nerve innervating it. Diagnostic positions test. In addition to parallel movement, note any nystagmus—a fine, oscillating movement best seen around the iris. Mild nystagmus at an extreme lateral gaze is normal; nystagmus at any other position is not. Nystagmus occurs with disease of the semicircular canals in the ears, a paretic eye muscle, multiple sclerosis, or brain lesions. Finally, note that the upper eyelid continues to overlap the superior part of the iris, even during downward movement. You should not see a white rim of sclera between the lid and the iris. If noted, this is termed "lid lag." (Jarvis 287-292)

Presbyopia

Presbyopia, the decrease in power of accommodation with aging, is suggested when the person moves the card farther away. (Jarvis 288-289)

Cranial Nerve VII

Provides motor innervation to the muscles of facial expression, posterior belly of the digastric muscle, and stapedius muscle. Also receives the special sense of taste from the anterior 2/3 of the tongue and provides secretomotor innervation to the salivary glands (except parotid) and the lacrimal gland. Bell's Palsy has damage to CN VII.

Cranial Nerve XII

Provides motor innervation to the muscles of the tongue (except for the palatoglossus, which is innervated by the vagus nerve) and other glossal muscles

koplik spots

Small blue-white spots with irregular red halo scattered over mucosa opposite the molars. An early sign, and pathognomonic, of measles. (Jarvis 379)

Epididymitis

Subjective: Severe pain of sudden onset in scrotum, somewhat relieved by elevation (a positive Prehn sign); also rapid swelling, fever Objective: Inspection—enlarged scrotum; reddened; Palpation—exquisitely tender; epididymis enlarged, indurated; may be hard to distinguish from testis. Overlying scrotal skin may be thick and edematous Acute infection of epididymis commonly caused by prostatitis, after prostatectomy because of trauma of urethral instrumentation, or due to chlamydia, gonorrhea, or other bacterial infection. Often difficult to distinguish between epididymitis and testicular torsion. Assessment: Tender swelling of epididymis (Jarvis 706)

Cranial Nerve X

Supplies branchiomotor innervation to most laryngeal and pharyngeal muscles (except the stylopharyngeus, which is innervated by the glossopharyngeal). Also provides parasympathetic fibers to nearly all thoracic and abdominal viscera down to the splenic flexure. Receives the special sense of taste from the epiglottis. A major function: controls muscles for voice and resonance and the soft palate.

Vital signs

Temperature. Changes in the body's temperature regulatory mechanism leave the aging person less likely to have fever but at a greater risk for hypothermia. Thus the temperature is a less reliable index of the older person's true health state. Sweat gland activity is also diminished. Pulse. The normal range of heart rate is 50 to 90 bpm, but the rhythm may be slightly irregular. The radial artery may feel stiff, rigid, and tortuous in an older person, although this condition does not necessarily imply vascular disease in the heart or brain. The increasingly rigid arterial wall needs a faster upstroke of blood, so the pulse is actually easier to palpate. Respirations. Aging causes a decrease in vital capacity and a decreased inspiratory reserve volume. You may note a shallower inspiratory phase and an increased respiratory rate. Blood Pressure. The aorta and major arteries tend to harden with age. As the heart pumps against a stiffer aorta, the systolic pressure increases, leading to a widened pulse pressure. With many older people, both the systolic and diastolic pressures increase, making it difficult to distinguish normal aging values from abnormal hypertension. (Jarvis 151)

Pulse locations

Temporal Artery The temporal artery is palpated in front of the ear, as discussed in Chapter 13. Carotid Artery The carotid artery is palpated in the groove between the sternomastoid muscle and the trachea and is discussed in Chapter 19. Arteries in the Arm The major artery supplying the arm is the brachial artery, which runs in the biceps-triceps furrow of the upper arm and surfaces at the antecubital fossa in the elbow medial to the biceps tendon (Fig. 20-1). Immediately below the elbow, the brachial artery bifurcates into the ulnar and radial arteries. These run distally and form two arches supplying the hand; these are called the superficial and deep palmar arches. The radial pulse lies just medial to the radius at the wrist; the ulnar artery is in the same relation to the ulna, but it is deeper and often difficult to feel. Arteries in the Leg The major artery to the leg is the femoral artery, which passes under the inguinal ligament (Fig. 20-2). The femoral artery travels down the thigh. At the lower thigh, it courses posteriorly; then it is termed the popliteal artery. Below the knee, the popliteal artery divides. The anterior tibial artery travels down the front of the leg on to the dorsum of the foot, where it becomes the dorsalis pedis. In back of the leg, the posterior tibial artery travels down behind the medial malleolus and in the foot forms the plantar arteries. (Jarvis 500)

Kinesthesia

Test the person's ability to perceive passive movements of the extremities. Move a finger or the big toe up and down, and ask the person to tell you which way it is moved (Fig. 23-26). The test is done with the eyes closed, but to be sure it is understood, have the person watch a few trials first. Vary the order of movement up or down. Hold the digit by the sides, since upward or downward pressure on the skin may provide a clue as to how it has been moved. Normally, a person can detect movement of a few millimeters. (Jarvis 651) Abnormal findings: Loss of position sense

aging skin

The Aging Adult Skin Color and Pigmentation. Common variations of hyperpigmentation are: Senile Lentigines. Commonly called liver spots, these are small, flat, brown macules (Fig. 12-20). These circumscribed areas are clusters of melanocytes that appear after extensive sun exposure. They appear on the forearms and dorsa of the hands. They are not malignant and require no treatment. Keratoses. These lesions are raised, thickened areas of pigmentation that look crusted, scaly, and warty. One type, seborrheic keratosis, looks dark, greasy, and "stuck on" (Fig. 12-21). They develop mostly on the trunk but also on the face and hands and on unexposed as well as on sun-exposed areas. They do not become cancerous. Another type, actinic (senile or solar) keratosis, is less common (Fig. 12-22). These lesions are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma. Moisture. Dry skin (xerosis) is common in the aging person because of a decline in the size, number, and output of the sweat glands and sebaceous glands. The skin itches and looks flaky and loose. Texture. Common variations occurring in the aging adult are acrochordons, or "skin tags," which are overgrowths of normal skin that form a stalk and are polyp-like (Fig. 12-23). They occur frequently on eyelids, cheeks and neck, and axillae and trunk. Sebaceous hyperplasia consists of raised yellow papules with a central depression. They are more common in men, occurring over the forehead, nose, or cheeks. They have a pebbly look (Fig. 12-24). Thickness. With aging, the skin looks as thin as parchment and the subcutaneous fat diminishes. Thinner skin is evident over the dorsa of the hands, forearms, lower legs, dorsa of feet, and over bony prominences. The skin may feel thicker over the abdomen and chest. Aging skin increases risk for pressure ulcer development (see Table 12-6, Pressure Ulcer [Decubitus Ulcer]). Mobility and Turgor. The turgor is decreased (less elasticity), and the skin recedes slowly or "tents" and stands by itself (Fig. 12-25). Hair. With aging, the hair growth decreases and the amount decreases in the axillae and pubic areas. After menopause, white women may develop bristly hairs on the chin or upper lip resulting from unopposed androgens. In men, coarse terminal hairs develop in the ears, nose, and eyebrows, although the beard is unchanged. Male-pattern balding, or alopecia, is a genetic trait. It is usually a gradual receding of the anterior hairline in a symmetric W shape. In men and women, scalp hair gradually turns gray because of the decrease in melanocyte function. Nails. With aging, the nail growth rate decreases and local injuries in the nail matrix may produce longitudinal ridges. The surface may be brittle or peeling and sometimes yellowed. Toenails also are thickened and may grow misshapen, almost grotesque. The thickening may be a process of aging, or it may be due to chronic peripheral vascular disease. Fungal infections are common in aging, with thickened, crumbling toenails and erythematous scaling on contiguous skin surfaces. (Jarvis 211-226)

Blood pressure JNC-VII guidelines

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. The Journal of the American Medical Association, 289(19):2560-2572; www.nhlbi.nih.gov/guidelines/hypertension. (Jarvis 156

ankle joint

The ankle, or tibiotalar joint, is the articulation of the tibia, fibula, and talus. It is a hinge joint, limited to flexion (dorsiflexion) and extension (plantar flexion) on one plane. Landmarks are two bony prominences on either side—the medial malleolus and the lateral malleolus. Strong, tight medial and lateral ligaments extend from each malleolus onto the foot. These help the lateral stability of the ankle joint, although they may be torn in eversion or inversion sprains of the ankle. (Jarvis 572)

basal ganglia

The basal ganglia are large bands of gray matter buried deep within the two cerebral hemispheres that form the subcortical associated motor system (the extrapyramidal system) (Fig. 23-2). They help to initiate and coordinate movement and control automatic associated movements of the body (e.g., the arm swing alternating with the legs during walking). (Jarvis 622)

Cerebellum

The cerebellum is a coiled structure located under the occipital lobe that is concerned with motor coordination of voluntary movements, equilibrium (i.e., the postural balance of the body), and muscle tone. It does not initiate movement but coordinates and smoothes it (e.g., the complex and quick coordination of many different muscles (Jarvis 622-623)

Function of Cerebrum

The cerebral cortex is the center for human's highest functions, governing thought, memory, reasoning, sensation, and voluntary movement (Fig. 23-1). Each half of the cerebrum is a hemisphere; the left hemisphere is dominant in most (95%) people, including those who are left-handed. Each hemisphere is divided into four lobes: frontal, parietal, temporal, and occipital. The lobes have certain areas that mediate specific functions. • The frontal lobe has areas concerned with personality, behavior, emotions, and intellectual function. • The precentral gyrus of the frontal lobe initiates voluntary movement. • The parietal lobe's postcentral gyrus is the primary center for sensation. • The occipital lobe is the primary visual receptor center. • The temporal lobe behind the ear has the primary auditory reception center with functions of hearing, taste, and smell. • Wernicke's area in the temporal lobe is associated with language comprehension. When damaged in the person's dominant hemisphere, receptive aphasia results. The person hears sound, but it has no meaning, like hearing a foreign language. • Broca's area in the frontal lobe mediates motor speech. When injured in the dominant hemisphere, expressive aphasia results; the person cannot talk. The person can understand language and knows what he or she wants to say, but can produce only a garbled sound. (Jarvis 621-622)

Medulla Oblongata

The continuation of the spinal cord in the brain that contains all ascending and descending fiber tracts. It has vital autonomic centers (respiration, heart, gastrointestinal function), as well as nuclei for cranial nerves VIII through XII. Pyramidal decussation (crossing of the motor fibers) occurs here. (Jarvis 623)

examining skin temperature

The dorsa (backs) of hands and fingers—best for determining temperature because the skin here is thinner than on the palms (Jarvis 116)

Extrapyramidal tract

The extrapyramidal tracts include all the motor nerve fibers originating in the motor cortex, basal ganglia, brainstem, and spinal cord that are outside the pyramidal tract. This is a phylogenetically older, "lower," more primitive motor system. These subcortical motor fibers maintain muscle tone and control body movements, especially gross automatic movements, such as walking. (Jarvis 625)

Valves

The four chambers are separated by swinging-door-like structures, called valves, whose main purpose is to prevent backflow of blood. The valves are unidirectional; they can open only one way. The valves open and close passively in response to pressure gradients in the moving blood. There are four valves in the heart (see Fig. 19-4). The two atrioventricular (AV) valves separate the atria and the ventricles. The right AV valve is the tricuspid, and the left AV valve is the bicuspid or mitral valve (so named because it resembles a bishop's mitred cap). The valves' thin leaflets are anchored by collagenous fibers (chordae tendineae) to papillary muscles embedded in the ventricle floor. The AV valves open during the heart's filling phase, or diastole, to allow the ventricles to fill with blood. During the pumping phase, or systole, the AV valves close to prevent regurgitation of blood back up into the atria. The papillary muscles contract at this time, so that the valve leaflets meet and unite to form a perfect seal without turning themselves inside out. The semilunar (SL) valves are set between the ventricles and the arteries. Each valve has three cusps that look like half moons. The SL valves are the pulmonic valve in the right side of the heart and the aortic valve in the left side of the heart. They open during pumping, or systole, to allow blood to be ejected from the heart. (Jarvis 459)

lymphatic system in children

The lymphatic system has the same function in children as in adults. Lymphoid tissue has a unique growth pattern compared with other body systems (Fig. 20-7). It is well developed at birth and grows rapidly until age 10 or 11 years. By age 6 years, the lymphoid tissue reaches adult size; it surpasses adult size by puberty, and then it slowly atrophies. It is possible that the excessive antigen stimulation in children causes the early rapid growth. Lymph nodes are relatively large in children, and the superficial ones often are palpable even when the child is healthy. With infection, excessive swelling and hyperplasia occur. Enlarged tonsils are familiar signs in respiratory infections. The excessive lymphoid response also may account for the common childhood symptom of abdominal pain with seemingly unrelated problems such as upper respiratory infections. Possibly the inflammation of mesenteric lymph nodes produces the abdominal pain. (Jarvis 504)

Infant exam

The parent always should be present to understand normal growth and development and for the child's feeling of security. • Place the neonate or young infant flat on a padded examination table (Fig. 8-11). The infant also may be held against the parent's chest for some steps. • Once the baby can sit without support (around 6 months), as much of the examination as possible should be performed while the infant is in the parent's lap. • By 9 to 12 months, the infant is acutely aware of the surroundings. Anything outside the infant's range of vision is "lost," so the parent must be in full view. Preparation • Timing should be 1 to 2 hours after feeding, when the baby is not too drowsy or too hungry. • Maintain a warm environment. A neonate may require an overhead radiant heater. • An infant will not object to being nude. Have the parent remove outer clothing, but leave a diaper on a boy. • An infant does not mind being touched, but make sure your hands and stethoscope endpiece are warm. • Use a soft, crooning voice during the examination; the baby responds more to the feeling in the tone of the voice than to what is actually said. • An infant likes eye contact; lock eyes from time to time. • Smile; a baby prefers a smiling face to a frowning one. (Often beginning examiners are so absorbed in their technique that they look serious or stern.) Take time to play. • Keep movements smooth and deliberate, not jerky. • Use a pacifier for crying or during invasive steps. • Offer brightly colored toys for a distraction when the infant is fussy. • Let an older baby touch the stethoscope or tongue blade. Sequence • Seize the opportunity with a sleeping baby to listen to heart, lung, and abdominal sounds first. • Perform least distressing steps first. (See the sequence in Chapter 27.) Save the invasive steps of examination of the eye, ear, nose, and throat until last. • If you elicit the Moro or "startle" reflex, do it at the end of the examination because it may cause the baby to cry. (Jarvis 123)

review of systems

The purposes of this section are (1) to evaluate the past and present health state of each body system, (2) to double-check in case any significant data were omitted in the Present Illness section, and (3) to evaluate health promotion practices. The order of the examination of body systems is roughly head-to-toe. (Jarvis 54)

costal angle

The right and left costal margins form an angle where they meet at the xiphoid process. Usually 90 degrees or less, this angle increases when the rib cage is chronically overinflated, as in emphysema. (Jarvis 412)

dimpling

The shallow dimple (also called a skin tether) shown here is a sign of skin retraction. Cancer causes fibrosis, which contracts the suspensory ligaments. The dimple may be apparent at rest, with compression, or with lifting of the arms. Also note the distortion of the areola here as the fibrosis pulls the nipple toward it. (Jarvis 404)

spinothalmic tract

The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch (i.e., not precisely localized). Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas those of crude touch form the anterior spinothalamic tract. (Jarvis 624)

TMJ

The temporomandibular joint (TMJ) is the articulation of the mandible and the temporal bone. The TMJ permits jaw function for speaking and chewing. The joint allows three motions: (1) hinge action to open and close the jaws; (2) gliding action for protrusion and retraction; and (3) gliding for side-to-side movement of the lower jaw. (Jarvis 567-569) With the person seated, inspect the area just anterior to the ear. Place the tips of your first two fingers in front of each ear and ask the person to open and close the mouth. Drop your fingers into the depressed area over the joint, and note smooth motion of the mandible. An audible and palpable snap or click occurs in many healthy people as the mouth opens Ask the person to: • Open mouth maximally. Vertical motion. You can measure the space between the upper and lower incisors. Normal is 3 to 6 cm, or three fingers inserted sideways. • Partially open mouth, protrude lower jaw, and move it side to side. Lateral motion. Normal extent is 1 to 2 cm (Jarvis 605)

Identify vertebrae

The vertebrae are 33 connecting bones stacked in a vertical column (Fig. 22-4). You can feel their spinous processes in a furrow down the midline of the back. Humans have 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 or 4 coccygeal vertebrae. • The spinous processes of C7 and T1 are prominent at the base of the neck. • The inferior angle of the scapula normally is at the level of the interspace between T7 and T8. • An imaginary line connecting the highest point on each iliac crest crosses L4. • An imaginary line joining the two symmetric dimples that overlie the posterior superior iliac spines crosses the sacrum. A lateral view shows that the vertebral column has four curves (a double-S-shape) Know picture on page 568 (Jarvis 569)

base & apex

Think of the heart as an upside-down triangle in the chest. The "top" of the heart is the broader base, and the "bottom" is the apex, which points down and to the left (Fig. 19-3). During contraction, the apex beats against the chest wall, producing an apical impulse. This is palpable in most people, normally at the fifth intercostal space, 7 to 9 cm from the midsternal line. Inside the body, the heart is rotated so that its right side is anterior and its left side is mostly posterior. Of the heart's four chambers, the right ventricle forms the greatest area of anterior cardiac surface. The left ventricle lies behind the right ventricle and forms the apex and slender area of the left border. The right atrium lies to the right and above the right ventricle and forms the right border. The left atrium is located posteriorly, with only a small portion, the left atrial appendage, showing anteriorly. The great vessels lie bunched above the base of the heart. (Jarvis 456-457)

Rheumatoid arthritis in hands

This is a chronic, systemic inflammatory disease of joints and surrounding connective tissue. Inflammation of synovial membrane leads to thickening; then to fibrosis, which limits motion; and finally to bony ankylosis. The disorder is symmetric and bilateral and is characterized by heat, redness, swelling, and painful motion of the affected joints. RA is associated with fatigue, weakness, anorexia, weight loss, low-grade fever, and lymphadenopathy. Associated signs are described in the following tables, especially Table 22-4. (Jarvis 608) CONDITIONS CAUSED BY CHRONIC RHEUMATOID ARTHRITIS Swan-Neck and Boutonnière Deformity Flexion contracture resembles curve of a swan's neck. Note flexion contracture of metacarpophalangeal joint, then hyperextension of the proximal interphalangeal joint, and flexion of the distal interphalangeal joint. It occurs with chronic rheumatoid arthritis and is often accompanied by ulnar drift of the fingers. In boutonnière deformity, the knuckle looks as if it is being pushed through a buttonhole. It is a relatively common deformity and includes flexion of proximal interphalangeal joint with compensatory hyperextension of distal interphalangeal joint. Ulnar Deviation or Drift Fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbalance. Also note subluxation and swelling in the joints and muscle atrophy on the dorsa of the hands. This is caused by chronic rheumatoid arthritis. (Jarvis 613)

Interpretation

This statement is not based on direct observation as with confrontation, but it is based on your inference or conclusion. It links events, makes associations, or implies cause: "It seems that every time you feel the stomach pain, you have had some kind of stress in your life." Interpretation also ascribes feelings and helps the person understand his or her own feelings in relation to the verbal message. Patient: I have decided I don't want to take any more treatments. But I can't seem to tell my doctor that. Every time she comes in, I tighten up and can't say anything. Response: Could it be that you're afraid of her reaction? You do run a risk of making the wrong inference. If this is the case, the person will correct it. But even if the inference is corrected, interpretation helps prompt further discussion of the topic. (Jarvis 34)

hernias

Umbilical hernia is a soft, skin-covered mass, which is the protrusion of the omentum or intestine through a weakness or incomplete closure in the umbilical ring. It is accentuated by increased intra-abdominal pressure as with crying, coughing, vomiting, or straining, but the bowel rarely incarcerates or strangulates. It is more common in premature infants. Most umbilical hernias resolve spontaneously by 1 year; parents should avoid affixing a belt or coin at the hernia because this will not help closure and may cause contact dermatitis. In an adult, it occurs with pregnancy, with chronic ascites, or with chronic intrathoracic pressure (e.g., asthma, chronic bronchitis). Epigastric Hernia A small, fatty nodule at epigastrium in midline, through the linea alba. Usually one can feel it rather than observe it. May be palpable only when standing. Incisional Hernia A bulge near an old operative scar that may not show when person is supine but is apparent when the person increases intra-abdominal pressure by a sit-up, by standing, or by the Valsalva maneuver. Diastasis recti, or a midline longitudinal ridge, is a separation of the abdominal rectus muscles. Ridge is revealed when intra-abdominal pressure is increased by raising head while supine. Occurs congenitally and as a result of pregnancy or marked obesity in which prolonged distention or a decrease in muscle tone has occurred. It is not clinically significant. (Jarvis 560-563)

thready pulse

Weak, "thready" pulse (1+) occurs with shock and peripheral arterial disease. See Table 20-1 on p. 519 for illustrations of these and irregular pulse rhythms. (Jarvis 517)

otoscope

funnels light into the ear canal and onto the tympanic membrane (Jarvis 119)

genital herpes

herpes simplex virus type 2 is incurable and produces episodes of fever, dysuria, and local pain. The vesicles rupture within 1-3 days leaving painful ulcers. Ignition infection lasts 7-10 days subsequent infections last 1-3 days with milder symptoms.

bruit

indicates turbulence due to a local vascular cause, such as atherosclerotic narrowing. (Jarvis 472)

tripod

leaning forward with arms braced against their knees, chair, or bed. This gives them leverage so that their rectus abdominis, intercostal, and accessory neck muscles all can aid in expiration. (Jarvis 428)

Empathy

means viewing the world from the other person's inner frame of reference while remaining yourself. Empathy means recognizing and accepting the other person's feelings without criticism. It is described as "feeling with the person rather than feeling like the person."

genital warts

painless warty growths are caused by the human papillomavirus and are one of the most common sexually transmitted diseases

holistic health

views the mind, body, and spirit as interdependent and functioning as a whole within the environment. Assessment factors are expanded to include such things as culture and values, family and social roles, self-care behaviors, job-related stress, developmental tasks, and failures and frustrations of life. (Jarvis 8)

subjective data

what the person says about himself or herself (Jarvis 49)