Health Assessment Test #1 COMBINED OFFICIAL

Summary

Condenses facts and validates what was discussed during the interview • Signals that termination of interview is imminent • Both client and examiner should be active participants

EOM function

Corneal light reflex, cover test, diagnostic positions test

Inspection

is concentrated watching. It is close, careful scrutiny, first of the individual as a whole and then of each body system. Inspection begins the moment you first meet the person and develop a "general survey." Inspection always comes first. Requires: - good lighting. - adequate exposure. - occasional use of instruments, including otoscope, ophthalmoscope, penlight, or nasal and vaginal specula, to enlarge your view.

Lacrimal apparatus

provides irrigation to the eye.

Ear test procedure

pull up and back -insert 1 to 1.5 cm

Sensorineural (or perceptive) hearing loss:

signifies pathology of inner ear, cranial nerve VIII, or auditory areas of cerebral cortex

Diagnostic Positions Test

six cardinal positions of gaze

Nociceptors

specialized nerve endings designed to detect painful sensations - Transmit sensations to central nervous system by two primary sensory (afferent) fibers: Aδ and C fibers

stridor

strained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx

Point of maximal impulse (PMI)

the point where the apex of the heart touches the anterior chest wall and heart movements are most easily observed and palpated

Acute Pain Behaviors

ØInvolve autonomic responses ØProtective purpose •Guarding, grimacing •Vocalizations such as moaning, agitation, restlessness, stillness •Diaphoresis, •Change in vital signs

The Aging Adult: Pain

No evidence exists to suggest that older individuals perceive pain to a lesser degree or that sensitivity is diminished. - Although pain is common experience among individuals 65 years of age and older, - it is not normal process of aging; it indicates pathology or injury. Pain should never be considered some Dementia does not impact ability to feel pain, but it does impact person's ability to effectively use self-report tools Older adults have additional fears about Øbecoming dependent, undergoing invasive procedures, taking pain medications, and having a financial burden.

Abnormal Findings: Eyelid Abnormalities

Periorbital edema Exophthalmos (protruding eyes) Enophthalmos (sunken eyes) Ptosis (drooping upper lid) Upward palpebral slant Ectropion Lower lid rolling out Entropion Lower lid rolling inCopyright © 2020 b

Conjunctiva

Transparent protective covering of the eye

Use penlight in mouth to find

Tongue blade, moistness, inflammation, ulcers, lesions, white patches. Parlor, cyanosis and jaundice are best seen here especially on dark skin tones

pneumothorax

air in the pleural cavity causing lung to collapse

Iris

functions as a diaphragm, varying opening at its center, the pupil

Ophthalmoscope

illuminates the internal eye structures. Its system of lenses and mirrors enables you to look through the pupil at the fundus (background) of the eye.

Other than detecting physical abnormalities, what benefits are there to performing a complete physical exam

- Establish therapeutic relationship -Educate and promote health

Eye exams include

- inspect eyes -check pupillary responses -Examining extraocular movement

A nurse is teaching an older adult client about health promotion. The nurse should instruct the client to have which of the following examinations preformed on a regular basis? (Select all that apply) 1.Vision screening every year 2.Hearing test every 5 years 3.Dental examination every 6 months' 4.Skin cancer screening every 2 years 5.Neurological check every 3 months

1.Vision screening every year 3.Dental examination every 6 months

Adult respiratory rate

12-20 breaths/min

Cushing syndrome

Classic "moonlike" face, red cheeks, and hirsutism

Rinne test

Normal finding—AC greater than BC, noted as positive finding Abnormal finding relates to:• Sensorineural loss: Normal ratio intact but reduced, the person hears poorly both ways

How much information should be included in a comprehensive physical exam

SBAR and SOAP -document

Glossopharyngeal and vagus cranial nerve (CN IX and X)

Uvula is midline and rises - ability to swallow

A nurse is assessing the mouth of a client who has candidiasis, an oral fungal infection. Which of the following findings should the nurse expect? 1. White patches on the tongue 2. Beefy red tongue 3. Petechiae on hard palate 4. Overgroth og gum tissue

White patches on the tongue

After assessing respiratory function, reassess by making the client...

cough

Terms of the contract include:

• Time and place of the interview and succeeding physical examination. • Introduction of yourself and a brief explanation of your role. • The purpose of the interview. • How long it will take. • Expectation of participation for each person. • Presence of any other people (e.g., family, other health professionals, students). • Confidentiality and to what extent it may be limited. • Any costs to the client.

Chronic Pain Behaviors

•Bracing, rubbing •Diminished activity •Sighing •Change in appetite

Four phases of Nociception

•Transduction •Transmission •Perception •Modulation

Are there specific considerations for conducting a general physical assessment on an older adult

-fatigue -energy level -rest -position changes -joint stiffness and pain with movement -allow more time -potential hearing or visual deficits

A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following instructions should the nurse include A) Insert the earpieces at the downward angle towards your nose B) Use the diaphragm to listen to low pitched sounds C) Drape the stethoscope over your neck when not in use D) Clean the stethoscope by immersing it in soapy water

A) Insert the earpieces at the downward angle towards your nose

Nose Abnormalities

Choanal atresia Epistaxis Sinusitis Seasonal allergic rhinitis (AR or hay fever) Furuncle Acute rhinitis (nonallergic) Foreign body Perforated septum Nasal polyps

Contract

Consider the interview a contract between you and your client. The contract concerns what the client needs and expects from health care and what you as a clinician have to offer. Your mutual goal is optimal health for the client.

Visual impairment (VI)

Not being able to see letters on the eye chart at line 20/50 or below

Cataract formation

Or lens opacity, resulting from a clumping of proteins in lens

Spinal accessory cranial nerve (CN XI)

Provide resistance, have the client turn head from side to side and shrug shoulders upward

Decenter

School-age children can decenter and consider all sides of a situation to form a conclusion. They are able to reason, but this reasoning capacity still is limited because they cannot yet deal with abstract ideas.

Breakthrough Pain

Transient spike in pain level with moderate to severe intensity in an otherwise controlled pain syndrome ØCan result from: •End of dose medication failure •Result of incident or episodic pain ØTreatment: •Shorten interval dosing and/or increase medication

C fibers

Unmyelinated and smaller, and transmit signal more slowly; sensations are diffuse and aching, and they persist after initial injury

A nurse is preparing to assess the eyes of a client who has liver disease. Which of the following findings should the nurse expect? 1. Ptosis of an eyelid 2.Yellow sclera 3.Edema of the eyelids 4.Reddened conjunctiva

Yellow sclera

Fixation

a reflex direction of eye toward an object attracting a person's attention

Power of attorney

a type of advance directive in which you name a person to make decisions for you when you are unable to do so.

Modulation: Phase 4

- Body has built-in mechanism to slow down and stop the process of a painful stimulus that inhibits and blocks pain. - Descending pathways release third set of neurotransmitters to produce analgesic effect. - Neurotransmitters include: - serotonin, norepinephrine, neurotensin, y-aminobutyric acid (GABA), and our own endogenous opioids, beta-endorphins, enkephalins, dynorphins

Initial Pain Assessment

- Clinician asks patients eight questions concerning location, duration, quality, intensity, and aggravating/relieving factors. - Furthermore, clinician adds questions about manner of expressing pain and effects of pain that impairs one's quality of life.

Perception: Phase 3

- Consciousness of awareness of pain signal - Cortical structures such as limbic system account for emotional response to pain. - Only when "pain" has reached the cortical structures can it be perceived as pain.

Nociciptive pain

- Develops when functioning and intact nerve fibers in the periphery and CNS are stimulated - Triggered by outside events from the nervous system as a result of actual or potential damage

Closing the interview

- Ending should be gradual thereby allowing for adequate closure to allow for final expression. - No new topics introduced - Summary provided as final statement

9 types of verbal responses:

- Facilitation—encourages patient to say more - Silence—directed attentiveness - Reflection—echoes to help express meaning - Empathy—names a feeling and allows its expression - Clarification—asking for confirmation - Confrontation—clarifying inconsistent information - Interpretation—makes association to identify cause or conclusion - Explanation—informing person by sharing factual and objective information - Summary—provides conclusion based on verified information which in turn identifies that the interview process is closing

EHR

- Federal government mandates so as to improve quality and safety. - Technology interface can affect communication in the health care provider-patient relationships. - Capturing of biomedical, psychological, and emotional information may not always be captured. - Do not allow the computer to become a "barrier" in the communication exchange process.

Structure and Function of Nose

- First segment of respiratory system - Upper third made up of bone; rest is cartilage - Nasal cavity divided medially by septum into two slit-like air passages - Anterior part of septum holds a rich vascular network, Kiesselbach's plexus, most common site of nosebleeds. - Lateral walls of each nasal cavity contain three parallel bony projections: superior, middle, and inferior turbinates. - Underlying each turbinate is a cleft, the meatus, which is named for turbinate above. - Sinuses drain into middle meatus, and tears from nasolacrimal duct drain into inferior meatus. Olfactory receptors, hair cells, lie at roof of nasal cavity and upper third of septum. -ØThese receptors for smell merge into olfactory nerve, cranial nerve I, which transmits to temporal lobe of brain. Paranasal sinuses: air-filled pockets within the cranium ØCommunicate with nasal cavity and are lined with same type of ciliated mucous membrane ØLighten weight of skull bones, serve as resonators for sound production, and provide mucus, which drains into nasal cavity ØSinus openings are narrow and easily occluded, which may cause inflammation or sinusitis. Two pairs of sinuses are accessible to examine. ØFrontal sinuses in frontal bone above and medial to orbits ØMaxillary sinuses in maxilla (cheekbone) along side walls of nasal cavity ØOther two sets are smaller and deeper. •Ethmoid sinuses between the orbits •Sphenoid sinuses deep within skull in the sphenoid bone Only maxillary and ethmoid sinuses are present at birth

Successful Interview Characteristics

- Gather complete and accurate data about person's health state, including description and chronology of any symptoms - Establish rapport and trust so person feels accepted and free to share all relevant data - Teach person about their health state - Build rapport to continue therapeutic relationship and to facilitate future diagnoses, planning, and treatment - Discuss health promotion and disease prevention

Neuropathic Pain

- Indicates type of pain that does not adhere to typical phases inherent in nociceptive pain - Pain due to a lesion or disease in the somatosensory system - Neuropathic pain implies an abnormal processing of pain message that is difficult to assess and treat. - Often perceived long after site of injury heals - Conditions that may lead to development: Diabetes mellitus, herpes zoster (shingles), HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, and/or chemotherapy

Transduction: Phase 1

- Occurs in response to noxious stimuli - Release variety of chemical mediators - Substance P, histamine, prostaglandins, serotonin, and bradykinin Neurotransmitters lead to pain propagation. - Along sensory afferent nerve fibers to spinal cord and terminate in dorsal horn - Second set of neurotransmitters carry pain signal—substance P, glutamate and adenosine triphosphate (ATP).

Pain Rating Scales

- Pain rating scales can indicate a baseline intensity, track changes, and give some degree of evaluation to a treatment modality. - There are different subtypes that use numbers, verbal description, visual analog, or descriptor scale. - Selection of pain rating scale is based on patient understanding and age of development.

Nonverbal modes of communication

- Physical appearance Posture Gestures Facial expression - Eye contact - voice - touch

The Older Adult: Interview Process

- Typically the interview process will take longer. - Consider appropriate pacing - Physical limitations - May need increased response time to process - May have more information to provide - Use therapeutic touch to provide empathy.

Respiratory assessment

- respiratory rate and rhythm -check oxygen saturation -inspect chest configuration and breathing - palpate and percuss anteriorly and posteriorly -auscultate lung sounds

What steps are important before i start a general survey

- wash hands - gather equiptment -introduce -privacy/comfort -wet lit -tell expectations

Middle ear

-Conducts sound vibrations from outer ear to central hearing apparatus in inner ear -Protects inner ear by reducing amplitude of loud sounds -Eustachian tube allows equalization of air pressure on each side of TM so that it does not rupture.

Inner Ear

-Contains the bony labyrinth, which holds sensory organs for equilibrium and hearing. -Although the inner ear is not accessible to direct examination, its functions can be assessed

ROS Approach

1. General overall health state 2. Skin and hair 3. Head - Eyes and ears - Nose and sinuses - Mouth and throat - Neck - Breast and axilla -Focus on body systems looking at specific indicators and focusing on health promotion: ØRespiratory ØCardiovascular ØPeripheral vascular ØGastrointestinal ØUrinary ØMusculoskeletal ØNeurologic ØHematologic ØEndocrine Focus on systems specific to gender looking at specific indicators and focusing on health promotion ØMale genital ØFemale genital ØSexual health

A nurse is obtaining a client's health history. Which of the following questions should the nurse ask the client to obtain a focused history of the ears? (select all that apply) 1. Have you had trouble hearing? 2. Do you ever lose your balance? 3. Have you ever used hearing aids? 4. Do you have ringing in your ears? 5. Do you have a problems with nasal drainage?

1. Have you had trouble hearing? 2. Do you ever lose your balance? 3. Have you ever used hearing aids? 4. Do you have ringing in your ears?

Skills required for physical examination:

1. Inspection 2. Palpation 3. Percussion 4. Auscultation (must be in this order)

A nurse is caring for a client who had a suspected stroke? Which of the following actions should the nurse take? (Select all that apply) 1. Make the client NPO. 2.Assess the client's orientation. 3.Check cranial nerves I, II, and V. 4.Inspect the client's muscular symmetry.

1. Make the client NPO 2. Assess the client's orientation

A nurse is assessing a client's head. Which of the following should the nurse identify as an unexpected finding? (Select all that apply) 1. Oval white patches in the client's hair 2.A lesion on the client's scalp 3.Protrusion of the client's head 4.Edema around the client's eyes 5.Protrusion of the client's mastoid bone

1. Oval white patches in the client's hair 2.A lesion on the client's scalp 3.Protrusion of the client's head 4.Edema around the client's eyes

A nurse is preparing to palpate a client's sinuses. Identify the sequence the nurse should follow when taking the following actions.

1. Position the thumbs on the supra orbital ridge just below the client's eyebrows to assess the clients frontal sinuses is the first step 2. Firmly press upward on the ridge and make sure not to apply pressure to the client's eyes is the second step 3. Ask the client if they detect tenderness or pain is the third step 4. Position the thumbs below the client's cheekbones with fingers alongside the client's head to assess the client's maxillary sinuses. 5. Apply firm, upward pressure and ask the client if hey detect tenderness or pain

Procedure for correct handwashing

1. Turn water on and make sure that it is warm 2. Wet hands and wrists thouroughly, keeping hands and forearms below the elbows 3. Dispense 1tsp of liquid soap into hands. Lather soap 4. rub hands together using firm circular motions for 20 seconds. wash all surfaces of the hands - palms, backs of hands, fingers, in between each fingers, each nail. 5. wash to at least 1in above the wrist 6. rinse hands and wrists keeping fingertips down. 7. raise hands above the elbows 8. use paper towel to pat hands dry and discard wet paper towel 9. use clean, dry paper towel to turn off water. and discard

Critical Characteristics of HPI

1.Location—be specific and precise 2.Character or quality—provide descriptive terms 3.Quantity or severity—use scales to identify intensity 4.Timing—onset, duration, and frequency 5.Setting—location and/or associated activity 6.Aggravating or relieving factors—what makes it worse or better 7.Associated factors—is the concern r/t any other symptom? 8.Patient's perception—how does it affect you?

Symptom

A symptom is a subjective sensation that the person feels from the disorder.

Which of the following is a good example of a well-written chief complaint? A. Patient complaining of chest pain for about 3 days that is worse with activity and relieved with rest. B. Pain is a 10/10. C. Patient complaining of chest pain. R/O MI. D. Patient states "I don't know what this pain is. This is the worst I have ever felt."

A. Patient complaining of chest pain for about 3 days that is worse with activity and relieved with rest. It provides a well-described clinical symptom with precipitating and alleviating factors. Option B provides a numerical answer which indirectly uses a scale but has no criteria in terms of actual scale parameters. Option C not only provides a clinical symptom but also includes a medical diagnostic statement. Option D only provides a patient's self-reported quote with no additional information r/t symptoms or signs or duration.

A patient who has been experiencing frequent, severe migraine headaches tells the nurse she has heard that biofeedback is effective in treating migraines. The patient asks the nurse to describe how this pain-relief method works. The nurse should reply that biofeedback involves A. measuring skin tension and using learned techniques to relieve pain. B. relating soothing visual images identified by the patient to promote relaxation. C. listening to an increasing volume of music until the pain subsides. D. stimulating the skin with a mild electric current when pain occurs.

A. measuring skin tension and using learned techniques to relieve pain This describes biofeedback, which gradually helps the patient to identify physiological responses that can control migraines and other types of pain.

Functional Assessment

ADLs Objectively measure functional status Relevant data r/t lifestyle and type of living environment

A nurse is performing a physical examination of the spine for an older adult client. The client should identify that which of the following findings is common with aging A) Lordosis B) Kyphosis C) Ankylosis D) Scoliosis

B) Kyphosis Lordosis- swayback Kyphosis- hunchback Ankylosis-immobility Scoliosis- lateral curve

A nurse is palpating a tender area on a clients abdomen. The nurse slowly applied pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document. A) Borborygmi B) Rebound tenderness C) Tympany D) Abdominal guarding

B) Rebound tenderness

A Nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first? a) Document accurate data B) develop a plan of care C) Validate previous data D) Evaluate outcomes of care

B) develop a plan of care

A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect? A) A continuous sensation of vibration felt over the second and third left intercostal spaces B) A high pitched scraping sound heard in the third intercostal space to the left of the sternum C)A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line D) A whooshing or swishing should over the seconds intercostal space along the left sternal border

C)A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line

A nurse is ascultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs? A. When the atria contracts vigorously B. As the ventricular walls contract C. When the semilunar valves close D. As the mitral valve snaps open

C. When the semilunar valves close

What nerves are checked during eye and ear

CN 2 ,3 ,4, 6, 8

Chronic Pain

Chronic pain can be further divided into malignant (cancer related) and nonmalignant. In contrast, chronic (or persistent) pain is diagnosed when pain continues for 6 months or longer. It can last 5, 15, or 20 years and beyond. - Malignant pain often parallels pathology created by tumor cells. - Pain induced by tissue necrosis or stretching of an organ by growing tumor. The pain fluctuates within the course of the disease - Chronic nonmalignant pain is often associated with: •musculoskeletal conditions, such as arthritis, low back pain, or fibromyalgia ØDoes not stop when the injury heals •It persists after the predicted trajectory. ØOutlasts its protective purpose •The level of pain intensity does not correspond with the physical findings. ØUnfortunately, many patients with chronic pain are not believed. •Often labeled as malingers, attention seekers, drug seekers, and so forth

Parkinson syndrome

Classic "maskline" appearance, elevated eyebrows, staring gaze, oily skin and drooling due to dopamine deficiency

Lip abnormalities

Cleft lip Herpes simplex 1 (HSV-1) Angular cheilitis (stomatitis, perlèche) Carcinoma Retention "cyst" (mucocele)

Purpose of Health History

Collect subjective data to combine with objective data from physical exam and lab studies to form the database. Provides a complete picture of patient's past and present health status Can be used as a screening tool for detection of abnormalities Sequence may vary in terms of obtained information. Focus may differ in terms of clinical practice setting and/or nature of complaint.

Deep Somatic Pain

Comes from sources such as blood vessels, joints, tendons, muscles, and bone. •Injury may result from pressure, trauma, or ischemia. •Described as aching or throbbing •Usually well localized and able to be identified •Like visceral pain it can be accompanied by nausea, sweating, tachycardia, and HTN.

Otosclerosis

Common cause of conductive hearing loss in young adults between ages of 20 and 40 -Gradual hardening that causes footplate of stapes to become fixed in oval window

Collecting Four Types of Data

Complete total health database -Describes current and past health state and forms baseline to measure all future changes. Episodic or problem-centered database - -Collect "mini" database, smaller scope and more focused than complete database. -Follow-up database- - Status of all identified problems should be evaluated at regular and appropriate intervals. Emergency database- Rapid collection of data often compiled concurrently with lifesaving measures.

Called the auricle or pinna

Consists of movable cartilage and skin - Characteristic shape serves to funnel sound waves into its opening, which is called the external auditory canal.

A nurse has a hunch that a patient's elevated blood pressure due to pain level however the patient recieved BP and pain meds 45 min ago- what should the nurse do?

Consult with the pain management team

Cranial nerve testing use a ...

Cotton ball and compare sensations bilaterally

A nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take? A. Instruct the client to breathe in and to exhale out as they normally do. B. Count the client's respirations for 15 seconds then multiply by 4. C. Determine if the client has a history of any chronic respiratory problems. D. Observe the client's chest movements while appearing to assess their pulse.

D. Observe the client's chest movements while appearing to assess their pulse.

Pain

Defined as an unpleasant sensory and emotional experience Associated with actual or potential tissue damage or described in terms of such damage ØPain is always subjective. ØPain is whatever the experiencing person says it is, existing whenever he or she says it does. ØSubjective report is gold standard of pain assessment.

severity of edema

Depth of indentation determines severity

Inspection and Palpation: Nose

External nose - Normally nose is symmetric, in midline, and in proportion to other facial features. - Inspect for any deformity, asymmetry, inflammation, or skin lesions. •If an injury is reported or suspected, palpate gently for any pain or break in contour. ØTest patency of nostrils. ØSense of smell, mediated by cranial nerve I, is usually not tested in a routine examination. Nasal cavity ØAttach short wide-tipped speculum to otoscope head and insert apparatus into nasal vestibule. ØView each nasal cavity with the person's head erect and then with head tilted back. •Inspect nasal mucosa, noting its normal red color and smooth moist surface. •Note any swelling, discharge, bleeding, or foreign body. Nasal septum ØObserve nasal septum for deviation. ØNote any perforation or bleeding in septum. Nasal turbinates ØInspect turbinates. ØSuperior turbinate may not be in view. ØMiddle and inferior turbinates appear the same light red color as nasal mucosa; note any swelling but do not try to push speculum past it. ØTurbinates are quite vascular and tender if touched. ØNote any polyps, benign growths that accompany chronic allergy, and distinguish them from normal turbinates.

PQRST Method of Pain Assessment

For each of the initials a series of questions are asked to help qualify patient's self-report of clinical symptoms P = Provocation/palliation Q = Quality/quantity R = Region/radiation S = Severity scale T = Timing

Subjective Data Questions: Mouth and Throat

Have you noticed any sores or lesions in the mouth, tongue, or gums? How long have you had it? Ever had this lesion before? Is it single or multiple? Does it seem associated with stress, season change, or food? How have you treated sore? Have you applied any local medication? Sore throat How frequently do you get them? Do you have a sore throat now? When did it start? Is it associated with cough, fever, fatigue, decreased appetite, headache, postnasal drip, or hoarseness? Is it worse when arising? What is humidity level in room where you sleep? Any dust or smoke inhaled at work? Do you usually get a throat culture for the sore throats? Were any documented as streptococcal? How have you treated this sore throat: medication, gargling? How effective are these? Have your tonsils or adenoids been taken out? Bleeding gums ØAny bleeding gums? How long have you had this? Toothache ØAny toothache? Do your teeth seem sensitive to hot, cold? Have you lost any teeth? Hoarseness ØAny hoarseness, voice change? For how long? ØFeel like having to clear your throat? Or, like a "lump in your throat?" Use your voice a lot at work, recreation? ØDoes hoarseness seem associated with a cold or sore throat? Dysphagia ØAny difficulty swallowing? How long have you had it? ØDo you feel as if food gets stopped at a certain point? ØAny pain with this? Altered taste or any change in sense of taste? Smoking, alcohol consumption ØDo you smoke? Pipe or cigarettes? Smokeless tobacco? How many packs per day? For how many years? ØWhen was your last alcohol drink? How much alcohol did you drink that time? How much alcohol do you usually drink? Patient-centered care ØHow often do you use a toothbrush and floss? ØLast dental examination? Do dental problems affect which foods you eat? ØDo you have a dental appliance: braces, bridge, headgear? ØDo you wear dentures? All of the time? How long have you had this set? How do they fit? ØAny sores or irritation on the palate or gums?

Interview Contract Terms

Location: Time and place with follow-up for physical exam Explanation: Introduction and delineation of role Purpose: Mutual goal is optimal health. Time frame: Length of time for process Participation: Expected participation and/or presence of others Confidentiality: Reasonable and/or limited as it applies to legal/ethical standards Cost: Disclosure of any financial costs

Weber test

Normal finding—sound is equally heard in both ears Abnormal finding—sound lateralizes to one ear Conductive loss—Sound lateralizes to poorer ear Sensorineural loss—Sound lateralizes to better ear

Pathways of hearing

Normal pathway of hearing is air conduction (AC) described previously; it is the most efficient. Alternate route is by bone conduction (BC). • Bones of the skull vibrate and are transmitted directly to inner ear and to cranial nerve VIII.

Summary Checklist: Nose, Mouth, and Throat Examination

Nose ØInspect external nose for symmetry, any deformity, or lesions. ØPalpation: test patency of each nostril ØInspect with nasal speculum nasal mucosa, septum, and turbinates. ØPalpate the sinus area. Mouth and throat ØInspect with penlight: mouth, teeth and gums, buccal mucosa, palate and tonsils, and pharyngeal wall. ØPalpate when indicated. •For adults bimanual palpation of the mouth •In neonate, palpate for integrity of palate and assess sucking reflex.

Numeric Rating Scales: Pain

Numeric rating scales patient to choose a number that rates level of pain, with 0 being no pain and highest anchor 10 indicating worst pain

Inspection of Throat

Observe oval, rough-surfaced tonsils. ØColor is same pink as oral mucosa, and their surface peppered with indentations, or crypts; there should be no exudate on tonsils. ØTonsils graded in size as follows: •1+ Visible •2+ Halfway between tonsillar pillars and uvula •3+ Touching uvula •4+ Touching each other ØYou may normally see 1+ or 2+ tonsils in healthy people, especially in children, because lymphoid tissue is proportionately enlarged until puberty. Enlarge your view of posterior pharyngeal wall by depressing tongue with tongue blade. ØScan posterior wall for color, exudate, or lesions. •Touching posterior wall with tongue blade elicits gag reflex; this tests cranial nerves IX and X, the glossopharyngeal and vagus. ØTest cranial nerve XII, hypoglossal nerve •Asking a person to stick out tongue; should protrude in midline; note any tremor, loss of movement, or deviation to side ØNotice any breath odor, halitosis. •Usually due to local cause; poor oral hygiene, consumption of odoriferous foods, alcohol, smoking, or dental infection

Techniques to Improve Health Literacy

Oral teaching Written materials Teach back

Structure and Function: Throat or Pharynx

Oropharynx: separated from mouth by a fold of tissue on each side, the anterior tonsillar pillar Tonsils: behind folds, each is a mass of lymphoid tissue look more granular, and surface shows deep crypts Tonsillar tissue enlarges during childhood until puberty. Posterior pharyngeal wall is seen behind these structures. Nasopharynx: continuous with oropharynx above oropharynx and behind nasal cavity Pharyngeal tonsils (adenoids) and eustachian tube openings are located here.

Equipment needed ear exam

Otoscope with bright light, fresh batteries give off white, not yellow light. -Pneumatic bulb attachment, sometimes used with infant or young child - Tuning forks in 512 and 1024 Hz

PQRSTU

P: Provocative or Palliative. What brings it on? What were you doing when you first noticed it? What makes it better? Worse? Q: Quality or Quantity. How does it look, feel, sound? How intense/severe is it? R: Region or Radiation. Where is it? Does it spread anywhere? S: Severity Scale. How bad is it (on a scale of 0 to 10)? Is it getting better, worse, staying the same? T: Timing. Onset—Exactly when did it first occur? Duration—How long did it last? Frequency—How often does it occur? U: Understand Patient's Perception of the Problem. What do you think it means? Understand Patient's Perception of the Problem. What do you think it means?

Objective Data

Preparation ØPosition a person sitting up straight with his or her head at your eye level. ØIf the person wears dentures, offer a paper towel and ask the person to remove them. Equipment ØOtoscope with short, wide-tipped nasal speculum ØPenlight ØTwo tongue blades ØCotton gauze pad, 4 × 4 inches ØGloves

What clinical data, if observed in this patient, would lead the nurse to believe that the patient is experiencing complex regional pain syndrome (CRP)?

RSD/CRPS is a chronic progressive nerve condition, characterized by burning pain, swelling, stiffness, and discoloration of the affected extremity. A key feature is that a typically innocuous stimulus (e.g., a light brush of a cotton ball or clothing) can create a severe, intense painful response. Other subjective data include Øburning pain often disproportionate to the degree of injury and joint pain during movement. Objective data include Øswelling, disappearance of skin wrinkles, cool skin temperature, discoloration, brittle nails, and finally atrophic changes (pale, dry, shiny skin and muscle atrophy). Treatment includes Ømedication to treat symptoms and physical therapy to regain limb function

A 52-year-old female presents with complaints of continuing pain across her lower back. Denies any injury or traumatic event but states that the pain is a 10 on a scale of 1 to 10 and that no one believes that she is really in "pain." Pain has been present for several months. What information would you as the nurse obtain in order to validate the patient's complaints?

Review information relative to subjective and objective data. ØSubjective data: •Ask the patient about her pain using basic-level questions to determine an initial baseline: Presence of pain, location of pain, onset of pain, Quality of pain, pain perception on a scale metric (0 to 10) Alleviating or worsening factors Does pain prevent you from performing ADLs or limit other activities? Reaction to pain—symptoms experienced Can use PQRST to obtain data relevant to pain health history ØObjective data: •Inspect the skin and tissues for color, swelling, and any masses or deformity. •Assess for changes in sensation.

SBAR

Situation, Background, Assessment, Recommendation (SBAR). S:Situation: Provide a brief description of the pertinent patient variables, demographics, clinical diagnosis, and location B: Background: Provide pertinent history as it directly relates to patients current health status A:Assessment: State pertinent assessment findings obtained with interpretation of data R:Recommendation/Request: State what you need or want for the patient in terms of medical treatment and/or assistance SBAR is used at health care facilities all over the country to improve communication and reduce errors.

Percussion Methods

Stationary hand: Pleximeter—middle finger hyperextension Striking hand: Plexor—striking finger

Nociceptors Fibers

Substantia gelatinosa: Specific area of cord in which fibers synapse with interneurons - A cross section shows that gray matter of the spinal cord is divided into a series of consecutively numbered laminae (layers of nerve cells). Considered to be lamina II, which receives sensory input from various areas of body - Pain signals then cross over to other side of spinal cord and ascend to brain by anterolateral spinothalamic tract.

The patient is still complaining of pain after having been medicated with morphine 1 mg given via intravenous route as an IVP. When you attempt to reposition the patient, she complains even more than just a "mere touch" causes her severe discomfort. How would the nurse interpret this finding?

The detection of pain etiology is a difficult process, especially when the patient presents with what appears to be a chronic pain presentation. Additional information relative to the patient's complaint would focus on Øpast medical/surgical history, current status relative to medications, both prescription and over-the-counter remedies. The nurse must be careful not to pass judgment at this time and continue to obtain relevant data necessary to determine the source of the patient's pain. Additional investigation must be performed in conjunction with the patient's complaint in order for the nurse to make an accurate determination. ØSevere pain upon touch indicates both an increased pain response (hyperalgesia) and allodynia (pain sensation evoked in response to a normal stimuli), which pose considerable concern about the patient's health status.

Blood Pressure

The force that blood exerts against the vessel wall. During a normal cardiac cycle, blood pressure reaches a high point and a low point. Systole: Occurs when the ventricles of the heart contract, forcing blood into the aorta. Contraction phase of the cardiac cycle. During this pahse blood is driven into teh aorta and pulmonary arteries. Diastole: occurs when the ventricles relax and minimal pressure is exerted against the vessel wall. Relaxation phase of the cardiac cycle where the heart muscle is relaxed and the chambers of the heart fill with blood.

Open-ended questions

The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. "Tell me how I can help you?" " What brings you into this hospital today?"

Palpation of Sinus Areas

Using thumbs, press frontal sinuses by pressing up and under the eyebrows and over maxillary sinuses below cheekbones. Transillumination ØYou may use this technique when you suspect sinus inflammation, although it is of limited usefulness. ØDarken room; affix strong narrow light to end of otoscope and hold it deep under superior orbital ridge against location of frontal sinus area; cover with your hand. ØA diffuse red glow is a normal response; it comes from light shining through air in the healthy sinus.

A nurse is assessing the eye of a client who experienced a subconjunctival hemorrhage as a result of vomiting. Which of the following findings should the nurse expect? 1. Defined reddened area of the sclera 2. Dropping of the eyelid 3. Cloudy pupil 4. Bulging eyes

defined reddened area of the sclera

Cutaneous pain

derived from skin surface and subcutaneous tissues injury is superficial, with a sharp, burning sensation

Mini-database

examine the body areas appropriate to the problem, collecting a mini-database.

hypoglossal cranial nerve (CN XII)

movement of tongue Test: Light, tight, dynamite

friction rub

scratching or squeaking sound when thoracic cavity is inflamed

Role of the nurse related to documentation.

• Subjective Data: A nurse should document subjective data as direct quotes, within quotation marks, or summarize and identify the information as the clients statement • Objective Data: Should be descriptive and should include what the nurse sees, hears, feels, and smells. ◦ document without any derogatory words judgements or opinions ◦ Must document the clients behavior accurately - instead of writing "client is agitate" the nurse should write " the client is pacing back and forth in the room, yelling loudly" ‣ Accurate and Concise: • Document facts and information precisely without any interpretations of the situation. • Exact measure establish accuracy • Only abbreviations approved by the Joint Commission and the facility are acceptable ‣ Complete and Current: • Document information that is comprehensive and timely • Never pre-chart an assessment, intervention, or evaluation ‣ Organized: • Communicate information in a logical sequence

Health promotion and disease prevention

Guide to Clinical Preventive Services—annual update

HEEADSSS

HEADSSS Assessment is an internationally recognised tool used to structure the assessment of an adolescent patient, encompassing: Home Education/Employment, Activities, Drugs, Sex and relationships, Self harm and depression, Safety and abuse. T The assessment starts with simple and easy questions about life to allow a rapport to be built, before delving into more personal and embarrassing aspects

Nursing Diagnosis

clinical judgment that helps nurses determine the plan of care for their patients. These diagnoses drive possible interventions for the patient, family, and community.

In aging persons, cilia lining ear canal become

coarse and stiff

To the outer ear and inner ear eustachian tube: opening that

connects middle ear with nasopharynx and allows passage of air

wheezes

constricted airway. bronchial inflammation, tumors, mucous plug

Tarsal plates

contain meibomian glands, which are modified sebaceous glands that secrete an oily lubricating material onto lids.

Hirschberg test

corneal light reflex

Facial cranial nerve (CN VII)

- Symmetry of facial expressions and test anterior 2/3 of the tongue for ability to taste

Eye: a sphere of three concentric coats

(1) the outer fibrous sclera, (2) the middle vascular choroid, (3) the inner nervous retina

Subjective Data

(Manifestations) : what the client tells the nurse •Collected during nursing history •Includes: Clients feelings Clients perceptions Clients description of health status Clients are the only ones who can describe and verify their own manifestations

Transmission: Phase 2

- Pain impulse moves from level of spinal cord to brain. - If pain is not stopped it moves via various ascending fibers within the spinothalamic tract to the thalamus.

Faces Pain Scale- Revised (FPS-R)

- 6 drawings of pain intensity from "no pain" on right (0) to "very much pain" on left (10) - Realistic facial expressions used

Interview Purpose:

- Best chance to gain an understanding of the patient's beliefs, concerns, and perception of their individual health state - Allows for compilation of subjective data and awareness of objective data (physical appearance, posture, ability to carry on a conversation, and demeanor)

Sutures—adjacent cranial bones mesh at sutures

- Coronal - Sagittal - Lambdoid

Standard Precautions

- based on the principle that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents. - Precautions apply to all patients, regardless of suspected or confirmed infection status, and in any setting in which health care is delivered. 1. Hand hygeiene 2. Use of gloves, gown, mask, eye protection or face shield 3. Respiratory hygiene, cough etiquette

Skin assessment for...

- consistently, color, hair -temp, texture, moisture -turgor and edema -nails for color, shape, thickness, lesions, clubbing, capillary refill

Referred pain

- felt at a particular site but originates from another location

Musculoskeletal exam

- functional assessment for safety -posture movement and symmetry - palpate spine for contour and tenderness - inspect limbs for skin changes and symmetry -palpate limbs for muscle mass, ton, strength join range of motion and crepitus -assess gait

Health Literacy

- includes understanding and following directions that lead to effective communication between the patient and the health care provider

visual acuity

- near vision (CN 2)

six cardinal fields of gaze

-12" away; Use finger or penlight -Have patient keep head straight and follow with eyes only -Go from center to periphery -Go clockwise -passing indicates intact oculomotor, trochlear and abducens cranial nerves 3,4, 6

Neuro test exam

-Assess mental status - Evaluate motor function, balance and coordination - Test reflexes -Assess sensory function -Test CN function

Romberg sign

-Assesses ability of vestibular apparatus in inner ear to help maintain standing balance -Also assesses intactness of cerebellum and proprioception as it is part of the neurologic system

Identify the recommendations of IOM.

-Effective policy framework and workforce planning demands an adaptable data collection systems and data infrastructural framework. -Nursing professionals should be engaged fully with other stakeholders including physicians in the process of redesigning health care in the country. -Nursing professionals should achieve advanced levels of education and capacity building through structured systems that promote seamless academic development. -Nursing professionals should optimize their practice with regards of their level of education and training

Subjective Data: head

-Headache -Head injury -Dizziness -Neck pain, limitation of motion -Lumps or swelling -History of head or neck surgery

Using an otoscope

1) make sure it is changed 2) Attack head to handle 3) Attach and twist deposable speculum to head 4) Turn on the light 5) handle the otoscope carefully and safety 6)Discharge speculum

deep tendon reflexes (DTR)

-Last part of neuro exam muscle contraction in response to a stretch caused by striking the muscle tendon with a reflex hammer. test used to determine if muscles are responding properly

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

Stethoscope

-auscultation -Bell (back) - Diagram (big part)

Tuning fork

-neuro exams -measured in hertz -High freq are used for hearing -Low frequency used for vibration

Head and neck inspection

-palpate face and skull -palpate for hair, parasites -Neck range of motion -Neck for contour and tracheal position -Palpate carotid arteries -Palpate cervical lymphnodes -Visual acuity -Nerve function

Endocrine gland

-straddles trachea in middle of the neck -Thyroxine (T4) and triiodothyronine (T3), which are hormones that stimulate rate of cellular metabolism

Monofilament

-test for sensation Diabetic feet skin

Muscle strength scale

0 No detection of muscular contraction 1 A barely detectable flicker or trace of contraction with observation or palpation 2 Active movement of body part with elimination of gravity 3 Active movement against gravity only and not against resistance 4 Active movement against gravity and some resistance 5 Active movement against full resistance without evident fatigue (normal muscle strength)

Gordon's Functional Health Patterns

1) Health Perception - Health Management Pattern 2) Nutritional - Metabolic Pattern 3) Elimination Pattern 4)Activity - Exercise 5) Pattern Cognitive - Perceptual Pattern 6) Sleep - Rest Pattern 7) Self-perception - Self-concept Pattern 8) Role - Relationship Pattern 9) Sexuality - Reproductive Pattern 10) Coping - Stress Tolerance Pattern 11) Value - Belief Pattern

A nurse is assessing a client who has a lump on their neck. Which of the following questions should the nurse ask the client? (select all that apply) 1. "Are you experiencing difficulty breathing?" 2."How long has the lump been on your neck?" 3."Is the lump causing you discomfort?" 4."Are you having difficulty swallowing?" 5."Have you started taking a new medication?"

1. "Are you experiencing difficulty breathing?" 2."How long has the lump been on your neck?" 3."Is the lump causing you discomfort?" 4."Are you having difficulty swallowing?"

A nurse is preparing to assess a client's conjunctiva. Identify the sequence the nurse should follow when taking the following actions

1. Apply examination gloves 2. Instruct the client to look up 3.Place the thumbs below each of the client's lower eyelids. 4. Gently pull the client's skin down to the top edge of the bony orbital rim 5. Inspect the color and condition of the conductive and sclera, noting any color change, swelling, drainage, or lesions

Health History Sequence

1. Biographical data 2. Source of history 3. Reason for seeking care 4. Present health or history of present illness 5. Past health 6. Family history 7. Review of systems 8. Functional assessment including activities of daily living (ADLs)

pulse points

1. Common carotid 2. Brachial 3. Radial 4. Femoral 5. Feet

Ten Traps of Interviewing

1. Providing false assurance or reassurance 2. Giving unwanted advice 3. Using authority 4. Using avoidance language 5. Engaging in distancing 6. Using professional jargon 7. Using leading or biased questions 8. Talking too much 9. Interrupting 10. Using "why" questions

A nurse is preparing to inspect the outer ears of a client who has been in a motor-vehicle crash. The nurse should identify that which of t the following findings indicates the client might have. Skull fracture? 1. Edema 2. Bloody drainage 3. yellow drainage 4. crushed skin

2. Bloody drainage

A nurse is assessing the mouth of a client who has a vitamin B12 insufficiency. Which of the following findings should the nurse expect? 1. White patches not he tongue 2. Bleeding of the gums 3. Beefy red tongue 4. Petechiae of the hard palate

3. Beefy red tongue

Heart rate of adult

60-100 bpm

Cone of light should be visable at

7:00 in left ear and 5:00 in right ear

Auditory canal

A cul-de-sac 2.5 to 3 cm long in adults that terminates at eardrum, or tympanic membrane -Lined with glands that secrete cerumen, a yellow waxy material that lubricates and protects ear

Living will

A living will is a written, legal document that spells out medical treatments you would and would not want to be used to keep you alive, as well as your preferences for other medical decisions, such as pain management or organ donation.

AVPU scale

A method of assessing the level of consciousness by determining whether the patient is awake and alert, responsive to verbal stimuli or pain, or unresponsive; used principally early in the assessment process.

Pedigree or genogram

A pedigree or genogram is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations such as parents, grandparents, and siblings

CAGE

A screening questionnaire to identify excessive or uncontrolled drinking such as the Cut down, Annoyed, Guilty, and Eye-opener (CAGE) test 1. Have you ever thought you should Cut down your drinking? 2. Have you ever been Annoyed by criticism of your drinking? 3. Have you ever felt Guilty about your drinking? 4. 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

Sign

A sign is an objective abnormality that you as the examiner could detect on physical examination or through diagnostic testing.

Who would we treat first A) 48 year old w chest pain B) 19 yr old with headaches and stable vital signs C) 68 yr who had a ground level fall

A) 48 year old w chest pain

A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the clients breathing. The nurse should identify this observation as which of the following findings A) crackles B) Stridor C) Wheezes D) Friction rub

A) Crackles

A nurse is caring for a patient just transferred from the PACU following an abdominal hysterectomy. The patient receiving PCA with IV morphine sulfate 2 mg every 15 min with a 30mg/4hr lockout. One hour after the patient has returned to the unit, the patient tells the nurse that her pain is still unbearable. The nurse checks the PCA monitor and determines that the patient has made six attempts within the last hour. Which of the following actions should the nurse take after performing a pain assessment? A. Check the IV site and PCA pump for proper functioning. B. Teach the patient proper use of the PCA system. C. Ask the provider to increase the morphine dose and shorten the interval between doses. D. Encourage family members to "push the pain button" when the patient is in too much pain to do it herself.

A. Check the IV site and PCA pump for proper functioning. The PCA delivery system should be assessed to determine if there is any malfunction in the delivery of the medication.

A nurse is collecting data about a client's respiratory condition. Which of the following actions should the nurse take to determine the depth of the client's respiration. A. Observe the degree of chest-wall movement during inspiration and expiration. B. Count how many breathing cycles are observed per minute. C. Notice whether or not expiration takes longer than inspiration. D. Measure the precise amount of air the client takes in and breathes out.

A. Observe the degree of chest-wall movement during inspiration and expiration.

A nurse is measuring a client's temperature orally. Which of the following actions should the nurse take? A. Place the probe in the posterior lingual pocket lateral to the midline. B. Rest the probe on the lower lingual frenulum. C. Place the probe centrally on top of the client's tongue. D. Rest the probe under the tongue just beyond the client's teeth.

A. Place the probe in the posterior lingual pocket lateral to the midline.

A nurse is preparing to measure a clients vital signs. The nurse should identify that which of the following factors will affect the methods that are used? A. The client who has a BMI of 35. B. The client has had nausea for 2 days. C. The client is reporting a "stuffy" nose. D. The client has been fasting for blood tests. E. The client is taking digoxin for an irregular heart rate. F. The client had a mastectomy 2 years ago.

A. The client who has a BMI of 35. C. The client is reporting a "stuffy" nose. E. The client is taking digoxin for an irregular heart rate. F. The client had a mastectomy 2 years ago.

The nurse is reassessing a patient's pain level after pain medication administration following a pain level of 9/10. The patient states that his pain level is now a 3/10. What should the nurse do next? A. Verify orders for medications and offer more pain medication, if appropriate. B. Continue to assess patient's pain level. C. Document the pain level in the chart. D. There is no need for action, because the patient's pain is manageable.

A. Verify orders for medications and offer more pain medication, if appropriate. Option 2 is incorrect because this patient needs intervention. Option 3 is incorrect because although the patient's pain level should be documented, this is not the main priority and offers no resolution for the patient's pain. Option 4 is incorrect because a pain level of 3/10 indicates that the pain is not manageable

Speculum

Available in 2 sizes: 2-mm for peds and 4mm for adult

Trigeminal cranial nerve (CN V)

Ability to bite and chew - sensation of skin on the face

Tympanic Membrane (TM)

Also called the eardrum, separates external and middle ear -Translucent membrane with a pearly gray color

Complex Regional Pain Syndrome (CRPS)

Also known as reflexive sympathetic dystrophy (RSD) - Chronic progressive nerve condition - Complex interaction of sensory, motor, autonomic nervous system, and immune system •Equally seen in gender, usually around ages 40 to 60 Key feature is an innocuous stimulus ØPresents with burning pain, swelling, stiffness, and discoloration of the affected extremity Treatment ØHigh doses of medications (e.g., prednisone, amitriptyline, pregabalin, clonidine) to decrease symptoms ØPhysical therapy to regain limb function

Buccal Mucosa Abnormalities

Aphthous ulcers Koplik spots Leukoplakia Candidiasis or monilial infection Candidiasis in adult Herpes simplex 1

Tongue Abnormalities

Ankyloglossia Geographic tongue (migratory glossitis) Smooth, glossy tongue (atrophic glossitis) Black hairy tongue Carcinoma Fissured or scrotal tongue Enlarged tongue (macroglossia)

Inspection of Palate

Anterior hard palate white with irregular transverse rugae Posterior soft palate is pinker, smooth, and upwardly movable. ØTorus palatinus: normal variation, is a nodular bony ridge down middle of hard palate; benign growth arises after puberty and is more common finding in American Indians, Inuits, and Asians Observe uvula ØNormally looks like fleshy pendant hanging in midline; ask a person to say "ahhh" and note soft palate and uvula rise in midline ØTests one function of cranial nerve X, the vagus nerve

In reviewing the patient's health record, the nurse notes that there have been multiple admissions for the same "pain complaint" and that the patient had been treated with a variety of pain medications ranging from nonsteroidal anti-inflammatory drugs (NSAIDs) to narcotics with little success. What recommendations might the nurse consider for this patient in order to manage her pain more effectively?

As the patient's history provides evidence of multiple admissions for the same "pain complaint," the nurse may want to consider Øimplementing an interdisciplinary health care team to help manage the patient's pain. ØInclusion of a pain management specialist would be beneficial so as to look at alternative methods of pain control. ØPharmacologic as well as nonpharmacologic measures might prove to be effective. Additionally, collaborative care with physical therapy and occupational therapy might help the patient become more in "control of her pain." The nurse should also review the patient's records for potential comorbidities such as Ødiabetes or shingles that might be a possible etiology to neuropathic pain. ØAs the pain pattern has persisted, the patient must be assessed for complex regional pain syndrome (CRPS) or reflexive sympathetic dystrophy (RSD).

Lacrimal Apparatus

Ask the person to look down; with thumbs, slide outer part of upper lid up along bony orbit to expose under lid; inspect for any redness or swelling.

conjunctiva and sclera inspection

Ask the person to look up; using thumbs, slide lower lids down along orbital rim, being careful not to push against eyeball.

Lips and mouth

Asses for mouth and lip color, symmetry, dryness, and cracking

Culture and genetics

Awareness of the emerging minority - Diversity and incorporation of "cultural health rights"

A nurse is performing a complete, head-to-toe physical examination for a client. Which of the following physical assessment techniques should the nurse perform first? A) Auscultation B) Inspection C) Percussion D) palpation

B) Inspection

A patient is crying and says, "Please get me something to relieve this pain." What should the nurse do next? A. Verify that the patient has an order for pain medications and administer order as directed. B. Assess the level of pain and ask patient what usually works for his or her pain, administer pain medication as needed, then reassess pain level. C. Assess the level of pain and give medications according to pain level, and then reassess pain. D. Reposition the patient, then reassess the pain after intervention.

B. Assess the level of pain and ask patient what usually works for his or her pain, administer pain medication as needed, then reassess pain level.

A nurse is caring for two patients of different cultural backgrounds. Both patients returned from the same type of surgery 2 hr ago. Which of the following should the nurse expect to be the same for both patients? A. Patient perception of the intensity of postoperative pain B. Class of medication used to treat acute postoperative pain C. Goal of pain management for each patient D. Level of pain indicated by each patient on a numeric pain scale

B. Class of medication used to treat acute postoperative pain Opioid analgesics are the class of medication used to treat acute postoperative pain; this is true regardless of the patient's cultural background.

A nurse is assessing a client's respiration. Which of the following actions should the nurse take? A. Have the client lie flat in bed with their head on a pillow. B. Elevate the head of the client's bed 45° to 60°. C. Encourage the client to breathe shallowly. D. Ask the client to take several deep breaths prior to the assessment.

B. Elevate the head of the client's bed 45° to 60°.

A nurse is caring for a patient admitted to the emergency department with severe pain following a fall from a ladder. The initial assessment reveals long-term use of opioids for chronic pain. Which of the following provider prescriptions for initial pain relief should the nurse question? A. Morphine sulfate B. Pentazocine (Talwin) C. Meperidine (Demerol) D. Hydromorphone (Dilaudid)

B. Pentazocine (Talwin) Pentazocine is an opioid agonist/antagonist agent. This is not an appropriate medication for this patient because it may cause opioid withdrawal in a patient who is physically dependent on opioids.

A nurse is preparing to record the difference between a client's systolic and diastolic blood pressure. Which of the following terms defines this information when documenting? A. Auscultatory gap B. Pulse pressure C. Orthostatic hypotension D. Pulse deficit

B. Pulse pressure

A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider? A. Oral temperature 37.8° C (100° F) B. Respirations 30/min C. BP 148/88 mm Hg D. Radial pulse rate 45 beats/30 seconds

B. Respirations 30/min

A nurse is preparing to obtain a clients blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately? A. Obtain the reading in the early morning. B. Use a cuff of the appropriate size for the client. C. Assist the client to the bathroom to void. D. Apply the cuff loosely around the client's arm.

B. Use a cuff of the appropriate size for the client.

Teeth and Gum Abnormalities

Baby bottle tooth decay Dental caries Tooth avulsion Epulis Gingival hyperplasia Gingivitis Meth mouth

Inspection of Mouth

Begin with anterior structures and move posteriorly; use tongue blade to retract structures and bright light for optimal visualization. Inspect lips: ØFor color, moisture, cracking, or lesions; retract lips and note inner surface. ØAfrican Americans normally may have bluish lips and a dark line on gingival margin.

FLACC pain scale

Behavioral Pain Scale (Infants and Toddlers) F: Faces. L: Legs. A: Activity. C: Cry C: Consolability

Is bell or diagram used for heart murmurs and bruits

Bell

Pilar cyst (Wen)

Benign growth that presents as smooth, fluctuant swelling on scalp

oropharynx abnormalities

Bifid uvula Oral Kaposi's sarcoma Peritonsillar abscess Acute tonsillitis and pharyngitis Cleft palate

Balance exams

Both musculoskeletal and neurological exam - Romberg test

Equal-status seating

Both you and the client should be comfortably seated, at eye level. - chairs at 90 degrees is good because it allows the person either to face you or to look straight ahead from time to time. - Make sure that you avoid facing a client across a desk because this creates a barrier. - Most important, avoid standing. Standing does two things: (1) it communicates your haste, and (2) it assumes superiority.

Is bell or diagram used for high pitched sounds such as heart, lung or bowel sounds

diagram

A nurse is assessing a client's peripheral vascular status of the lower extremities. The nurse should place their fingertips on the tip of a clients foot, between the tendons of the great toe and those of the toe next to it, in order to palpate which of the following pulses A) Posterior tibial B) Popliteal C) Dorsalis pedis D) Femoral

C) Dorsalis pedis

A nurse is performing an abdominal assessment on a client. Over which of the following areas of the clients abdomen should the nurse attempt to auscultate active bowel sounds first A) RUQ B) LUQ C) RLQ D) LLQ

C) RLQ

During a pain assessment, a nurse asks questions about the quality of an adult patient's pain. Which of the following statements by the patient refers to pain quality? A. "The pain in my abdomen began last night and has gotten worse and worse." B. "My pain is at a 9 on a scale of 0 to 10." C. "My pain feels like I'm being stabbed by a knife." D. "The pain is worse when I bend over at my waist."

C. "My pain feels like I'm being stabbed by a knife." This statement describes the quality of the patient's pain.

Client-centered care

Client-centered care is about treating clients as they want to be treated, with knowledge about and respect for their values and personal priorities.

A nurse is preparing to ascultate a clients pulse at the Point of Maximum Impulse. In which of the following positions should the nurse position the stethoscope? A. Over the right midclavicular line B. Over the angle of Louis C. Overt the fifth intercostal space at the left midclavicular line D. Over the suprasternal notch

C. Overt the fifth intercostal space at the left midclavicular line

A nurse is preparing to use a tympanic thermometer to acquire a clients temperature. Which of the following actions actions should the nurse take to ensure an accurate reading? A. Attach the disposable probe cover. B. Assess the external ear for redness. C. Pull the pinna back and upward gently. D. Replace the thermometer in its charger.

C. Pull the pinna back and upward gently.

A nurse is about to use the Wong-Baker FACES pain scale to assist a patient in assessing his pain level. Which of the following should the nurse know in order to use this pain scale? A. Face #10 is chosen when the patient is crying because of severe pain. B. Face #0 is chosen when the patient "hurts a little bit." C. This scale is useful for adult patients who have cognitive impairments. D. The nurse matches a face on the scale with that of the patient's face when he is in pain.

C. This scale is useful for adult patients who have cognitive impairments. This pain scale is used for young children as well as for adult patients who have cognitive impairments that create difficulty with descriptive and numeric pain scales.

Inner canthus

Caruncle is small fleshy mass containing sebaceous glands

Most common causes of decreased visual functioning in older adults are the following:

Cataract -glaucoma -age related macular degeneration - Diabetic retinopathy

Olfactory Cranial nerve (CN 1)

Check for recognizing familiar scent

Inspection of Tongue

Check tongue for color, surface characteristics, and moisture. Ask the person to touch tongue to roof of mouth. ØVentral surface looks smooth, glistening, and shows veins. With a glove, hold tongue with a cotton gauze pad for traction and swing tongue out and to each side; inspect for any white patches or lesions; normally none are present. ØIf any occur, palpate these lesions for induration. Inspect carefully entire U-shaped area under tongue behind teeth. ØOral malignancies are most likely here. Note any white patches, nodules, or ulcerations. ØIf lesions are present, or with any person over 50 years old or with a positive history of smoking or alcohol use, use your gloved hand to palpate area. ØPlace your other hand under jay to stabilize tissue and to "capture" any abnormality; note any induration.

Past Medical History

Childhood illnesses Accidents or injuries Serious or chronic illnesses Hospitalizations Operations Obstetric History Immunizations Last Examination Allergies Current Medications

Short-form McGill Pain Questionnaire

Clinician asks patient to rank list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain.

Brief Pain Inventory

Clinician asks patient to rate pain within past 24 hours on graduated scales (0 to 10) with respect to its impact on areas such as mood, walking ability, and sleep.

HPI

Collect all provided data and identify eight critical characteristics - Make sure that collected data are precise and accurate. ØUse measureable standards and/or patient's own words as qualifiers. - Use standardized indicators to document findings ØReliability and validity of reported results

Inspect tympanic membrane

Color, characteristics, position, and integrity

Inspection of Teeth and Gums

Condition of teeth is an index of the person's general health. Note any diseased, absent, loose, or abnormally positioned teeth. Compare number of teeth with number expected for the person's age. Ask the person to bite as if chewing something, and note alignment of upper and lower jaw. Normal occlusion: ØIn back, upper teeth rest directly on lowers. ØIn front, upper incisors slightly override lower incisors. Gum margins are tight and well defined. Check for swelling; retraction of gingival margins; and spongy, bleeding, or discolored gums.

Test visual fields

Confrontation test

Movement of the extraocular muscles stimulated by three cranial nerves

Cranial nerve VI: abducens nerve, innervates lateral rectus muscle, which abducts eye Cranial nerve IV: trochlear nerve, innervates superior oblique muscle Cranial nerve III: oculomotor nerve, innervates all the rest: the superior, inferior, and medial rectus and the inferior oblique muscles

What evaluates facial symmetry

Cranial nerve VII- ask client to smile and puff out cheeks

A nurse is assessing a client's cranial nerves. Which of the following client actions is an indication that cranial nerve 1 is intact a) The client can stick their tongue out b) The client can smile symmetrically C) The client can hear whispered words D) The client can identify a minty scent

D) The client can identify a minty scent

A nurse is performing preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following characteristics? a) Gait B) hearing C) Vision D) balance

D) balance

A nurse is performing a general client survey and finds that the client has a BMI of 23. Which of the following should the nurse document. A) no nutritional issues B) High risk for obesity C) The client will need referral to a dietitian D)The client has a BMI within the expected range

D)The client has a BMI within the expected range

A nurse is planning to administer a dose of intravenous morphine sulfate for a postoperative patient. Which of the following is a pain management protocol that should be used by the nurse in this situation? A. Withhold this medication for a respiratory rate of less than 14/min. B. Perform the intravenous injection over 1 min. C. Avoid administering opioid agonists on a fixed schedule. D. Have an opioid antagonist available during the administration.

D. Have an opioid antagonist available during the administration. The nurse should assure that an opioid antagonist, such as naloxone (Narcan), is available, as well as equipment for providing respiratory support.

Initial Pain Assessment Questions

Do you have pain? Where is your pain? When did you pain start? What does your pain feel like? 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 react when you are in pain? What does pain mean to you?

A nurse is taking an adult client's temperature rectally. Which of of the following actions should the nurse take? A. Rotate the probe if any resistance is met as the thermometer is inserted. B. Insert the probe to aim at the client's pelvic area. C. Dip the probe about 0.58 cm (2 in) into a tube of lubricant. D. Insert the probe about 2.5 cm (1 in) into the client's anus.

D. Insert the probe about 2.5 cm (1 in) into the client's anus.

A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to? A. It corresponds to the client's systolic pressure. B. It is the second diastolic pressure to record. C. It is the loudest of the Korotkoff sounds. D. It might not follow with a fifth Korotkoff sound.

D. It might not follow with a fifth Korotkoff sound.

When planning to assess the client, which of the following actions should you take to prevent activity intolerance

Perform the assessment at the same time as the clients bath

The nurse is preparing to do a physical assessment on a patient who is end-stage HIV positive. What should the nurse do for self-protection? A. Wash hands and don gloves, gown, and protective face shield. B. Don gloves and wash hands after examination; no other protective equipment is necessary. C. Wash hands and don two pairs of gloves and gown. D. Wash hands, don gloves, and wash hands after examination; no other protective equipment is necessary.

D. Wash hands, don gloves, and wash hands after examination; no other protective equipment is necessary. The nurse should always wash hands prior to the examination. This patient should be treated with "standard precautions." Gloves are necessary with all patients, regardless of HIV status Option A is incorrect because a gown and face shield are not necessary for use with patients who have HIV. Option B is incorrect because hands should be washed prior to physical examination. Option C is incorrect because double-gloving is not necessary.

A nurse is assessing an older adult clients mouth. The nurse should identify that which of the following is an expected variation for this client 1.Yellowing of the hard palate 2. Red spots on the hard palate 3. White patches not he Tonge 4. Darkening of the mucosa

Darkening of the mucosa

Descriptor Scales

Descriptor scales in which patients are asked to indicate their pain by using selected pain term words

Lymphatic System

Detects and eliminates foreign substances from body -Helps to prevent potentially harmful substances from entering the circulation

Subjective Data:Nose

Discharge Frequent colds (upper respiratory infections) Sinus pain Trauma Epistaxis (nosebleeds) Allergies Altered smell Discharge ØAny nasal discharge or runny nose? Continuous? ØIs discharge watery, purulent, mucoid, bloody? - Frequent colds ØAny unusually frequent or severe colds (upper respiratory infections)? How often do these occur? - Sinus pain ØAny sinus pain or sinusitis? How is this treated? ØDo you have chronic postnasal drip? - Trauma ØEver had any trauma or a blow to the nose? ØDo you breathe through your nose? - Epistaxis, nosebleeds ØAny nosebleeds? How often? ØHow much bleeding, a teaspoonful or does it pour out? ØColor of the blood, red or brown? Clots? ØFrom one nostril or both? ØAggravated by nose-picking or scratching? ØHow do you treat nosebleeds? Are they difficult to stop? - Allergies ØAny allergies or hay fever? To what are you allergic, for example, pollen, dust, or pets? ØHow was this determined? ØWhat type of environment makes it worse? Can you avoid exposure? ØDo you use inhalers, nasal spray, or nose drops? How often? Which type? ØHow long have you used this? - Altered smell ØExperienced any change in sense of smell?

DNR/DNI

Do not resuscitate Do not intubate To establish DNR or DNI orders, tell your doctor about your preferences. He or she will write the orders and put them in your medical record.

Subjective Data ear

Earache Infections Discharge Hearing loss Environmental noise Tinnitus Vertigo Patient-centered care

A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39 celsius (102 degrees f). Which of the following other vital signs should the nurse expect? A. An elevated pulse rate B. A decreased blood pressure C. An elevated blood pressure D. A decreased pulse rate

Elevated pulse rate

Auscultation Basic Principles

Eliminate extra noise. Keep environment warm and warm your stethoscope. Avoid listening over hairy body areas. Never listen through a patient's gown or clothing. Avoid your own artifact.

Palpebral fissure

Elliptical open space between eyelids

Acromegaly

Elongated head, massive face, overgrowth of nose, lower jaw, heavy eyebrow ridge, and coarse facial features

A nurse is performing a head and neck assessment on a client. The client reports a high-pitched ringing in their ears. In which of the following sections of the client's electronic health record (EHR) should the nurse document this finding? 1. Encounter 2. Vital signs 3. Patient information 4. Allergies and home medications

Encounter

Simple diffuse goiter (SDG)

Endemic goiter due to iodine deficiency that results in chronic enlargement of the thyroid gland

Jugular Venous Distention

Engorged appearance of jugular veins seen when pressure on the right side of the heart is elevated.

Process of Communication: External Factors

Ensure privacy—aim for "geographic" privacy but ensure "psychological" privacy Avoid interruptions—minimize and/or refuse Physical environment—"equal status" seating Dress—appearance and comfort Note-taking—keep to a minimum, offer "focused" attention

Peripheral sensory Aδ and C fibers

Enter spinal cord by posterior nerve roots within dorsal horn by tract of Lissauer

Evidence-based practice and assessment-

Evidence-based practice (EBP) - -Integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences -Clinical decision making = best evidence from literature review + patient's own preference + clinician's experience/expertise + physical exam

Otoscopic examination

External canal—redness or swelling - Cerumen discharge, foreign bodies, or lesions

Ophthalmoscope

Eyes, red reflex

Facial expression

Facial expressions formed by facial muscles

Objective data

Findings : data the nurse obtains through observation and examination •Collected during physical examination and observation •Includes: ◦What the nurse feels, sees, hears, and smells ◦Data the nurse collects from other sources like health care professions, medical records, labs

Palpation Techniques:

Fingertips: best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps Fingers and thumb: detection of position, shape, and consistency of an organ or mass Dorsa of hands and fingers: best for determining temperature because skin here is thinner than on palms Base of fingers or ulnar surface of hand: best for vibration

Priority Problems Level

First-level priority -Emergent, life threatening Second-level priority -avoid deterioration Third-level priority - not very urgent Collaborative problems -multiple disciplines

Structure and Function of Mouth

First segment of digestive system and an airway for the respiratory system Oral cavity: short passage bordered by lips, palate, cheeks, and tongue Lips: anterior border of oral cavity, transition zone from outer skin to inner mucous membrane lining the oral cavity ØPalate: arching roof of mouth divided into two parts ØHard palate: anterior part made up of bone ØSoft palate: posterior part, an arch of muscle that is mobile ØUvula: free projection hanging down from middle of soft palate ØCheeks are the side walls of oral cavity. Floor of mouth consists of the horseshoe-shaped mandible bone, tongue, and underlying muscles. ØTongue: striated muscle arranged in a crosswise pattern so that it can change shape and position •Papillae: rough, bumpy elevations on its dorsal surface •Ventral surface: smooth, shiny and has prominent veins •Frenulum: midline fold of tissue connecting tongue to floor of mouth ØTongue's ability to change shape and position enhances its functions in mastication, swallowing, cleansing teeth, and the formation of speech. ØFunctions in taste sensation Mouth contains three pairs of salivary glands. ØParotid gland lies within cheeks in front of ear. •Stensen's duct runs forward to open on buccal mucosa opposite second molar. ØSubmandibular gland lies beneath mandible at angle of jaw. ØWharton's duct runs up and forward to the floor of mouth and opens at either side of frenulum. ØSublingual gland, the smallest, almond-shaped, lies within floor of mouth under tongue and has many small openings along sublingual fold under tongue. Glands secrete saliva, the clear fluid that moistens and lubricates the food bolus, starts digestion, and cleans and protects the mucosa. Adults have 32 permanent teeth; 16 in each arch. ØEach tooth has three parts: crown, neck, and root. Gums (gingivae) collar the teeth. ØThick fibrous tissues covered with mucous membrane ØDifferent from rest of oral mucosa because of their pale pink color and stippled surface

Conjugate movement.

Four straight, or rectus, muscles are superior, inferior, lateral, and medial rectus muscles. • Two slanting, or oblique, muscles are superior and inferior muscles.

Cranial bones

Frontal Parietal Occipital Temporal

Sternomastoid enables

Head rotation and flexion and divides each side of neck into two triangles: anterior and posterior triangles

Anthropometric measurements

Height, weight, bmi

HCAHPS

Hospital Consumer Assessment of Healthcare Providers and Systems survey is the first national, standardized, publicly reported survey of patients' perspectives of hospital care. 3 Goals: 1. produce data about patients' perspectives of care that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. 2. public reporting of the survey results creates new incentives for hospitals to improve quality of care. 3. public reporting serves to enhance accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment.

Bell

The bell endpiece has a deep, hollow, cuplike shape. It is best for soft, low-pitched sounds such as extra heart sounds or murmurs.

Holistic model assessment

Incorporation of impact of external and interpersonal environment on one's mind and body

Stages of Cognitive Development

Infants: (Birth to 12mos): gentle handling with quiet, calm voice Toddler: 12-36mos: give one direction at a time and provide simple explanations PreK: 3-6yrs: short directions with concrete explanation school-age: 7-12yr: ask questiosn to gather data and be nonjudgemental adolescents: starts at puberty: respectful honest attitude with focus on the individual

Peripheral vascular assessment

Inspect lower extremities for color, edema, shiny

Abdominal examination

Inspect skin, contour, umbilics, pulsation and hair distribution -Auscultate for bowel sounds and bruits - percuss abdomen -palpate for rigidity, masses, and tenderness

Otoscope

Instrument used to examine ears and tympanic membranes

Murmurs grading

Intensity (loudness) 1 = faint 6 = extremely loud (heard with a stethoscope even when slightly REMOVED from the chest)

nystagmus

Involuntary rapid eye movements

Objective Data: Pain

Joints ØNote size, contour, and circumference of joint. ØCheck active or passive range of motion. ØJoint motion normally causes no tenderness, pain, or crepitation. Muscle and skin ØInspect skin and tissues for color, swelling, and any masses or deformity. Abdomen ØObserve for contour and symmetry. ØPalpate for muscle guarding and organ size. ØNote any areas of referred pain. Ø

A nurse is admitting a client who has had a stroke. Which of the following actions should the nurse take. 1. Keep the bedside table at the end of the client's bed 2. Place a towel not he client's bathroom floor 3. Raise the four side rails of the clients's bed 4. Keep the client's bed in the lowest position

Keep client's bed in the lowest position

Equilibrium

Labyrinth in inner ear constantly feeds information to brain about body's position in space.

Diabetic retinopathy

Leading cause of blindness in adults ages 25 to 74 years of age

Process of Communication: Internal Factors

Liking others—using a "genuine" approach Empathy—develop an understanding and sensitivity for others feeling's Ability to listen—using an "active" process Self-awareness—be aware of "implicit bias"

Jaundice

Liver issue

Pallor

Loss of color

Rhonchi

Low pitched wheeze

CRIES pain scale

Neonatal Postoperative Pain Measurement Score Crying- characteristic of pain Requires O2 for SaO2 ,95% Increased Vital signs Expression Sleepless

Standard Equipment

Measurement of vital signs requires platform scale (with height attachment), stethoscope, sphygmomanometer, and thermometer. Pulse oximetry reading can be included. Other equipement: Otoscope, ophthalmoscope, penlight, and pocket vision screener Skinfold calipers, skin marking pen, and tuning fork Nasal speculum, tongue depressor, and cotton balls Flexible tape measure and ruler, sharp object (split tongue valve), reflex hammer Bivalve vaginal speculum, materials for cytology, lubricant, and fecal occult blood materials

Two trapezius muscles

move shoulders and extend and turn head.

Aδ fibers

Myelinated and larger in diameter, and they transmit pain signal rapidly to CNS; localized, short-term, and sharp sensations result from Aδ fiber stimulation

Biographic Data:

Name, address, and phone number Age, birth date, and birthplace Gender (identification) and relationship status Race and ethnic origin Occupation: usual and present Primary language

NANDA-

North American Nursing Diagnosis Association) is a professional organization of nurses interested in standardized nursing terminology

Inspect ocular fundus.

Optic disc, retinal vessels, general background, and macula

Age-related macular degeneration (AMD)

Or breakdown of cells in macula of retina; loss of central vision

Glaucoma

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

Thyroid Disorders: Hypothyroidism

Physical presentation neck and face Puffy edematous face Periorbital edema Coarse facial features Coarse hair and eyebrows

Graves Disease

Physical presentation neck and face Goiter Eyelid retraction Exophthalmos

Old people eyes

Pupil size decreases. - Presbyopia - Lens loses elasticity, becoming hard and glasslike, which decreases ability to change shape to accommodate for near vision. - 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.

Reveiw of Systems

Purpose of ROS - Evaluate past and present state of each body system - Assess that all pertinent data relative to each body system have been noted - Evaluate health promotion practices - cephalocaudal apprach - do not include objective data - include all relevant body systems

Source of History

Record who furnishes information, usually the person, although source may be relative or friend. - Judge reliablity of informant

SOAP Notes

S-Subjective O-Objective A-Assessment includes nursing diagnosis based on the assessment P-Plan - type of problem-oritented medical records

Cornea and Lens

Shine light from side across cornea, and check for smoothness and clarity.

Acute Pain

Short-term and self-limiting: •Often follows a predictable trajectory, and dissipates after an injury heals Self-protective purpose: •Acute pain warns individual of actual or potential tissue damage. Incident pain: •Type of acute pain that occurs predictably with certain movements

_____ muscles attach eyeball to its orbit and direct eye to points of a person's interest.

Six -Give eye both straight and rotary movement.

Inspect external ear

Size and shape of auricle, position and alignment on head Note skin condition. Check auricle and tragus for tenderness. Evaluate external auditory meatus.

Subjective Data: Mouth and Throat

Sores or lesions Sore throat Bleeding gums Toothache Hoarseness Dysphagia Altered taste Smoking, alcohol consumption Patient-centered care ØDental care pattern ØDentures or appliances

Inspection of Buccal Mucosa

Stensen's duct: opening of parotid salivary gland is an expected finding ØLooks like a small dimple opposite upper second molar. Leukoedema: a benign grayish opaque area, more common in African Americans and East Indians ØSeverity of condition increases with age, looking grayish white and thickened; cause of condition is unknown. ØDo not mistake leukoedema for oral infections, such as candidiasis, thrush. Fordyce's granules: small, isolated white or yellow papules on mucosa of cheek, tongue, and lips ØThese little sebaceous cysts are painless and not significant.

Major neck muscles

Sternomastoid and trapezius are innervated by cranial nerve XI.

Basic Principles of Percussion

Structure with more air produces louder, deeper sound compared with denser structure. Variations occur in clinical practice based on individual anatomical differences.

Fragrance (coffee or mint)

Testing the first cranial nerve (the olfactory nerve) -test one nostril at a time -do not use alcohol wipes

Components of quality improvement:

The problem The goal The aim The measures The Analytics

Pathological Pain

Two main pathways: - Nociceptive and/or neuropathic processing Patients present with different types of symptoms - Thereby differing in clinical response to therapy Need for accurate pain assessment - Better able to develop non-pharmacologic and/or pharmacologic strategies to obtain improved clinical results

Communication with Different Ages

Use "Stages of cognitive development" as a guideline to facilitate communication.

General terms

Use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic. "Tell me how I can help you."

Eversion of the Upper Lid

Used when one suspects foreign body or eye pain

Verbal Descriptor Scale: Pain

Verbal descriptor scales have the patient use words to describe pain

Subjective eye

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

Visual Analog Scale

Visual analog scales have the patient mark the intensity of the pain on a horizontal line from "no pain" to "worst pain."

Can I perform a general patient survey without specialized equipment?

Yes.

pulsation

a beat or throb; rhythmic vibration.

Bruits

abnormal "swishing" sounds heard over organs, glands, and arteries

atelectasis

absence of breath sounds due to collapse of alveoli

bronchial breath sounds

anteriorly over trachea - loud, high pitched, hallow sound

Optic disc

area in which fibers from retina converge to form optic nerve

Closed or direct questions

ask for specific information. They elicit a one- or two-word answer, a "yes" or "no," or a forced choice. Whereas the open-ended question allows the client to have free rein, the direct question limits his or her answer.

PAINAD scale

assessment tool for pain; assesses 5 common behaviors: breathing vocalization facial expression body language consolability. A score of 4 or above indicates a need for pain management.

cyanosis

blueish- decreased oxygenation

Stethoscope

body sounds are very soft and must be channeled through a stethoscope The stethoscope does not magnify sound but does block out extraneous room sounds.

Outer one third of canal is _______

cartilage

A nurse is preforming a focused assessment on a client who reports having difficulty swallowing and a continuous headache. The nurse should identify that these findings can indicate which of the following conditions? 1. Chest disorder 2. Thyroid disorder 3. Musculoskeletal disorder 4. Central nervous system disorder

central nervous system disorders

Glasgow Coma Scale

eyes, verbal, motor Max- 15 pts, below 8= coma

Diaphragm

flat edge of stethoscope is best for high-pitched sounds—breath, bowel, and normal heart sounds.

Otoscope

funnels light into the ear canal and onto the tympanic membrane.

Choroid:

has dark pigmentation to prevent light from reflecting internally and is heavily vascularized to deliver blood to retina

Vesicular breath sounds

heard over lunch tissue -soft, fine , breezy low pitched sounds

Bronchovesicular breath sounds

heard over mainstem bronchi - medium pitched quieter sounds

Amplitude

intensity of sound loud or soft sound

Percussion

is tapping the person's skin with short, sharp strokes to assess underlying structures. The strokes yield an audible vibration and a characteristic sound that depicts the location, size, and density of the underlying organ. Works to: - Mapping out the location and size of an organ - Signaling the density (air, fluid, or solid) of a structure by a characteristic note - Detecting an abnormal mass if it is fairly superficial; - Eliciting pain if underlying structure is inflamed - Eliciting a deep tendon reflex using the percussion hammer

ausculation means...

listening to sounds made by body (use stethoscope)

Auscultation

listening to sounds produced by the body, such as the heart and blood vessels, the lungs and abdomen.

Conductive hearing loss

mechanical dysfunction of external or middle ear

Pupillary light reflex

normal constriction of pupils when bright light shines on retina

Palpation

often confirms what you noted during inspection. Palpation applies your sense of touch to assess the following factors: texture temperature moisture organ location and size and any swelling, vibration or pulsation, rigidity or spasticity, crepitation presence of lumps or masses presence of tenderness or pain.

Pitch

or frequency the number of vibrations per second

Quality of sound

or timbre a subjective difference caused by the distinctive overtones of a sound

Problem-oriented medical records

organized by problem or diagnosis and consist of a database, problem list, care plan, and progress notes

Visceral Pain

originates from larger interior organs. •Stems from direct injury to organ or from stretching of organ from tumor, ischemia, distention, or severe contraction •Pain impulse transmitted by ascending nerve fibers along with nerve fibers of autonomic nervous system •Presents with autonomic responses such as vomiting, nausea, pallor, and diaphoresis

A nurse is inspecting the sinuses of a client who has allergies. Which of the following findings should the nurse expect? 1. Pale mucosa 2. Bright red mucosa 3. Green discharge 4. Yellow discharge

pale mucosa

Cornea

part of refracting media of eye, bending incoming light rays so that they will be focused on inner retina

Documentation:Narrative

records information as a sequence of events in a story-like manner

Documentation: Flow Charts

show trends in vital signs, blood glucose levels, pain level, and other frequent assessments

A nurse is preforming a head and neck assessment on a client. After checking the client's vision, the nurse notes the client has a difficulty reading fine print. In which of the following sections of the client's electronic health record should the nurse document this finding? 1. Vital signs 2. Review of system 3. Allergies and home medications 4. Patient information

review of systems

Pupil

round and regular; size determined by balance between parasympathetic and sympathetic chains of autonomic nervous system

pericardial friction rub

scraping or grating noise heard on auscultation of the heart; suggestive of pericarditis

Pen light pupillary responses provide

tangential lighting when examining skin surfaces tangential lighting: Lighting set to a low angel relative to a surface. It highlights protrusions by casting a shadow and small movements by flickering light

percussion

tapping on a surface to determine the difference in the density of the underlying structure -we want a resonance, low pitched, hallow sound

Angle of Louis

the junction between the body of the sternum and the manubrium; the starting point for locating the ribs anteriorly

Duration of sound

the length of time the note lingers.

pain tolerance

the level of pain a person is willing to endure

Pain threshold

the point at whiich a person percieves pain

Retina

the visual receptive layer of eye where light waves change into nerve impulses

A nurse is preforming a head-to-toe assessment on a client and notes a lump on the anterior portion of their neck. The nurse should identify that this finding can indicate which of the following conditions? 1. Infection 2. Cancer 3. Thyroid disorder 4. Chest disorder

thyroid disorder

palpate

to examine by touch

Sclera

tough, protective, white covering -Continuous anteriorly with smooth, transparent cornea, which covers iris and pupil

A nurse is preforming an eye assessment on a client. Which of the following should the nurse identify as the cornea of the eye? 1. Outer layer of the eyeball 2. Mucous membrane that lines the eyeball 3. Transparent layer that covers the iris and pupil 4. Colored portion in the center of the eye

transparent layer that covers the iris and pupil

Sound waves produce vibrations on_______

tympanic membrane

Presbycusis

type of hearing loss that occurs with aging, even in people living in quiet environment

Snellen chart

used to measure visual acuity of FAR vision

Charting by exception:

uses standardized forms that identify norms and allows selective documentation of deviations from these norms

Telegraphic speech

usually a combination of a noun and a verb and includes only words that have concrete meaning. simple two-word phrases—"all gone," "me up," "baby crying."

Crackles in the lungs

wet popping sounds when air is moving through liquid - collapsed alveoli

advance directive

written, legal instructions regarding your preferences for medical care if you are unable to make decisions for yourself. Advance directives guide choices for doctors and caregivers if you're terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life.

if clients heart rate is irregular you need to... ?

you need to assess pulse deficit (difference between radial pulse and apical pulse) - 2 or more beats is bad bad