Holistic Health Assessment Test 2

Erb's Point

3rd ICS left sternal border

A hospitalized patient is experiencing unilateral sharp, deep muscle pain, worse with dorsiflexion of the foot, redness, swelling and tenderness. What risk factors would contribute to this: Select all that apply.

BEDREST USE OF ORAL CONTRACEPTIVES HYPERCOAGULABILITY

Ethnocentrism

Belief in the superiority of one's nation or ethnic group. •universal tendency of humans to think their ways of thinking, acting, and believing are the only right, proper, and natural ways.

CAM-ICU Delirium Assessment Tool

Confusion Assessment Method for ICU

Extra Heart Sounds (Diastole S3) Ventricular Gallop

During early diastole (S1 S2S3) • Ventricular resistance to rapid filling (ineffective contraction) • Physiologic S3: normal in children, pregnancy (3rd trimester) and well-trained athletes • Pathologic S3: CHF, volume overload r/t vascular disease EARLY SIGN OF HEART FAILURE BEST HEARD AT APEX WITH BELL IN LATERAL POSITION

Assessment and Preparation Peripheral Vascular Disease

Early detection of peripheral vascular disease- inspection, palpation and auscultation Compare arms and legs bilaterally Includes groin exam (not for class) Position from sitting for exam of arms; lying down for exam of legs/groin

New Memory Assessment

Giving them 3 words to remember after 5, 10 and 15 minutes

Surface Anatomy of Breasts

Paired mammary glands, breasts lie anterior to pectoralis major and serratus muscles located between 2nd and 6th ribs male/female breast similar until puberty

Barriers to Pain Assessment Based on Beliefs

Pt is weak not manly pain is punishment may indicate the condition is getting worse pain meds-addictive, side effects pain is a part of aging

Cardiac Conduction

SA node, AV node, Bundle of His, Purkinje fibers left bundle branch interventricular septum

A client enters the emergency department moaning and complaining of severe pain in his lower back. Which of the following clinical manifestations should the nurse expect to see in this client as a physiologic response to pain? Select all that apply

Sleeplessness Perspiration Increase HR

Assimilation

The gradual adoption and incorporation of characteristics of the prevailing culture

Jugular venous pulse should not be

VISIBLE with client sitting at 45 degree angle or more. IF seen: right ventricular failure, pulmonary hypertension, pulmonary emboli, fluid overload.

Compartments Syndrome

What complication can be caused by eschar where it acts as a tourniquet and occludes blood flow

As part of the mental status examination, a nurse assesses the cognitive ability of a client. Which question should the nurse ask to assess recent memory in the client?

What did you have for breakfast yesterday?

Wrist ROM

Wrists flexion/extension hyperextension, adduction, radial/ulnar deviation

p wave

atrial depolarization contraction of atria

Pain Assessment Tools: Numeric Rating Scale (NRS)

best for older adults with no cognitive impairment

Distention of the neck veins may indicate elevation of the

central venous pressure commonly assoc. with congestive heart failure and fluid overload

Auscultation of Heart

clean stethoscope w alcohol stand on clients right side auscultate rate and rhythm, rhythm varies w breathing, sinus arrhythmia check pulse deficit if irregular: • Palpate the radial pulses & the apical pulse at the same time for 1 full minute. • pulse deficit (Apical -radial ) indicates afib, a-flutter • REFER for further evaluation

Abduction

client brings both hands together overhead, elbows straight

CBE

clinical breast exam

Axillary Lymph Nodes

concentrated in armpit, receive lymph from upper limb and female breast - Anterior (pectoral) - Posterior (subscapular) - Lateral (brachial) - Central (mid-axillary)

Knee ROM

flexion, extension

Cultural imposition

intrusive application of the majority group's cultural view upon individuals

Breast Cancerous Tumors are

irregular, firm, hard, not well defined masses may be fixated OR mobile usually NONTENDER usually occur after age 50

Pain Assessment Tools: Faces Pain Scale Revised (FPS-R)

is best in cognitively impaired adults

Degenerative joint disease does not usually cause the joints to be reddened and hot because

it is not an inflammatory process

Simple Descriptive Pain Intensity Scale

no pain, mild, moderate, severe, very severe, worst possible

ROM assessment

preform flexion (towards the body), extension (away from the body), pronation (inward), supination (outward). First assess ROM try against gravity, then against resistance

Physiological heart murmur

pregnancy, hyperthyroidism, exercise and anemia with temporarily increased blood flow- early systolic, auscultate pulmonic area on supine with bell or diaphragm

Supernumerary nipples

presence of more than one nipple on a breast

Semilunar Valves:

pulmonary and aortic valves located between the right ventricle and the pulmonary artery and between the left ventricle and the aorta

Pain Assessment Tools: Visual Analog Scale (VAS)

ratio-level scale of a 100-mm line anchored on each end with words or symbols

Religion

rituals, practices, and experiences shared within group, involve a search for the sacred •Formal, Organized, Group oriented, Ritualistic, Objective- measurable (e.g., church attendance)

Lordosis

seen in pregnant woman

Cultural diversity

the co-exsistence of a difference in behavior, traditions, and customs-in short often resulting from cross border population flows "pluralism"

The "stroke belt" is located in which part of the world?

the southern united states

Culture

the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways and all other products of human work and thought characteristic of a population or people that guide their worldview and decision making

Virchow's Triad

venous stasis, endothelial injury, hypercoagulable state

QRS complex

ventricular depolarization (contraction)

t wave

ventricular repolarization (diastole)

To assess judgment in a client ask

what the client does when he or she is in pain

Breasts Objective Data INSPECTION

• Client sitting up facing examiner, then supine • Symmetry of size, shape - Slight asymmetry is common - Sudden increase in size = inflammation or new growth • Skin- smooth, even color with no redness, edema, dimpling • Stretch marks may be seen - Abnormal: Peau D'orange (orange peel appearance) from edema with metastatic disease • Inspect for superficial venous pattern - Veins more prominent during pregnancy • Inspect areolas - Vary from dark pink to dark brown - Round and vary in size - Abn. Peau d-orange skin, red, scaly crusty skin in Paget's disease • Nipple: nearly equal bilaterally in size, same location on each breast; - Usually everted, may be flat inverted - No discharge seen - Distinguish a recently retracted nipple from one previously inverted - Supernumerary nipple common, normal variation

Structure and Function Nociceptors

• Designed to detect painful sensations from periphery to CNS • Stimulated by trauma, injury or by chemical mediators released from the site of tissue damage Carry pain signal to CNS

BREAST SELF EXAM

• Teach breast self-exam • Establish a regular schedule - Right after menstrual period, or 4th-7th day when breasts smallest, least congested - Pregnant, menopausal women: choose familiar date, same day each month • Focus on the positive aspects • Encourage reporting-unusual findings • Keep teaching simple; return demonstration • Women in 20s,educate about benefits and limitations

Osteoporosis MODIFIABLE risk factors

◦ Alcohol use, smoking, low BMI, poor nutrition, Vitamin D deficiency, Eating disorders, insufficient exercise or sedentary lifestyle

Osteoporosis Cultural Factors

◦ Bone Density - ◦ Men > women, AfricanAmerican > Caucasian ◦ Caucasian > Chinese, Japanese, and Eskimo

Mitral Stenosis Murmur

"early to mid diastolic low pitch rumble murmur best heard at apex in left lateral decubitus position. with bell May also have presystolic murmur."

Which one is not related to auscultation of heart? (a) Auscultate heart rate and rhythm (b) Auscultate heart sound with only diaphragm of the stethoscope (c) Auscultate for heart murmurs (d) Auscultate heart sounds in different body positions.

(b) Auscultate heart sound with only diaphragm of the stethoscope use bell too!

Rating Pulses

+3- bounding +2- normal +1- diminished 0- absent

Paget's Disease

- Redness, mild scaling & flaking of the nipple; tingling, itching - Usually 1 side only - May be associated with a lump or mass

Breast Cancer ACS recommends

- Yearly mammograms starting at age 40 - Yearly CBE after 40 - With greater risk factors, begin screening by age 30 - Breast self-exam (BSE) is an option for women starting in their 20s - In 20s and 30s women should have a clinical breast exam (CBE) at least every

Numeric Pain Intensity Scale

1-10

S1 Heart sound: LUB

AV VALVE CLOSING

ACS

American Cancer Society

Pain Tool

Assessment Tools for adults without cognitive impairment - Visual Analog Scale (VAS) (vertical v. horizontal) - Numeric Pain Intensity Scale - Numeric Rating Scale (NRS) shown to be best for older adults without cognitive impairment. - Categorical Rating Scale: None (0), Mild (1), Moderate (2), or Severe (3)

Nociception Transmission

Bidirectional axons synapse in the dorsal horn of the spinal cord Signal continues to the brain where it's processed Pain Impulse to spinal cord to brainstem and thalamus to cortex

During a cardiovascular assessment, the nurse hears a loud, blowing sound when auscultating the carotid arteries. The nurse should document this finding as which of the following?

Bruit Hear the bruit, feel the thrill

Phalen's Test

Carpal Tunnel Assessment Test

Objective Data: SPINE

Cervical, thoracic, and lumbar spine: ◦ Observe the cervical, thoracic, lumbar curves (Double S curve). ◦ Note symmetry of shoulders and iliac crests ◦ Palpate the spinous processes and paravertebral muscles for tenderness or pain

Assessing Cognitive Abilities Concentration

Concentration: (ability to stay focused and attentive, follow directions) ◦ Abn. Distraction and inability to focus could be anxiety, fatigue, attention deficit disorders & impairment

Assessing LOC: Painful Stimuli

Decorticate posture Decerebrate posture

Types of Peripheral Edema

Lymphedema and Chronic Venous Insufficiency

Breast Self Exams (BSE)

Monthly when the breast are non tender or swollen. It is more important for the client to be able to detect changes rather than to do BSE regularly. Post menopause teaching If a woman is found to have painful, tender breasts upon examination you must FIRST assess for any changes in relation to her menstrual cycle.

Objective Data Hands/Fingers

Normally symmetric, nontender & without nodules. No swelling or deformities; full ROM and equal strength against resistance

Myocardial Infarction Tests

Obtain detailed history; Dx tests - EKG, enzymes

A nurse reviews the documentation of the nurse on the previous shift and finds that the client was obtunded. The nurse anticipates that the client will respond to stimulation in what manner?

Opens eyes to a loud voice and answers with confusion

SAD PERSONS

Risk factors for Suicide Sex Age Depression Previous attempts Ethanol Rational thinking (loss of) Sickness Organized plan No social support Stated future intent

Retracted Nipple

Suggests malignancy

Decerebrate posture

The arms and legs are out straight and rigid, the toes point downward, and the head is arched backward.

The S2 heart sounds are louder in the

aortic and pulmonic areas

scoliosis

curvature of spin.

Breast Fibroadenomas are

lesions are lobular, ovoid or round firm, well defined, usually singular and mobile seldom tender occur more commonly between puberty and menopause

Nipple

located center of breast contains tiny openings of lactiferous ducts for milk

Retracted Breast Tissue Suggests

malignancy

Nociception

transduction, transmission, perception, modulation

Breasts Developmental Competence: Older Adults

• After menopause, estrogen & progesterone decrease - Breast glandular tissue atrophies - Replaced with fibrous connective tissue • Decreased breast size makes inner structures more prominent - Lumps may become more palpable

Auscultating the Carotid Arteries

• In older clients or CVD suspected • before palpation to avoid slowing the heart by triggering vagal stimulation • Ask pt. to hold the breath after exhalation Use BELL for Bruits • Bruit (Blowing, swishing sound): Stenosis of carotid arteries • May hear aortic stenosis murmur • Risk of TIA, Stroke

Abnormal Levels of Consciousness

• Lethargy: Client opens eyes, answers questions, and falls back asleep. • Obtunded: Client opens eyes to loud voice, responds slowly with confusion, and seems unaware of environment. • Stupor: Client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep. • Coma: Client remains unresponsive to all stimuli; eyes stay closed.

Special Populations and Pain

• Nonverbal or Preverbal Patients • Adults with dementia or cognitive impairment • Infants and Preverbal Toddlers • Intubated and Unconscious Patients • Patients with Addictive Diseases Patients can still be in pain if asleep, if a little baby, if they do not state they intubated etc.

Assessing Joints and Muscles Guide Assessment Joints

◦ Inspect size, shape, color, symmetry ◦ Note masses, deformities, atrophy bilaterally ◦ Palpate for edema, heat, tenderness, pain, nodules, or crepitus bilaterally ◦ Teach each joint's ROM; move through normal motions. Demonstrate passive, then active

Mental Status observe thought process for clarity, content and perception

◦ Use statements such as "Tell me more about what you just said" or ask client to elaborate on health ◦ Client should express full, free-flowing thoughts, follow directions accurately, express realistic perceptions, makes sense; denies suicide thoughts. ◦ Abnormal processes include persistent repetition of thoughts, invention of words, flight of ideas, rhymes, delusions, compulsions and obsessions, confabulation

Female Heart Attack

- Chest pain or discomfort(not always), - More frequently pain in the neck/jaw/throat, arms, upper abdomen or back, - Indigestion, heartburn, - nausea/vomiting, - Extreme fatigue, - Shortness of breath • Easy to ignore

Peau D'Orange

- Results from edema, an orange peel appearance associated with cancer

Palpation of Breasts: Abnormal Findings: FIBROADENOMAS

- Small round/oval, firm, solid, elastic, nontender, single/multiple masses; in 1 or both breasts

Hypertension Blood Pressure is

140/90 mm Hg or higher

Glasgow coma scale

<10 needs emergency attention <7= patient is in a coma

Risk Reduction Osteoporosis

Adequate calcium and Vitamin D intake Adequate nutrition Regular, weight-bearing exercise No smoking or quit smoking Avoid heavy drinking Middle-aged & older adults assess risk factors, decrease risk of fractures

Assessing Cognitive Abilities Remote Memory

Ask about past events (verifiable) - what happened 9/11/2001? ◦ Abn. Inability to recall recent events—delirium, dementia, depression and anxiety ◦ Abn. Inability to recall past events is seen with cerebral cortex disorders

Nociception Perception

Conscious awareness of painful sensation (emotional response, parietal lobe)

Atrioventricular AV Valves

Entrance into the ventricles -Tricuspid valve: rt ventricle -Bicuspid (Mitral) Valve: It ventricle

HOPE acronym

H - sources of hope, meaning, comfort, strenght, peace, love & connection O - organized religion P - personal spirituality & practice E - effects on medical care & end of life issues

Herberden's Nodes

Hard nodules or enlargements of the distal interphalangeal joints of the fingers DIP joints

Nursing Diagnoses Musculoskeletal

Impaired Physical Mobility Acute Pain Chronic Pain

Nociception Transduction

Noxious stimulus causes tissue injury; release of neurotransmitters

Bouchard's nodes

Osteoarthritis (PIP swelling 2° to osteophytes)

Arterial Insufficiency

Patho: blood is not circulating down to the lower extremities in the first place S/S: Dry, shiny, cold, pale, hairless, poor capillary refill, decreased or absent pulses, pale with elevation of extremities Ulcers- circular, painful deep Risk factors- smoking, diabetes, obesity, high BP

Religious

Rituals, practices, and experiences involving the search for the sacred. Formal, organized, group oriented

Dimpling of Breast

Suggests malignancy Dimpling a sign of skin retraction

Deep Vein Thrombophlebitis is

a vein occluded by a thrombus causing inflammation, blocked venous return, cyanosis, and edema cause: prolonged bedrest, hx of varicose veins, trauma, infection, use of oral contraceptive meds daily exercise recommended to keep blood flowing to the feet

A score of 7 or lower on the Glasgow Coma Scale means

coma

Crepitus

crunching sensation with joint movement, or cartilage wear. Crepitus can often be felt more easily than heard. Crepitus can be felt as a crunching sensation under your hand with movement of a joint through ROM.

Limited ROM is the most sensitive sign of

joint disease

Benign Breast Disease (Fibrocystic Breast Disease)

round, elastic, defined, tender and mobile cysts most common from age 30 to menopause then decreases

Breast Exam IMPLANTS

• Breast implants: perform BSE monthly. Ask surgeon to identify implant edges • Press firmly inward at the edges of the breast implants to feel the ribs beneath • Check for lumps or bumps - Do not squeeze valve which may cause leakage and make the implant deflate - Abn. Any new lumps or lesions should be evaluated with a biopsy

Chronic Pain

• Diagnosed pain 6 mos. or longer • Doesn't stop after recovery • Can adapt to chronic pain • Use tools to assess intensity AND affect on life

Culture and Pain

• How people respond to pain varies with the meaning placed on pain and the response expected in a patient's culture • Table 9-1 Cultural expressions; be careful not to stereotype • Nurses must examine their own responses to pain • Denial of pain? Respond verbally and loudly? Stoic? • Develop culturally competent skills in pain management • Ask each patient how he or she typically behaves when in pain

Acute Pain

• Short-term, dissipates after injury heals • Self-protective purpose • Warns individual of actual or potential tissue damage

Mental Status Observe dress and grooming and hygiene

◦ Dress is appropriate for occasion and weather; varies with age, SES, developmental and culture ◦ Client is clean and groomed appropriately for occasion (based on developmental, socioeconomic level and culture). (review abnormal findings)

Range of Motion Passive ROM

◦ Normally no tenderness, pain, crepitation ◦ If limitation observed, anchor joint with 1 hand, use other hand to move the joint to its limit; no angles Limited ROM is most sensitive sign of joint disease

Palpating the carotid arteries

*always auscultate before palpating- if an occlusion is detected, palpate very lightly to avoid completely blocking circulation

Palpation of Breasts: Abnormal Findings: MALIGNANT TUMORS

- Most often-upper outer quadrant of breast - Usually unilateral, irregular, poorly delineated borders - Hard, nontender, - fixed to underlying tissue

Myocardial Infarction Treatment

1. ABCs 2. MONA: Morphine Oxygen Nitroglycerin Aspirin (Morphine if pain is still present)

Palpating Pulses

1. Ulnar-difficult to detect 2. Brachial 3. Femoral 4. Radial 5. Popliteal- behind the knee, also hard to detect 6. Dorsalis pedis

Pulse rating

3+ increased, full, bounding 2+ normal 1+ weak 0 absent

Tinel's Sign

A distal tingling sensation on percussion of median nerve of the inner wrist; characteristic of carpal tunnel syndrome

Spiritual Assessment

Active and ongoing conversation, assesses spiritual needs of the client. •Formal or informal, Respectful, Nonbiased

Nursing Diagnoses for Pain

Acute Pain RT trauma AEB patient report of pain 7/10 on pain scale; guarding affected area. • Chronic Pain RT long-term process AEB patient rubbing and bracing affected part (leg, arm); irritability, and report or inability to sleep

Auscultation of Heart A PET MONKEY

Aortic Pulmonic Area Erbs Point Tricuspid Area Apical/Mitral Valve • Identify auscultatory areas APETM (ape to man): Sound resonance areas not physical locations • Listen all over the chest as areas overlap; cover the precordium • Auscultate to identify S1 (lub) and S2 (dubb) • S1 loudest at apex • S2 loudest at bas

Objective Data Hips

Buttocks equal size; iliac crests symmetric in height; hips stable, nontender & without crepitus; full Rom and equal strength against resistance

Mental Status Observe behavior and affect

Client is cooperative and purposeful in interactions with others; affect is appropriate for the client's situation

Mental Status

Client's level of cognitive functioning and emotional functioning Mental health is an essential part of one's total health "Health is a state of complete physical, mental, and social well-being, not merely the absence of disease" (WHO, 2010) Healthy mental status is needed to think clearly and respond for optimal life function You CANNOT directly measure mental status

During a cardiovascular assessment, the nurse observes the neck veins of a client, sitting in a position higher than 45 degrees. The neck veins are fully distended. This finding is most commonly seen in clients with which condition?

Congestive heart failure and fluid overload

Cardiac Cycle SYSTOLE

Contraction and emptying of ventricles av valves shut s1 after blood filling in ventricles higher pressure in ventricles with isovolumic contraction semilunar valves open ventricular systole emptying semilunar valve close s2 ventricular pressure falls with isovolumic relaxation ventricular diastole (filling)

Dementia and delirium are differentiated by

Dementia has a gradual deterioration and delirium has a rapid onset.

Lymphatic System

Drains excess fluid and plasma proteins from bodily tissues and returns them to the venous system During circulation more fluid leaves the capillaries than veins can absorb; draining excess fluid prevents edema. Fluids & proteins absorbed become lymph from lymph nodes where microorganisms, foreign materials, dead blood cells and abnormal cells are trapped and destroyed. Nodes vary from small, nonpalpable to 1‐2 cm.; grouped together; accessible for exam in neck, arms and legs

Over what area of the chest would the nurse expect to hear S1 and S2 heart sounds that are relatively equal in intensity? Select the correct pre-labeled spot

Erb's Point which is located at the left sternal border, 3rd to 5th intercostal space

The Heart Wall and Pump

Heart Wall Pericardium : Outer most, double - walled pericardial sac with fluid, friction-free Myocardium: Middle, Contracting heart muscle -Endocardium: Inner most thin layer of endothelial tissue

Coronary Artery Disease Risk Factors

High blood pressure High cholesterol Smoking Diabetes Poor diet Physical inactivity Overweight/ obesity

Assess Suicide Risk

Identify suicidal tendencies or thought processes. ◦ Client should verbalize positive, healthy thoughts about the future and self ◦ Abn. Clients who are suicidal may share past attempts of suicide, give plan for suicide, verbalize worthlessness about self, joke about death frequently. ◦ Abn. Clients who are depressed or feel hopeless are at higher risk for suicide. HIGHEST risk is person with a realistic plan and means to carry out the plan. ◦ Abn. depression early in life have a twofold risk for dementia

Heart Sound (Split s2)

Increased venous return during inspiration delays P2 -Physiologic split S2 on inspiration is normal -Pathologic split S2 indicates RBBB, pulmonary hypertension, pulmonic stenosis, mitral regurgitation/ventricular septal defect, atrial septal defect

TMJ Objective Data

Inspect & palpate the TMJ. Index and middle fingers anterior to external ear opening Move jaw from side to side Protrude and retract jaw ◦ Full ROM: Normally mouth opens 1-2 inches; mouth closes smoothly; jaw moves laterally; jaw protrudes and retracts ◦ Snapping and clicking MAY be felt and heard in normal clients ◦ Abn. decreased ROM, swelling, tenderness, or crepitus seen with arthritis ◦ Abn. Decreased ROM, clicking, popping, grating sound with TMJ dysfunction

Osteoporosis Risk Factors

Late menarche, Early menopause, Diuretics, Steroids, Smoking, Alcohol, Caffeine

Mental Status Facial Expression

Normal: maintains eye contact appropriate to culture. ◦ Abnormal Findings: ◦ Reduced eye contact is seen in depression or apathy; extremes of emotions (happiness, anger, fright may be seen in anxious clients ◦ With Parkinson's disease may have a mask-like, face. ◦ Inappropriate facial expressions (smiling when expressing sad thoughts) may indicate mental illness. ◦ Drooping or marked facial asymmetry may occur with Bell's palsy or stroke.

Referred Pain

Perceived in body areas AWAY from the pain source

Normal Heart Sounds

S1-S2 LUBDUBB

Hierarchy of Pain Assessment Techniques

Self-report Search for potential causes of pain Observe client behaviors Surrogate reporting Attempt an analgesic trial

Areola

Surrounds the nipple contain small elevated sebaceous glands (montgomery's glands) secretes protective lipid substance during lactation nipple, areolae have darker pigmentation

Objective Assessment Data Knees

Symmetric, hollows present on both sides of the patella without swelling or deformity; lower leg in alignment with upper leg. Nontender and cool. Muscles firm without nodules. No bulge or fluid appears on medial side of knee Full ROM with equal strength to resistance No pain or clicking sound; no crepitus

Nociception Modulation

The body activates needed inhibitory responses to the effects of pain changes/inhibits pain messages relay in spinal cord

Palpate Across the Precordium

Use palmar aspect of 4 fingers to feel other pulsations, thrills Apex, Left sternal border Base • Lift/heave - visible upward thrust of the heart against chest wall at LSB - Right ventricular hypertrophy (RVH) • Thrill-palpable vibration with murmur; turbulent blood flow Normally no lift/heave/thrills

Fibromyalgia

Widespread pain with fatigue, sleep, memory, and mood changes.

Verruca Vulgaris is a painful wart that occurs under

a callus

Chronic Venous Insufficiency

a condition in which venous circulation is inadequate due to partial vein blockage or leakage of venous valves pitting 1+ to 4+ usually bilateral skin ulceration and pigmentation could be present

Spirituality

a search for meaning and purpose in life. Informal, nonorganized, self reflective

Asking the client about the difference between 2 objects would elicit

abstract reasoning

Palpation of Breasts: Abnormal Findings: BRUISING FROM INJURY

collection of blood appears as lump dissipates, may need draining

Cardiac Pathways SA node is the pacemaker ->

conduced across the atria to AV node to AV bundle or bundle of HIS to down the right and left bundle branches to Purkinje Fibers in myocardium

A nurse is assessing a client for possible fluid overload. Which assessment finding is most consistent with this diagnosis?

crackles during auscultation

Auscultation: listen first with the

diaphragm at each auscultatory area, then with the thrill • pt. supine, "Z" pattern • Listen for S1 & S2; Focus on systole/diastole • Listen with the bell for extra heart sounds (S3, S4) on apex • Listen with the bell for murmurs; timing, intensity and location. • Listen on other positions (left lateral, sitting up leaning forward).

Ankle ROM

dorsiflexion and plantar flexion

Rheumatoid arthritis can occur in any joint but usually affect the _______ first

hands

Pain Assessment Tools: The Universal Pain Assessment Tool

intended to help patient access pain according to individual patient needs -0-10 scale several tools, translation to other languages

Lymphnodes

organs of the lymphatic system that filter fluids deposited by the circulatory system; if cancer is detected here, it indicates metastasis has occurred

The S1 sound is louder in the

tricuspid and mitral areas

Pain is often

undertreated the 5th vital sign Inadequate treatment- physiologic, psychological, emotional distress leads to chronic pain Healthy PPL 2020 pain management do better

Physiologic Responses to Pain

• Anxiety, fear, suicide thoughts, hopelessness • Reports of pain, cries and moans, frowns, grimaces Decrease in cognitive function, mental confusion, dilated pupils • Increased heart rate and blood pressure • Muscle spasm • Increased respirations & sputum retention, results in infection & atelectasis • Decreased gastric & intestinal motility • Decreased urinary output -> retention • Increased hormone response, hyperglycemia

Auscultation (Use this sequence for OSCE)

• Aortic 2nd right intercostal space (ICS) • Pulmonic 2nd left ICS (2nd or 3rd per W&K) • Erb's Point 3 rd left ICS (3rd-5th ICS per W&K) • Tricuspid 4 th left ICS or Left lower sternal border • Mitral 5th left ICS at midclavicular line (MCL)

Chest Pain: COLDSPA questions

• Character - crushing, stabbing, burning, squeezing, tightness • Onset - when, how long, had this type before • Location: where, radiation • Duration: how long, how often • Severity: 0-10 pain scale • Patterns: Brought on by: activity, rest, sex, weather, position, relieved by rest or nitro • Associated Factors: • Dyspnea • Diaphoresis • Pale clammy skin • Nausea/vomiting • Heart beat skips or speeds up

Subjective Data: Breast Cancer

• Lumps or swelling in breast or axilla - New onset - Increased in size • Redness, warmth, dimpling, rash • Pain - COLDSPA • Change in size or firmness of breasts • Nipple discharge Past History - Age of menarche - Menopause - What age childbirth - LMP Self-care behaviors - BSE (breast self exam) - Mammography - Clinical Breast Exam - Alcohol, caffeine, exercise, diet Child/Adolescent - Developing breasts - Other body changes - Abnormal breast development in male Pregnant Female - Breast fullness - Tenderness/tingling - Inverted nipple - Plan breastfeeding? Menopausal Woman -change in contour, size, firmness

Barriers to Pain Assessment Healthcare provider's beliefs

• Patients-if complain are drug seekers or addicts • Need physical or behavioral signs to validate pain • Old people have more pain • Inability to feel pain in very old, neonates, fetuses • Sleeping pts. have no pain • Meds are addictive or cause respiratory depression • Give pain med at night so pt. will sleep

Heart sounds split s1

• Split S1 (M1, T1): - Increased venous return during inspiration delays T1 - Best heard at tricuspid area, Supine, Diaphragm - Normal split S1 in children/adolescents; young adults; 3rd trimester of pregnancy - Pathologic split S1 in delayed conduction with RBBB or A-fib

The Male Breast

• Thin disk of undeveloped tissue underlying nipple • Areola is well developed; nipple is relatively small •Adolescents: gynecomastia (enlarged breast tissue) - Reassurance needed - Usually unilateral & temporary • Gynecomastia in aging male RT testosterone deficiency

When Palpating the NIPPLE

• Wear gloves; gently compress with thumb & index finger • Nipple may become erect, areola may pucker • Note discharge - Discharge may be seen in endocrine disorders and certain medications - Abn. Discharge - 1 breast indicates papilloma, fibrocystic disease or cancer; sometimes appears watery, pink • Refer to provider

Enculturation

•A natural conscious/unconscious conditioning process of learning accepted cultural norms, values, and roles in society and achieving competence in one's culture through socialization.

Neurovascular Assessment

•Assessment of circulation, motor, sensation(CMS) •Critical assessment if pt. had limb injury/trauma, fracture, or have a cast or restrictive bandages •The 5 (or 6 or 7) Ps: • Pain • Paralysis (Movement) • Paresthesia (Sensation) • Pulses (or pulselessness) and capillary refill • Pallor and -Temperature • (Some say either "Poikilothermia or Polar" for cold) • Some say Pressure (able to detect pressure applied) •ASSESS: Recognize and/or prevent Compartment Syndrome. Pressure in the muscles builds; decreasing blood flow, which prevents oxygen from reaching nerve. •Medical or surgical emergency!!!!!

Culture Assessment

•Part of patient's initial assessment and possibly ongoing assessment •Contexts for assessment: •Values- learned beliefs that are perceived to be appropriate or inappropriate •Race- not a physical characteristic, social construct held by large group •Racial categories- based on society rather than genetics( ex. US census) •Minority- society implies group has less power, means smaller population

Rheumatoid Arthritis

◦ A chronic, systemic inflammatory disease of joints and surrounding connective tissue; inflammation of synovial membrane leads to thickening, then fibrosis, which limits motion, and finally to bony ankylosis (fixation) ◦ Associated with fatigue, weakness, anorexia, weight loss, low-grade fever and lymphadenopathy ◦ Involves symmetric, bilateral joints ◦ Pain and stiffness is worse in the morning when arising and after rest periods ◦ Movement DECREASES pain

Abnormal Findings in Elbow Assessment

◦ Bursitis/ arthritis= Redness, heat, & swelling ◦ RA- Firm, nontender nodules ◦ Tenderness or pain in the lateral epicondyle (tennis elbow) RT repetitive movements ◦ Decreased ROM or strength with disease or injury

Mental Status: Observe client's level of consciousness

◦ Normal- client is alert and oriented to person (name of self/family), place time and date -if no response, try to wake patient up verbally. they should be awake and alert with eyes open and respond. -if no response to calling or shaking, may use tactile or painful stimulus. begin with least invasive -reduced orientation may be organic brain disorders or psychiatric illness

Range of Motion Active (Voluntary) ROM

◦ Stabilize the body area proximal to the area being moved; observe for limitations

SPINE Assessment cervical, thoracic and lumbar spine.

◦ Test ROM of the cervical, thoracic, lumbar spine. ◦ Repeat cervical ROM against resistance ◦ Test for back and leg pain. ◦ Measure leg length Normal: Spine is straight when observed behind; nontender spinous processes, full ROM, (cervical full ROM against resistance); no pain; equal leg length

Assessing Joints and Muscles Guide Assessment Muscles

◦ Test muscle strength, move each extremity through full ROM against resistance ◦ Apply some resistance against the part being moved ◦ If client cannot move the part against resistance, ask the client to move against gravity; if not, move passively

Subjective Data of Peripheral Artery Disease

Color, temperature or texture change in skin? Pain or cramping in the legs; with walking? Intermittent claudication: weakness, cramping, aching, fatigue or pain in calves or thighs; relieved by rest; may indicate peripheral arterial disease Heaviness and aching sensation aggravated by standing or sitting for long periods of time and relieved by rest associated with venous disease Lack of pain may indicate neuropathy leg veins rope like, bulging, contorted sores/open wounds location pain? swelling in legs, what time of day swollen lymph glands male clients, change in sexual activity erectile dysfunction hx of circulatory problems blood clots, ulcers, poor healing history of heart surgery or blood vessel treatment etc fam hx of diabetes htn cad, claudication hyperlipidemia smoking, exercise contraceptives support hose

Barriers to Pain Assessment Physical Conditions

Current disease/ others are causing pain

Abnormal Findings in TMJ

Decreased ROM, swelling, tenderness, or crepitus may be seen in arthritis. Decreased muscle strength with muscle and joint disease. Decreased ROM, and a clicking, popping, or grating sound may be noted with TMJ dysfunction. A client with arthritis in the jaw has decreased range of motion of the jaw, and crepitus is felt when the jaw is palpated. A grating sound may be heard in a client with temporomandibular joint (TMJ) dysfunction.

A nurse recognizes which finding as an indication of an ulcer due to arterial insufficiency?

Deep ulcers that often involve joint space

Arteries

Deliver oxygen-rich blood to capillaries to tissues - Blood is propelled under pressure from the left ventricle - Heartbeat forces blood through arteries creating a surge, "arterial pulse" - Artery walls are thick and strong with elastic fibers - Head and neck: Temporal and carotid - Arms: Brachial, radial, ulnar - Legs: Femoral, popliteal, dorsalis pedis & posterior

Evidence Based: Dementia/Alzheimer's Disease

Dementia is a set of symptoms associated with loss of cognitive function General symptoms ◦ Memory loss ◦ Challenges in problem solving ◦ Difficulty completing tasks ◦ Confusion with time or place ◦ Trouble understanding visual images or spatial relationship ◦ New problems with words ◦ Decreased or poor judgment ◦ Misplacing things or losing ability to retrace steps ◦ Withdrawal from work or social activities ◦ Changes in mood or personality Aging has common forms of decline that are often MISTAKEN for dementia: ◦ Slower thinking, problem solving, learning, and recall; decreased attention or concentration; distraction Differentiate aging v. dementia

What should a nurse do to ensure an effective face-toface interaction with clients from different cultural background?

Develop a cultural habit and build effective relationships

Cardiac Cycle: Diastole

Diastole: Relaxation and filling of ventricles AV valves open and the ventricles are relaxed Higher pressure in the atria than in the ventricles blood rush through AV Valves from atria to ventricles rapid filling then slow passive filling followed by atria contraction atrial kick

Peripheral Arterial Disease (PAD)

Disease increases with age; associated with diabetes Major cause of impaired ambulation, extremity wounds and amputations Occurs with reduced blood flow to limbs, usually from atherosclerosis Calf pain is most common symptom - Others include numbness, weakness, coldness, sores on toes, change in skin color of legs, hair loss, slow growth on legs, shiny skin, slow‐growing toenails, diminished pulses in legs and feet and erectile dysfunction in men

Assessment of Pulses

Dorsalis pedis pulse- Dorsiflex the foot & apply light pressure lateral to & along the side of the extensor tendon of the big toe Assess at the same time; 0- 3+ scale • Posterior tibial pulse Palpate behind & just below the medial malleolus (the groove between the ankle & Achilles tendon) Assess same time; 0-3+ scale

Assessing Cognitive Abilities: Visual, perceptual and construction ability

Draw the face of a clock well Copy simple figures ◦ Abn. Inability to draw the clock face or the simple figures is seen with mental retardation, dementia, or parietal lobe dysfunction

The breast has how many quadrants?

FOUR Upper Inner Upper Outer* Lower Inner Lower Outer

Spiritual Assessment FICA

Faith Importance Community Address

FICA acronym

Faith and beliefs "do you consider yourself spiritual and religious" Importance and influence "what importance does spirituality have in your life" Community "are you apart of a spiritual community" Address "how would you like me to address these spiritual issues in your health care"

Mental Status of Depressive Symptomatology (self report)

Falling asleep Sleep during the night Waking up too early Sleeping too much Feeling sad Decreased or increased appetite Decreased or increased weight (within last 2 weeks) Concentration/decision making Perception of oneself Thoughts of death or suicide General interest Energy level Feeling sluggish Feeling restless

Joints

Fibrous joints (immovable) Cartilaginous joints (between vertebrae) Synovial joints (space contains synovial fluid; promotes a sliding movement of the ends of the bones Ligaments (strong bands of connective tissue; join bones in synovial joints) Bursae (small sacs filled synovial fluid to cushion joints)

Cardiac Cycle

Filling and emptying of the heart's chambers Systole: emptying by contraction of the ventricles Diastole: filling by relaxation of the ventricles

Abnormal Breast Findings

Fixation: Asymmetry, distortion or decreased mobility seen as cancer becomes invasive; fibrosis fixes the breast to the underlying pectoral muscles

Shoulder ROM

Flexion and Extension Adduction and Abduction Inward and Outward Rotation Horizontal Flexion and Extension

Collection of Objective Data Musculoskeletal

Gait: observe gait ◦ Normally evenly distributed weight; toes point straight; posture erect; rhythmic, coordinated movements ◦ Abn. Uneven weight bearing, limping, shuffling, widebased gait Assess fall risk ◦ Client should not fall backward ◦ Abn. seen with cervical spondylosis & Parkinson's

Osteoporosis Unmodifiable Risk Factors

Gender, age, body size, ethnicity, history of bone fractures; race/ethnicity, menopause or hysterectomy, long-term glucocorticoid therapy, rheumatoid arthritis

Abnormal Findings Knee

Genu valgum (knock knees) or bowed legs (genu varum) Swelling around patella; synovial fluid; medial bulge Osteoarthritis with decreased ROM with synovial thickening and crepitation (crepitus) Flexion contracture (inability to extend knee) Pain or clicking with torn meniscus Limited ROM or decreased muscle strength

Breasts Internal Anatomy

Glandular tissue • Fibrous tissue (including ligaments) • Mammary ducts • Fatty tissue

A present to the health care clinic with reports of a swollen, tender, reddened joint in the left big toe. The nurse recognizes this finding as an indication of what inflammatory process?

Gouty Arthritis

Structure and Function of Heart and Vessels

Great Vessels Pulmonary artery: carry blood to lungs Superior and inferior vena cava: Return the blood Pulmonary veins: Return oxygenated blood Aorta: Transport oxygenated blood

Intractable Pain

High resistance to pain relief. ( need a lot of medication)

Collection of Subjective Data: Musculoskeletal

History of present health concern ◦ Weight gain, difficulty chewing or pain, joint, muscle or bone pain, stiffness, swelling or limitation of movement Past health history ◦ Past problems or injuries; immunizations, dx of diabetes, sickle cell, lupus, osteoporosis Family history ◦ Rheumatoid arthritis, gout or osteoporosis Lifestyle and health practices ◦ Activities, medications, tobacco, alcohol, caffeine, diet including milk, calcium supplements, exercise, posture, ADLs, MS problems, bone density screening

Structure of Heart

Hollow, muscular, four chambered Vertical: Lt 2nd ICS to Lt 5th ICS - Horizontal: Rt edge of the sternum to Lt MCL - Inverted cone (triangle) shape: Base at the top Apex at the bottom - Precordium Anterior chest wall over the heart and great vessels

Pulse rate deficit

If you detect an irregular rhythm, auscultate for a pulse rate deficit-palpate radial pulse while auscultating the apical pulse- ~should be equal-if not, refer client to physician

The nurse is teaching the client about breast self-examination. The client asks, "Are there any areas of the breast where cancer is more likely to occur?" What is the nurse's best response?

In the upper outer quadrant The incidence of breast cancer is highest in the upper outer quadrant of the breasts, including the tail of Spence. If the mass is in the tail of Spence, it must be distinguished from enlarged lymph nodes. Breast cancer is not commonly detected in the nipple area, the inferior portion of the breasts, or near the sternal border of the breasts

Pathological Murmur

Increased velocity of blood, structural valve defects, Valve malfunction, Abnormal chamber opening (Septal defect)

Assessing Cognitive Abilities: New Learning & Abstract Reasoning

New Learning: Ask client to report 4 unrelated words ◦ Have them repeat the words ◦ Ask them to repeat again in 5, 10, and 30 min. ◦ Abn. Inability to recall is seen in anxiety, depression or Alzheimer's disease Abstract reasoning: Ask client to compare objects (how are an apple and orange the same?) or explain a proverb (less often used) ◦ Abn. Inability to compare/contrast is seen with schizophrenia, mental retardation, delirium & dementia

Cap refill

- finger or toenail - >2-3sec suggest peripheral vascular disease, arterial blockage, heart failure, or shock

Heart Failure

-Cardiac Output down -Circulation backed up and congested UP The heart's inability to pump Insufficient blood for systemic circulation Increased blood volume and venous return worsening congestion Increased blood volume and venous return worsening congestion (kidney compensation by renin angiotensin system)

Women and Heart Disease

1 in every 4 female deaths by heart disease -Almost two-thirds (64%) of women died suddenly of coronary heart disease with no previous symptoms.

Structure- Bones

206 Bones ◦ Store calcium, produce blood cells ◦ Serve as levers Axial skeleton: (head and trunk) Appendicular skeleton (extremities, shoulders and hips)

Nonverbal behavior involving Chronic Pain

Adaptation/Bracing (supporting, ie a joint), rubbing, diminished activity, sighing, change in appetite, sleeping, irritability

Spiritual Care

Addressing the spiritual needs of the client through spiritual assessment. •Individualistic, Client oriented, Collaborative

Veins

Blood vessels that carry deoxygenated, nutrient-depleted waste-laden blood from tissues back to the heart No force to propel forward blood flow; blood from legs must flow upward with no pumping action of heart 3 mechanisms: 1. One-way valves prevent blood backflow, 2. Skeletal muscular contraction; squeeze blood toward the heart, 3. Pressure gradient through breathing If these mechanisms fail, venous return is impeded and venous stasis results Venous stasis: Blood pooling in lower legs which increases pressure in the veins Risk factors: long periods of standing still, sitting, or lying down; lack of muscular activity; varicose veins (lead to incompetent valves)

Pain Classification

DURATION/ETIOLOGY: • Acute pain (recent injury) • Chronic non-malignant pain (cause or injury and persists > 6 months • Cancer pain LOCATION: • Cutaneous (skin or SQ tissue) • Visceral (abdominal cavity, thorax, cranium) • Parietal (ligaments, tendons, bones, blood vessels, nerves)

Substance Abuse (Evidence Base)

Healthy People 2020 is addressing substance abuse in adolescents and military personnel serving overseas Goal: to reduce substance abuse to protect the health, safety and quality of life for all Screening: Use simple tools to identify risk -CAGE -AUDIT Teach clients and family

ethnicity

Identity with a group of people that share distinct physical and mental traits as a product of common heredity and cultural traditions.

EGK Reading

P Wave: atrial DEPOLARIZATION QRS: ventricular DEPOLARIZATION ST SEGMENT: period between ventricular depolarization and beginning of ventricular repolarization T Wave: ventricular repolarization a depol, v depol, v REPOL

Radiating Pain

Perceived at source and extending to other tissues

Physical Exam: Scoliosis

Screen for scoliosis (Forward bend test) ◦ Inspect spine for alignment. ◦ Shoulders, scapulae & iliac crest = elevation ◦ Palpate spinous processes Scoliosis

Mental Status Observe posture, gait and body movements

Should appear relaxed, with shoulders & back erect when standing or sitting. Gait is rhythmic and coordinated, symmetric arm swing ◦ Abn. Slumped posture may indicate powerlessness, depression or organic brain disease ◦ Abn. Bizarre movements may be seen in schizophrenia or a side effect of med

Objective Data Shoulders, Arms, Elbows

Shoulders & Arms: should be symmetrically round w/o redness, swelling, heat, deformity, tenderness with full ROM and equal muscle strength against resistance Elbows: Symmetric, without deformities, redness, swelling, tenderness or nodules; full ROM & equal muscle strength against resistance

The obtunded client opens the eyes to

a loud voice and answers with confusion. If the client opens eyes, answers the question, and falls back to sleep, the client is said to be lethargic. If the client awakens to a vigorous shake or painful stimuli, he is in a stupor stage. If the client is unresponsive even to painful stimuli, the client is in a coma.

Internal Rotation

brings flexed elbows behind the back

rheumatoid arthritis

burning, throbbing pain on both sides of body, worse with rest, inconsistent pattern boutonniere and swan neck deformities

Gynecomastia

can be common in young males and usually temporary. If seen in order adult could be a cause of hormonal imbalances

fatty tissue on breast

decreases with age

Osteoarthritis Knee

knee pain with motion, limited ROM, redness, swelling, visible deformity cartilage worn, tiny holes in damaged cartilage, bone spurs form at joint margins

Spirituality

search for life meaning/purpose, seeks to understand life's ultimate questions in relation to the sacred. •Informal, Nonorganized, Self-reflective, May involve spiritual experiences, Subjective- difficult to consistently measure (e.g., daily spiritual experiences, spiritual well-being, etc.)

Palpation of Breasts: Abnormal Findings: INTRADUCTAL PAPILLOMAS

small growths inside milk duct, often near areola, harmless and occur in women over 50

chordae tendineae (heart strings)

strong fibrous strings that anchor the valves; prevents valves from inverting anchor AV valves to papillary muscle

Elbow flexes and extends forearm ROM

supination and pronation

Jugular Venous Pulse JVP

Internal JV: deep, medial to SCM - External JV: superficial, lateral to SCM --Return blood to the heart -Jugular venous pressure reflects central venous pressure -Increased JVP indicates right-s

Myocardial Infarction (MI)

Interruption of blood supply to the heart Blockage of coronary artery Ruptured plaque Blood clotting Heart muscle injury or death

Foot ROM

Inversion/eversion of forefoot -Flexion, extension, abduction, adduction of toes

Which one is not a proper description of assessment technique? (a) Inspection is a close careful scrutiny. (b) Palpation detects texture, temperature, and organ location and size. (c) Auscultation starts lightly to detects surface characteristics. (d) Percussion involves strokes to detect density of the underlying organ.

(c) Auscultation starts lightly to detects surface characteristics.

Which question is least used to collect subjective data for heart assessment? (a) Have you experienced chest pain? (b) Have you ever had rheumatic fever? (c) Do you recall having severe sunburns as a child? (d) Do you experience dizziness?

(c) Do you recall having severe sunburns as a child?

Which one is wrong anatomic landmarks on the chest wall for the heart sound auscultation? (a) Aortic area: 2nd ICS tat the RSB (b) Pulmonic area: 2nd or 3rd ICS at the LSB (c) Erb's point: 3rd ICS at the LSB (d) Mitral: 4th or 5th ICS at the LSB

(d) Mitral: 4th or 5th ICS at the LSB

3 Methods of Palpating Breasts

- A. Vertical strip pattern (up-and-down vertical pattern), is most effective for covering entire breast. - B. Wedged (sometimes called "spokes on a wheel") - C. Circular or clockwise

Heart Disease and Stroke Statistics

- About 92.1 million American adults- cardiovascular disease or the after-effects of stroke - Nearly half of all African American adults: cardiovascular disease (Female 47.7% , Male 46.0 %) - About half of all Americans (47%): at least 1/3 key risk factors for heart disease: HTN, high cholesterol, and smoking - 1 in 7 death in the US: by Heart disease - Risk factors: Socioeconomic status, ob

Risk Factors for Peripheral Arterial Disease

- Age <50yrs with DM or atherosclerosis, smoking, dyslipidemia - Age 50-69yrs and history of smoking or DM - Age 70 or older - Claudication - Abnormal pain in lower extremity - Known atherosclerotic coronary, carotid, or renal artery disease -Smoking, diabetes, hypertension, obesity, high cholesterol, family hx of heart disease

Breast Changes Age Specific: Childbearing Women

- Breast changes start in 2nd month; early sign of pregnancy - Tingling sensations; tenderness - Enlargement of breast and nipple; hyper-pigmentation of areolae & nipple - Enlargement of Montgomery tubercles - Prominence of superficial veins - Development of striae - Colostrum may be expressed in 2nd and 3rd trimester - Breasts enlarge and feel more nodular. Nipples are larger, darker and more erectile.

Dyspnea: COLDSPA

- Characteristics: What type of activity now vs. 6 months ago - Onset: when, how long, had this type before - Location - Duration: How long, how often - Severity: ex) Modified Medical Research Council (MMRC) Dyspnea scale 0-4 Awaken you from sleep, Interfere with ADLs - Pattern: DOE (Dyspnea on exertion), PND (Paroxysmal nocturnal dyspnea) , affected by position, - Associated factors: with chest pain, anxiousness, fatigue, dizziness, cough • Orthopnea - # of p

Evidenced Based Info Breast Cancer NON MODIFIABLE RISK FACTORS

- Female gender - Risk increases with age - Hereditary (BRCA) - Race/ethnicity - Family history - Personal history of breast cancer - Denser breasts - Early menstruation (before age 12) or later menopause (older than 55)

Nipple Discharge

- Milky discharge is normal with pregnancy. Other causes are from hypothyroidism, pituitary adenoma, oral contraceptives, antihypertensive, and tranquilizers Bloody- papilloma in duct Greenish- draining breast cyst Clear- (unilateral) cancer **Any type of discharge must be collected and sent to the lab.

Evidence Based Breast Cancer Client Education

- Women AND men can have breast cancer; both should note changes in size, shape - Get intentional exercise 45-60 min per day for 5 or more days/week - Avoid alcohol intake of > 1 drink/day - Avoid excessive weight gain - Be aware of all risk factors as applies to you - Note breast consistency; with denser breasts work with provider re: screening

INSPECTION AND PALPATION OF AXILLA

-Examine w/patient sitting up; inspect skin for rashes, infection - Use 3 fingerpads; palpate in 4 directions - First palpate high into the axillae, moving downward against the ribs to feel central nodes - Move down posterior axillae - Use bimanual palpation for anterior nodes - Palpate down the inner aspect of upper arm - No nodes or 1-2 less than 1 cm. discrete nodes may be palpable ABN- May enlarge with local infection or breast CA metastases ABN - Nodes > 1 cm. may indicate infx of hand or arm; if fixed and hard, may be malignancy, MAY INDICATE UNDERLYING MALIGNANCY

Systolic Heart Murmur

-High-pitched murmur best heard at apex -pathologic: Mitral or tricuspid valve prolapse -usually mitral valve prolapse(MVP) -MVP with mid-systolic click followed by high-pitched murmur WILL NOT ASK TO DIFFERENTIATE HEART MURMURS

Alzheimers Disease: Warning Signs

1. asking same question over and over again. 2. repeating the same story, word for word, again and again 3. forgetting how to cook, make repairs or how to play cards-activities that were previously done with ease and regularity 4. losing one's ability to balance check book or pay bills 5. getting lost in familiar surroundings and misplacing household objects 6. neglecting to bathe or wearing same clothes over and over and over again, while insisting that they have taken a bath or their clothes are clean 7. relying on someone else, such as a spouse, to make decisions or answer questions they previously would have handled themselves

While assessing a client's peripheral pulses, the nurse notes the amplitude of the radial pulse as increased, full, bounding. This finding should be documented as which of the following

3+/+3 (means increased, full or bounding)

Extra Heart Sounds Diastole S4 Atrial Gallop

4: "Atrial gallop" • During late diastole (S4S1, S2) • Forced contraction due to noncompliant LV (ineffective relax) • Physiologic S4: Well-trained athletes, after exercise, • Pathologic S4: CHF, systemic HTN, CAD, acute MI • Best heard at apex on lateral and supine position

Why is it important for a nurse to gather information about a client's past experiences with pain?

A. Provides insight into positive or negative expectations for relief Past experiences with pain may shed light on the previous history of the clients in addition to possible positive or negative expectations of pain therapies. Identifying factors that increase or decrease pain, assessing how much it impacts the client's lifestyle, and understanding the course of the pain are questions that assist the nurse to elicit important information about the pain itself.

Spine Assessment: ABNORMAL

Lateral curvature of thoracic spine (scoliosis) Exaggerated lumbar curve (lordosis) Kyphosis (exaggerated thoracic curve/older adults, associated with osteoporosis) Unequal hip height= unequal leg length R/O scoliosis Unequal leg length- R/O scoliosis Pain & tenderness of spinous processes Limited ROM and decreased ROM to resistance

Abnormal Findings Ankles and Feet

Laterally deviated great toe; with bunion on the medial side with hallux valgus Flat feet, high arches, corns and calluses, warts or plantar warts Ankle sprains Gouty arthritis (tender, painful, red, hot & swollen toe) Rheumatoid arthritis or DJD on joints or heel Decreased ROM or muscle strength Hammer toe

Assessing Cognitive Abilities Recent Memory

Ask about weather or what time arrived at the clinic (verifiable)

Assessing Cognitive Abilities: Judgment

Ask client a question that involves problem solving: "What would you do if driving and a police officer behind you turned on the lights and siren? ◦ Should be able to demonstrate sound rationale ◦ Abn. Impaired judgment may be seen in organic brain syndrome, emotional disturbances, mental retardation or schizophrenia.

Breasts Inspect for Retraction and Dimpling

Ask client to raise her arms overhead; then press her hands against her hips. Next ask her to press her hands together. These actions contract the pectoral muscles. Finally ask the client to learn forward from the waist. • Normal: no retraction or dimpling; breasts hang freely & symmetrically • Abnormal: - Dimpling or retraction- seen with malignancy - Restricted movement or nipple retraction-fibrosis and fixation of underlying tissues due to malignant tumor

Mental Status Mood, Feelings, Expressions

Ask the client "How are you feeling today?" and "What are your plans for the future?" ◦ Should express feelings appropriate to situation, verbalize positive feelings re: future and positive coping mechanisms ◦ Abn. Flat affect, euphoria, anxiety, fear, ambivalence, irritability, depression, and/or rage are examples of altered mood (depression, manic episodes, anxiety, obsessive-compulsive disorders). Screen the client for depression and suicide thoughts

Assessment of Lower Extremity for Varicosities and Thrombophlebitis

Ask the client to stand to make any varicose veins more visible; as the client stands inspect for superficial vein thrombophlebitis Palpate for suspected thrombophlebitis Normally veins are flat and barely seen; no redness or discoloration is seen Varicose veins appear as distended, bulging or tortuous; result from incompetent valves Blood flow is decreased; may see redness or swelling; with pt. complaint of aching or cramping with walking

Neurovascular Assessment

Assessment of circulation, motor, sensation Critical assessment if limb injury/trauma, fracture, or cast/restrictive bandages Ps: - Pain - Paralysis (Movement) - Paresthesia (Sensation) - Pulses (or pulselessness) and capillary refill -pallow and temp (cold) -some say pressure (able to detect pressure) -assess: Recognize and/or prevent Compartment Syndrome. Pressure within the muscles builds to dangerous levels; decreasing blood flow, which prevents oxygen from reaching nerve and muscle cells. Some causes: fracture, cast or tight bandage. Symptoms: pain, burning, tingling, full or tight feeling. Medical or surgical emergency!

Subjective Data: History Mental Status

Be alert to verbal & nonverbal cues; determine validity (reliability) of client responses Explain the purpose of Qs Other body systems may affect mental status (metabolic, neurologic) In-depth history is required ◦ May include sensitive issues ◦ Sexuality, dying, spirituality Note questions and rationale for asking each Biographical data History of present health concern: ◦ What is most urgent health concern now? ◦ COLDSPA Personal health history: ◦ Past tx or hospitalization for mental health issue? ◦ Head injury, neurologic problems Family history Lifestyle and health practices ◦ Diet, exercise, elimination, sleep, caffeine, alcohol and substance use, exposure to environmental toxins,

Substance Abuse: CAGE Self Assessment Tool

C Have you ever tried to cut back on your use? A Have you ever been annoyed/angered when questioned about your use? G Have you ever felt guilt about your use? E Have you ever had an eye-opener to get started in the morning? Scoring: One "yes" answer suggests a possible alcohol problem. More than one "yes" answer means it is highly likely that a problem exists.

Cancer Pain

May reflect all of pain types at same time or at diff times. Cancer pain may be caused by cancer, its treatment or metastasis • Acute (sudden & severe) or chronic > 3 mos. • Somatic, visceral, neuropathic pain • Causes breakthrough pain • Depends on cancer stage • May be triggered by blocked blood vessels or pressure on a nerve from the tumor • Side effects of Ca. tx such as surgery, radiation and chemotherapy include pain • 90% with advanced cancer experience severe undertreated pain • R/T: blocked blood vessels, bone fracture from metastasis, infection, inflammation, psych. problems, tx. side effects or tumor pressure on a nerve

Complete Mental Status Exam

Mental status exam is incorporated with the health history Much of objective data also involves questioning, performing various verbal tests Perform MSE early in head to toe exam to determine validity of client's information Perform full MSE if: ◦ Screening suggests anxiety, depression, cognitive impairment ◦ Family member concern RT behavioral changes ◦ Memory loss ◦ Inappropriate social interaction ◦ Brain lesions, aphasia or other symptoms

Heart Murmurs Mid Systolic Murmur

Mid-systolic murmur: Aortic/ pulmonic valves Between S1 and S2 Medium to high-pitched Heard at aortic area, or pulmonic area on supine with bell or diaphragm -Physiologic: pregnancy, hyperthyroidism, exercise and anemia -Pathologic: Aortic stenosis, pulmonic stenosis, hypertrophic obstructive cardiomyopathy (HCOM) & atrial septal defects

Evidence Based Breast Cancer MODIFIABLE RISK FACTORS

Modifiable - Having no children or giving birth to 1st child after age 30 - Recent oral contraceptive use - Menopausal hormones - No history of breastfeeding - Alcohol use - Excess weight/obesity - Weight gain as adult - Limited physical activity 8/13/202

Assessment of Upper Extremity for Peripheral Vascular Disease

Observe arm size & venous pattern; assess for edema - If an observable difference in size, measure bilaterally, arm circumference at same location Arms bilaterally symmetric without edema, prominent venous patterning Lymphedema/prominent venous patterning(may affects 1 extremity) Palpate for temperature of fingers, hands and arms - Should be equal bilaterally A cool extremity may be sign of arterial insufficiency; or Raynaud's Inspect coloration of hands and arms-should be equal bilaterally Abn: Raynaud's disorder is a vascular disorder caused by vasoconstriction or vasospasm of fingers or toes with color change Palpate to assess capillary refill; normal is capillary beds refill less than 2 seconds - > 2 seconds may indicate vasoconstriction, decreased cardiac output or arterial occlusion Palpate radial pulses for elasticity and strength - Normal 2+/3+ and bilaterally strong, artery walls resilient Ulnar pulses not commonly palpated should be equal strong assess nail angle should be 160 degrees clubbing indicate hypoxia palpate epitrochlear nodes enlarged epitrochlear nodes may indicate an infection in hand or forearm generalized lymphadenopathy or lesion

Objective Data and Pain

Observe posture • Normal- upright; client appears comfortable • Abn. slumped; inattentive, agitated; guarding, distress, breathing problems Observe facial expression • Client smiles; maintains eye contact • Abn. Face- distress and discomfort; poor eye contact; possibly frown, moan, cry, grimacing Inspect joints and muscles • Appear normal without edema; relaxed muscles • Abn. Joint edema indicates injury; pain with muscle tension Observe skin for scars, lesions, rashes, changes or discoloration • No inconsistency, wounds, or bruising noted • Abn. Bruising, wounds, edema Vital Signs Measure heart rate, respirations, blood pressure • ABN: Increased heart rate, respirations, irregular or shallow breathing or increased BP

Abnormal Findings Hands and Fingers

Pain, tenderness, swelling, deformity with fracture ◦ Swelling, stiffness, tenderness in acute RA with Boutonniere deformity & Swan-neck deformity ◦ Hard, painless nodules (Heberden's & Bouchard's nodes in OA ◦ Decreased strength with muscle or joint disease

Venous Insufficiency Symptoms

Pain: Aching, cramping Pulses: Present but may be difficult to palpate through edema Skin Characteristics: - Pigmentation in medial & lateral malleolus - Skin thickened & tough - May be reddish‐blue - Associated w/dermatitis Ulcer Characteristics: - Location: Medial malleolus or anterior tibial - Pain: If superficial, minimal pain, but may be very painful - Depth of ulcer: superficial - Shape: Irregular border - Ulcer base: Beefy red to yellow - Leg edema: Moderate to severe

arterial insufficiency symptoms

Pain: Intermittent claudication to sharp, unrelenting, constant Pulses: diminished or absent Skin Characteristics: - Dependent rubor - Dry, shiny skin - Cool to cold temperature -loss of hair over toes and foot -nails thickened and ridged Ulcer Characteristics Location: tips of toes, toe webs, heel or other pressure areas if confined to bed -pain: very painful -depth of ulcer -deep often involving joint space -shape circular ulcer base -pale black to dry and gangrene -leg edema -minimal unless extremity dependent pos

Gouty Arthritis

Painful, reddened, hot, and swollen metatarsophalangeal joint in the great toe is seen in gouty arthritis. This is an inflammatory condition caused by an abnormal buildup of uric acid in the body and becomes deposited in the joints.

Venous Insufficiency

Patho: blood is getting trapped down in the lower extremities. S/S: edema, reddish/blue coloration, pulses are hard to palpate because of edema, thick/tough skin Ulcers-superficial, irregular borders

Phantom Pain

Perceived in nerves left by a missing, amputated or paralyzed body part

How to incorporate spirituality

Providing a time of silence Encourage spiritual practices such as meditation Gather family members or clergy to participate in a prayer ritual Collaboration and referral with pastoral chaplains or clergy of different faiths. Nurse should be respectful, open, and willing to discuss spiritual issues if seen as appropriate. Nurse should avoid conveying a judgmental attitude toward the client's spiritual beliefs and religious practices.

Inspect and Palpate the TMJ

Put your index and middle fingers just anterior to the external ear opening. Ask client to open the mouth as widely as possible and the tips of your fingers should drop into the joint spaces. Move jaw from side to side. Protrude (push out) and retract (pull in) jaw Snapping and clicking may be felt and heard in the normal client. Mouth opens 1-2 inches b/w upper and lower teeth, Jaw moves laterally 1-2 cm. Jaw protrudes and retracts easily Ask the client to open the mouth and move the jaw laterally against resistance.

Signs and Symptoms of Myocardial Infarction

Remember the mnemonic: CRUSHING Chest pain (intense, heavy) Radiating chest pain that goes to left arm, jaw, back Unrelieved by nitroglycerin or rest (chest pain) Sweating (cold) Hard to breathe (shortness of breath) Increased heart rate, blood pressure or irregular heart rate Nausea with vomiting Going to be anxious and scared

Modified SAD PERSONS Suicide Risk Assessment

Risk Factors S- Sex A- Age D- Depression P- Previous Attempt E- Ethanol Abuse R- Rational thinking loss S- Social support lacking O- Organized plan N- No Spouse S- Sickness Some tools include another A for availability of means

Pericardial Friction Rub

Rubbing sounds between two surfaces of inflamed pericardial sack due to pericarditis High pitched, scratch and scraping sounds Auscultation: sitting upright and leaning forward; holding breath in expiration; at Erb's point with diaphragm

A nurse must perform a non formal spiritual assessment if a client. Which tool would be most appropriate for the nurse to use?

SPIRIT assessment tool

Capillaries

Small blood vessels that allow the circulatory system to maintain equilibrium between the vascular and interstitial spaces • Hydrostatic force involved with interstitial fluid diffusing out of capillaries into tissue spaces • Fluid re‐enters capillaries by osmotic pressure; • Lymphatic capillaries remove excess fluid left

Mental Status Speech

Speech: moderate tone, clear with moderate pace, and culturally appropriate. ◦ Abn. Slow, repetitive speech is characteristic of depression or Parkinson's disease. -Loud, rapid speech is seen with manic phases of bipolar disorder. ◦ Abn. Dysarthria, difficulty forming words may be seen with neurologic disorder.

Client Education of Peripheral Artery Disease

Stop smoking - Manage diabetes, if present - Regular exercise 30 minutes 3x a week MD-lower cholesterol and bp maintain healthy weight

Inspect Jugular Venous Pulse (JVP)

Supine with 30˚-45˚ • Neck rested and turn to left • Apply tangential light • Inspect suprasternal notch or around clavicles for internal jugular pulsation • Check distention, protrusion, or bulging (2-4 cm elevated from angle of Luis is normal) • Full distension above 45˚; ventricular failure, pulmonary hypertension, pulmonary embolism, or cardiac tamponade

Abnormal Assessment Findings for WRIST

Swelling, tenderness, nodules with rheumatoid arthritis Ganglion cyst (nontender, round, enlarged, swollen, fluid-filled). Cause uncertain but risk factors are wear tear arthritis or prev. injury. Fracture with pain, tenderness, limited ROM Ulnar deviation with limited ROM in RA Lateral or medial epicondylitis; pain with extension against resistance Carpal tunnel syndrome with numbness, tingling, pain or shocking sensation or thumb weakness

Objective Data Wrists

Symmetric, without redness, swelling, tenderness or nodules; full ROM and equal strength against resistance Assess for carpal tunnel syndrome: perform Phalen's Test and Tinel's Sign ◦ Normal is no tingling, numbness or pain with Phalen's test and no shocking sensation with Tinel's Sign Assess for thumb weakness: Normally client can raise thumb up from the plane and stretch the thumb finger pad to the little finger pad

SPIRIT acronym

S—Spiritual belief system P—Personal spirituality I—Integration with a spiritual community R—Ritualized practices and restrictions I—Implications for medical care T—Terminal events planning

Test Muscle Strength

Test strength of the prime mover muscle groups for each joint Ask client to flex and hold muscle as you apply opposing force Should be equal bilaterally, should fully resist your opposing force 0-5 for grading of strength ◦ Use numerator/denominator, i.e. 4/5 or 5

Allen Test

The Allen Test evaluates patency of the radial or ulnar arteries; implemented when patency is questionable or before procedures like radial artery puncture - Normal pink coloration returns to the palms within 3‐5 seconds - With arterial insufficiency or occlusion of the artery, pallor persist

Decorticate posture

The body is rigid, the arms are stiff and bent, the fists are tight, and the legs are straight out.

Embryonic Life

The first 8 weeks of gestational development. epidermal ridges (milk lines) present from axilla to groin occasionally, supernumerary nipple persists, visible along mammary ridge track

Worldview

The way individuals or groups of people look at the universe to form basic assumptions and values about their lives and the world around them; includes cosmology, relationships with nature, moral and ethical reasoning, social relationships, magic, religious beliefs, and aesthetics

Skeletal Muscles

Three types: skeletal, smooth, and cardiac ◦ Skeletal (voluntary) muscles, under conscious control ◦ Tendons (skeletal muscles attach to bones by tendons) Movements: abduction, adduction, circumduction, inversion, eversion, extension, flexion, pronation, supination, protraction, retraction, rotation ◦ Know which way each joint is supposed to

Objective Data Ankles and Feet

Toes point forward and lie flat and are in alignment with the lower leg Smooth, rounded medial malleolar prominences with prominent heels and metatarsophalangeal joints Skin smooth & free of corns and calluses Most weight bearing is on midline foot No pain, heat, swelling or nodules Full ROM and equal muscle strength to resistance

Heart Murmurs

Turbulent blood flow through incompetent or stenotic valves, HIGH blood velocity, LOW blood viscosity • Swishing or blowing • Timing: Systolic vs Diastolic • Location: landmarks • Intensity: soft, or loud: (Rt inspiration vs Lt expiration) • Duration: short, long, or holosystolic • Pitch: low, medium, high pitch • Shape: crescendo, decrescendo, diamond or rectangular

Assessment of Lower Extremity

With client supine, groin area draped, observe skin color, hair distribution & for lesions/ulcers Pink color for light-skinned clients is normal; pink or red tones visible under darker-pigmented skin Hair should be seen on legs and dorsal area of toes; legs are free of lesions or ulcerations Abnormal findings include pallor, rubor, cyanosis, rusty/brownish pigmentation; hair loss with thin shiny skin, ulcers on toes or ankles Inspect for edema; measure if asymmetric Normally identical size/shape without swelling or atrophy Bilateral: systemic problem, i.e. CHF; unilateral with local problem (lymphedema or or prolonged standing) Palpate for edema to determine if pitting or nonpitting; press with tips of fingers; hold for a few seconds then release Pitting edema associated with systemic problems (CHF) or local cause (venous stasis) 1+ to 4+ scale (or measure with tape) Assess temperature legs/feet, compare symmetrically - should be warm and = bilat Feet may be slightly cooler but bilaterally equal Generalized coolness in 1 leg suggests or cooler down the leg suggests arterial insufficiency; increased warmth may be RT thrombophlebitis Palpate inguinal lymph nodes -Normal is nontender, movable lymph nodes up to 1-2 cm. Nodes larger than 2 cm. with or without tenderness may be from a local infection or generalized lymphadenopathy Palpate femoral artery pulse; strong & = bilat Popliteal pulse (difficult to localize) - Place thumbs on the knee, with fingers deep in bend of the knee, lateral to the medial tendon -easier with pt. prone

Pain Assessment Tools: Verbal Descriptor Scale

a rating scale on which people are asked to describe their pain by choosing the phrase that most closely resembles the pain that they are experiencing

Ethnicity

a socially, culturally, and politically constructed group that holds in common a set of characteristics not shared by others with whom members of the group come into contact

Hammer toe

a toe that is curled due to a bend in the middle joint of the toe

Neuropathic Pain

abnormal processing of pain message From past damage-peripheral or CNS R/T neurochemical levels • No predictable path; difficult to treat, perceived after healing • Nociceptive pain can change to neuropathic with poor control • Ex: Diabetic neuropathy, shingles, HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, & chemotherapy

Varicose Veins

abnormally swollen, twisted veins with defective valves; most often seen in the legs

Atypical Heart Attack (MI) Symptoms

abrupt change in how body feels discomfort, heaviness, burning, tightness, fullness in left or right arm, upper back, shoulder, neck, jaw, abdomen, throat weakness/fatigue/unusual fatigue shortness of breath restlessness, insomnia, anxiety bluish color or numbness in lips, hands, feet nausea, vomiting dry barking persistent cough sense of impending doom.

Pain

an unpleasant sensory and emotional experience associated with actual or potential tissue damage Pain is whatever and wherever the person says it is

Venous Insufficiency Ulcers may be located in the

anterior tibial area irregular borders associated with moderate to severe edema

S2 Heart Sound: DUB

aortic and pulmonic valves close (semi lunar valves)

A PET MONKEY

aortic, pulmonic, erb's point, tricuspid, mitral aortic: 2nd ics RSB pulmonic: 2nd or 3rd ics LSB erbs point: 3rd ICS LSB Tricuspid: 4th or 5th LSB Mitral (apex) 5th ICS, MCL

Faces Pain Scale

appropriate for ages 3 and up. Best suited for very young patients, confused patients, patients that have difficulty communicating (confused, non-English speaking, etc.)

Palpation of Breasts: Abnormal Findings: LIPOMAS

are fatty tissue that appear as a lump

S1 LUB

beginning of systole. -Sound with AV valves (mitral valve and tricuspid) shut -Heard over the entire precordium. Best heard at the apex -Coincides with the carotid arterial pulse

Osteoarthritis

begins on one side of the body deep joint pain improves with rest stiff in morning, improves throughout day heberden nodes, bouchard nodes caused by bony overgrowth of osetoarthritis

Carotid Artery Pulse

between trachea & sternocleidomastoid (SCM) muscle -Coincides with ventricular systole (S1) -Smooth, rapid upstroke and gradual downstroke

External Rotation

brings hands together behind head with elbows flexed

The nurse is assessing a client with a cardiac condition who complains of fatigue and nocturia. The nurse should recognize what implication of this statement?

client may be experiencing symptoms of heart failure With heart failure, increased renal perfusion during periods of rest or recumbency may cause nocturia. This does not signal CAD, a conduction problem, or adequate compensation

Patient history of smoking and possible damage over the 20yrs he was smoking exacerbates the possible damage to his lung tissue. Patient was experiencing 2+ pitting edema bilaterally. Crackles were noted only at the bases posteriorly. The heart rate was irregular with atrial fibrillation not regular

compare measurements of both extremities If the legs appear asymmetric, the nurse should measure each leg and then compare the measurements to confirm the difference. The Allen test is used to evaluate the patency of the radial or ulnar arteries. Checking for bilateral varicosities is not indicated, as the client's assessment findings are unilateral edema. Assessment of femoral pulses is unrelated to edema; if a concern for circulation arises, assess the more distal pulses.

Heart Failure Symptoms

dilated pupils; skin pale, grey, cyanotic; dyspnea, orthopnea, crackles, wheeze, coughing; decreased BP; nausea and vomiting; ascites (fluid in liver); dependent, putting edema; anxiety; falling O2 saturation; confusion; jugular vein distention; MI; fatigue; tachycardia; enlarged spleen and liver; decreased during output; weak pulse, cool, moist skin

heart murmurs are harsh blowing sounds caused by

disruption of blood flow into the heart between the chambers of the heart or from heart into pulmonary or aortic systems

The pericardium is

double-layered membrane that encloses the heart

S2 DUBB

end of systole (beginning of diastole) - Sound with semilunar valves closure (aortic and pulmonic valve) -Heard best at pulmonic area

Recent memories

evokes day to day events

Tail of Spence

extension of breast tissue into the axilla

FLACC

face, legs, activity, cry, consolability pain scale for neonates and infants

When doing a mental exam

first always explain what/why you are doing this, examples of they type of questions you are going to ask (no surprises)... Then you can assess LOC, orientation, ect. How do you assess orientation?- person, place, time

Hip ROM

flexion with knee flexed & extended, extension and hyperextension, circumduction, internal & external rotation, abduction, adduction

Toe ROM

flexion, extension, abduction, adduction

Finger ROM

flexion, extension, abduction, adduction circumduction

Thumb ROM

flexion, extension, opposition

Vertebrae ROM

flexion, hyperextension, lateral bending, rotation

Acculturation

gives up traits of his/her culture of origin as a result of context with another culture

Nonverbal Behavior involving acute pain

guarding (protecting, acute abdominal pain), grimacing, restless, diaphoresis, change in VS

S4 Arterial Gallop

heard with CAD, hypertensive heart disease, cardiomyopathy, and aortic stenosis

S3 Ventricular Gallop

heard with ischemic heart disease. hyperkinetic states (anemia), restrictive myocardial disease, early sign of heart failure

Aortic Regurgitation

high pitch heart murmur during first half of diastole best heard at erbs point sitting up and leaning position with holding breath after expiration

Tricupsid Regurgitation

high-pitched murmur best heard at lt lower sternal border during inspiration

new memories

hippocampus

fibrous tissue on breast

increases with age

Glasgow Coma Scale (GCS)

internationally recognized scale that assesses neurological functions such as reflexes and responses to sound and touch Eye opening response Most appropriate verbal response Most integral motor response (arm) Score 3-15 Score of 7 or lower is considered coma ***not used in intubated or aphasic patients

Clients with ulcers due to arterial insufficiency usually have deep ulcers that often involve

joint space. Located on tips of toes, toe webs, heels, or other pressure areas if confined to bed. These ulcers are painful and CIRCULAR IN SHAPE

Palpation of Breasts: Abnormal Findings: Milk cysts/infections (mastitis)

may turn to abscess; breastfeeding or recently given birth

Remote memories

memories for events that occurred long ago

Breast size has no relation to the amount of...

milk produced

Fibrocystic Breasts

more than ½ of women experiences fibrocystic breast changes at some point

adduction

moving hands in front of body past midline elbows straight

Spiritual Assessment Client is the focus and most are

nonformal. Nurse does not have to be spiritual to take a spiritual assessment. Objectivity is a key component. Questions probe for beliefs that could affect care. Divulged information is then utilized to support, encourage, or lead clients in harmonizing their personal relationship to spirituality and health. Some may not be connected to religious group or interest in spirituality. Clients are encouraged in whatever provides strength in dealing with health care issues (e.g., family, friends, nature, etc.).

Kyphosis is a

normal age related change

Stereotyping

overgeneralization or oversimplification of beliefs about a particular group based on hearsay or limited personal experience

Homan's Sign

pain in *calf upon dorsiflexion* of foot and may indicated thrombophlebitis DVT's

Thrill

palpable vibration on the chest wall accompanying severe heart murmur

During the patient scenario for Charles Jones, what were the priority findings related to their congestive heart failure?

patient's history of smoking Patient history of smoking and possible damage over the 20yrs he was smoking exacerbates the possible damage to his lung tissue. Patient was experiencing 2+ pitting edema bilaterally. Crackles were noted only at the bases posteriorly. The heart rate was irregular with atrial fibrillation not regular

Subculture

people with culture that differentiates from the larger culture of which they are apart of

Asking about activities within last 24-48 hours would be

recent memory assessment

Asking about someone's first job would assess

remote memory

A 70-year-old patient with swelling in his ankles is seen in the clinic. When lying supine, and the head of the bed is elevated greater than 45 degrees, the nurse observes the external jugular veins are full and distended. The nurse knows this is as a result of

right sided heart failure

a gallop or

s3 heart sound present in an adult may indicate decreased compliance of ventricles as seen in heart failure

Lymphedema

swelling of the tissues due to an abnormal accumulation of lymph fluid within the tissues usually bilateral could be uni. no skin ulceration or pigmentation

murmurs

swishing sound can be detected or subside depending on client's position reposition and listen again.

Rheumatoid arthritis usually affects joints

symmetrically. Begins in a couple of joints only and most frequently attacks wrists, hands, elbows, shoulders, knees, and ankles

TMJ ROM

temporomandibular joint opens/closes mouth; side to side; projects & retracts jaw

The precordium is:

the area on the anterior chest overlying the heart and great vessels

Cultural relativism

the belief that the behaviors and practices of people should be judged only from the context of their cultural system

Colostrum

thin, milky fluid secreted by the breast during pregnancy and during the first days after birth before lactation begins

Most breast tumors are in which quadrant?

upper outer quadrant upper outer quadrant extends into axillary area referred to as Tail of Spence.

Innocent Murmur

usually soft best at 2nd or 3rc It ICS disappears with sitting

Cardiac Nursing Diagnoses

• Activity Intolerance R/T compromised oxygen supply AEB exertional angina • Acute Pain R/T tissue ischemia AEB reports of chest pain7/10 (0-10 scale), change in pulse and BP • Anxiety R/T threat of death AEB fearful attitude, restlessness • Risk for Ineffective Tissue Perfusion R/T interruption of blood flow • Risk for decreased cardiac output R/T damaged heart muscle

Breast Self-Exam

• Become familiar • Lie down to spread breast tissue, making it easier to feel • Use 3 middle finger pads, circular motions • Up-and-down vertical pattern best • Light pressure close to skin; firm pressure close to chest & ribs • Move across breast to middle of sternum • Stand in front of a mirror; press hands on hips; look for dimpling • Examine both underarms

Subjective Data for Heart Disease

• Chest pain or tightness • Dyspnea/Orthopnea • Tachycardia or palpitations • Fatigue • Cough • Cyanosis/pallor • Edema • Dizziness • Nocturia • Heartburn • Cardiac history or defects, murmurs, surgery • EKG, Blood lipids, medications • Family cardiac history • Personal habits, risk fact

Pain Assessment Tools How to Choose

• Choose reliable/valid tools based on purpose, time to administer, patients ability to comprehend • Multidimensional v. unidimensional • Use standardized tools; teach pt. how to use • Enlarge print if needed

Cough: COLDSPA

• Cough -Characteristics: Dry, hacking, barky, hoarse, congested, productive (mucus, blood), odor, blood-tinged -Onset: when, how long, had this type before, -Location -Duration: How long, how often -Severity: ex) Visual analogue scales (VAS) 0-5 score -Pattern: Made better/worse by activity, position, anxiety, talking, nocturnal or relieved by rest or med -Associated factors: with chest pain, wheezing, runny nose, sore throat, night sweat, difficulty swallowing

Male Breast Exam

• Do not omit; but it can be abbreviated • Combine with exam of anterior thorax • Palpate the flat disc and note any swelling, nodules or ulceration; none should be present • Normal- flat disc of undeveloped breast tissue beneath the nipple - Soft, fatty enlargement is seen in obesity - Gynecomastia (smooth, firm, movable disc) seen in 1 breast in puberty, usually temporary - May be RT hormonal imbalances, drug abuse, cirrhosis, - Hard, irregular nodules with cancer

Dietary Guidelines for Americans

• Evidence-based: Healthy eating patterns and regular physical activity maintain good health and reduce chronic disease. • Follow a healthy eating pattern across the life span • Focus on variety, nutrient density, and amount • Limit calories from added sugars and saturated fats and reduce sodium intake • Shift to healthier food and beverage choices • Support healthy eating patterns for all

Breasts Age Specific Exam Older Adults

• Examine for symmetry. In clients with pendulous breasts, assist client to lean forward • Glandular tissue decreases whereas fatty tissue increases; may feel more fibrotic • Nipples may turn in slightly • Inspect skin under breasts • Abnormal: Pain to palpation may indicate infection or cancer; tenderness may be SE of HRT. Retracted nipples that cannot be everted may indicate cancer • Male gynecomastia may occur RT decreased testosterone

Hierarchy of Pain Assessment

• For nonverbal pts. or those with cognitive impairment: - Always try to get a self‐report - Search for potential causes of pain - Observe patient behaviors - Surrogate reporting (family members, parents, caregivers) of pain and behavior/activity changes - Note discrepancies - Attempt an analgesic trial; observe for changes in self‐ report

Breasts Age Specific Children and Adolescents

• Growth stimulated by estrogen at onset of puberty • Between 8 and 13 years of age thelarche (breast development) may occur - Breast enlarge primarily as a result of fat deposits - Tender, asymmetric development is common • Beginning of breast development precedes menarche by about 2 years.

Breast Palpation

• Have client lie down; place overhead the arm on the same side as the breast being palpated - Use a pillow or rolled towel under breast • Use the flat pads of 3 fingers • Palpate every square inch of the breast, from nipple and areola to the periphery, and up into the tail of Spence • Vary pressure- light, medium, and firm

Assessment for Arterial Insufficiency

• If pulses in the legs are weak, assess for arterial insufficiency • Client in supine position; support the ankles & knees; raise legs about 12 inches above the heart level; ask client to pump feet up and down for a minute to drain venous blood • Ask client to sit up and dangle off the exam table and note time for color to return to both feet - Feet should be pink to slightly pale with elevation; pinkish color should return to tips of toes in 10 sec. - Marked pallor with legs elevated or return of color that takes > 10 seconds suggests arterial insufficiency

Breasts Age Related: NEWBORNS AND INFANTS

• Milk lines run from the axilla to medial thigh • True breasts develop along thoracic ridge • At birth, lactiferous ducts present in nipple • Supernumerary nipples may be present • Breasts may be temporarily enlarged from the effects of maternal estrogen

Palpate Breasts for Masses

• No masses should be palpated - A firm, infra-mammary ridge may be normally palpated at the base of the breasts • Abn. If a mass is present, note: - Location, size in centimeters, shape, mobility, consistency, tenderness, and condition of the skin over the mass - If you detect a lump, refer the client for further evaluation • Fibrocystic breast tissue (also called benign breast disease) is a normal finding - Texture feels ropy, lumpy or bumpy - Multiple, bilateral, firm, regular, rubbery, mobile nodules with well-demarcated borders • Pain and fullness occurs just before menses

Joint Commission Standards for Pain Management

• Pain Standards-accreditation of hospitals • Pt rights to pain assessment/management • Screen initially/assess periodically for pain • Record assessment results/reassessments • Assess and educate staff in pain management • Establish organizational policies • Educate patients and families • Address patient needs; collect data

Palpate Carotid Arteries

• Palpate one at a time! • Use index and middle fingers medial to the SCM muscle on the neck • Avoid vagal stimulation • Equal pulse strength (0-3+ scale) smooth contour, elastic and no thrills • Abnormal is unequal pulses, weak, or bounding; loss of elasticity may indicate arteriosclerosis; thrills may indicate narrowed arteries • Bruit (blood vessels) vs murmur (heart valves & structures)

Palpating the Breasts

• Palpate- texture, elasticity, tenderness & temperature - Normally smooth, firm, elastic, normal temp. - A generalized increase in nodularity & tenderness may be normal RT menstrual cycle or hormonal medications - Abn. Thickening may be RT malignant tumor - Abn. Painful, tender breasts may indicate fibrocystic breasts, especially right before menstruation - Abn. Pain may occur with a malignant tum

When Palpating Mastectomy or Lumpectomy Site

• Perform thorough exam post operative - Scar- whitish, with no redness, swelling, lesions lumps or tenderness • Palpate-scar, any remaining breast or axillary tissue for redness, lesions, lumps, swelling or tenderness - Abn. Redness or inflammation- infection -Abn. Refer for LESIONS, LUMPS, TENDERNESS

7 Dimensions of Pain

• Physical: anatomic structure • Sensory: Qualitative/quantitative descriptions of pain • Behavioral: Verbal & nonverbal behaviors • Sociocultural: social & cultural backgrounds • Cognitive: Thoughts, beliefs, attitudes, intentions, motivations R/T pain • Affective: Feelings/ emotions R/T pain • Spiritual: meaning and purpose R/T pain, self, others, and the divine

Subjective Data and Pain

• SELF REPORT IS BEST • COLDSPA • Open-ended questions; listen to pt./quote terms used • Ask about effect on ADLs, mood, emotions, sleep, joy of life, appetite, concentration • Facial expressions/ grimaces • DO NOT put words in the client's mouth • Past experiences • BELIEVE client's expression of pain

Patho of Pain

• Source of pain stimulates peripheral nerve endings (nociceptors) which transmit sensations to the CNS Nociceptors- peripheral end of nerve endings involved w sensation for temperature, heat, cold, pain (noxious stimuli) Distributed in the body, skin, SQ tissue, skeletal muscle, joints, peritoneal surface, pleural membranes, dura mater, and blood vessel walls

Inspect Precordium; Inspect and Palpate Apical Impulse (PMI)

• Supine at 30-45° • patient's right side • Use tangential lighting-may visible • Palpate the apical impulse (PMI) (Lt lateral position) • Hold breath after exhalation; use 1-2 fingerpads • 4 th-5th ICS & MCL • ABNORMAL is -a heave or lift (upward thrust), -Double impulse -Displaced under 5th ICS or laterally rotated- hypertrophic cardiomyopathy

Exam Preparation for Cardiac Exam

• Supine position • Head elevated about 30 degrees • Auscultation & palpation of neck vessels • Inspection, palpation and auscultation of precordium • Auscultation of heart on supine, left lateral and then sitting up leaning forward positions • STAND ON THE PERSON'S RIGHT side • Environment: warm room temperature; privacy; drape female breast; ask client to pull her breast upward and to her side when auscultating

Breasts Age Related: Tanner Staging

• Tanner Staging: Sexual Maturity Rating depicts the 5 stages of breast development - 1. Prepubertal: Elevation of nipple only - 2. Breast bud stage: Small mound, breast/nipple develops; areola widens - 3. Breast and areola enlarge - 4. Areola/nipple form a secondary mound over the breast - 5. Adult configuration. Only the nipple protrudes • Teach adolescents normal developmental stages and assure his/her own normal progress

Factors Affecting Mental Health

•Economic and social factors •Unhealthy lifestyle choices •Exposure to violence •Personality factors •Spiritual factors •Cultural factors •Changes or impairments in the structure and function of the neurologic system •Psychosocial developmental level and issues

Culture Affects on Care

•Nutrition- dietary considerations are part of assessment, compare ingredients in culturally based foods •Pain- some may not want to take medications •Blood transfusions- some religions may not allow (Jehovah's Witness) •Death rituals- practices depend on customs

Osteoarthritis (Degenerative Joint Disease)

◦ A noninflammatory, localized, progressive disorder involving deterioration of articular cartilages and bone, and formation of new bone (osteophytes) at joint surfaces ◦ Joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine ◦ Affected joints have stiffness, swelling with hard, bony protuberances; pain with motion and limitation of motion ◦ OA is worse later in the day; movement INCREASES pain

If client has difficulty with speech, perform this:

◦ Ask client to name familiar objects, read age-appropriate written print and write a coherent sentence with correct spelling & grammar. ◦ Abn. If client cannot name objects, read or write sentences, they should be referred for neurologic assessment for cortex problems

Cognitive Abilities Assess orientation

◦ Ask client's name and names of family (person) ◦ Place (where the client lives or is now) ◦ Time (hour, day, date or season) ◦ With a change in orientation, time is lost first and person is lost last. ◦ Older adults in a new setting may seem confused but should know who and where they are and the current month/y

Abnormal Findings in Shoulder/Arm Assessment

◦ Dislocation=Less-rounded ◦ Nerve/muscle damage or disuse= muscle atrophy ◦ Shoulder strain or DJD= tenderness, swelling & heat ◦ Rotator cuff tear= Painful, limited abduction with weakness ◦ Tendinitis= Chronic pain ◦ Nerve damage=inability to shrug shoulders to resistance

Client Education Dementia/Alzheimer's Disease

◦ Engage in mentally challenging activities ◦ Maintain healthy aging behaviors ◦ Healthy weight ◦ Avoid tobacco use and excessive alcohol intake ◦ Stay socially connected ◦ Exercise body and mind ◦ Avoid activities that increase head trauma risk ◦ Ask about HRT ◦ Heart healthy diet/exercise

Modifiable risk factors for dementia/alzheimer's disease

◦ Hypertension/ cholesterol ◦ Head trauma ◦ Smoking ◦ Dysrhythmias, depression ◦ HRT

Nonmodifiable risk factors for dementia/alzheimer's disease

◦ Increasing age ◦ Genetic predisposition and family history ◦ Latino or African American descent due to higher vascular disease rate

Abnormal Assessment Findings HIP

◦ Instability, inability to stand and/or deformed hip area are indicative of a fracture ◦ Groin pulls and hamstring strains in athletes ◦ Limited ROM or strength ◦ Bursitis of the hip

Objective Data: Physical Assessment Level of Consciousness and Mental Status

◦ Level of consciousness ◦ Posture, gait, body movements ◦ Behavior and affect ◦ Dress and grooming ◦ Hygiene ◦ Facial expressions and speech ◦ Mood, feelings and expressions ◦ Thought processes and perceptions Cognitive abilities ◦ Orientation ◦ Concentration ◦ Recent and remote memory ◦ Use of memory to learn new information ◦ Abstract reasoning ◦ Judgment ◦ Visual, perceptual, and constructional ability ◦ Confusion Assessment Model