Physical Examination Notes Exam One, Two, and Three

SOAP note

Different from nursing process but part of the assessment in the nursing process - subjective - objective - assessment - planning

Flat percussion

Heard over the sternum, muscle or areas of atelectasis.

Physical Exam Techniques

Inspection Palpation Percussion Auscultation

inspection

Inspection is concentrated watching. It is close, careful scrutiny, first of the individual as a whole and then of each body system. Inspection begins the moment you first meet the person and develop a general survey.

medical diagnosis vs nursing diagnosis

Medical Diagnosis: is used to evaluate the cause or etiology of disease Nursing Diagnosis: clinical judgements about a persons response to an actual or potential health state

Arm band

Patient identifiers

How to do percussion

Use the middle finger as the striking finger and other hand to lay out of body.

pitch

a tone's experienced highness or lowness; depends on frequency

Environment

every nongenetic influence, from prenatal nutrition to the people and things around us

Percussion

tapping the persons skin with short, sharp strokes to assess underlying structures.

palpation: base of the fingers or ulnar surface of the hand

vibration

Outcome Identification

· Identify expected outcomes · Individualize to the person · Culturally appropriate · Realistic and measurable · Include a timeline

Implementation

· Implement in a safe and timely manner · Use evidence based interventions · Collaborate with colleagues · Use community resources · Coordinate care delivery · Provide health teaching and health promotion · Document implementation and any modification

Mobility equipment in room

· Walker · Wheelchair · Gait belt · Transfer equipment

Disease based precautions - airborne

- N95 respirator - gloves - gown

Toddler age

1-3 years

Adolescent age

12-18

Preschooler age

3-5 years

tympany

A bell-like noise when tapping the abdomen

Primary care

A doctor who provides general medical care and coordinates other health care.

Allergies

Allergies and need to know their reactions(itchiness vs shortness of breath)

Ask Tell Ask

A simple reminder to clinicians to increase their chances of their advice sticking to the patients - ask permission to give advice - ask what they know or want to know - tell simply and things personal and specific to that individual - ask what they think of the info or ask teach back question to check understanding

Sinus Arrhythmia

A sinus rhythm in which the rate varies with respiration, causing an irregular rhythm. Increase with inhale and decrease with exhale

acute illness

A sudden illness from which a person is expected to recover

Culture and Genetics: PAD - ABI

ABI is a noninvasive screening tool for PAD

Rinne test normal finding

AC greater than BC

diastole - Rapid filling

AV open, blood going to atria and ventricles

What is the most common location for an aortic aneurysm

Abdominal aorta - lose a lot of blood quickly

CN VI

Abducens controls lateral rectus muscle that abducts eye

---- is very common in our society and impacts client care in every nursing context.

Abuse(drug/alcohol)

CN XI

Accessory Nerve swallowing, head, neck, and shoulder movements

AIDET procedure

Acknowledge Introduce Duration Explain Thank

Adventitious sounds

Added sounds that are not normally heard in the lungs - crackles - rhonchi - wheezing - stridor - pleural friction rub

Sutures

Adjacent cranial bones mesh at sutures - coronal, sagittal, lambdoid

Simpler term for respiratory dead space

Air that goes into nasal cavity and goes down into trachea and does not actually get down into the lungs for gas exchange - ventilation without perfusion

Bronchioles

Airways in the lungs that lead from the bronchi to the alveoli.

What causes a high risk of breast cancer?

Alcohol use - screening mammograms are important at the age of 40 and should continue

Precordium Auscultation Points

All People Enjoy Time Magazine - Z pattern

What happens when measuring infant blood pressure when crying?

Allow crying infant to become quiet for 5 to 10 minutes before measuring the BP, crying may elevate the SP by 30-50 mmHg

Trachea

Allows air to pass to and from lungs. Midline and has cartilage which gives ridgitidy and protection

Abnormal findings: Lumps and Lesions on External Ear - chondrodermatitis nodularis helicis

Along helix of ear, due to mechanical pressure(MMA fighters), red, painful, hardened area

Leukonychia

Also known as white spots, whitish discoloration of the nails caused by injury

Important things for assessing for vascular and peripheral circulation

Always look at bilateral extremities and compare them when assessing. Assess both radial pulses. Use both hands and compare each side.

Inspection of the Face: Facial structures

Always should be symmetric - when smile are lips the same

Dementia

An abnormal condition marked by multiple cognitive defects that include memory impairment.

obsessive-compulsive disorder

An anxiety disorder characterized by unwanted repetitive thoughts (obsession) and/ or actions (compulsions).

Physical examination: Infants and children - Neck appearance

An infant's neck looks short; it lengthens during the first 3 to 4 years

Medications that cause gynecomastia

Anabolic steroids and estrogens and methadone

Nurse palpates sternum and finds a horizonal ridge, what is this?

Angle of Louis

precordium

Anterior portion of the chest that lays over the - great vessels(connected to the heart) - location of base and apex

Posterior assessment - inspection: AP diameter

Anterior posterior in comparison to transverse diameter - transverse should be longer than anterior and posterior - AP:T = 1 to 2

When asked a personal question

Anwser then direct it back to them

Subjective Questions: Earache - any?

Any accompanying cold symptoms or sore throat? Any problems with sinuses or teeth?

Vision Difficulty Questions

Any difficulty seeing or any blurring? Blind spots? Come on suddenly or slowly? One eye or both? Constant, or does it come and go? Do objects appear out of focus or clouding of objects? Do spots move in front of your eyes? One or many? In one or both eyes? Any halos, rainbows, rings around objects? Any blind spot? Does it move as you shift your gaze? Any loss of peripheral vision? Any night blindness?

Subjective data questions: mouth and throat - dysphagia

Any difficulty swallowing? how long have you had it? do you feel as if food gets stopped at a certain point? any pain with this?

Subjective Questions: Infections and Discharge - Discharge

Any discharge from your ears? Does it look like pus, or is it bloody? Any odor to the discharge? Any relationship between discharge and ear pain?

Additional History for Infants and Children questions

Any dryness in the mouth? are you taking any medications? have you had any loss of teeth? can you chew all types of food? are you able to care for your own teeth or dentures? have you noticed a change in your sense of taste or smell?

Subjective Questions: Infections and Discharge - Infections

Any ear infections? As an adult or in childhood? How frequent were they? How were they treated?

Eye pain questions

Any eye pain? please describe. Come on suddenly? Burning or itching? or sharp, stabbing pain; pain with bright light? A foreign body sensation? or deep aching? or headache in brow area?

Past history of ocular problems questions

Any history of injury or surgery to eye? any history of allergies?

Subjective data questions: nose - frequent colds

Any unusually frequent or severe colds(upper respiratory infections)? How often do these occur?

Watering and discharge questions

Any watering or excessive tearing? Any discharge? Any matter in the eyes? Is it hard to open your eyes in the morning? what color is the discharge? how do you remove matter from eyes?

Abnormal Findings: Pediatrics - Allergic salute and crease

Appearance of transverse line on the nose in response to chronically repeated use of hand to push the nose up and back

Iris

Appears flat, with round regular shape and even coloration

Weight in adults adults

Appears sharper in contour with more prominent bony landmarks than younger adult - weight decreases during 80s and 90s; this factor more evident in males - distribution of fat also changes during 80s and 90s

culturally appropriate

Applying underlying background knowledge necessary to provide the best possible health care

Abnormal percussion - pleural effusion

Area of dullness

What is the difference with arterial and venous issues?

Arterial is there is too much blood returning to the heart while with venous there is trouble getting it back to the heart and there is extra blood flow in a specific area

Arterial and Venous insufficiency - Nails

Arterial: Thick and brittle Venous: normal

Arterial and Venous insufficiency - Pain

Arterial: Worse with elevation and exercise; sudden and severe; rest pain; claudication; no compression socks Venous: Better with elevation; dullness or heaviness

Arterial and Venous insufficiency - Temperature of extremity

Arterial: cool Venous: warm

Arterial and Venous insufficiency - Pulses

Arterial: decreased, weak or absent Venous: normal or bounding

Arterial and Venous insufficiency - Ulcers

Arterial: dry and necrotic Venous: moist

Arterial and Venous insufficiency - color

Arterial: pale Venous: Ruddy

Auscultation - Breath Sounds

Ask patient to take deep breath each time move stethoscope. Move it each side 9 times - voice sounds - adventitous sounds

Health Promotion and Patient Teaching - Appropriate aspirin therapy

Aspirin prevent cardiac or stroke event - when the potential benefit of preventing a heart attack outweighs potential bleeding

Inspection and Palpation: Skin - Edema

Assess for fluid accumulation in the interstitial space - push and see if there is an indentention in skin

Inspection and Palpation: Skin - vascularity or bruising

Assess for presence of tattoos and/or variations

Infants and children visual fields

Assess peripheral vision with confrontation test in children older than 3 years

Inspection and Palpation: Skin - Mobility and turgor

Assess skin elasticity on sternum or wrist - pinch and skin will stay raised w222222

Corneal Light Reflex (Hirschberg Test)

Assess the parallel alignment of the eye axes by shining a light toward the person's eyes. Direct the person to stare straight ahead as you hold the light about 30 cm away. Note reflection of light on corneas; should be in exactly same spot on each eye

Pain scores

Assigned using pain assessment tools

Physical examination: Infants and children - two common variations in newborn cause shape of skull to look markedly?

Asymmetric due to birth trauma

Additional History for Infants and Children questions: Ear Infections

At what age was child's first episode? How many ear infections in past 6 months? How many total? How were these treated? Has child had any surgery, such as insertion of ear tubes or removal of tonsils? Are infections increasing in frequency, in severity, or staying same? Does anyone in the home smoke cigarettes? Does child receive care outside your home? In daycare center or someone else's home? How many children in group care?

High-Pitched, Polyphonic Wheeze

Auscultated mainly in expiration - high pitched musical instrument with more than one type of sound quality - asthma/lung disease

Low-Pitched, Monophonic Wheeze

Auscultated mainly in expiration - low pitched whistling tune or whine with one type of sound quality - asthma/lung disease

Does it matter what time of the month a women performs the self breast exam? If so, how would you educate them?

BSE should be performed after the menstrual period. I would tell the patient to perform the exam in the day or two after their period ends for the most accurate results.

Health promotion - average-risk women should not perform?

BSE. Several studies have shown lack of benefit and a higher rate of breast biopsy that shows benign disease with routine BSE. Up-to-date

Health

Balance of a person is complex, interrelated phenomenon - within one's being: physical, mental, spiritual - in outside world: natural, communal, metaphysical

abnormal inspection - increase AP diameter

Barrel chest commonly seen in COPD because have enlarged lungs from overinflating - ribs horizontal rather than slope - 1:1

Developmental Competence: Children

Be on the lookout for poor weight gain, developmental delay, persistent tachycardia, tachypnea, dyspnea on exertion, cyanosis, and clubbing - palpate apical pulse

What is not a way to show empathy?

Be stone faced while listening

Objective data - Preparing for the assessment: Infection control

Be sure to clean the stethoscope

Inspection of the mouth

Begin with anterior structures and move posteriorlu; use tongue blade to retract structures and bright light for optimal visualization

Annular or Circular

Begins in center and spreads to periphery(round shape)

The spirit of MI is based on what four elements?

Being collaborative, evocative, respectful of autonomy, compassionate

Which side of the stethoscope should you use to listen to a patient's blood pressure?

Bell or diaphragm

Physical examination: Infants and children - Face - Parotid gland enlargement

Best seen when child looks up; swelling appears below angle of jaw

Common skin lesions - Tinea pedis(ringworm of the foot - athletes foot)

Between the toes, contagious

Seizure activity

Bicycling motion or sucking movements are manifestation of seizure.

Double Billing

Billing more than one client for the same billable time period. Safeguards to prevent this

Health history includes

Biographic data, reason for seeking care, present health or history of present illness, past history, medication reconciliation, family history, review of systems, functional assessment or activities of daily living

Liniagura

Black line that forms on the belly, usually goes away

Abnormal findings: ear canal abnormalities - excessive cerumen

Blocking the entire eardrum

venoustasis

Blood that sits still in the vessels - if there is a dysfunction in the three things

Facial nerve palsy

Borrelia burgdorferi (Lyme disease)

equal-status seating

Both you and the patient should be comfortably seated at eye level, about 4-5 feet apart. Avoid standing which communicates haste and superiority

What is the best method to assess heart rate in an infant?

Brachial pulse when larger but for an infant auscultate the heart rate.

What is one of the most important ways to interrupt the spread of infection?

Breaking the chain at the 'mode of transmission'

Developmental Competence - Puberty

Breast begin to enlarge and alveoli

Aging women breasts - on palpation

Breasts feel more glandular; terminal ducts around nipple feel more prominent and stringy

What does it mean when breasts feel more glandular?

Breasts will feel more lumpy, this isnt concerning for aging women because they couldve been always present so since the skin is changing they may become more prominent

Do you breathe in or out in a spirometer?

Breath in

Abnormal respiratory patterns - hyperventilation

Breathing fast and breathing deep - fully expand and bring air in - putting off more CO2 so use paper bag to breath it back in

Abnormal respiratory patterns - Hypoventilation

Breathing slow and shallow - not blowing off waste products so patient can become acidotic state(sleepy, LOC)

Reason for seeking care

Brief statement in the persons own words that describes the reason for the visit.

Infants and Children: Special procedures - auscultation

Bruits are common in skull of children under 4 or 5 years or children with anemia - systolic or continuous; heard over temporal area

spinal nerves

C3, C4, C5 keep your diaphragm alive - if damaged will not be able to breath on their own

Farenheit to Celsius

C= 5/9 (F-32)

Alcohol, benzodiasepines(xanax, valium, ativan, ambien), opioids(oxycodone, morphine, methadone) behaviors

CNS depressants: somnolent, sleep apnea - calming effect so counters withdrawal symptoms

Cocaine, amphetamine behaviors

CNS stimulants: intense high, agitation, paranoid

Abnormal inspection - neck muscles

COPD - neck muscles and shoulder muscles are bulked up and skin is pulled in which is a sign of respiratory distress - acute respiratory distress can also have these retractions

Those with DVT may also have a Homans' sign which is?

Calf pain brought on by dorsiflexion of the foot - not advised and not a reliable predictor - most reliable is ultrasound of the leg

Health Promotion and Patient Teaching - Smoking cessation

Can damage lining of arteries which can cause plaque buildup

Abnormal findings: Lumps and Lesions on External Ear - sebaceous cyst

Can get anywhere on body, sebaceous material can cause a pimple or cyst on back of ear

What does CRAFFT stand for?

Car Relax Alone Forget Friends Trouble

CRAFFT

Car Relax Alone Forget Friends Trouble - teens

veins - intraluminal valves in veins

Cause blood to flow in one direction, shaped like SL valves

Abnormal findings: ear canal abnormalities - polyp

Causes irritation and block the hearing

Abnormal findings: red eye - vascular disorders - Iritis(circumcorneal redness)

Causes pain, more redness, irregular shape from swelling, light sensitivity, constricted pupil, throbbing, referral, blurring

Stetching of the skin

Causes stretch marks and scarring, very vascularized and cant resist sunlight

pustule

Cavity filled with fluid but filled with exudate, purdulent drainage

Developmental Competence: The aging adult - Skin breakdown due to multiple factors

Cell replacement is slower and wound healing is delayed due to thinner skin, less fat,

Occasionally ear canal partially filled with?

Cerumen, which obstructs view of TM

Heart structures - Chambers - left atrium

Chamber that receives oxygenated blood from the pulmonary veins and pumps it into systemic circulation.

generalized anxiety disorder

Characterized by excessive anxiety or worry about numerous things, lasting for 6 months or longer.

Physical examination: Infants and children - Face

Check facial features for symmetry, appearance, and swelling - note symmetry of wrinkling when infant cries or smiles(normally no swelling is evident)

Ask the person to bite as if?

Chewing something, and note alignment of upper and lower jaw

Past health

Childhood Illnesses, accidents or injuries, serious or chronic illnesses, hospitalizations, operations, obstetric history, immunizations, last examination date, allergies, current medications.

When should a doppler be used?

Children younger than 3 have small arm vessels which is hard to hear Korotkoff sounds, use a doppler ultrasound device to amplify the sounds

confrontation

Clarifying inconsistent information Focusing client's attention on an observed behavior, action, or feeling

Names of opioids

Class 2 oxycodone, morphine, methadone, OxyContin, fentanyl

A 67 year old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved when sitting.

Claudication

rhinorrhea

Clear nasal discharge, "runny nose"

mental disorder

Clinically significant behavior that is cognitive or emotional that is associated with significant distress or disability involving social, occupational, or key activities(affecting every day life)

Who is the first and most frequent person to come in contract with a someone using substances that can complete the screening?

Clinician

Grouped

Cluster of lesions(shingles or scabies)

Lymphatics

Collects excess fluid and plasma proteins from the interstitial spaces and returns it to the blood stream

Common skin lesions - erythema migrans of lyme disease

Common with tic bite, center red mark or target appearance ask if they have been biten, been outdoors, and is it in the time frame that tics are out

Communicating with toddler

Communicate with limited vocab, telegrpahic speech is a combination of noun and verb. Older toddlers want to know why so provide simple explanation and keep it simple

Ankle Brachial Index

Comparison of the blood pressure in the leg vs. the arm; normal ratio is greater than 1 - can determine the extent of peripheral artery disease

Which of the following actions is appropriate for a nurse who has witnessed a breach of a patient's privacy in a primary care providers office?

Complete a health information privacy complaint form and submit it to the appropriate agency

Attention Span

Complete a thought without wandering

Complete database

Complete health history and full physical examination. It describes the current and past health state and forms a baseline against which all future changes can be measured. Yields the first diagnoses. Collected in primary care setting. For well and ill people, it must screen for pathology and determine the ways people respond to that pathology or to any health problem. In acute hospital care it is gathered on admission to the hospital.

carotid sinus hypersensitivity

Condition in which pressure over the carotid sinus leads to a decreased heart rate, decreased BP, and cerebral ischemia with syncope. May occur in older adults with hypertension or occlusion of the carotid artery

Cooper ligaments are?

Connective tissue and support the breast

Objective data preparation

Consciously attend to skin characteristics; the danger is one of omission

Communicating with adolescent

Consider attitude, respectful, communication needs to be honest, stay in chracter, focus on person not the problem, be positive, confidentiality

holistic health

Consideration of the whole person is the essence of holistic health. It views the mind, body, spirit as interdependent and functioning as a whole within the environment. In a holistic model, assessment factors are expanded to include such things as lifestyle behaviors, culture and values, family and social roles, self care behaviors, job-related stress, developmental tasks, and failures and frustrations of life. All are significant to health.

When performing a respiratory assessment on a client, the nurse notes breath sounds that are of medium pitch and loudness with a ratio of inspiration and expiration being equal near the anterior sternal area:

Considers these normal bronchovesicular breath sounds for this location

After completing a respiratory assessment, the nurse documents: AP:T diameter 1:2, symmetrical chest expansion, respiratory rate 16 and regular:

Considers these normal findings

What causes increased fremitus?

Consolidation in the lung tissue because sound is conducted better in dense structure - pneumonia

Reporting a violation

Contact the privacy officer for first point of contact and he will investigate and document privacy breach

Heart Structures - Layers Pericardial cavity

Contains fluid that lubricates the heart and its layers

What does the diaphragm do?

Contracts and relaxes to allow a person to breath

Rate

Counting that rate over a minute, count the number of beats in 30 seconds and multiply by 2. Lower you go the more likely you will have errors. If abnormal do the whole minute. When begin to count the rate start with 0 then count.

Scale

Debris on the surface but usually dead keratinized skin cells building up causing scaley surface(scorisis)

veins - Inspiration pump

Decreases thoracic pressure and increase abdominal pressure which helps flow

Abnormal respiratory patterns - kussmaul

Deep and shallow breaths but rapid breathing - diabetic ketoacidosis

Abnormal respiratory patterns - cheyne-stokes respiration

Deep respirations, shallow respirations, and periods of apnea - close to death - regular(pattern)

Ulcer

Deeper depression that extends into the dermis that causes bleeding and is irregular shape

Heritage consistency

Degree to which a person's lifestyle reflects his or her traditional heritage

conjunctiva

Delicate membrane lining the eyelids and covering the eyeball

Example of Nursing Plan Outcome

Demonstrate relief of pain as evidenced by stable vital signs, absence of muscle tension and restlessness 30 minutes after administration of medications

Atherosclerosis

Deposits of fatty plaques in the layers of the arterial wall - related to diet exercise and obesity

Inspection and Palpation: Nails - capillary refill

Depress nail edge to blanch and then release, noting return of color; indicates status of peripheral circulation

Abnormal Conditions of the Nails - habit-tic dystrophy

Depression down middle of nail or multiple horizontal ridges, caused by continuous picking of cuticle by another finger of same hand, which causes injury to nail base and nail matrix.

Ethnicity

Describes a group united by the following: - common geographic origin - migratory status - religion - race - language - shared values, traditions, or symbols - food preferences

Nursing Process Planning

Determine an outcome(goal) for the patient related to their nursing diagnosis

School age child major task

Develop industry. Basic competency in school and social and desires the approval of caregivers and teachers and has feeling of accomplishment.

Toddler major task

Developing autonomy, so may cling to caregiver

Preschool child major tasks

Developing initiative, tasks independently, plans the tasks and sees them through. Cooperative, helpful, and easy to involve. Fears body injury and mutilation.

Abnormal Findings: Primary Headaches

Diagnosed by patient history with no abnormal findings on exam or lab results

Common skin lesions in children - diaper dermatitis

Diaper rash, inflammation of diaper area, red, moist, burning - leave diaper off, baking soda bath, zinc oxide

The bases of the lungs rest on the?

Diaphragm bilaterally

Hearing loss Questions: Every had any trouble hearing? Onset

Did loss come on slowly or all at once?

Abnormal findings: tympanic membrane - insertion of tympanostomy tubes

Did not heal right and can see the bones

If hearing loss was noted, what questions do you use?

Did you obtain a hearing aid? How long have you had it? Do you wear it?How does it work? Any trouble with upkeep, cleaning, changing batteries?

Clinical Portrait of Heart Failure

Dilated pupils, skin pale, gray or cyanotic, dyspnea, orthopnea, crackles, cough, decreased BP, N&V, ascites, pitting edema, anxiety, falling O2 sat, confusion, JVD, MI, fatigue, S3 gallop, enlarged spleen, decreased urine output, weak pulse.

Signs of Retraction and Inflammation

Dimpling Fixation Edema (peau d'orange) Deviation in nipple pointing Nipple Retraction

Common skin lesions in children - Chickenpox(varicella)

Discrete vesicles, herpes zoster is latent version of this - measles, german measles(rubella)

Discrete

Distinct and separate

Common skin lesions in children - Intertrigo(candidiasis)

Distinct borders, a brighter red, due to yeast infection, aggrevated by heat, moisture, burning, hurts when go to bathroom

Concussion symptoms

Dizziness Confusion Trouble concentrating Headache Memory loss Balance/coordination problems light sensitivity nausea behavior changes - how many concussions have you had

Hearing loss Questions: Every had any trouble hearing? Efforts to treat:

Do you have any hearing aid or other device? Anything that helps hearing?

Environmental noise questions - coping strategies

Do you take any steps to protect your ears, such as headphones or earplugs?

A patient is brought to the emergency department after a motor-vehicle crash. She is unresponsive due to a head injury. Permission for emergency surgical stabilization of a cervical injury was obtained over the phone from her husband, who is currently overseas. Which of following should the assigned nurse document to verify HIPAA guidelines were maintained?

Document the patient's condition and that consent was obtained after the primary care provider discussed the proposed surgery with the husband.

Additional history for infants and children - mouth infections or sores

Does child have any mouth infections or sores, such as thrush or canker sores? how frequently? Does child have frequent sore throat or tonsillitis? how often? how are these treated? have they ever been documented as streptococcal infections?

Subjective Questions: Earache - Location

Does it feel close to surface or deep in head? Does it hurt when you push on ear?

Abnormal findings: cornea and iris - pterygium

Does not need treatment, happens with those in hot, dry, sandy areas - thin tissue growing into the cornea from the conjunctiva, usually caused from sun exposure

Region and radiation

Does your pain radiate? Where does it spread? Point to where it hurts the most. Where does you pain go from there?

Abnormal findings: eyelid abnormalities - upward palpebral slant

Down syndrome

Veins

Drain deoxygenated blood and waste products from tissues and return it to heart

Common skin lesions in children - Atopic dermatitis(eczema)

Dry scaley skin and itches bad, papules or vesicles

Lower extremities - peripheral heart

Due to calf muscle contraction and relaxation which moves blood closer to the heart - mobility

spider veins

Due to the weight gain and skin color changes

stridor

During inspiration - high pitched whistling or gasping sound with harsh sound quality - croup or epiglottitis, airway obstruction - requires medical treatment

Physical Examination: Pregnant Female

During second trimester - chlosma may shoe on face(blotchy, hyperpigmented area over cheeks and forehead that fades away after delivery) Thyroid gland may be palpable normally during pregnancy

Infants and children - lumen surrounded by lymphoid tissue, which increase?

Duroing childhood and is easily occluded - these factors place infants at greater risk for middle ear infections than adults

Example of nursing assessment

EKG abnormal, chest pain, abnormal vital signs, troponins elevated

Abnormal findings: ear canal abnormalities - Otitis externa

Ear canal is swollen with drainage

Communicating with preschooler

Egocentric, and view world from their point of view. Scared.

HIPPA mandated that health care entities implement which of the following strategies to help reduce Medicare fee-for-service error rate and prevent payment for potential fraudulent activity?

Electronic health records

Goal of healthy people?

Eliminate health disparities. A health disparity is a type of health difference that is closely linked with social, economic, and environmental disadvantage - health disparities affect groups of people who have experienced obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, age, mental health, sexual orientation, geographic location

Abnormal Facial Appearances - Acromegaly

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

What does mental status mean?

Emotional and cognitive functioning of a patient - cannot be explored as directly like characteristics of a physical assessment

Abnormal Findings: Swellings of Head and Neck - simple diffuse goiter

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

what are the four tasks of MI?

Engage, Focus, Evoke, Negotiate

A 35 year old man is seen in the clinic for an infection in his left foot. Which of these findings may be an expected finding during an assessment?

Enlarged and tender inguinal nodes

Epitrochlear lymph nodes

Epitrochlear lymph nodes- drains from the hand and forearm proximally via epitrochlear lymph node. Near brachial pulse. Not palpable. - HIV, lymphoma

Which of the following is an example of a best practice strategy to prevent fraud, waste, and abuse?

Establish procedures for maintaining and distributing medication samples

Subjective Questions: Earache - past injuries

Ever been hit on ear or on side of head or had any sport injury? Ever had any trauma from a foreign body?

Tinnitus questions

Ever felt ringing, crackling, or buzzing in your ears? When did this occur? Does it seem louder at night? Are you taking any medications?

Vertigo questions

Ever felt vertigo, that the room is spinning around or feel that you are spinning? Ever felt dizzy, like you are not quite steady, or falling or losing your balance? Giddy, light-headed?

lymph nodes

Everything that goes through lymphatics goes through lymph nodes. Inflamed with infection because filtering it and doesn't want to return it back to the heart. - don't feel unless there is an inflammatory response going on

Keloid

Excessive scaring when scar tissue grows a lot. Raised scarring. More often in dark skinned patients

Developmental competence - The pregnant women: skin color

Expected skin color changes due to increased hormone levels

What are the four basic principles of MI?

Express empathy, develop discrepancy, roll with resistance, support self-efficacy

broca aphasia

Expressive aphasia. The person can understand language but cannot express himself or herself using language. This is characterized by nonfluent, dysarthric, and effortful speech. The speech is mostly nouns and verbs (high-content words) with few grammatic fillers, termed agrammatic or telegraphic speech. Repetition and reading aloud are severely impaired. Auditory and reading comprehensions are surprisingly intact. Lesion is in anterior language area called the motor speech cortex or Broca area.

Eyeballs

Eyeballs aligned normally in their sockets with no protrusion or sunken appearance African Americans normally may have slight protrusion of eyeball beyond supraorbital ridge

Celsius to Fahrenheit

F=(9/5*C) + 32

External carotid supplies?

Face, salivary glands, and superficial temporal area

CN VII

Facial Facial expression and produces both saliva and tears.

Aging adult

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

Inspection of Face: Note?

Facial expression and appropriateness to behavior or reported mood

Abnormal Respiration Patterns - tachypnea

Fast breathing, normal depth just fast. Greater than 18-20 range

Developmental competence - The pregnant women: Fat deposits

Fat deposits are laid down as maternal reserves for nursing baby - teeth, bones weaken if not get proper nutrition and too much can cause diabetes and high blood pressure

Adolescent preparation

Feedback that their body is healthy, Communicate with some care, Promote wellness

Why is the femoral artery not good for placement?

Femoral artery is a location of infection and bad hygiene so need to replace after 24 hours or take it out.

Apical pulse is found where?

Fifth intercostal mid clavicular line

First level priority

First level: life threatening/emergent/ABC's(establishing an airway or supporting breathing)

Mouth

First part of the digestive system, airway for respiratory system - oral cavity has hard and soft tissue(palate, cheek, tongue, salivary gland)

APGAR score

First respiratory assessment that is performed on a newborn and scored on what they look like - appearance, pulse, grimace, activity, respiration 1-5 min after birth

Macule vs Patch

Flat discoloration in skin - macule is small one cm or less freckle - patch is larger one that is greater than one cm

Cyst

Fluid filled sac under the skin can tap and feel the fluid, drain the cyst and it will usually refill compared to cutting it out

Spirituality

Focused on a connection of something larger than oneself and belief in transcendence

Baby's temperature in the rectum

For best results in babies and toddlers up to 3 years of age, take temp in rectum. Place in anus. This method is accurate and gives a quick reading of the baby's internal temperature. For infants and toddlers, be sure to use a rectal thermometer correctly. A rectal thermometer may accidentally poke a hole in the rectum.

Why is educating a patient on quadrants important?

For patient education, upper outer quadrant and axillary tail of Spence are the spots where most breast cancers arise - convenient map to describe clinical findings

What are you assessing for with the Six P's

For some type of arterial issue

Test Near Vision

For those who report increasing difficulty reading - test near vision with handheld vision screener with various sizes of print(Jaeger card)

Blood pressure

Force of blood pushing against the side of its container

Developmental Competence: The aging adult - Hair matrix

Functioning melanocytes decrease, leading to gray fine hair(usually on head then coarser and gray in other spots)

Abnormal findings: tympanic membrane - fungal infection(otomycosis)

Fungi in ear and needs antibiotics

The RNs first assessment is the?

General Survey. This is a high frequency assessment as the RN performs a general survey with each client encounter.

Epidermis

Gives color and ridgidness

Waist to Hip Ratio gives what information?

Gives general health information and risk assessment for diseases like diabetes

CN IX

Glossopharyngeal Nerve taste and touch from tongue; control of a pharynx muscle

Which piece of legislation mandated the establishment of a joint Health Care Fraud and Abuse Control program?

HIPPA

Clergy visits

HIPPA allows as long as patients approve of it, the person has to have closure of this information unless a patient has restricted this - if patient cant agree or object the disclosure may be made if they have indicated before

Vistors

HIPPA does not reject visitors unless patient has rejected - clergy can ask for religious affiliation without names if patient has given it

Abnormal Hair Conditions - Traction alopecia

Hair loss that is the result of prolonged, tightly pulled hairstyles

What is a pneumothorax?

Happens when there is air or gas in the parietal space between the lungs and the chest wall which causes the lungs to collapse

Nails

Hard plates of keratin on dorsal edges of fingers and toes

Hearing loss Questions: Every had any trouble hearing? Character

Has all your hearing decreased or just on hearing certain sounds?

high oncotic pressure from plasma proteins

Has to do with pressure and pulling power that plasma proteins have - to big to be pushed out of arterioles but can be pushed into venules, pulling power to where fluid can be pulled back into vessels

Kussmaul

Have rapid breathing and will be irregular shallow. - diabetic ketoacidosis

What do you have to do for orthostatic hypotension?

Have the client in supine, sitting, and standing position for 3-5 minutes before taking heart rate and blood pressure again.

Additional history for aging adults questions

Have you noticed any visual difficulty with climbing stairs or driving? any problem with night vision? when was last time tested for glaucoma? any aching pain around eyes? any loss of peripheral vision? if you have glaucoma, how do you manage your eyedrops? if there history of cataracts? any loss or progressive blurring of vision? do your eyes every feel dry or burning? what do you do for this? any decrease in usual activities, such as reading or sewing?

Sternomastoid enables

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

During fetal period, head growth predominates:

Head size is greater than chest circumference at birth and reaches 90% of final size at 6 years old

Healthly vs abnormal costal angle

Healhy people have a less than 90 degree costal angle. Someone with enphazema or overinflation of lungs the costal angle is increased

Cardiac output is an indicator of?

Heart function - dependent on metabolic demand - normal adult 4-6L/min(average 5L/min)

Abnormal Conditions of the Nails - Splinter hemorrhages

Hemorrhages caused by trauma or injury to the nail bed that damage the capillaries and allow small amounts of blood flow.

Signs of health care fraud

Higher than average numbers of patient encounters, diagnostic tests and procedures, fees for service, patients from distant locations, prescriptions for certain drugs

Nystagmus test

Horizontal gaze eye test used for testing sobriety levels.

Patient-Centered Care Questions

How do you clean your ears? Last time you had your hearing checked?

Hearing loss Questions: Every had any trouble hearing? Coping strategies:

How does loss affect your daily life? Any job problems? Feelings of embarrassment or frustration? How do your family and friends react?

ABG is the most accurate way to know?

How much oxygen is in the blood - more accurate than pulse oximeter

Subjective data questions: mouth and throat - Patient-centered care

How often do you use a toothbrush and floss? last dental exam? do dental problems affect which foods you eat? do you have a dental appliance: braces, bridge, headgear? do you wear dentures? all of the time? how long have you had this set? how do they fit? any sores or irritation on the palate or gums?

Why are fluids in interstitial spaces?

Hydrostatic pressure in arterioles(extra force). To much force for veins to take - w/o = edema

Health Promotion and Patient Teaching - Blood pressure control

Hypertension is often silent killer - educate patient on checking BP and what numbers are warning signs

CN XII

Hypoglossal Nerve tongue movement

Teach Back Examples

I want to make sure I gave you the correct referral information. Could you let me know what you will do when you get home?

DVT Prevention

If a patient has vessel damage, hypercoaguability, stasis - early mobilization - hydration - medications - compression stockings, SCDs

Why would it be important to assess last menstrual cycle as part of the "breast history questions?"

If there are concerns with the breasts, those symptoms or concerns could be associated with the menstrual cycle, therefore, you need to know when the last period was to factor out some possibly abnormal findings.

Culture and genetics: PAD and CAD

If you have PAD(peripheral), you're at risk for CAD(coronary) = essential to screen and treat

Lymphatics forms a major part of the?

Immune system that defends body against disease - detects and gets rid(infection or foreign body)

Abnormal inspection - position

In a tripod position commonly seen in acute and chronic lung problems

You can only place an IV catheter in?

In a vein because it is returning to the heart - never in artery or in valve - find vein, occlude the vein, push blood out, where it backflows that is the vein

thyroid gland has two lobes connected?

In middle by a thin isthmus and above that by the cricoid cartilage or upper tracheal ring

Infants and children eyelids and lashes - setting-sun

In newborns, setting-sun sign common; eyes appear to deviate down with white rim of sclera visible over iris

With infant how to take vital signs?

In opposite order

Hearing loss Questions: Every had any trouble hearing? Other questions

In what situations do you notice loss: conversations, using telephone, listening to TV, at a party? Do people seem to shout at you? Do ordinary sounds seem hollow, as if you are hearing in a barrel or under water? Have you recently traveled by airplane? Do you have a family history of hearing loss?

Blood viscosity

Increase viscosity(increased hematocrit in polycythemia)

Moro reflex

Infant reflex where a baby will startle in response to a loud sound or sudden movement.

Pain differences

Infants have the same capacity for pain as adults, but we measure different for the ages, and the cognitive processes are different for those who can rate it and those who cannot understand it. Gender differences also affects it and cultural and genetic differences.

Physical examination: Infants and children - Neck - children have a higher incidence of?

Infection, so you will expect a greater incidence of inflammatory adenopathy; no other mass should occur in the neck

Dental caries

Infectious process leading to tooth decay due to interaction of bacteria is on the rise

Abnormal Findings: Lesions on the eyelids - blepharitis

Inflammation of the eyelids, staph infection, burning, itching, pain, tearing, foreign body sensation, dermatitis, no antibiotic

Abnormal Findings: Lesions on the eyelids - Dacryocystitis

Inflammation of the lacrimal sac

What information does palpation of pulse provide?

Info about the heart and the quality of the artery

What prevention steps can you take or educate your patient's parents about burns, skin lesions/illnesses, and safety?

Informing patient's parents about effects of too much skin exposure is crucial for the child's safety. Steps I can take to inform these individuals of risks include doing a universal skin cancer screening, regarldess of age. Explaining to the parents why we do skin screenings. Teaching ways to avoid sun exposure which would minimize risk of lesions and illnesses. Like wearing SPF 30+, seeking shade, wearing hats, limiting time outside.

Skin has two layers - dermis

Inner supportive layer - connective tissue or collagen - elastic tissue

Heart Structures - Layers - Endocardium

Innermost layer

fine crackles

Inspiration - high pitched, crackling sound(fire crackling)

Drug diversion can be defined as the:

Intentional misuse of a drug intended for medical purposes and recreational use of a prescription or a scheduled drug

Nurse is reviewing venous blood patterns. Which of these statements best describes that mechanisms by which venous blood returns to the heart?

Intraluminal valves ensure unidirectional flow towards the heart.

Rhythm

Is it regular(boom boom boom boom), is it irregular, what fingers are you using, do not use thumb because of your own pulse.

What is the lymphatic system a major part of the immune system?

It detects and eliminates foreign substances from the body

Anterior landmarks - suprasternal notch

It is a common landmark on the anterior chest which is a hollow U-shaped depression that is between the clavicles - where the first part of the sternum starts(manubrium)

Broken nose?

It may swell and have hematoma. can they breath out of both sides? are they breathing normally and in a normal pattern?

Jittery Movements

Jitteriness most commonly occurs in well appearing infant on the first day of life. Most common cause is hypoglycemia so any baby with this kind of activity on exam should have glucose level checked.

Abnormal Hair Conditions - AIDS-related Kaposi Sarcoma: Patch Stage

Kaposi sarcoma (KS) is a vascular tumor and is the most common tumor in HIV-infected persons. Considered an AIDS-defining illness, KS can occur at any stage of HIV infection. Here multiple patch-stage early lesions are faint pink on the temple and beard area. They easily could be mistaken for bruises or nevi and be ignored.

Triple negative breast cancer

Kind of breast cancer that does not have any of the receptors that are commonly found in breast cancer. - estrogen, progesterone, HER2

Anterior landmarks - sternum

Known as the breastbone and it is the center of the anterior chest

ADDITIONAL THINGS TO DO

LOOK OVER TEXTBOOK AND REVIEW GUIDES

Abnormal findings: ear canal abnormalities - furuncle

Large painful red infected hair follicle

Patient Centered Care questions

Last vision test? ever tested for color? any environmental conditions at home or at work that may affect your eyes? If so, do you wear goggles to protect your eyes? What medications are you taking? systemic or topical? any specifically for eyes? do you smoke? if you have experienced vision loss, how do you cope? do you have books with large print, books on audio tape, braille? do you maintain living environment the same? do you sometimes fear complete loss of vision?

Health Promotion and Patient Teaching - Cholesterol control

Late 30s or 40s is when screening begins and how it may cause coronary artery disease. - how often and what they mean and what to d(diet changes, exercise)

Where is the location for dorsalis pedis pulse?

Lateral to the extensor tendon of the great toe

Diagnostic Positions test

Leading patient through six cardinal positions of gaze: - follow movement of penlight or object proceeding clockwise - assess for potential EOM muscle weakness, nystagmus, or lid lag

5 areas for listening to the heart - Pulmonic

Left 2nd intercostal space - pulmonary valve closure

5 areas for listening to the heart - mitral

Left 5th intercostal, medial to midclavicular line

What is on either side of the mediastinum and contain the lungs?

Left and right pleural cavities

Where does a cardiac catheter go into?

Left side artery to go to left side of the heart - puts at risk for bleeding

Temperature in aging adults

Less reliable due to hypothermia and decreased sweat gland activity

Postnasal drip

Less swelling, see the postnasal drip

Zosteriform

Linear arrangement following a unilateral nerve route(goes with dermatome)

Nasal cavity

Lined by mucous cells that have lyzozymes which kill bacteria and trap debris forming boogers.

increased incidence of oral cancers

Linked to HPV and changes in sexual norms

Complications r/t periodontal disease

Linked to type 2 diabetes

Common skin lesions - labial herpes simplex

Lips, HSV 1, cold sores - can pass HSV 1 to genitals

Assessment

List of diagnoses/differential diagnoses

Abnormal findings: Lumps and Lesions on External Ear - tophi

Little pieces of uric acid that you can see on boarders on ear, may be from gout

Abnormal percussion - adolectasis

Lobe has collapsed so in that area you will hear a dull note because dont have airflow like you typically would

Aortic artery disease(aneurysms)

Localized dilation of an artery. Forms when the middle layer of the artery is weakened and produces a stretching effect on the inner and outer layers - diameter of artery can be enlarged to at least 2x's the normal circumference

Related organs - thymus

Located behind sternum above mediastinum - inflammatory response and filters things - after puberty it shrinks and replaced by fat. During growth it is important because involved in development in disease fighting cells

Carotid artery pulse

Located in the groove between the trachea and the sternomastoid muscle - never check both at the same time

achondroplastic dwarfism

Long bones stop growing in childhood Normal torso, short limbs Failure of cartilage growth in metaphysis Spontaneous mutation produces mutant dominant allele

Order of preparing eardrum

Look first with otoscope, irrigate, then relook to make sure eardrum is intact and there is no irritation or bleeding to that skin

Precordium Inspection and Palpation - Pulsations

Look over chest to look for pulsations especially the apical pulse

When looking for accommodation what are you looking for?

Looking for lens changing shape from distance to up close.

Illness

Loss of a person's balance - within one's being: physical, mental, spiritual - in outside world: natural, communal, metaphysical

5 areas for listening to the heart - Tricuspid

Lower left sternal border 4th intercostal

Fourth function of the respiratory system

Maintains heat exchange(not very important in humans, think about dogs panting)

Third function of the respiratory system

Maintains homeostasis in the body by balancing acid and base in arterial blood

Posterior assessment - inspection: Skin color

Make sure it matches the patients genetic background, look for scars, lesions, uneven pigmentation

What is the recommended guideline that men and women should follow in regard to limiting the amount of drinks consumed per day?

Males: 2 a day Females: 1 a day

What amount of alcohol consumed by men and women in a single setting is considered binge drinking?

Males: 5+ drinks Females: 4+ drinks

What is the best test to find breast cancer early?

Mammograms

The sternum is made up of what three sections?

Manubrium, body, and xiphoid process - doing CPR do not press process because will break and puncture liver or spleen

Aging women breasts - nipples

May be retracted but can be pulled outward

Preschool position

May hold by caregiver or sit on table

Physical examination: temporal arteries

May look twisted and prominent

Aging adult ocular structures - eyebrows

May show loss of outer one third to one half of hair because of decrease in hair follicles; remaining brow hair is coarse

Tuning Fork Tests

Measure hearing air conduction or by bone conduction, in which sound vibrates through cranial bones to the inner ear

head circumference

Measure infant's head circumference at birth and at each well visit up to age 2 years and then yearly up to 6 years Circle tape around head at prominent frontal and occipital bones; widest span is correct. Compare infant's head size with that expected for age.

Health-Related Behaviors affected by Religion

Meditating Exercising/physical fitness Sleep habits Vaccinations Willingness to undergo physical examination Pilgrimage Truthfulness about how patient feels Maintenance of family viability Hoping for recovery Coping with stress Genetic screening and counseling Living with a disability Caring for children Fasting

Patterns of alcohol use - moderate drinking

Men - less than 2 a day Women - less than 1 a day

Capillaries

Microscopic vessel through which exchanges take place between carbon dioxide and oxygen - waste product is carbon dioxide or carbonic acid from body processes

The RN is caring for client who had an ABI. the brachial finding for left arm was 160 and the ankle finding for the left leg was 130. These findings suggest?

Mild(some) peripheral artery disease

Aging adults developmental competence - Dysrhythmias are?

More common in aging adults - CAD and cardiac related deaths incidence increases with age

Scar

More permanent due to break in the skin and the fabric tissues are coming together to heal it.

Abnormal Findings: Pediatrics - Down syndrome

Most common chromosomal abnormality with characteristic facial abnormalities - upslanting eyes - flat nasal bridge and small, broad nose - protruding thick tongue and ear dysplasia - broad beck with webbing and small hands with single palmar crease

in 2012, over 21% of Americans over 5 years of age speak a language other than English in their homes

Most common non-english language is spanish

Contact

Most frequent mode of transmission of health care associated infections and can be divided into direct and indirect

Muddy brown sclera

Mostly only elderly African Americans

How if RN practice guided by law?

NC Nurse Practice Act

Two client identifiers

Name and DOB

Opiods antidote

Narcan/Naloxone

Gastrointestinal pain

Nausea, vomiting

FLACC

Neonatal and less than or equal to 3 y/o · Face, legs, activity, cry, consolability · Each category is scored 0-2, scores are added · Total score range: 0-10

Cries

Neonatal post op. Crying, increase in oxygen requirement from baseline, increase in vital sings from baseline, expression on face, sleeping

Infants and children conjunctiva

Newborn may have transient chemical conjunctivitis from instillation of silver nitrate; appears within 1 hours and lasts nor more than 24 hours after birth

Direction of drainage patterns of lymph nodes

Nodes abnormal - check area they drain for source of problem Explore area proximal (upstream) to location of abnormal node - flows down from the face and up from the neck

Abnormal Findings: Lesions on the eyelids - Chalazion

Nodule that is on the inside of the eyelid, not painful, lasts longer, compress, can turn into stie

Physical examination: In some aging adults, a mild rhythmic tremor of head may be?

Normal - senile tremors are benign and include head nodding and tongue protrusion

If women have different tanner staging for hair and breasts?

Normal - breasts develop sooner

Tanner 2 breasts, tanner 1 genitalia, growing and developing normally

Normal deviation which is benign, breast development is early, reassurance is needed

With preschooler how to take vital signs?

Normal fear of body mutilation increased with any invasive procedure(no rectal) and want reverse order. Have to show them on your finger.

When performing respiratory assessment on adult, note costal angle of 80 degrees.

Normal finding

When performing an assessment on a 3 y/o, note childs chest is cylindrical in shape and is using abdominal muscles.

Normal findings

Child height and weight recorded at every health care visit to determine

Normal growth patterns.

External nose appearance

Normally nose is symmetric, in midline, and in proportion to other facial features - inspect for any deformity, asymmetry, inflammation, or skin lesions

Decrease risk of CVD

Not smoking, active, healthy weight, healthy diet

NPO

Nothing by oral route. Which means we will not bring them a breakfast trey because they have disease process or procedure coming up.

Abnormal findings: Visual Field Loss

Notice any loss, refer, help with ADLs, set up their lunch and tell them where it is all at(milk is at 2:00), stand where they can see you

Common skin lesions - Herpes zoster(shingles)

Numbness or tingling neurological pain before getting the rash, get vesicles or target which move into a crusty - cant pass shingles but if that person has never had chicken pox they can get chicken pox , can be detrimental to pregnant woman's baby, stress

Why does it take 17 years for research to be implemented into practice?

Nurses lack research skills, are isolated from those knowledgeable, do not have time, lack confidence

Physical examination: Infants and children - head and neck control

Observe for appearance of tonic neck reflex which disappears between 3 and 4 months of age - tummy time

Abnormal Findings: Pediatrics - hydrocephalus

Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head

Otitis Media

Obstruction of eutachian tube or passage of nasopharyngeal secretions into middle ear - one of the most common illnesses in children

Abnormal palpation - Subcutaneous emphysema(krepadis/tissue emphysema)

Occurs when air gets trapped underneath skin and as moved into the tissue - chest or neck area most common - result of surgery, trauma, injury to thoracic cavity or facial bones. Feels like it is made of air.

Cranial Nerve III

Oculomotor eyelid elevation, pupil constriction and accommodation

A patient feels his privacy has been violated and wants to file a formal complaint. Through which of the following agencies should the nurse instruct the patient to file the complaint?

Office of Civil Rights

Which of the following agencies of the US government has the authority to exclude individuals and entities from participating in federal health care programs?

Office of inspector general

Usual dosages for means by mouth - opiods

Often combined with Tylenol. This combination can lead to liver damage related to Tylenol overdose.

Cranial Nerve I

Olfactory - ask about any changes to sense of smell

Results of height and weight are plotted?

On growth charts based on data from National Center for Health Statistics

Cardiac cycle is?

One heartbeat(lub and dub)

Pupil Abnormalities - Monocular blindness

One sided blindness

Cranial Nerve II

Optic Nerve - see if eyes dilate

Religion and Spirituality

Organized system of beliefs versus individual's unique experience

Abnormal findings: ear canal abnormalities - osteoma

Ossification looking like single stone hard nodules that affect the eardrum

Abnormalities of external ear: Cellulitis

Otitis externa or media has spread to surrounding tissue and given that skin an infection

Skin has two layers - epidermis

Outer highly differentiated layer - basal cell layer forms new skin cells - outer horny cell layer of dead keratinized cells

Nails are a good indication of what?

Overall health, can indicate if something is going on like lupus, cardiac disease, anemia

Abnormal findings: tympanic membrane - cholesteatoma

Overgrowth of epidermal tissue that grows over middle ear or temporal bone, can erode the bone so need to refer

Parts of an EKG?

P wave, PR segment, QRS complex, ST segment, T wave, U wave, PR interval, QT interval

Use an observational tool such as

PAINAD to measure the presence of pain

Six P's of Arterial Insufficiency

Pain Pallor Pulselessness(faint or gone) Paresthesia(arm falling asleep) Paralysis Poikilothermia (coolness)

Define pain

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of damage. Pain is subjective thus a careful assessment and evaluation is needed.

Nursing Diagnosis - Alteration in comfort,

Pain r/t surgical procedure as evidenced by... Pain r/t chronic back pain as evidenced by...

breakthrough pain

Pain that occurs between doses of pain medication

Somatic pain

Pain that originates from skeletal muscles, ligaments, or joints.

Herpes Zoster Oticus (Ramsay Hunt Syndrome)

Painful chicken pox or shingles-like rash involving the pinna and ear canal Viral infection typically occurs in adults Can cause SNHL, vertigo and facial palsy

Physical examination: Infants and children - Neck - During infancy, cervical lymph nodes are not?

Palpable normally, but child's lymph nodes are palpable - palpable nodes less than 3 mm are normal

Posterior Assessment - Palpation: Tactile fremitus

Palpable vibration when speaking - either use palm of fingers or ulnar side of hands - side to side or bilateral at the same time - get patient to say ninety nine - avoid scapula area

Inspection and Palpation of the Neck: Lymph nodes

Palpate nodes noting location, size, shape, delimitation, mobility, consistency, and tenderness - slow, circular motion

Inspection and Palpation of the Skull: temporal area

Palpate temporal artery above zygomatic(cheek) bone between each eye and top of ear

Course of veins?

Parallel to arteries, bur direction of blood flow is opposite

Abnormal findings: extraocular muscle dysfunction - Diagnostic positions test

Paralysis indicates cranial nerve dysfunction

A client reports having difficulty breathing in supine position and requires two or three pillows to breathe comfortably. What is this consistent with?

Paroxysmal noctural dyspnea

Subjective Data Health History Questions

Past history of skin disease, allergies, hives, psoriasis, or eczema? Change in pigmentation or color, size, shape, tenderness? Change in mole(size or color?) Excessive dryness or moisture? Pruritus or skin itching? Excessive bruising? Rash or lesions? Medications: prescription and over-the-counter? Hair loss? Change in nails' shape, color, or brittleness? Environmental or occupational hazards? Patient Centered care?

Abnormal Hair Conditions - Toxic Alopecia

Patchy, asymmetric balding that accompanies severe illness or use of chemotherapy where growing hairs are lost and resting hairs are spared. Regrowth occurs after illness or discontinuation of toxin.

Acute Behavior

Patient isnt used to, short term and self limiting, stops once healed - Guarding - Grimacing - Vocalization - Agitation - Restlessness - Stillness - Diaphoresis - Vital Sign Change

Teach Back

Patients have to state to you in their own words what you were saying - doctors teach in too much detail - ensures patient education - validates patient clear understanding and show us how well we gave the info

Self-report

Patients unable to understand instructions and point or verbalize(most reliable)

Do not irrigate if history or exam suggests?

Perforation or infection

Posterior Assessment - Palpation: Symmetric expansion

Place thumbs along spinal column where the bottom of the ribs are so you can feel if both sides are expanding symmetrically

Health Assessment

Plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.

Objective Data Preparation

Position sitting up straight with head and eye level

Abnormal Findings: Pediatrics - Plagiocephaly

Positional or deformational due to sleeping position

Culturally sensitive

Possessing basic knowledge of and constructive attitudes toward diverse cultural populations

Abnormal Findings: Pediatrics - Craniosynostosis

Premature closing of one or more cranial sutures that leads to head malformation

A nurse is examining lymphatic system of a healthy 3 year old. Which finding is within normal limits for this child.

Presence of palpable lymph nodes

Why would someone have jugular vein distention?

Pressure in right atrium is increased from more fluid. Increased central venous pressure = fluid volume overload - fluid starts to back up.

What is communication?

Process of sending and receiving messages through verbal and nonverbal means

Related Organs - Tonsils(palatine, adenoid, and lingual)

Produce local inflammation when something is going on in that region

Anti-kickback Statute

Prohibits offering, paying, soliciting or receiving anything of value to induce or reward referrals or generate federal healthcare program business.

Stark Law

Prohibits physicians or their family members who own health care facilities from referring patients to those entities if the federal government, under Medicare or Medicaid, will pay for treatment.

Lichenification

Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen)

ABCDEF Skin Assessment

Promoting health and self-care - teach skin self exam using this rule to detect suspicious lesions - asymmetry - border irregularity - color variations - diameter greater than 6mm - elevation or evolution - funny looking - different from others

SBAR - Background

Provide pertinent history as it directly relates to patient's current health status

Developmental Competence - Birth

Puberty inverted nipple, flat, no alveoli

Arteries

Pump oxygenated blood to all body tissues - strong walls to withstand HIGH pressure system - smaller than veins - walls of arteries are thicker than veins

Heart structures - Chambers - left ventricle

Pumps oxygenated blood to the rest of the body

Review of systems

Purpose of this section are to evaluate the past and present health state of each body system, to double-check in case of any significant data were omitted in the Present Illness section, roughly head to toe.

Abuse Assessment Screen (AAS)

Questions that measure the amount of violence in pt's life - introduce the topic before giving the screening instrument to make them trust you - "because domestic violence is so common in our society, we are asking all patients the following questions"

Physical examination: Infants and children - Assess muscle development with gentle passive?

ROM - cradle infant's head with your hands and turn it side to side and test forward flexion, extension, and rotation - note resistance to movement, especially flexion

Physical examination: aging adult - maintain patient safety by indicating patient peform

ROM and position changes slowly - minimize potential for dizziness

Papule vs Plaque

Raised and elevated - papule is raised but very small and in superficial thickening of epidermis - plaque is multiple papules together so much larger

Nodule vs Tumor

Raised large lesions, hard or soft - soft nodule or hard nodule and does it move around(that would be cyst). Nodule is 1cm or less - tumor is much larger and goes down to dermis

Vesicle vs Bulla

Raised lesion and clear fluid filled - vesicle is 1mm or less or single blister - bulla is 1cm or less single blister that is large. Deeper than vesicle

Common skin lesions - Psoriasis

Raised red scaley to it, can be white and plaque like, knees, elbow, lower back

What is the difference between rectal and oral thermometers?

Red is rectal, blue is oral. - probe of rectal is smaller - oral thermometer to take axillary, but rectal is only for rectal

sucking reflex

Reflex that causes a newborn to make sucking motions when a finger or nipple if placed in the mouth

Second function of the respiratory system

Removes carbon dioxide from the body, which is a waste product of energy reactions at the cellular level

Target or Iris

Resembles iris of eyes, concentric rings(bullseye rash - tic bite)

shallow respirations

Respirations characterized by little movement of the chest wall (reduced tidal volume) or poor chest excursion.

The Aging Adult Ocular Fundus

Retinal structures generally have less shine; blood vessels look paler, narrower, and attenuated; arterioles appear paler and straighter, with a narrower light reflex Drusen, or benign degenerative hyaline deposits, are normal development on retinal surface Often symmetrically placed in eyes with no effect on vision

Routine audits

Reviewing and analyzing data of security procedures and activities as in integral part of continual security awareness.

5 areas for listening to the heart - aortic

Right 2nd intercostal space - aortic valve closure

What is the difference with the right and left bronchi?

Right main bronchus is where most people get pneumonia because it is more vertical than the left and easier for food and fluid to pass there

Skull

Rigid box that protects the brain - includes bones of cranium and face - supported by cervical vertebra

Abnormal Hair Conditions - Tinea Capitis (Scalp Ringworm)

Rounded, patchy hair loss on scalp, leaving broken-off hairs, pustules, and scales on skin. Caused by fungal infection; lesions may fluoresce blue-green under Wood's light. Usually seen in children and farmers; highly contagious; may be transmitted by another person, by domestic animals, or from soil.

5 areas for listening to the heart - Erb's point

S1, S2 - left 3rd intercostal space

Lactrimal apparatus check by pressing finger against?

Sac, just inside lower orbital rim, not against side of the nose - pressure will slightly evert lower lid, but there should be no other response to pressure

Laying for an infant is the --- position.

Safest.

Infants pain

Same capacity as pain as adults. Inhibitory neurotransmitters are insufficient until birth at full term. Therefore the preterm infant is rendered more sensitive to painful stimuli. Preverbal infants are at risk for undertreatment of pain.

CIWA

Scale measuring objective data related to withdrawal of patient - vital signs(Similar to pain) - ox sat - sweating - agitation

Common skin lesions - Tinea corporis(ringworm of the body)

Scale, inside that is white and very red border, contagious

Color Analog Scale

Score recorded in centimeters(0-10)

Visual Analog Scale

Score recorded in centimeters(0-10) - no pain, worst possible pain no numbers

Linear

Scratch, streak, line or stripe(poison ivy)

Abnormal findings: tympanic membrane - retracted drum

See more bones than supposed to

Posterior thoracic landmarks - the inferior border of the scapula

See the inferior border protruding. Do not listen over scapula because wont hear anything. Listen in intercostal spaces on both sides of spine until you get below scapula you can go laterally. Anterior, posterior, laterally.

race and ethnicity

Self-identification and social group

Developmental Competence - Tanner Staging

Sexual maturity rating 1 - preadolescence: small elevated nipple 2 - breast bud stage: small amount of nipple and breast and alveoli widen 3 - breast enlarge and nipple is flush with breast surface 4 - nipple forms secondary mound 5 - mature: nipple protrudes(tanner stage)

Malignant skin lesions - Squamous cell carcinoma

Sharp margins, one cm or more, central ulceration and redness - stay out of sun - skin protection

Whispered voice test step two

Shield your lips so the person cannot compensate for a hearing loss(consciously or unconsiously) by lip reading or using the "good" ear

SMAST-G

Short Michigan Alcohol Screening Test - Geriatric Version - yes/no questions to address aging adults' specific emotional and physical reactions to drinking any amount of alcohol

Why do people get shorter with age?

Shortening in spinal column, thinning of vertebral disks, shortening of individual vertebrae, and kyphosis, and slight flexion in knees and hips.

Biots

Similar to Cheyne stokes but more irregular and seen with head injuries and traumas, heat stroke, etc.

Additional Health History Questions - adolescents

Skin problems such as pimples, blackheads?

What side should a pregnant women sleep on?

Sleep on the left side because the heart is on the left side making the hearts pumping action easier and keeps uterus off the liver

Abnormal respiratory patterns - bradypnea

Slower respirations than 10-12 range

Culture and Genetics: PAD - environmental factors

Smoking, diabetes, hypertension, total levels of cholesterol and obesity, and genetics

Abnormal findings: ear canal abnormalities - exostosis

Soft bony hard nodules that can cover the epithelium, impairs hearing

New Learning

Specific test that validates memory - pick 4 words and ask them to remember them, ask them to recall the 4 words later

Common skin lesions in children - Impetigo

Staff or strep infection on skin that gives honey colored crust. Vesicles to a crusty top to it. Contagious

Abnormal findings: Opacities in the lens - star-shaped opacity - cortical cataract

Star shaped, rapid and progressing

SBAR - Assessment

State pertinent assessment findings obtained with interpretation of data. Your clinical evaluation

SBAR - Recommendation or Request

State what you need or want for the patient in terms of medical treatment and/or assistance. Your interpretation and solution

Abnormal findings: extraocular muscle dysfunction - asymmetric corneal light reflex

Strabismus - esotropia: inward turning of eye - exotropia: outward turning of eye

thyroid - Endocrine gland

Straddles trachea in middle of the neck

Grasp Reflex Foot

Stroking middle of foot will make the babys toes curl under

Pain Assessment "OPQRSTU"

Subjective Assessment(SOAP)

Nurses on a clinical unit wish to research the incidence of falls among patients following joint replacement surgery. Which of the following should they do to ensure the study complies with the HIPAA Privacy Rules?

Submit their proposal to the institutional review board for review and describe how they will de-identify patient information

Precordium Inspection and Palpation - Apical Impulse

Supine or on left side 4th or 5th intercostal space mid clavicular line

Eyes - External Anatomy: bony orbital cavity

Surrounded by cushion of fat that protects the eye

Heart Structures - Layers - Parietal pericardium

Surrounds the pericardial cavity and is a tough fibrous layer

Extra Heart Sounds - Murmurs

Swooshing sound heart on the chest wall. Conditions cause blood flow to be more turbulent - may be benign - blood flow increases, viscosity decreases, structural defect

Abnormal Hair Conditions - Folliculitis barbae

Synonym tinea barbae. Also known as barbers itch, inflammation of the hair follicles caused by a bacterial infection from ingrown hairs. The cause is typically from ingrown hairs due to shaving or other epilation methods.

Blood pressure in aging adults

Systolic may be lower

Neck vessels - auscultate carotid artery

Take a breath and exhale and hold - 3 spots

When should serial blood pressure be taken?

Take serial measurements when you suspect volume depletion, when the person is known to have hypertension or is taking antihypertensive medications, or when the person reports fainting or syncope.

Places where you can take pulse?

Temporal artery, facial artery, carotid artery, brachial artery, radial artery, femoral artery, popliteal artery, posterior tibial artery, dorsalis pedis artery

whispered voice test step one

Test one ear at a time while masking hearing in other ear by placing one finger on tragus and rapidly pushing it in and our of auditory meatus

The adolescent health history

The HEEADSSS method of interviewing focuses on assessment of the Home environment, Education and employment, Eating, peer related Activities, Drugs, Sexuality, Suicide and depression, and Safety from injury and violence.

If a client scores 0 on the CRAFFT, what additional services need to be rendered?

The administrator of the CRAFFT should still provide brief advice or provide praise and encouragement

Mobility wise in the hospital, how would an adult stand on the weight?

The bed can weigh the patient. But pillows and clothing can affect it so have to 0 it out.

The angle of louis is where?

The bronchi bifurcate into the left and right stem main bronchi

atherosclerotic plaque

The cholesterol-rich material that is deposited in the arteries of individuals with atherosclerosis. It consists of cholesterol, smooth muscle cells, fibrous tissue, and eventually calcium. - platelets prevent total blockage of artery

If you have atherosclerosis which is causing PAD,

The fat buildup wont be specific and will happen throughout body so need to screen for cardiovascular disease if have PAD

Which two types of questions should be asked for pre-screening and screening all young adults?

The friend and C or CAR questions

How do we assess pain?

The kid-friendly basics: - Speak calmly and gently - Get down on their level - Use the child's name - Ask the parents to remain calm - Physical exam and pain scores

Neuropathic Pain

The nerve fibers themselves may be damaged, dysfunctional, or injured. These damaged nerve fibers send incorrect signals to other pain centers. Falling asleep on arm, hitting funny bone. Hot and cold, numbing. A small neuropathic pain or stimulus can cause significant pain

Transmission

The pain impulse moves from the spinal cord to the brain

What is the difference between the right and left lung?

The right lung has 3 lobes and the left lung only has 2. - left only has superior and inferior lobe

Follow-Up Database

The status of any identified problems should be evaluated at regular and appropriate intervals. This type of database is used in all settings to follow up both short term and chronic health problems.

Client that has strained trapezius muscle, and now complaining of shortness of breath. Why would this be?

The strained muscle is an assessory muscle of respirations

Why is it important for health care providers to be familiar with the CRAFFT model?

The structured screening device would most likely improve identification of adolescents with substance related pathology

If there is a tracheal shift?

The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax. The trachea is pulled toward the affected side with large atelectasis, pleural adhesions, or fibrosis

Respiratory dead space

The volume of a breath that does not participate in gas exchange. This is about 150 cc of air in an adult

cardiac output

The volume of blood ejected from the left side of the heart in one minute.

Neuropathy Pain scale

There are several different aspects of pain which we are interested in measuring: pain sharpness, heat/cold, intensity, overall unpleasantness, and surface vs deep pain

Folk Healers

There are traditional treatments in folk healers that we may not see in our region

Why do nurses not perform fremitus test a lot?

There as to be gross change, a lot of change, a lot of consolidation

Abnormal findings: tympanic membrane - blue drum(hemotympanum)

There has been skull damage, need to go to ER

Crust

Thickened and dryed out exudate, scab crusty part of pustule drained

Heart Structures - Layers - Myocardium

Thickest layer

Emergency database

This is an urgent, rapid collection of crucial information and often is compiled concurrently with lifesaving measures. Diagnosis will be swift and sure.

Focused or Problem-Centered Database

This is for a limited or short term problem. Here you collect a "mini" database, smaller in scope and more targeted than the complete database. It concerns mainly one problem, one cue complex, or one body system. It is used in all settings.

Nociceptive Pain

This is the normal functioning nerve pattern, when the nerve is intact(transduction, transmission, perception, modulation). Typical type of pain.

Anterior landmarks - The Angle of Louis(the sternal angle)

This is where the manubrium meets the sternum. It is continuous with the second rib and is where you can start counting ribs

Pharynx

Throat - nasopharynx(soft palate and valve close when swallow) - oropharynx - laryngopharynx(larynx - voicebox)

thyroid gland synthesizes and secretes what?

Thyroxine(T4) and triiodothyronine(T3), which are hormones that stimulates rate of cellular metabolism

Structure and Function: Middle ear

Tiny filled cavity inside temporal bone - contains tiny ear bones: malleus, incus, and stapes

Structure and Function: Middle ear - several openings are present

To the outer and inner ear eustachian tube: opening that connects middle ear with nasopharynx and allows passage of air - normally closed, but opens with swallowing or yawning

Communicating with school age child

Tolerate and understands others viewpoints. Wnat to know how things work and why things are done.

New enginered body parts

Took cells out of lung and put it into chamber and let it grow and was made in the lab - take a long time(10-12) years on pigs then humans because dont know if it will do gas exchange - there is a synthetic trachea already

Eyes - External Anatomy: Conjunctiva

Transparent protective covering of the eye

What suture closes first on baby?

Triangle than diamond - use fontanel to help you determine developmental stages and hydration

CN V

Trigeminal general sensation chewing

Arm abnormalities - Raynaud phenomenon

Triggered by cold vibration or stress. - the arteries constrict and causes abnormal shape paleness(white, blue and red)

CN IV

Trochlear eye movement, superior oblique muscle

Gyrate

Twisted, coiled, or snakelike(not common)

Abnormal Facial Appearances - Stroke or brain attack

UMN lesion leading to paralysis of lower facial muscles

culturally competent

Understanding and attending to total context of patient's situation including the following: Immigration status Stress and social factors Cultural similarities and differences

Prebycusis is accentuated when?

Unfavorable background noise is present - gender and ethnic differences

Teeth may look slightly yellowed, but color is?

Uniform - yellowing results from dentin visible through worn enamel

S-creening

Universal screening for quickly assessing use and severity of alcohol; illicit drugs; and prescription drug use, misuse, and abuse

How to measure infant?

Until age 2, measure infant's body length supine by using a horizontal measuring board. Above age 2 can stand and take height. If adult cant stand you can measure height by laying on flat surface.

Eversion of the upper lid

Used when one suspects foreign body or eye pain

Clarification

Useful when person's word choice is ambiguous or confusing Summarize person's words, simplify the statement, and ensure that you are on the right track

Examining lymph nodes

Using a gentle circular motion of finger pads, palpate lymph nodes Beginning with preauricular lymph nodes in front of ear, palpate the 10 groups of lymph nodes in routine order Many nodes are closely packed, so you must be systematic and thorough in your examination Do not vary sequence or you may miss some small nodes

palpation of sinus areas

Using thumbs, press frontal sinuses by pressing up and under the eyebrows and over maxillary sinuses below cheekbones

Prebycusis onset

Usually occurs in 50s and slowly progresses - first notice a high frequency tone loss - ability to localize sound is impaired

Numeric/descriptive scales

VAS: Adults

CN X

Vagus -assess mouth for movement of soft palate and the gag reflex -assess swallowing and speech

Veins carry? Arteries carry?

Veins carry deoxygenated blood and arteries carry oxygenated blood - pulmonary is the exception

Cardiac Cycle: Systole

Ventricles contract Blood pushes against AV valves and they shut Blood pushes through open semilunar valves into aorta and pulmonary trunk

Cardiac Cycle: Diastole

Ventricles relaxed Blood entering atria Blood flows through AV valves into ventricles Semilunar valves are closed

Abnormal findings: tympanic membrane - bullous myringitis

Vesicle(blisters) on the eardrum from bacterial or viral infection, refer out and may cause permanent damage, pain

Developmental Competence Aging Adult: Arteriosclerosis

Vessels become more rigid with age - DP and PT pulses may become more difficult to find - changes associated with arterial insufficiencies

arteriosclerosis

Vessels become more rigid with age - related to age

CN VIII

Vestibulocochlear Sensory: equilibrium (vestibular portion) Hearing (cochlear portion)

Which of the following methods of information exchange is in compliance with HIPPA?

Walking rounds that involve two nurses discussing an assigned patient at his bedside in a private room

Communicating with older adult

Want to have a purpose, address by last name, be slow, like touch

Infants and children respirations

Watch infant's abdomen for movement

Posterior assessment - inspection: Position

Watch patient as take breath and make sure theyre relaxed and dont use extremities to support breathing

Abnormalities of external ear: Otitis externa(swimmers ear)

Water becomes trapped by a cyst, bone growths, earwax plugs or swelling caused by allergies.

Clinical

We learn from other nurses and other faculty health assessment practices in a hospital.

How to weigh infant?

Weigh infant on a platform-type balance scale

BMI calculation

Weight(lbs)/Height(inches) * 703

Lymphoid tissue

Well developed at birth and grows to adult size when the child is 6 y/o

Situation

What brought you here, what is your main health problem, who have you all seen today in the hospital?

Quality

What does it feel like? Can you describe it?(throbbing, stabbing, dull)

Recent Memory

What have you had to eat in 24 hours, when did you get to the hospital?

Subjective Questions: Earache - At home

What have you tried to relieve pain?

Ask Me 3

What is my main problem? What do I need to do? Why is it important for me to do this? - People who know the anwsers get better quicker, better manage conditions

Severity

What is the intensity(pain scale of 1-10, visual scales of the symptoms? Right now? At worst? Are there any other symptoms that accompany the pain? Pain scales

Cumulative violence

When a patient has experienced more than one violence - severe mental and physical health problems are associated with cumulative trauma from abuse

Asymmetric crying facies

When baby cries, the mouth is pulled downward on one side while not moving on the other side.

Protective reflex

When eyes and nose are covered with cloth the baby makes effort to push it away. Enables baby to breath while breastfeeding.

Cheyne Stokes

When people are nearing the end of life. Times when they will stop breathing rapid and shallow then no breathing.

Apex of the heart

When the heart contracts you can feel the contraction on the chest wall called the apical pulse - bottom of the heart

Place

Where are we, what hospital are we at

Posterior thoracic landmarks - the vertebra prominens

Where you can feel on your posterior neck the bony prominences(C7 and thoracic vertebra 1)

Infants and Children: Special Procedures - Percussion

With an infant you may directly percuss with your plexor finger against head surface - this yields resonant or "cracked pot" sound, which is normal before closure of fontanels

All individuals have varying amounts(red, yellow, brown)

With relative proportion affecting prevailing color. Also modified by thickness of skin and presence of edema(elderly have thinner skin so more pale) - genetically determined, environmental(where you live and what you eat)

Whispered voice test step three

With your head 1 to 2 feet from the persons ear, exhale and whisper slowly some two syllable words. Normally, the person repeats each word correctly after you say it

When do you measure infant blood pressure?

You dont, less than 2 years do not measure it. Unless right after birth or if there are problems

Observational or behavioral

Young or cognitively impaired patients(pre-verbal; unable to understand self-report scale)

hyoid bone

a U-shaped bone in the neck that supports the tongue.

rooting reflex

a baby's tendency, when touched on the cheek, to turn toward the touch, open the mouth, and search for the nipple

third degree burn

a burn involving all layers of the skin; characterized by the destruction of the epidermis and dermis, with damage or destruction of subcutaneous tissue. white to brown with dry leathery texture, no pain due to so deep - ER and elevation

Thrill is compared to what

a cat purr

It is important to catch any problem early because?

a child with hearing loss is at risk for delayed speech and social development and learning deficit

What is motivational interviewing?

a client-centered, method to encourage change within client

bifid uvula

a condition in which uvula is spit either completely or partially; occurs in 10% of some American Indian groups

incentive spirometer

a device used to force the client to concentrate on inspiration and promote full inflation of the lungs, while providing immediate feedback; used particularly after surgery and in lung disorders. - does not measure oxygenation just pulmonary function

Assess respirations for how long?

a full minute to look for irregularities - normally pulse and respiratory rates rise as a response to exercise or anxiety

flat affect

a lack of emotional responsiveness

Trachea

a large membranous tube reinforced by rings of cartilage, extending from the larynx to the bronchial tubes and conveying air to and from the lungs; the windpipe.

Resonance (percussion sound)

a low-pitched, hollow sound, usually heard over normal lung tissue

isthmus of thyroid

a narrow band of tissue that connects the two lobes of the thyroid gland

Baby's temperature on the forehead

a newer method to take temperature is called temporal artery thermometry. This is also very accurate. It measures the temperature of the blood flowing through the temporal artery, on the forehead. Less stressful to a newborn.

Erb's Palsy

a paralysis of the arm that most often occurs as an infant's head and neck are pulled toward the side at the same time as the shoulders pass through the birth canal

What is collaboration?

a partnership

visceral pain

a poorly localized, dull, or diffuse pain that arises from the abdominal organs, or viscera. originates from larger internal organs. Dull, deep, squeezing, or cramping. Pain can stem from direct injury to the organ or stretching of the organ from tumor, distention, or severe contraction. Ulcer pain, appendicitis. The pain impulse is transmitted by ascending nerve fibers along with nerve fibers of ANS.

Montgomery glands in breasts secrete?

a protective liquid material during lactation

Depression

a sadness and hopelessness that keeps a person from carrying out everyday activities

Glasgow Coma Scale (GCS)

a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints - eye opening response, verbal response, motor response

Darwin's tubercle

a small painless nodule at the helix; this is a congenital variation and not significant

podiatrist

a specialist in care for the feet

Delerium

a state of temporary but acute mental confusion,signs; anxiety, tremors, allucinations, delusions, attention problems, decline in level of conciousness, memory problems

arterial blood gases (ABGs)

a test performed on arterial blood to determine levels of oxygen, carbon dioxide, and other gases present - respiratory therapist normally does it - acidic or alkalotic(CO2 = acidic)

whispered pectoriloquy

a whispered phrase heard through the stethoscope that sounds faint and inaudible over normal lung tissue - abnormal would be clear - consolidation

Steps with physical exam are all the same except for?

abdominal exam

varicose veins

abnormally swollen, twisted veins with defective valves; most often seen in the legs - risk factor for venoustasis

Risk factors of otitis media

absence of breastfeeding in first 3 months of life, preterm birth, secondhand tobacco smoke exposure, daycare attendance, male sex, pacifier use, seasonality(fall and winter), and bottle-feeding

With cilia becoming coarse and stiff cerumen does what?

accumulate and oxidize which reduces hearing - cerumen is drier because of atrophy of apocrine glands - reversible cause of hearing loss

Oral temperature is?

accurate and convenient

Making a loud noise to 3-4 months

acoustic blink reflex, infant stops movement and appears to listen, halts sucking, quiets if crying, cries if quiet

Summary Checklist: Head, Face, and Neck, including regional lymphatics examination - Inspect and palpate the neck

active ROM, potential enlargement and position of trachea

Example of nursing diagnosis

acute pain related to decreased myocardial blood flow(chest pain/heart attack) as evidence by "stabbing" substernal pain radiating down left arm an dup to left side of the jaw, patient states pain is 9 out of 10, patient is diaphoretic, and patient is restless

Different classes based on

addiction and seriousness

Nose develops during?

adolescence, along with other secondary sex characteristics - this growth starts at 12-13, reaching full growth at age 16 in females and age 18 in males

Adults health promotion

advise to stay at moderate consumption

inappropriate affect

affect clearly discordant with content of person's speech

Vital signs are done differently depending on?

age

Glaucoma incidence increases with?

age - african americans 3 to 6 times more likely to develop than Caucasian Americans - primary angle glaucoma is leading cause of blindness in African Americans and Hispanics - family history increases risk

Pulse normally varies with?

age and gender

Why? HEENT - understanding changes in these body areas based on?

age or abnormalities is important to your nursing practice

What affects blood pressure?

age, weight, stress, motion, exercise, sex and race

Aging adult respirations

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

Sinuses

air-filled spaces in the skull that open into the nasal cavity - frontal, maxillary, ethmoid, sphenoid

Tools to assess alcohol and drug use - AUDIT

alcohol consumption, drinking behavior, adverse consequences

Opiods interactions with food/drink

alcohol exaggerates side effects

Abnormal percussion - emphysema

alveoli are ballooned out, overextended lung - should hear resonance but this causes hyper resonance

Diminished sense of taste and smell decreases

an aging persons interest in food and may contribute to malnutrition

PTSD

an anxiety disorder characterized by haunting memories, nightmares, social withdrawal, jumpy anxiety, and/or insomnia that lingers for four weeks or more after a traumatic experience

anorexia nervosa

an eating disorder in which an irrational fear of weight gain leads people to starve themselves

Ischemia

an inadequate oxygenated blood supply to an organ or part of the body, Caused by obstruction of that artery. - complete blockage tissue will die - partial will notice when exercising

Abnormal Hair Conditions - seborrheic dermatitis

an inflammation that causes scaling and itching of the upper layers of the skin or scalp

Critical thinking must be applied to achieve?

an interpretation

A sign

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

Psychiatric mental illness

an organic(brain) etiology has not yet been established (anxiety disorder or schizophrenia) - Do not know the cause like an organic disorder

How to calculate ABI

ankle pressure signal/brachial pressure signal

Subjective data questions: nose - allergies

any allergies or hay fever? to what are you allergic, for example, pollen, dust, or pets? how was this determined? what type of environment makes it worse? can you avoid exposure? do you use inhalers, nasal spray or nose drops? how often? which type? how long have you used this?

Subjective data questions: mouth and throat - bleeding gums

any bleeding gums? how long have you had this?

Subjective data questions: mouth and throat - altered taste or?

any change in sense of taste?

Olfactory nerve

any changes in sense of smell

Subjective Questions: Earache

any earache or other pain in ears?

Strabismus, diplopia

any history of crossed eyes? now or in the past? does this occur with eye fatigue? - ever see double? constant, or does it come and go? In one eye or both?

Subjective data questions: mouth and throat - hoarseness

any hoarseness, voice change? for how long? feel like having to clear your throat? or, like a "lump in your throat?" use your voice a lot at work, recreation? Does hoarseness seem associated with a cold or sore throat?

pressure ulcer

any lesion caused by unrelieved pressure that results in damage to underlying tissue

Subjective data questions: nose - discharge

any nasal discharge or runny nose? continuous? is discharge watery, purulent, mucoid, bloody?

Subjective data questions: nose - nosebleeds

any nosebleeds? how often? how much bleeding, a teaspoonful or does it pour out? color of the blood, red or brown? clots? from one nostril or both? aggrevated by nose-picked or scratching? how do you treat nosebleeds? are they difficult to stop?

Redness, swelling questions

any redness or swelling in eyes? any infections? now or in the past? when do these occur? in a particular time of the year?

Subjective data questions: nose - sinus pain

any sinus pain or sinusitis? how is this treated? do you have chronic postnasal drip?

Subjective data questions: mouth and throat - toothache

any toothache? do your teeth seem sensitive to hot, cold? Have you lost any teeth? last dental exam?

Additional history for infants and children questions

any vaginal infections in mother at delivery? considering age of child, which developmental milestones of vision have you(parent) noted? does child have routine vision testing at school? are you(parent) aware of safety measures to protect child's eyes from trauma? do you inspect toys? have you taught child safe care of sharp objects and how to carry and how to use them?

Blood pressure in aging adult

aorta and major arteries tend to harden with age increasing blood pressure - as heart pumps against stiffer aorta, SP increases, leading to widened pulse pressure

Where do you palpate or auscultate a pulse for infants and children?

apical rate - count pulse for full minute

Anxiety

appear unhurried, take time to listen, avoid interview traps

Eversion of upper lid procedure may cause?

apprehension; therefore use directed, deliberate approach - multi-step procedure using applicator stick - color change, swelling, lesion, evidence of foreign body

Why? HEENT - the nose mouth and throat

are important areas of the respiratory and gastro-intestinal system and many health care devices are inserted in the body openings. Your assessment of these areas is an important step before insertion

General survey - body structure - position

arms relaxed at sides - leaning forward, curled in fetal position

Arterial and Venous insufficiency - edema

arterial: none or minimal venous: usually present

posterior tibial artery

artery supplying the foot, behind the medial ankle

General survey - behavior - speech

articulation - speech defect, monotone, few words, constant talking

Abnormal palpation - decreased or increased fremitus

as assess for it make note of things not equal on both sides

Asymmetric Tonic Neck Reflex

as the infant's head is turned to one side, the arms will briefly come into a fencers position, with the arm on the same side as the face stright out to the side and the arm behind the head flexed at the elbow

Developmental Adaptation - Children

ask child questions and gather more information from family

Time

ask day of the week, season, year - many have troubles knowing what day of the week and date

Open ended questions

ask for narrative information. It states the topic but only in general terms. - unbiased

Closed or direct questions

ask for specific information - one or two word answer, elicit specific information.

Lacrimal Apparatus test

ask the person to look down; with thumb, slide outer part of upper lid up along bony orbit to exposure under lid; inspect for any redness or swelling

Conjuctiva and Sclera test

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

To test cranial nerve XII, hypoglossal nerve?

asking a person to stick out tongue; should protrude in midline; note any tremor, loss of movement, or deviation to side

Initial pain assessment

asks the patient to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors.

The short-form McGill Pain Questionnaire

asks the patient to rank a list of descriptors in terms of their intensity and to give an overall intensity rating to their pain

The brief pain inventory

asks the patient to rate the pain within the past 24 hours using graduated scales with respect to its impact on areas such as mood and ability to sleep

optic nerve

assess pupil size and alignment, visual acuity(snellen chart), pupil reflexes(direct and consensual), accommodation reflex(constriction and convergence), assess color vision, visual fields

Glossopharyngeal and vagus nerve

assess soft palate and uvula rise, assess swallow for vagus

Is visual acuity even lower,

assess whether the person can count your fingers when they are spread in front of eyes or distinguish light perception from your penlight

Acculturation

assimilation is one dimensional, and biculturalism/integration is bidimensional

What is the most common thing that weakens the middle layer?

athersclerosis

diastole - Presystole

atria give a little squeeze to give rest of blood to ventricles - atrial kick

P wave

atrial depolarization - atria contracting

Extra Heart Sounds - S4

atrial gallop during ventricular diastole - heard at cardiac apex with bell - diastolic heart failure, ventricular hypertrophy, active cardiac ischema(heart fails to relax) - tennesee(S4, S1, S2)

Ventricular diastole is happening when there is?

atrial systole

Inspection and Palpation - nasal cavity

attach a short wide-tipped speculum to otoscope head and insert apparatus into nasal vestibule - view each nasal cavity with the person's head erect and then with head tilted back

Conduction - heart has unique ability:

automaticity - can contract by itself independent of any signals or stimulation from body - contracts in response to an electrical current conveyed by a conduction system

Laterally, the lungs extend from the ---- down to the -----

axilla area; 7th or 8th rib

Baby's temperature in the armpit

axillary measurement. May be used as a first way of checking to see if a child may have a fever. If this shows a fever, the temperature should then be checked by rectum or forehead.

Salivation starts at 3 months:

baby will drool periodically for a few months before learning to swallow saliva

Weight

balance scales, electronic scales, bed scales

Should you measure someones blood pressure on a bare arm or over clothing?

bare arm

The neck is delimited by?

base of skill and inferior border of mandible above, and by manubrium sterni, clavicle, first rib, and first thoracic vertebra below

Lymph nodes: occipital

base of skull

popliteal artery

behind the knee

Abnormal Findings: Swellings of Head and Neck - pilar cyst

benign growth that presents as smooth, fluctuant swelling on scalp

Trained interpreter is the?

best option - Family members who speak the same language may invade confidentiality and other problems

Heart Structures - Valves - left semilunar valve

between left ventricle and aorta(aortic valve)

Heart Structures - Valves - right semilunar valve

between right ventricle and pulmonary trunk(pulmonary valve)

Developmental competence pregnant women: expect diffuse?

bilateral pitting edema in the lower extremities especially at the end of the day

Upcoding

billing for a service at a higher level than was actually provided

Cataracts are leading cause of?

blindness worldwide - estimated that 80% are preventable or curable with surgery

peripheral arterial disease (PAD)

blockage of arteries carrying blood to the legs, arms, kidneys and other organs - obstruction of artery(aging, poor diet, exercise)

Subcutaneous

blood vessels, adipose tissue, nerves,

Abnormal inspection - cyanosis

blue/purple common with lack of oxygen

Personal hygiene

body odor, scent of alcohol, unkempt appearance

Abnormal Hair Conditions - furuncle and abscess

boil; suppurative inflammatory skin lesion due to infected hair follicle

Inner Ear contains

bony labyrinth, which holds sensory organs for equilibrium and hearing

Full pulse force

bounding pulse denotes increased stroke volume

In pit of elbow pulse

brachial artery

Atrophic scar

break in the skin and fabric tissues coming together. Due to loss of skin or thinning kind of look like stretch marks

School age preparation

break the ice with small talk, child should undress, leave underpants on and use gown, demonstrate equipment because curious, comment on the body and how it works

American cancer society no longer recommends?

breast self-exam as a screening tool for women with an average risk of breast cancer

American College of Obstetricians and Gynecologists guidelines dont recommend?

breast self-exam for average-risk women - screening mammogram annual starting at age 40 for average risk

Aging women breasts - on inspection

breasts look pendulous, flat, and sagging

B-rief I-ntervention

brief motivational and awareness-raising intervention given to risky or problematic substance users

Abnormal findings: ear canal abnormalities - foreign body

bugs, toys get trapped in wax, dont irrigate if it is alive

second degree burn (partial thickness)

burn affecting the epidermis and part of the dermis and characterized by redness, blistering or larger bullae, and pain with little or no scarring - cool water several minutes, ointment, bandage

fourth degree burn

burn in which full thickness of the skin and underlying muscle and bone is damaged - ER and elevation

Although the inner hear is not accessible to direct examination, its functions?

can be assessed

Infants and children eyelids and lashes - many infants have an epicanthal fold,

can excess skinfold extending over inner corner of eye, partly or totally overlapping inner canthus

Otoscopic examm is not performed at birth because

canal is filled wtih amniotic fluid and vernix caseosa; after a few days the TM is examined

Things to do when documenting EHR

cannot document before you do something(legal purposes) document in real time. Do not avoid early warning signs - never leave workstation open, violation of privacy - do not leave papers out in the open

Vital signs are accessible measures of?

cardiac and pulmonary function. There are physiologic limits to them and they provide a quick assessment of an individual's health status when combined with the general survey.

Infant position

caregiver present, place baby on flat padded examination table

clouding of the lens

cataract

Inspection of tongue

check tongue color, surface characteristics, and moisture

A chest tube does what?

chest tube with suction which reestablishes lung pressure by draining fluid. Lets them expand back to normal size

Physical growth charts is perhaps the best index of a?

child's general health. Measure on growth chart than by itself so you can see the trend of a growth spurt or growth hormone issue.

Complex Regional Pain Syndrome or Reflexive Sympathetic Dystrophy

chronic progressive nerve condition characterized by burning sensation, swelling, stiffness, discoloration. Men and women around 40-60 y/o and occurs weeks to months after a nerve injury(carpal tunnel syndrome, broken leg).

mucociliary escalator

cilia that transport mucus and foreign material out of the respiratory tract

Abnormal Facial Appearances - parkinson syndrome

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

Abnormal Facial Appearances - Cushing syndrome

classic "moonlike" face, red cheeks, and hirsutism

What does autonomy mean?

clients right to make their own choices

Vestibular nerve

close eyes and march standing up

General survey - behavior - dress

clothing too large, too tight, Velcro present

Abnormal findings: Opacities in the lens - central gray opacity - nuclear cataract

cloudiness and thickness, look for after the age of 40, slow development and causes vision changes

In aging persons, cilia lining ear become

coarse and stiff

Inspection of face: Abnormal facial features

coarse facial features, exophthalmos, changes in skin color or pigmentation, or abnormal swellings

atelectasis

collapsed lung; incomplete expansion of alveoli

Toddler sequence

collect objective data during the history, begin with games, start with nonthreatening areas.

If any discharge is present note?

color and odor

Inspection of throat - observe oval, rough-surfaced tonsils

color is same pink as oral mucosa, and their surface peppered with identations, or crypts; there should be no exudate on tonsils

Deep somatic pain

comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Pain may result from pressure, trauma. Aching or throbbing

Internal carotid branches off?

common carotid and runs inward and upward to supply brain

Adults - Otosclerosis:

common cause of conductive hearing loss in 20-40 adults - gradual hardening that causes footplate of stapes to become fixed in oval window(progressive deafness)

In aging adults pingueculae

commonly show on sclera

silence

communcates that client has time to think, provides you with a chance to obseve the client and note nonverbal cues

Plain language

communication your client can understand the first time they read it or hear it

Fraud detection methods - complex reviews

complete medical history analysis

Physical examination: aging adult - neck may show an increased

concave curve - to compensate for kyphosis

Summary

condenses facts and validates what was discussed, both client and examiner should be active participants, signals termination of interview is imminent

Wernicke's aphasia

condition resulting from damage to Wernicke's area, causing the affected person to be unable to understand or produce meaningful language

motivating often means resolving --- and --- feelings and thoughts

conflicting, ambivalent

Tetralogy of Fallot

congenital malformation involving four (tetra-) distinct heart defects. missing part of the septum in the heart so blood flows

Cultural and Lingustic Competence

congruent behaviors, attitudes, and policies that come together in a system among professionals that enables work in cross cultural situations

If pain is suspected,

consider a time limited trial of an appropriate type and dose of an analgesic agent. Use self-report and observational pain measures to evaluate the pain before and after administering the analgesic

Age greater than 12

consider using self-report scale such as NRS, numeric, visual or color analog scales

Respectful care

considers values, preferences, and expressed needs of patient

direct light reflex

constriction of the same-sided pupil

Abnormal Hair Conditions - Scabies

contagious skin disease transmitted by the itch mite, commonly through sexual contact

Eyes - External Anatomy: Tarsal plates

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

Common vehicle applies to microorganisms that are transmitted by?

contaminated items such as food, water, medications, medical devices and equipment.

RNs interpret vital signs in?

context.

Heart Structures - Valves - right atrioventricular valve (tricuspid valve)

controls the opening between the right atrium and the right ventricle

Primary care is one of the most?

convenient points of contact for substance issues. Many patients are more likely to discuss this subject with their family physician than a relative, therapist or rehab specialist

Eyes - External Anatomy: Lower lid margin, at limbus, borders between

cornea and sclera - canthus: corner of eye, angle where lids meet - inner canthus: caruncle is a small fleshy mass containing sebaceous glands

Trigeminal nerve

cotton ball on face

With a glove, hold tongue with a?

cotton gauze pad for traction and swing tongue out to each side; inspect for any white patches or lesions; normally none are present - if any occur, palpate these lesions for induration

hemoptysis

coughing up blood

hemaptysis

coughing up blood(lung cancer)

Eyes - External Anatomy: Cornea

covers and protects the iris and pupil

visceral pericardium (epicardium)

covers the heart's outer surface (ON the surface)

tension headache

crosses midline, any part of the head, grip tightness not throbbing, gradual onset(2 days), stress, depression

Being bilingual does not mean that the interpreter is?

culturally aware

Abnormal inspection - scoliosis

curvature in spine from posterior view to the left or the right

As cited by Miller and Rollrick, MI is compared to a

dance

Developmental Competence: The aging adult - sweat and sebaceous glands

decrease in number and function, leaving skin dry

Blood volume

decrease volume(hemorrhage), increase volume(increased sodium and water retention, intravenous fluid overload)

Side effects of opiods

decreased respirations, decreased blood pressure, decreased response to stimuli

Lymph nodes: deep cervical

deep under the sternomastoid muscle

hypopituitary dwarfism

deficiency in growth hormone in childhood results in retardation of growth below the 3rd percentile, delayed puberty, adrenal insufficiency.

Abnormalities of external ear: Brachial remnant and ear deformity

deformity in ear and facial remnant, embroytic stages

P-R segment

delay in impulse through AV node(before ventricular contraction)

cultural sensibility

deliberate proactive behavior by heath care providers who examine cultural situations through thoughtful reasoning, responsiveness, and discreet interactions

superior oblique muscle

depresses eye and turns it laterally

inferior rectus muscle

depresses eye and turns it medially

Enlarge your view of posterior pharyngeal wall by?

depressing tongue with tongue blade - scan posterior wall for color, exudate, or lesions - touching posterior wall with tongue blade elicits gag reflex; this test cranial nerves IX and X, the glossopharyngeal and vagus

Poorly controlled chronic pain

depression, isolation, limited mobility and function, confusion, family distress, diminished quality of life

Cutaneous pain

derived from skin surface and subcutaneous tissues. Superficial, sharp, or burning.

Tattoos are injected into the?

dermis layer of the skin

A complete family history is to send home a?

detailed questionnaire before the health care/hospital encounter because the information takes time to compile and often comes from multiple family members.

gynecomastia

development of breast tissue in males during adolescence. It is normal for it to appear but should disappear but can reappear with aging due to testosterone deficiency and medications

Inspection and Palpation: Skin - moisture

diaphoresis, dehydration

The inferior part of the thoracic cage is the?

diaphragm which is made up of muscles and tendons

Trouble with mastication can lead to?

dietary pattern changes which may place the older adult at risk for nutritional deficits(protein, vitamins, and minerals)

Certain skin presentations are associated with?

different ethnic groups

Dyspnea

difficulty breathing or shortness of breath

dysphonia

difficulty producing speech sounds, usually due to hoarseness

Arteries are capable of?

dilating and constricting to control rate of blood flow

Common finding for acutely ill patients

diminished or decreased breath sounds - secretions, mucus, foreign body which obstructs air flow - pneumothorax - pleural effusion

If any discharge is present clean any?

discharge from speculum before examining other ear to avoid contamination with possible infectious material

Developmental Competence: The aging adult - senile purpura

discoloration due to increasing capillary fragility

peripheral vascular disease (PVD)

disease of blood vessels away from central region of body, most typically in legs; symptoms include pain, numbness, and impaired circulation

In the age of genomics an accurate family history highlights what?

diseases and conditions for which a particular patient may be at increased risk.

test for accommodation by asking the person to focus on a?

distant object - this dilates pupils; then have the person shift gaze to near object, such as your finger held about 7-8 cm from nose

For aging adults - patient-centered care health history questions

dizziness and/or neck pain(how does it affect your daily activities?)

Anger

do not ask about the anger and hear the person out

Additional History for Infants and Children - did child's teeth erupt on time?

do teeth seem straight to you? is child using a bottle? does child sleep with a bottle? noticed any thumb sucking after child's secondary teeth came in? have you noticed child grinding his or her teeth?

Subjective data questions: mouth and throat - smoking, alcohol consumption

do you smoke? pipe or cigarettes? smokeless tobacco? how many pack per day? for how many years? what was your last alcohol drink? how much alochol did you drink that time? how much alcohol do you usually drink?

Use of glasses or contact lenses questions

do you wear glasses or contact lenses? how do they work for you? last time your prescription was checked? was it changed? if you wear contact lenses, are there any problems such as pain, photophobia, watering, or swelling? how do you care for contacts? how long do you wear them? how do you clean them? do you remove them for certain activities?

Developmental competence pregnant women: growing uterus obstructs?

drainage of iliac veins and inferior vena cava - leads to dependent edema, varicosities in legs and vulvs, and hemorrhoids - do not sleep on back because uterus will occlude vena cava

Abnormal findings: eyelid abnormalities - ptosis

drooping upper lid, lazy eye

You may elicit these maneuvers to assess?

drum mobility - avoid them with an aging person because they may disrupt equilibrium

Biculturalism

dual pattern of identification and often of divided loyalty

Increased risk for dental disease

due to socioeconomic status, lack of access and comorbidities

Which of the following health care resources or services is most vulnerable to fraud, waste, and abuse?

durable medical equipment

At lower oxygen saturations what probe is more accurate?

earlobe probe is more accurate and less affected by peripheral vasoconstriction

Thyroid Palpation: Anterior Approach

easier from posterior but use the right thumb to displace and the left thumb to palpate - posterior the right hand palpates and the left hand displaces

reflection

echoes client words by repeating part of what person has said, express feelings behind words, helps elaborate on problem

Physical examination: Infants and children - two common variations - caput succedaneum

edematous swelling that is self-limiting and extends across suture lines

Why? HEENT - sensory problems(eyes and ears)

effect a person's ability to function well in our society without assistance

diastolic pressure

elastic is resting or recoiling and getting ready to repump

EASI

elder abuse suspicion index

respirations

electronic, visual, and palpated

inferior oblique muscle

elevates eye and turns it laterally

superior rectus

elevates eye and turns it medially

Eyes - External Anatomy: palpebral fissure

elliptical open space between eyelids

Abnormal findings: red eye - vascular disorders - Primary angle-closure glaucoma

emergency treatment, abnormal pupil and coloring

What is the thoracic cage?

encloses and protects the lungs. It is in the shape of a cone

Facilitation

encourages client to say more, shows person you are interested

lymphadenopathy

enlarged lymph nodes

Summary Checklist: Head, Face, and Neck, including regional lymphatics examination - auscultate thyroid if?

enlarged, for bruit

Pregnant female - thyroid glande

enlarges slightly during pregnancy as a result of hyperplasia of tissue and increased vascularity

chronic pain

episode of pain that lasts for 6 months or longer; may be intermittent or continuous

General survey - body structure - symmetry

equal parts - unilateral atrophy

The infant major task

establishing trust because it is dependent on the caregiver for his and her basic needs

Abnormal findings: red eye - vascular disorders - herpes simplex virus

evaluation because if virus affects optic nerve then can have permanent visual changes - viral illness

General survey - physical appearance - skin color

even pigmentation varying with background, skin intact with no lesions, make note of tattoos and piercings and stage of healing - pallor, jaundice

What is the normal rhythm of pulse?

even tempo

regular pulse

evenly spaced beats, 60-100bpm

Subjective data questions: nose - trauma

ever had any trauma or a blow to the nose? do you breathe through your nose?

According to Miller and Rollnick, MI is about ---- what is already present, not installing what is missing.

evoking

Preschool sequence

exam thorax, abdomen, extremities, and genitalia first. Head, eye, ear, nose last

Aging adult preparation

examination pace to meet the slowed pace of aging person, use physical touch, do not mistake diminished vision or hearing for confusion, more stress - Head to toe approach

If crying episodes occur earlier,

examine open mouth and oropharynx

hypercapnia

excessive carbon dioxide in the blood

Abnormal Hair Conditions - hirsutism

excessive hair growth over the body

abnormal inspection - kyphosis

excessive outward curvature of the spine, causing hunching of the back. Common in elderly

Gigantism

excessive secretion of growth hormone by the pituitary results in overgrowth of the entire body

Acromegaly

excessive secretion of growth hormones in adult after normal completion of body growth causes overgrowth of bone in face, head, hands, and no change in height.

Developmental competence infants and children - with infection, what happens?

excessive swelling and hyperplasia

euphoria

excessive well being, unusually cheerful which is inappropriate considering physical and mental condition

cardiac stress testing

exercise tolerance test to raise your heart rate and monitor the effect on cardiac function - exercise or medications

Child's age in months minue 6 should equal?

expected number of deciduous teeth

Subjective data questions: nose - altered smell

experienced any change in sense of smell? COVID 19

Naturalistic - hot/cold theory

explantory model with origins in greece. The four humors of the body - blood, phlegm, black and yellow bile - regulate body functions and are described in terms of temperature, dryness, and mositure. The treatment of diseases consists of adding or subtracting these elements restores health.

Most important environmental risk factor for skin cancer is?

exposure to UV radiation both from sun and indoor tanning sources

sternomastoid muscle

extends from the sternum upward along the side of the neck to the mastoid process

Abducens nerve

eye movement left and right

Abnormal findings: eyelid abnormalities - periorbital edema

eyelids are swollen and puffy, excessive fluid, local infections, crying really hard, trauma from getting hit in the eye, allergies

Facial expressions are formed by?

facial muscles, which are mediated by cranial nerve VII, the facial nerve

Communication techniques

facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, summary

neglect

failure to provide for a childs basic needs. prenatal drug exposure, child abandoment.

Descriptor Differential Scale

faint(+/-), moderate(+/-), barely strong(+/-), intense(+/-), weak(+/-), strong(+/-), very mild(+/-), extremely intense(+/-), very weak(+/-), slightly intense(+/-), very intense(+/-), mild(+/-)

The goal of the self breast exam is for women to become?

familiar with their breast

specific phobia

fear of objects or specific situations or events

agoraphobia

fear of open spaces

CNS pain

fear, anxiety, fatigue

Depersonalization

feelings of detachment from one's mental processes or body

General survey - mobility - gait

feet are shoulder width apart - wide base, stumbling, dragging

If bronchial breath sounds were heard in the peripheral of the lungs, this could be a?

finding which is abnormal and suspicious for pneumonia, pleural effusions or atelectasis

How to assess a patient in clinical

first measure height, weight, blood pressure, temperature, pulse, and respirations. Use an icebreaker. Ask the person to change into an examining gown leaving underwear on, reenter the room and clean your hands in the persons presence, touch hands, write out examination sequence, offer teaching about body, if linger in one location to concentrate on finding reassure them, summarize your findings, and share the information with the person.

General survey - behavior - facial expression

flat, depressed, angry, sad, anxious

Tympanic membrane: position: TM is

flat, slightly pulled in at center, and flutters when a person performs Valsalve maneuver or holds nose and swallows

Physical examination: Infants and children - skull - positional molding

flattening of the head due to infant sleeping position

catheter

flexible tube that is going into a narrow body cavity

pleural effusion

fluid or pus in thoracic cavity where lung cant expand all the way

Communicating with acutelly ill

focus on making them comfortable first, then ask priority questions.

Fetal circulation

foramen ovale open so can move right and left side of heart. Can go out pulmonary artery but connects to aorta(ductus aneseus) - heart problems can be from these places not closing. Close within 24 hours.

Inspection and Palpation of the Skill: Size and shape - bones

forehead, lateral edge of parietal bones, occipital bone, and mastoid process behind each ear

Cranial Bones

frontal, parietal, occipital, temporal

Abnormal Conditions of the Nails - onychomycosis

fungal infection of the nail

Abnormal Inspection - pectus excavatum

funnel chest - chest hollowed out. May be congenital

rage

furious, loss of control

Extra Heart Sounds - S3

gallops - best heard at cardiac apex, heard with bell - low pitched(kentucky - S1, S2, S3) - most common

Marfan Syndrome

genetic connective tissue disorder that can cause a ruptured aorta

Disease based precautions - enteric

gloves and gown

Disease based precautions - protective

gloves, gown, masks/respirators, goggles, face shield

Office of the Inspector General (OIG)

government agency that investigates and prosecutes fraud

Disease based precautions - contact

gown and gloves

Tonsils grading

grade 0: cant see them at all grade 1: barely visible 2: not touching uvula but swollen 3. touching the uvula

Dry cerumen

gray, flaky, and frequently forms thin mass in ear canal

arcus senilis

gray-white arc or circle around the limbus due to deposition of lipid material - as more lipids accumulate, cornea may look thickened and raised, but arcus has no effect on vision - aging adults

femoral artery pulse

groin

Signs of respiratory distress in infant

grunting and nasal flares, retraction

Teeth may look longer as ----- recede

gum margins - old dental work deteriorates, teeth loosen with bone resorption - tongue looks smoother as a result of papillary atrophy - aging buccal mucosa is tinned and may look shiner

Gum inspection

gum margins are tight and well defined - check for swelling, retraction of gingival margins; and spongy, bleeding, or discolored gums

Lymph nodes: submandibular

halfway between angle and tip of mandible

Glaucoma questions

have you ever been tested for glaucoma? what were the results? do you have any family history of glaucoma?

Subjective data questions: mouth and throat - sores or lesions

have you noticed any sores or lesions in the mouth, tongue, or gums? how long have you had it? every had this lesion before? is it single or multiple? does it seem associated with stress, season change, or food? how have you treated sore? how you applied any local medication?

During infancy, trunk growth predominates so that?

head size changes in proportion to body height

Adolescent sequence

head to toe, genitalia last and do it quickly.

A persons culture defines

health and illness, identifies when treatment is needed and which treatments are acceptable, and informs a person of how symptoms are expressed and which symptoms are important

Technology play a critical role in

health care fraud, use, and abuse

First and landmark standard

health care organizations should ensure that all patients receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language

Sharing protected information

health care staff can share info with family friends and primary care provider as long as the patient does not object - if cannot respond, then can share if in the best interest of patient

Naturalistic - yin yang theory

health exists when all aspects of the person are in perfect balance

Summary Checklist - Teach self examination

health promotion

Acoustic

hearing

JVD is common with?

heart failure - hear S3 most commonly

Electrical conduction does not mean that the?

heart muscle is functioning properly

Hypothalamus/body balances what?

heat production(from metabolism, exerecise, food digestion, external factors) with heat loss(through radiation, evaporation of sweat, convection, conduction)

anthropometric measurements

height and weight

General survey - body structure - stature

height is within normal range - too tall or too short

the use of electronic medical records

helps maintain a clear process between the services providers render and the use of accurrate diagnostic and billing codes

Lymphatic drainage does what?

helps prevent potentially harmful substances from entering the circulation

Abnormal Findings: Swellings of Head and Neck - Congenital torticollis

hemotoma in one sternomastoid muscle, probably injured by intrauterine malposition, results in head tilt to one side and limited neck ROM to opposite side

Deflating cuff too slowly

high

Failure to wait 1-2 minutes before repeating reading

high

Under the heart

high

leg position

high

too loose

high

too narrow

high

Person supports own arm

high diastolic

drive to breathe in healthy individuals

high levels of CO2 in pts with COPD: low levels of oxygen

If i am looking to assess the apex of the lung where would you assess?

high up in clavicle area

Measuring thigh pressure will be --- due to ---

higher; larger artery

Lumps or swelling health history questions

history of recent infection, radiation, smoking, alcohol, difficulty swallowing, thyroid issues

Screening for hearing deficit begins during?

history; how well does a person hear conversational speech?

Jaeger card instructions

hold card in good light about 35 cm (14 in away) from the eye this distance equls the print size on the 20 ft chart. test each eye separately, with glases on. A normal result is 14/14 in each eye, read without hesitancy and without moving the card closer of farther away - when no card is available ask the person to read from a magazine or newspaper

Abnormal findings: tympanic membrane - perforation

holes that should ear on their own

Wet cerumen

honey brown to dark brown and moist

Position of eardrum is more

horizontal in neonate, making it more difficult to see completely and harder to differentiate from canal wall

General survey - behavior - mood and affect

hostile, distrustful, crying

Additional History for Infants and Children - patient-centered care

how are child's dental habits? use a toothbrush regularly? how often does child see a dentist? do you use fluoridated water or fluoride supplement? are vaccinations up to date?

Subjective data questions: mouth and throat - sore throat

how frequently do you get them? do you have a sore throat now? when did it start? is it associated with cough, fever, fatigue, decreased appetite, headache, postnasal drip? or hoarseness? is it worse when arising? what is humidity level in room where you sleep? any dust or smoke inhaled at work? do you usually get a throat culture for the sore throats? were any documented as streptococcal? how have you treated this sore throat: medication, gargling? how effective are these? have your tonsils or adenoids been taken out?

Oral temperature - external and internal environment may cause?

hypothermia or fever due to infections, neurological problems, stroke, cancer

Pulmonary pain

hypoventilation, hypoxia, decreased cough

Risk factors will decrease if?

identification, early treatment, health promotion

Goal of SBIRT

identify and effectively intervene with those who are at moderate or high risk for psychosocial or health care problems related to their substance use

Communicating with infant

ifants use coos, gurgles, and cries to identify their needs. Nonverbal communication is the primary method of communicating with infants.

Essential to determine patency of nares in?

immediate newborn period

Immune pain

impaired cellular immunity, impaired wound healing

What is RN practice implemented and supported by?

implemented by the nursing process and supported by policy and procedure.

Lymph nodes: preauricular

in front of the ear

On infants how do you measure vital signs?

in reverse(respiration, pulse, temperature, blood pressure)

lymph nodes: posterior cervical

in the posterior triangle along the edge of the trapezius muscle

Natural tooth loss is exacerbated by?

inadequate dental care, poor oral hygiene, and tobacco use - can lead to malocclusion leading to further tooth loss and pain

Hallucinogens

inappropriate sometimes violent behavior, super human strength and insensitivity to pain

Children health history is adapted to

include information specific for the age and developmental stage of the child. Developmental history and nutritional data are listed as separate sections because of their important for current health.

What is the most common error with blood pressure measurements

incorrect cuff size

Peripheral vascular resistance

increase resistance(vasoconstriction), decrease resistance(vasodilation)

Elasticity of vessel walls

increase rigidity, hardening as in arteriosclerosis(heart pumping against greater resistance)

Cardiac output

increase with heavy exercise to meet body demand for increased metabolism, decrease with pump failure

Tacile fremitus will increase or decrease with pneumonia?

increase(more solid) - voice sounds will also be more clear as well due to consolidation and dull percussion - decreases when less solid(less air flow - obstruction or pneumothorax)

In many older people, both systolic and diastolic pressure?

increase, making it difficult to distinguish normal aging values from abnormal hypertension.

Endocrine pain

increased adrenergic activity

Succession of genetic mutations leading to?

increased chromosome sensitivity to sun damage - dark skinned

Increased risk for melanoma <=

increased number of sunburns during ones lifetime

Older adult health promotion

increased risk - less muscle mass - prescription drug interactions - decreased kidney and liver function - increased risk for; falls, depression, GI problems(bleeding)

Nasal stuffiness and epistaxis may occur during pregnancy as a result of?

increased vascularity in the upper respiratory tract

If you start with a different vital sign on children you may get a strong reading because they may cry which = ?

increasing the rates of respiratory and heart rate.

condition of teeth is an?

index of the person's general health - note any diseased, absent, loose, or abnormally positioned teeth

Regional physical examination

individuals may seek health care for skin problems and assessment focused on skin alone

As you introduce an object to infant's line of vision, not these attending behaviors: by 1 month

infant can fixate and follow light or bright toy

As you introduce an object to infant's line of vision, not these attending behaviors: 6-10 months

infant can fixate and follow toy in all directions

As you introduce an object to infant's line of vision, not these attending behaviors: 2-4 weeks

infant can fixate on an object

As you introduce an object to infant's line of vision, not these attending behaviors: 3-4 months

infant can fixate, follow, and reach for toy

Making a loud noise to 6-8 months

infant turns head to localize sound; responds to own name

Heart rate normally fluctuates more with who?

infants and children than adults from exercise, emotion, and illness

Abnormal Hair Conditions - pediculosis capitis

infestation of the hair and scalp with head lice

conjuctivitis

inflammation of the conjunctiva (pink eye)

Abnormal Conditions of the Nails - paronychia

inflammation of the nail fold

Explanation

informing patient, sharing information

Thickening of the what, for aging women?

inframammary ridge at lower breast is normal, feels more prominent with age - women over 50 y/o have increased risk of breast cancer

inhalation and exhalation

inhalation lungs contract and exhale lungs relax which pushes air out

Color blindness

inherited recessive X-linked trait affecting about 8% of White males and 4% of African American males; rare in females

Transduction

injured tissue releases chemicals that propagate pain message. Action potential moves along an afferent fiber to the spinal cord.

defensive wounds

injury typically on the victim's hands and ulnar side of the arms

How to test sucking reflex

insert gloved finger into baby's mouth and palpate hard and soft palate as baby sucks - sucking reflex can be elicited in infants up to 12 months

Conjuntiva and sclera inspect

inspect exposed area; eyeball should look moist and glossy - numerous small blood vessels normally show through transparent conjunctiva

Hypoglossal nerve

inspect tongue at rest, stick tongue out, press tongue into fingers

opthalmoscope

instrument used to examine the interior of the eye

social anxiety disorder

intense fear of social situations, leading to avoidance of such

The five social determinants of health are?

interconnected and affect a persons health from preconception to death - poverty has the greatest influence on health status

Red reflex

interruption indicates opacity in the cornea or lens. Absent red reflex occurs with congential cataracts or retinal disorders

Developmental Competence Aging Adult: Enlargement and loss of?

intramuscular calf veins and loss of lymphatic tissue which decreases lymph nodes and size of lymph nodes

Inspection of face: note any --- movements

involuntary(tics) in facial muscles; normally none occur

nystagmus

involuntary, jerking movements of the eyes

Indirect

involves contact between a person and a contaminated object. This is often a result of unclean hands contaminating an object or environment. The microorganism remains on this surface to be picked up by the next person who touches it.

Direct

involves direct body surface to body surface contact and physical transfer of microorganism between an infected or colonized person to another person by touch.

Culturally based variability present in color of?

iris and retinal pigmentation

Infants and children iris and pupils

iris normally blue or slate grey in light-skinned newborns and brown in dark-skinned infants; by 6 to 9 months, permanent color differentiated

Pedigree or genogram

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

Subjective Questions: Earache - Character

is it dull, aching, or sharp, stabbing? Is it constant or does it come and go? Is it affected by changing position of head?

Adolescent major task

is self identity. They are self conscious

General survey - physical appearance - age

is stated age - appears older than stated age with chronic illness or chronic alcoholism

The head being larger than body causes what?

issues with walking and coordination

pruritus

itching

Inspect nasal mucosa, noting?

its normal red color and smooth moist surface - note any swelling, discharge, bleeding, or foreign body

elation

joy and optimism, overconfidence, increased motor activity, not necessarily pathologic

Lymph nodes: supraclavicular

just above and behind the clavicle, at the sternomastoid muscle

Gradual loss of subcutaneous fat starts during?

later middle adult years, making the nose appear more prominent in some people

Most common causes of decreased visual functioning in older adults - diabetic retinopathy

leading cause of blindness in adults ages 25-75 years of age

Four basic concepts of culture(characteristics of culture)

learned, shared, adapted, dynamic

confluent

lesions run together (hives)

Right side of the heart has --- pressure?

less pressure than the left because pulmonary system has lower pressures. Systemic pressure is much higher.

Tools to assess alcohol and drug use - CAGE

less than a minute: - has anyone ever asked you to cut down, has anyone been annoyed, eye opener

Aging adults developmental competence - must consider what?

lifestyle, habits, and disease

General survey - mobility - range of motion

limited joint range of motion, paralysis

Common skin lesions - primary contact dermatitis

linear shape, vesicles or papular, scales, hives, itchy what caused this? what came into contact? - red

interpretation

links events implies cause, not based on direct observations, but on conclusion, incorrect but helps further discussion

Lobes are composed of?

lobules, and lobule clusters of alveoli produce milk

Developmental competence infants and children - vaccines can produce

local lymphadenopathy(enlargement)

Posterior thoracic landmarks - twelfth rib

located midway between the spine and the patient's side

Bundle of His (AV bundle)

located next to the AV node; provides the transfer of the electrical impulse from the atria to the ventricles - then to right and left bundle branches to perkinjie fibers

Microorganisms carried airborne remain suspended in the air for?

long periods of time and can be dispersed widely by air currents. Because of this, there is risk that all the air in a room may be contaminated.

Third level priority

long term problems, require a collaboration between patient and health care provider, ie. Sedentary lifestyle, readiness for enhanced self-concept, chronic low self-esteem

Chronic Behavior

longer than 6 months, cancer related or not, doesn't stop once pain heals. Shingles causes long lasting pain. - Bracing - Rubbing - Decreased activity - Sighing - Change in appetite - Sleeping - Self-distracting - Prayer

Posterior assessment - inspection: Muscle Development

looking at muscles in neck and shoulders because if someone has trouble breathing then they would be using those muscles more

Trochlear nerve

looking down

Oculomotor nerve

looking up

Developmental Competence: The aging adult - elasticity

loses elasticity; skinfolds and sags

hypotonia

loss of muscular tone or a diminished resistance to passive stretching

acculturative stress

losses and changes associated with integration of new beliefs

Rhonchi

loud rumbling sounds heard on auscultation of bronchi obstructed by sputum

Above the heart

low

Deflating cuff too quickly

low

Pushing stethoscope on artery

low

not inflating high enough

low

hypotensive

low blood pressure - 90/60. Shock, hemorrhage, vasodilation, Addison disease, acute myocardial infarction, decreased cardiac output, low BP, increased pulse, dizziness, confusion, blurred vision, cool and clammy, shoulder pain

Veins are a ----- system?

low pressure system that lies closer to skin surface - thin walled with large diameter(hold more blood)

Physical examination: aging adult - if some teeth have been lost

lower face looks unusually small, with mouth sunken in

Abnormal findings: eyelid abnormalities - entropion

lower lid rolling in, irritation which is the eyelashes in the eye

Abnormal findings: eyelid abnormalities - ectropion

lower lid rolling out, irritation, dryness

Blink and pupillary reflex indicate that the?

lower portion of the visual apparatus is intact. But cannot infer that infant can see; that requires later observation to show that brain has received images and can interpret them

The lymphatic system as a rich supply of what?

lymph nodes - greatest supply is in the head and neck

The breast has an extensive?

lymphatic drainage - around nipples - outward direction around that - towards the neck/armpit by armpit

What is the purpose of assessment?

make a judgement or diagnosis

Sexually aggressive people

make it clear that you are a health professional but that you also accept the person

tonsils

masses of lymphatic tissue in the back of the oropharynx. Borderline of mouth and throat

Gums may be hyperemic and softened in pregnant women and may?

may bleed with normal tooth brushing

Aging adult lacrimal apparatus

may decrease tear production, causing eyes to look dry and lusterness and the person to report a burning sensation

Aging adult cornea

may look cloudy with age

Physical examination: Infants and children - Skull

measure infants head at each visit up to age 2 years and yearly to age 6 - note infant's head posture and head control; infant can turn head side to side by 2 weeks

Functional assessment

measures a persons self care ability in the areas of general physical health such as bathing, toileting, eating, walking, independent living, nutrition/elimination, social relationships, self concept, and home environment, activity/exercise, sleep/rest, interpersonal relationships/resources, spiritual resources, coping and stress management, personal habits, alcohol, illicit or street drugs, environment/hazards, intimate partner violence, occupational health.

It is imperative that the nurse's care tailored to?

meet the person's perceived needs

Basal layer(dermis)

melanocytes(cancer), sweat glands, hair, hair follicle

Tympanic membrane(eardrum)

membrane stretched across a surface. Can concave or convex depending on sound and fluid in middle ear - maleus and cone of light: cant see means swelling. If prominate then there is pressure and fluid

Why are there droplet and contact precautions required at the same time?

microorganisms are relatively large and travel only short distances (up to 6 feet/2 metres). However these infected droplets may linger on surfaces for long periods of time, so these surfaces (within the range of the coughing/sneezing person) will need additional cleaning.

Posterior Assessment - How to do percussion sounds

middle finger of nondominant hand on patient and elevate other fingers and use other hand middle finger to tap

The mediastinum makes up the?

middle section of the thoracic cavity and it houses the esophagus, trachea, heart, and great blood vessels

Lymph nodes: submental

midline, behind tip of mandible

Overall pain assessment tools

more useful for chronic pain conditions or problematic acute pain problems.

cleft lip and cleft palate

most common in Asians, intermediate in whites, and least common blacks

CVD (cardiovascular disease)

most common underlying cause of death globally

Two trapezius muscles do what?

move shoulders and extend and turn head

medial rectus muscle

moves eye medially

Abnormal Findings: Swellings of Head and Neck - Thyroid - Multinodular goiter

multiple nodules usually indicate inflammation or multiodular goiter rather than a neoplasm; however, suspect any rapidly enlarging or firm nodule

If salivary glands are enlarged what could it mean?

mumps

Making loud noise to preschool and school age child

must be screened with audiometry

Biographic data include:

name, address, and phone number; age, birth date, birthplace, gender, relationship status, race, ethnic origin, and occupation.

empathy

names a feeling and allows its expression, allows person to feel accepted, useful when client hasnt identified the feeling

Abnormal Findings: Pediatrics - Fetal alcohol spectrum disorders

narrow palpebral fissures, epicanthal folds, thin upper lip, and midfacial hypoplasia, short nose, low nasal bridge, minor ear abnormalities

Avoid ----- ------ when examining infant and young child

nasal speculum - instead, gently push up the tip of the nose with your thumb while using your other hand to shine light into naris - with a toddler, be alert for possible foreign body lodged in nasal cavity

Steps for ABI for arm

need doppler and blood pressure cuff - remind patient not to speak and have lie down for 10 minutes to stabilize blood pressure - apply blood pressure cuff and use doppler to listen for brachial pulse - inflate the cuff to eliminate the signal and deflate the cuff until hear the signal(return of signal is the denominator) - repeat process of other arm and choose the highest measure for denominator - numerator will be the leg number

Modulation

neurons from brainstem release neurotransmitters that clock the pain impulse

Strep throat symptoms

no coughing, sore throat, exudate, fever, fatigue, decreased appetite, swollen red tonsils, nausea, vomiting

Verbal pain intensity scale

no pain, mild pain, moderate pain, severe pain, very severe pain, worst possible pain - Where is your pain?: Mark on the drawings to areas where you feel pain. E if external and I if internal. EI if both.

Health Promotion - under 21 and pregnancy

no safe level - legal risk - accident risk

General survey - physical appearance - overall appearance

no signs of distress - cardiac or respiratory signs, clutching the chest, pain, wheezing

Why is the jugular vein assessment important?

no valve between superior vena cava and right atrium, so indicator of heart function

Tender vs Non-tender lymph nodes

non-tender classical for malignancy

Epstein pearls on palate are --- finding in newborns and infants

normal - small, whitish, glistening, pearly papules along median raphe of hard palate an on gums, where they look like teeth - small retention cysts that disappear in first few weeks

Inspection and Palpation of the Skill: Size and shape - Cranial bones that have?

normal protrusions

Inspection and Palpation: Skin - texture

normal skin feels smooth and firm with even surface

torus palatinus

normal variation, is a nodular bony ridge down middle of hard palate; benign growth arises after puberty and is more common finding in American Indians, Inuits and Asians

Abnormal findings: red eye - vascular disorders - subjunctival hemorrhage

normal when coughing hard, self resolving as long as not going into cornea area

Observe uvula

normally looks like fleshy pendant hanging in midline; ask a person to say "ahhh" and note soft palate and uvula rise in midline - tests on function of cranial nerve X, the vagus nerve

Most newborns are obligate?

nose breathers - nares blocked with amniotic fluid are suctioned gently with a bulb syringe - if obstruction suspected, a small-lumen catheter is passed down each naris to confirm patency

When you are born, cranial bones are?

not fused together - brain needs time to grow - birthing process

For a person with a hearing aid,

note any irritation on canal wall from poorly fitting ear molds

Lashes

note that eyelashes are evenly distributed along lid margins and curve outward

Compare number of teeth with?

number expected for the person's age

Heart rate

number of complete cardiac cycles/min

Percussion sounds may sound different on?

obese and body builders so a lot of nursing professionals do not use this - scapula, vertebrae, and below 10th vertebrae sound different

endogenous obesity

obesity caused by hormonal disorders

Vital signs

objective measure of the body's basic functions.

Age less than four

observational/behavioral scale such as FLACC

Physical examination: Infants and children - skull - fontanels

observe anterior and posterior fontanel to see if bulging or sunken, if theyre closed

Inspection and Palpation: Nails - Consistency

observe for smooth, regular, not brittle or splitting, uniform nail thickness

Inspection and Palpation: Skin - thickness

observe for thickened areas(callus formation)

Chemotherapy-induced pain

occurs during or after chemotherapy treatment for cancer. Risk increases with the number of agents used in the course of treatment, higher doses, preexisting neuropathy. Numbness, burning, shooting pain.

DVT complications - pulmonary embolism

occurs when a dislodged blood clot travels to the lungs, where it can partially or completely block a pulmonary artery or one of its branches - 1/3 of DVT patients - thrombosis is a fixed clot

decreased fremitus occurs with

occurs when anything obstructs transmission of vibrations. i.e. obstructed bronchus, plerural effusions or thickening, emphysema, pneumothorax

early clubbing

occurs with congenital heart disease, hypoxia, lung cancer, cystic fibrosis, graves disease, chronic lung disease, malabsorbtion, crohns the angle straightens out to the nail base feels spongy to palpation, then the nail becomes convex as the digit grows - make a heart with pointer fingers and if no gap with light = clubbing

Posterior thoracic landmarks - The spinous processes

on all vertebrae for ligament and muscle attachment project posteriorly.

AV node (atrioventricular node)

on base of right atrium(backup pacemaker - slower) Receives impulse from SA node and slowly passes the signal to the AV bundle. Pause for atrial kick before sending signal.

Common skin lesions - Tinea versicolor

on light complection it is scaley of pink, tan or white irregular color - where you are hot and sweaty, fungi gets overgrown

bronchus

one of the two tubes that connect the lungs with the trachea

Alcohol abuse

one or more of these - legal trouble, failure to fulfill a role, social problems, continued use

Cluster headache

one side, behind eye/temple/forehead/cheek, piercing, burning, continuous, alcohol, stress, wind/heat exposure, napping

Migraine

one side, stabbing/throbbing going through the eye, rapid onset with peak in 2 hours can last 72 hours, can have back to back, genetic related, hormonal flucuation

Cornea and lens test - there should be no

opacities(cloudiness) in cornea, anterior chamber, or lens behind the pupil - do not confuse an arcus senilis with an opacity; arcus senilis is normal finding in aging persons

open/closed comodone

open: black head closed: white head

The AUDIT does not screen for what?

opioids

Opioid

opium or any of the drugs derived from opium, including morphine, heroin, and codeine

Most common causes of decreased visual functioning in older adults - Age-related macular degeneration

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

Most common causes of decreased visual functioning in older adults - glaucoma

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

Most common causes of decreased visual functioning in older adults - cataract formation

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

Neural control - humoral regulation

or the change in carbon dioxide and oxygen levels in the blood and to a lesser extent, the hydrogen ion levels is what causes us to breathe

Inspect carefully entire U-shaped area under tongue behind teeth

oral malignancies are most likely here

Abnormalities of external ear: Mastoiditis(mastoid bone involvement)

otitis media can lead to this, severe, if going into bone and getting it infected the patient can go septic, if there are lots of pain in ear after antibiotics want to make sure the bone is or is not involved, ER if it is, IV antibiotics

For adults, BMI is a good indication for?

overall health for adults, based on height and weight

Abnormal findings: Lumps and Lesions on External Ear - keloid

overgrowth of scar tissue

Lymph Nodes: superficial cervical

overlying the sternomastoid muscle

Physical examination: Infants and children - skull - molding

overriding of the cranial bones during birth process that resolves over a few days or a week

The provider needs to be attune to and monitor his or her ---- as well as the client's.

own aspirations

inflating too high

pain

Effects of opiods

pain relief and euphoria

PAINAD

pain scale for older adults who have advanced dementia

referred pain

pain that is felt in a location other than where the pain originates

acute pain

pain that is felt suddenly from injury, disease, trauma, or surgery

claudication

pain, tension, and weakness in a leg after walking has begun, but absence of pain at rest

Lymph nodes and thyroid gland should not be

palpable - if have issues with lower one want to check upper one so can look for drainage

Developmental competence infants and children - superficial nodes may be?

palpable even when child is healthy because they are larger in general - note characteristics of any palpable lymph nodes and if they are local or generalized

If an injury is reported or suspected,

palpate gently for any pain or break in contour

Where do you palpate the carotid artery?

palpate middle of neck or lower because higher up there is a coronary sinus that will make the heart rate drop

Neck Vessels - Palpation and Auscultation - palpate carotid artery

palpate only one carotid artery at a time to avoid compromising arterial blood to brain - not doing pulse, just quality - smooth contour and amplitude(2+),

Abnormal Facial Appearances - Bell palsy

paralysis on one side of the face as a result of LMN lesion

The first four vital aspects of the spirit of MI is that it involves?

partnership

patent ductus arteriosus

passageway between the aorta and the pulmonary artery remains open after birth. hasnt closed correctly

The health history provides a complete picture of the persons?

past and present health. It describes the individual as a whole and how the person interacts with the environment. It records health strengths and coping skills. The history should recognize and affirm what the person is doing right.

Make sure to include cultural and genetic questions where?

patient-centered care to indicate risk factors or additional health promotional items - goggles for hob, sunglasses, eye wear for sports

database

patients record and lab studies. From the database you can make clinical judgements or diagnosis about the individual's health state, response to actual or potential health problems, and life processes.

Aging adult: May have ____ earlobes with linear wrinkling because of loss of elasticity of pinna

pendulous

Nociception

perception of pain

panic attack

period of extreme fear or discomfort that develops abruptly; symptoms of panic attacks are both physiological and psychological

General survey - physical appearance - level of consciousness

person is alert and oriented - confused, drowsy, lethargic

General survey - body structure - posture

person stands erect as appropriate for age - rigid spine, moves as one unit, stuff, tense

Every SPO2 result must be evaluated in context of?

person's hemoglobin level, acid-base balance, and ventilatory status(rate and pattern, ventilator)

Hypertensive

pertaining to or suffering from high blood pressure - 130 or higher, 80 or higher

As you proceed through the health history, the measurements and vital signs, consider to make notes on:

physical appearance, body structure, mobility, and behavior

Age 4-12

pictorial self-report scale such as Wong Baker Faces, FPS, and oucher scale

abnormal inspection - pectus carinatum

pigeon chest - a chest that protrudes like the keel of a ship

chloasma

pigmentary skin discoloration usually occurring in yellowish brown patches or spots

Inspection and Palpation of the Skill: Size and shape - Assess shape

place fingers in person's hair and palpate scalp

The agency privacy officer is the first?

point of contact for privacy issues, their job to inspect the privacy breach

Patients who have limited English proficiency are at risk for?

poor health care outcomes due to the barrier that language presents during health care delivery instructions - health care facilities may have established interpreters who can assist with therapeutic communication

Objective Data Preparation

position a person standing for vision screening; then sitting up with head at your eye level

Effective care

positive outcomes and satisfaction for patient

Fraud detection methods

post payment claim reviews, recovery audit contractors

Mean arterial pressure

pressure that propels blood to tissues. Greater than 60 mmHg to maintain adequate tissue and organ transfusion. - SP+2(DP)/3

Neural control - our breathing is?

pretty much automatic without our awareness in response to cellular needs

Health prevention

prevention can be achieved through counseling from primary care providers designed to change people's unhealthy behaviors related to smoking, alcohol and other drug use, lack of exercise, poor nutrition, injuries, and STIs. Health promotion is a set of positive acts that we can take.

acculturation

process of adapting to and acquiring another culture

Diagnostic reasoning

process of analyzing health data and drawing conclusions to identify diagnosis.

Socialization

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

Assimilation

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

Inspection and Palpation: Nails - Shape and contour

profile sign: view index finger at its profile and note angle of nail base; it should be about 160 degrees

School age sequence

progress from head to toe like an adult, examine alone

Vibrations are most prominent where?

prominent between scapula and around sternum(major bronchi - closest to chest wall) and will decrease as move down. Easier to feel on someone with thin chest wall - Obese or muscle harder to feel.

Genetic attributes of dark-skinned individuals afford?

protection against skin cancer due to melanin

perception of pain

protects the body from damage, and is stimulated by extremes of pressure and temperature, as well as chemicals released from damaged tissues

Arm abnormalities - Lymphedema

protein rich fluid accumulates in interstitial spaces of arm - when remove axillary lymph nodes(breast cancer) - need to wear a compression garment, strength draining, elevation

Abnormal findings: eyelid abnormalities - exophthalmos

protruding eyes, eyes are opened and widened, lid is lagging, hyperthyroidism

meningomyelocele

protrusion of the spinal cord and meninges through a defect in the vertebral arch of one or more vertebrae

SBAR - situation

provide a brief description of pertinent patient variables, demographics, clinical diagnosis, and location

Why? HEENT - the eyes

provide information about neurological function

Eyes - External Anatomy: Lacrimal apparatus

provides irrigation to the eye

What does the pulmonary artery and pulmonary veins do?

pulmonary artery carries deoxygenated blood to the lungs and the pulmonary veins carry oxygenated blood back to the heart from the lungs

When assessing for the presence of bronchophony, the nurse notes clear and more distinct words over left upper lobe:

pulmonary consolidation(pneumonia)

Measurement of oxygen saturation

pulse oximeter - arterial oxygen saturation

Pulse oximeter

pulse rate and oxygenation

veins - skeletal muscle pump

pumping effect of contracting skeletal muscles on blood flow through underlying vessels

Heart structures - Chambers - Right ventricle

pumps deoxygenated blood to the lungs

Normal response includes

pupillary constriction, convergence of axes of eyes - record normal response to all these maneuvers as PERRLA, or Pupils Equal, Round, React to Light, and Accommodation

turbinates (conchae) are

quite vascular and tender if touched - note any polyps, benign growths that accompany chronic allergy, and distinguish them from normal turbinates

Some groups carry an excess burden of CVD?

race, ethnicity, gender, socioeconomic status, education - less access to care, not educated on ways to decrease CVD, lack of money for healthy food

Side of the thumb pulse side

radial pulse

In children older than 2, where do you find pulse?

radial site - count pulse for full minute

Facial nerve

raise eyebrows, close eyes as tight as can, puff out cheeks, purse lips, bare teeth

Tachypnea vs bradypnea

rapid breathing vs slow breathing

Abnormal Findings: Swellings of Head and Neck - parotid gland enlargement

rapid painful enlargement seen in response to mumps, blockage of duct, abscess, or tumor

Lability

rapid shift of emotions

atrial fibrillation

rapid, random, ineffective contractions of the atrium - easier to have a clot and stroke

Health literacy is more than just the ability to?

read - includes understanding and following directions that lead to effective communication between the patient and the health care provider - a patient may be literate but not have health literacy

External Canal - note any

redness and swelling, lesions, foreign bodies, or discharge

Routine practices are designed to

reduce the risk of transmission

R-efferal to T-reatment

referrals to specialty care for patients with substance use disorders

As you introduce an object to infant's line of vision, not these attending behaviors: birth to 2 weeks

refusal to reopen eyes after exposure to bright light; increasing alertness to object; infant may fixate on an object

What is breathing normally like?

relaxed, regular, automatic, and silent - passive activity

Bronchophony

repeat 99 in auscultation locations or abnormal location - if clearly say it then abnormal - normal is indistinct - consolidation

Abnormal findings: tympanic membrane - scarred drum(TM)

repetitive damage and scar tissue overgrows

Stronger, more efficient heart muscle pushes out a larger stroke volume with each beat, thus?

requiring fewer beats per minute to maintain a stable cardiac output

Afterload

resistance the ventricles must overcome to eject blood into systemic circulation - high blood pressure ventricle will have to squeeze harder

systemic vascular resistance

resistance to blood flow out of the left ventricle created by the systemic circulatory system. Raises blood pressure

Viscosity

resistance to flow

Why is respiratory system important in babies?

respiratory arrest in peds is common cause of heart stopping. All respiratory issues taken seriously - Small airways and less control of breathing

Neural control - involuntary control of breathing is regulated by the?

respiratory center in the brainstem which is the pons and the medulla

Nose

responsible for warming, moistening, and filtering incoming air, begins respirations

Oral sublingual site has?

rich blood supply from cartid arteries that quickly responds to changes in inner core temperature.

Which veins are involved in returning fluid to venous system?

right and left subclavian which returns to venous system which then returns to heart

Listen laterally on the patients chest in order to hear the?

right middle lobe and some of the lower lobes on the patients sides

tinnitus

ringing or buzzing in the ears

Ask the person to touch tongue to?

roof of mouth - ventral surface looks smooth, glistening, and shows veins

Testing hearing acuity for infants and young children - environment

room should be silent and baby contented; make a loud sudden noise

lateral rectus

rotates eye laterally

Inspection and Palpation of the Skill: Size and shape - normocephalic

round and symmetric

deep veins

run alongside deep arteries and conduct most of the venous return from the legs - femoral, popiteal, anterior and posterior tibial

Egophony

say "E" and hear "A" due to distortion caused by consolidation of a lung - normal hear E - pleural effusion

Infants and children sclera

sclera should be white and clear, although it may have a blue tint as a result of thinness at birth; lacrimal glands are not functional at birth

Erosion

scooped out, shallow depression in skin, if something sits on the skin for too long. Diapers

Key points for screening include all the following except:

screen only indicated patients/clients

SBIRT defined

screening, brief intervention, and referral to treatment(SBIRT) is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services. It is used for - persons with substance use disorders - those whose use is at higher levels of risk

Breast cancer is the?

second most common cancer among women in the US

Developmental competence - the pregnant women: increase in metabolism leads to increase?

secretion of sweat and sebaceous glands to dissipate heat

Excoriation

self-inflicted abrasion on skin due to scratching

External ear

sensing organ, important to hear to sense our surroundings

Air conduction route through ear canal and middle ear usually the more

sensitive route

Title VI of Civil Rights Act of 1964

services cannot be denied to people of limited English proficiency

National standards for culturally and linguistically appropriate services in health care

set of 15 standards provides blueprint to improve quality of care and eliminate health disparities for culturally diverse populations.

General survey - physical appearance - sex

sexual development is appropriate for sex and age, if transgender, note the stage of transformation - delayed or precocious puberty

Cornea and lens test

shine light from side across cornea, and check for smoothness and clarity - oblique view highlights any abnormal irregularities in corneal surface

If the person is unable to see even the largest letters,

shorten distance to chart until the person sees it, and record that distance

Infant's and young child's external auditory canal is?

shorter and has a slope opposite to that of adult's

Accessory nerve

shrug shoulders and dont let push down, turn head to right and dont let hand stop you

Once you complete data collection, develop a list of?

significant signs and symptoms. cluster together the assessment data that appear to be associated or causal. Validate information and fill in the gaps.

Amphetamines

similar to cocaine, talkativeness, agitiation, impaired judgement - withdrawal: similar to cociane

Consensual light reflex

simultaneous constriction of the other pupil

Aging adult position

sitting on table, frail may need to lay supine, arrange the sequence as few position changes, rest period when needed

Adolescent position

sitting on table, try to keep street clothes on and work around them

School age position

sitting or lying on the table. Let 11-12 decide if want caregiver present

Toddler position

sitting up on the caregivers lap for all the examination, supine, enlist caregiver to help position toddler during invasive procedures

What do note for iris and pupil?

size, shape, equality of pupils; normally pupils appear round, regular, and of equal size in both eyes

Burns

skin injuries caused by heat, electricity, radiation, chemicals - treatment based on size and layers of skin affected - seek treatment if its 3 in in diameter, located on face, hands, feet, groin, major joint

Sinus Arrhythmia

skipping a beat

Infant sequence

sleeping baby to listen to heart, startle reflex at the end

Pleurae are?

slippery, serous membranes - visceral: surrounds lung themselves - parietal: surrounds cavity - fluid allows them to slide easily

Abnormal Findings: Lesions on the eyelids - Hordeolum(stye)

small purulent infection of sebaceous gland of eye treated with hot compresses and surgical incision; also called hordeolum

Objective Data Equipment needed

snellen eye chart, handheld visual screener, opaque card or occluder, penlight, applicator stick, opthalmoscope

New health care delivery frameworks must strive for?

social and physical environments that promote quality of life free from preventable illness, disabiility, and premature death.

An individuals health status is influenced by a constellation of factors known as?

social determinants of health. - economic stability - education - social and community context - neighborhood - built environment - health and health care

Aging adults - xanthelasma

soft, raised yellow plaques occurring on lids at inner canthus - they commonly occur around fifth decade of life and more frequently in women, occur with both high and normal levels of cholesterol, and have no pathologic significance

Consistency of lymph nodes

soft, rubbery, hard

If TM intact and no current infection present, a method of cleaning canal is to?

soften cerumen with a warmed solution of mineral oil and hydrogen peroxide - irrigate with warm water with a bulb syringe or a low-pulsatile dental irrigator - direct fluid to posterior wall; leave space around irrigator tip for water to escape

intercostal space

space between the ribs

Musculoskeletal pain

spasm, joint stiffness

communicating with deaf

speak slow and supplement with hand gestures, dont speak loud, written communication or interpreter

Developmental Adaptation last population

special needs population - drug and alcohol abuse - emotional distress

How does heart rate vary with the respiratory cycle?

speeding up at peak of inspiration and slowing to normal with expiration. - inspiration momentarily causes a decreased stroke volume from left side of the heart. To compensate, heart rate increases.

global aphasia

spontaneous speech is absent or reduced to few words or sounds. Comprehension is absent or reduced to only their name and select words

Making a loud sudden noise in newborn

startle(moro) reflex, acoustic blink reflex

Malignant skin lesions - basal cell carcinoma

starts as very small, pink/red papule, goes to translucient top, difficult to remove due to bleeding, red ulcerated center that can look like a large pore

To activate tuning fork, hold it by?

stem and strike tines softly on back of your hand - perform weber and rinne tests

Major neck muscles

sternomastoid and trapezius are innervated by cranial nerve XI

What is the thoracic cage made up of?

sternum, twelve pairs of ribs, and twelve thoracic vertebrae

exotropia strabismus

strabismus in which there is deviation of the visual axis of one eye away from that of the other eye, resulting in diplopia; also called wall-eye and divergent strabismus

Contractility

strength of contraction

What is force of pulse?

strength of heart stroke volume

Normal ranges of blood pressure are affected by?

stress, exercise, age, weight, emotions, gender, race, so will vary throughout the day.

Abnormal findings: red eye - vascular disorders - allergic conjunctivitis

stringy, red, injected look - bilateral, itching, thin, stringy clear discharge

systolic pressure

strongest, maximum pressure

Nose may appear more prominent on face from loss of?

subcutaneous fat - in edentulous person, mouth and lips fold in, giving a purse-string appearance

Beneath these layers is a ---- layer of ---- tissue

subcutaneous; adipose - stores fat for energy, provides insulation for temperature control and aids in protection

A symptom

subjective sensation that the person feels from the disorders

Physical examination: Infants and children - two common variations - cephalohematoma

subperiosteal hemorrhage, well defined over one cranial bone over periosteum reabsorbed during first few weeks of life

Mouth and throat normal finding in infants is

sucking tubercle, a small pad in middle of upper lip from friction of breastfeeding or bottle-feeding - note number of teeth and, if appropriate for childs age - note pattern of eruption, position, condition, and hygiene

paroxysmal nocturnal dyspnea

sudden awakening from sleeping with shortness of breath

Abnormal findings: eyelid abnormalities - enophthalmos

sunken eyes

Abnormal Facial Appearances - Cachectic appearance

sunken eyes, hollow cheeks, and defeated expression that accompanies chronic wasting diseases

Aging adult eyes may appear

sunken from atrophy of orbital fat; orbital fat may herniate, causing bulging at lower lids and inner third of upper lids

Lymph nodes: posterior auricular(mastoid)

superficial to mastoid process

first degree burn

superficial, red, dry, no blisters, mild pain, epidermis - cool water, antibitoic ointment, bandage

Disease Causation Theories - magicoreligious

supernatural powers predominate in area of health and illness - voodoo, witchcraft, faith healing

coronary arteries

supply oxygen-rich blood to the myocardium - decrease in blood flow = heart attack

First function of the respiratory system

supplying oxygen to the body for use in the body to maintain functions of life at the cellular level - capillaries

Risk factors or venoustasis

surgery, prolonged standing or sitting, bedrest, trauma to vessel, hypercoaguable state(blood clot easier)

Precordium Inspection and Palpation - Heaves and Lifts

sustained forceful thrusting - right is at the sternal border - left is at the apex - due to heart enlargement (hypertrophy)

Bones of neonatal skull are separated by?

sutures and fontanels, spaces where the sutures intersect - these membrane-covered "soft spots" allow growth of brain during first year; gradually ossify

Abnormal findings: tympanic membrane - otitis media with effusion

swollen ear drum, fluid

Peripheral Neuropathy

symmetric damage to peripheral nerves, resulting in pain without stimulation of the nerves. Numbness or tingling.

General survey - physical appearance - facial features

symmetric with movement - immobile, drooping

A full mental status exam is what?

systematic check of emotional and cognitive functioning, health history interview is when can be done, but not always needed to be done - find abnormality in behavior .

Cardiac pain

tachycardia, elevated blood pressure, increased myocardial oxygen demand, increased cardiac output

rapid respirations

tachypnea - over 20 breaths per minute

Crying enhances?

tactile fremitus and breath sounds - have parent hold baby - breath sounds when sleeping - warm stethoscope

Height measurements

tape measures, wall mounted, scale

Polycyclic

target shapes coming together

Compliance and Code of Ethics

teaches polices that prevent violation of federal and state laws that address fraud, abuse, and waste prevention

Thermometer

temporal artery, tympanic membrane, rectal, oral(mercury, electronic)

The temporal artery lies superior to?

temporalis muscle, and pulsation is palpable anterior to ear

Abnormalities of external ear: frostbite

tenderness, burning, swollen, redish blue, could cause permanent damage

Posterior Assessment - Palpation: Chest wall

tenderness, lumps, masses, skin temperature, moist or dry skin

hypothesis

tentative explanation for a cue or set of cues that can be used as a basis for further investigation.

Denver II screening test

test gives a chance to interact directly with child to assess mental status -For child from birth to 6 years of age, Denver II helps identify those who may be slow in development in behavioral, language, cognitive, and psychosocial areas -An additional language test is the Denver Articulation Screening Examination

Infants and children color vision test

test only boys for color vision, once between ages 4-8; use ishihara test

Sense of smell, mediated by cranial nerve I, is usually not?

tested in a routine exam

Preload

the degree of myocardial fiber stretch at the end of diastole and just before contraction - how much blood is returning to the heart and able to fill the heart before systole

health literacy

the degree to which someone can obtain, process, and understand basic health care and services needed to make appropriate decisions - what do you clients really understand?

ambivalence

the existence of opposing emotions toward an idea, object, person

The interview

the first point of contact with a client and the most important part of data collection

Health history for the ill person

the health history includes a detailed and chronologic record of the health problem.

Health history for everyone

the health history is a screening tool for abnormal symptoms, health problems, concerns.

Health history for the well person

the history is used to assess his or her lifestyle

dysarthria

the inability to use speech that is distinct and connected because of a loss of muscle control after damage to the peripheral or central nervous system

Neural control - Hypercapnia

the normal stimulus to breath is an increase in carbon dioxide in the blood which is called this - low oxygen levels too

Try to reduce any anxiety so that the data will more closely describe?

the persons natural state. Act like a patient so that you can deal with the real situation while still in a safe setting

The costal angle

the right and left costal margins form an angle where they meet at the xiphoid process. - wider in old age, pregnant women, children

Heart structures - Chambers - Right atrium

the right upper chamber of the heart that receives blood from the venae cavae and coronary sinus

What is the general survey?

the study of the whole person. begin at the moment you first encounter a person, kind of like a judgement call, but dont make assumptions.

During the first few days, TM often looks

thickened and opaque; may look "injected" and have mild redness from increased vascularity - looks injected after crying

Sublingual glands

third pair of salivary glands that lies in the floor of the mouth

Present health or history of present illness for the well person

this is a short statement about the general state of health

JVD (jugular vein distention)

this is bulging of the external jugular vein which indicates increased blood volume and usually congestive heart failure (CHF)

Present health or history for the ill person

this section is a chronological record of the reason for seeking care, from the time the symptom first started until now

Lungs are located in the?

thoracic cavity

Respiratory dead space is important for?

those on ventilators because when a patient is on one it increases their dead space so need to make sure setting is correct to not cause lung injury with too much dead space

Culture

thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups

Weak pulse force

thread pulse reflects a decreased stroke volume

Alcohol dependence

three or more of these - tolerance, diminished effect, withdrawal, investment in drinking/use behavior, unable to cut down

Dull

thudlike sounds are normally heard over dense areas such as the heart or liver

General survey - mobility - no involuntary movement

tics, tremors

Because oral exam is intrusive for infant or young child, ---- is?

timing is best toward end with ear exam

Infant preparation

timing should be 1 or 2 hours after feeding, maintain warm environment, diaper only, touched is okay keep warm, soft voice, eye contact, smile, smooth movements, pacifier for crying, bright toys.

Alveoli

tiny sacs of lung tissue specialized for the movement of gases between air and blood

Be discriminating in use of?

tongue blade; it may be necessary for a full view of oral structures, but it produces a strong gag reflex in infant - may avoid tongue blade completely with cooperative preschooler and school-age child

Mobility should allow ---- to extend at least as far as ----

tongue; alveolar ridge - note any bruising or laceration on buccal mucosa or gums of infant or young child

Tonsils in infants and children

tonsils are not visible in newborn; gradually enlarge during childhood, remaining proportionately larger until puberty - tonsils appear still larger if infant is crying or gagging

Taking blood pressure reading when person is angry or active

too high

Dorsal pedis (pulse site)

top of foot - if can't find pulse get a doppler and mark it so can find it, if can't find then there is a problem

Bednar aphthae are?

traumatic areas or ulcers on posterior hard palate on either side of midline; result from abrasions while sucking

Mitral valve closes just before?

tricuspid so may here two sounds during lub. Aortic closes before pulmonary.

Bruit

turbulent blood flow from narrowing or occluding of artery

Aging adult: presbycusis

type of hearing loss that occurs with aging, even in people living in quiet environment - gradual sensorineural loss caused by nerve degeneration in inner ear or auditory nerve

History of head or neck surgery health history questions

type of surgery, reason for surgery, response to surgery

Atrophic tissues ---- easily

ulcerate - increasing risk for older people for infections, such as oral moniliasis and malignant lesions

Abnormal Findings: Lesions on the eyelids - Basal cell carcinoma

ulceration

Abnormal findings: Lumps and Lesions on External Ear - carcinoma

ulceration or destroyed tissue which will bleed

side of pinky pulse

ulnar pulse

Wood's light

ultraviolet light used for diagnosing skin conditions - other(magnifying glass, potassium hydroxide and glass slide)

BMI underweight is considered

under 18.5

Lymph Nodes: Jugulodiagastric

under the angle of the mandible

Proficient nurse

understands a patient situation as a whole rather than a list of tasks.

Pain in older adults if very often?

undertreated, and it may be especially so in older adults with severe dementia. Changes in a patient's ability to communicate verbally present special challenges in treating pain, since self-report is considered the gold standard of pain assessment

palmar erythema

unusual redness of the palms of the hands

According to recent estimates, which of the following sources of health care waste has had the largest financial impact?

unwarranted use of medical resources or services

Avoid middle ear insufflation in a person with?

upper respiratory infection because it could propel infectious matter into middle ear

By age 2 or 3, use what type of scale?

upright scale, for age 2-3, measure child's height by standing child against pole on platform scale or back against a flat ruler taped to the wall

Second level priority

urgent/require prompt intervention to halt further deterioration(ie. Mental status, acute pain, urinary elimination problems, risk for safety, risk for infection)

Rental pain

urinary retention

Unbundling

use multiple codes that can be represented by a single code

Toddler preparation

use symbols, greet the child, do not like taking off clothes, like to make choices, demonstrate procedures on caregiver, praise the child

crying

use touch, gained insight to a serious concern

Snellen alphabet chart is most commonly?

used and accurate measure of visual acuity - it has lines of letters arranged in decreasing size

When documenting for hearing acuity

useful to document presence of hearing loss - refer to any abnormal findings for more accurate measures with pure tone audiometry

Notice any breath odor, halitosis

usually due to local cause; poor oral hygiene, consumption of odor food, alcohol, smoking, or dental infection

Teeth, both sets, begin development in?

utero

Facial bones grow at?

varying rates - in toddler, mandible and maxilla are small and nasal bridge is low

Developmental competence pregnant women: hormonal changes cause?

vasodilation and a resulting drop in blood pressure

expert nurse

vaults over the steps and arrive at a clinical judgement in one leap.

superficial veins

veins located near the body surface - cephalic, cubital, saphenous

QRS complex

ventricular contraction(depolarization)

T wave

ventricular repolarization(relaxing)

Preschool preparation

verbal communication, but understanding limited, underdress, explain steps of exam, enhance autonomy, allow child to play with equipment to reduce fears, use games, use slow approach, give feedback, compliment the child

Posterior thoracic landmarks - Reference Lines

vertebral line scapular line

Surface of incisors may show?

vertical cracks from a lifetime of exposure to extreme temperatures

What structures are in the neck?

vessels, muscles, nerves, lymphatics, and viscera of respiratory and digestive systems

What composes the vestibular apparatus?

vestibule and semicircular canals within bony labyrinth - cochlea contains central hearing apparatus

Childs age determines

visual acuity screening measures used

Stroke volume

volume of blood ejected from left ventricle with each cardiac cycle; influenced by 3 variables(preload, afterload, contractility)

Cardiac output

volume of blood in liters is ejected by heart each minute - CO = HR * SV

Prevention

wash off makeup, wash eyelids, wash and dry hands before touching eyes, keep contacts clean, replace eye makeup, dont rub the eyes

Function of skin

waterproofing, protecting, adaptive, sensation, temperature regulation, self identifying, communicate with body, wound repair, vitamin D

General survey - body structure - Nutrition

weight normal for height and body build - obesity, cachetic, emaciated

Provoking or palliating factors

what brings it on? What makes it better? What makes it worse? What makes it better or worse?

Understanding your impact

what do you believe is causing this? How is this affecting your ADLs you and/or your family? Do you have any other concerns?

person

what is your name?

When should thigh pressure be obtained?

when blood pressure at the arm is abnormally high, it should be compared to thigh pressure

Time and treatment

when did he symptoms first begin? What medications are you currently taking for this? How effective are these? Side effects? Intermittent, constant?

Onset

when did it begin? How long does it last in duration? How often does it occur? What were you doing when the pain started?

Transmission occurs when?

when droplets containing microorganisms generated during coughing, sneezing and talking are propelled through the air. These microorganisms land on another person, entering that new person's system through contact with his/her conjunctivae, nasal mucosa or mouth

Stepping reflex

when placed upright with weight bearing on the feet, a baby will make stepping motions

Abnormal findings: Lumps and Lesions on External Ear - battle sign

when there is trauma to side of head that leads to fracture behind the ear

The only places in your heart that do not contain valves are?

where the little holes of the heart are(where backing up and increase in pressure is)

Ask family or caregivers what?

whether the patient's behavior is different from their customary behavior.

Abnormal Conditions of the Nails - Beau lines

white lines across the fingernails; usually a sign of systemic disease or injury

Increased likelihood of skin cancer in?

whites than in black and hispanic populations - if blacks get than its later detected and more serious

Common skin lesions - allergic drug reaction

widespread red rash that is generalized

From an MI perspective, the assumption is there is a deep well of ---- and ----- within the person from which the counselor can draw - a key element in MI

wisdom and experience

size of lymph nodes

with less than 2 cm considered insignificant

Where does the motivation for change come from?

within the client

anxiety

worried, uneasy, apprehensive from the anticipation of a danger whose source is unknown

Aging adult - as a result of atrophy of elastic tissues, skin around eyes may show

wrinkles or crows feet; upper lid may be so elongated as to rest on lashes, resulting in pseudoptosis

icteric sclera

yellow sclera

What do safety assessments protect?

you and your clients

Gift from a patient

you must maintain professional integrity, if gift has cash value cannot accept, if edible can accept it.

Wong Baker FACES

· 0 = no hurt · 2 = hurts little bit · 3 = hurts little more · 6 = hurts even more · 8 = hurts whole lot · 10 = hurts worse Used in children 4-12 years. Score 0-10.

CHEOPS

· 6 categories, each with 3-4 levels · Total score 4-13

Assessing pain

· Assess pain as part of general patient care · Every patent experiencing pain should be considered a candidate for pain management, regardless of transport time

Alder Hey Triage Pain Score

· Developed specifically for emergency setting · Total score range 0-10

Normal temperature is influenced by?

· Diurnal cycle: of 1F to 1.5F, with trough occurring in early morning hours and peak occurring in late afternoon to early evening · Menstruation cycle in women; progesterone secretion change normal temperature variations · Exercise · Age - smoking, chewing gum, hot or iced liquids

Planning

· Establish priorities · Develop outcomes · Set timelines for outcomes · Identify interventions · Integrate evidence-based trends and research

Aging adult pain

· No evidence suggests that older individuals perceive pain to a lesser degree or that sensitivity is diminished. Not a normal process of aging. Many clinicians assume that pain should be expected in aging, which leads to underreporting of pain and less aggressive treatment. · Dementia does not impact the ability to feel pain but cant report as well

Numerical Rating Scale(NRS)

· Scored 0-10 - Also known as Verbal Numerical Scale(VNS) · Record score as number- 0 0 no pain, 5 moderate pain, 10 worst possible pain

Oucher

· Used in children 4-12 years · Patients point to face that represents pain · Score 0-10

Use a standarized tool to assess pain intensity such as?

· a numerical rating scale(NRS) or verbal descriptor scale(VDS)

Airborne transmission of infectious agents occurs either by?

• Airborne droplet nuclei (small particles of 5 mm or smaller in size) • Dust particles containing infectious agents.

Fraudulent billing

"...the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to himself/herself or some other person..." or "...to purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced."

A nurse is orienting to his new place of employment. Information is being provided regarding HIPPAs privacy rule. Which of the following comments by the nurse indicates an accurate understanding of these standards?

"I can give information about a patient over the phone if the patient gives his permission"

nurse is discussing the use of a computer to document in the clients health record with a newly licensed nurse. which one of the following comments by the new nurse indicates an understanding of the information

"I should remain aware of my surroundings when documenting on the computer."

A 70 year old patient is scheduled for open heart surgery. THe surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, "what happens to my circulation when this vein is removed?"

"This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition"

The pleural cavity is?

"potential space"

Culture has four basic characteristics

(1) learned from birth through the processes of language acquisition and socialization; (2) shared by all members of the same cultural group; (3) adapted to specific conditions related to environmental and technical factors and to the availability of natural resources; and (4) dynamic and ever changing.

Remote memory

(long term memory), verify past events - describe past health history, when is their birthday, what was your first job

Heart Structures - Valves - left atrioventricular valve

(mitral or bicuspid valve) Blood leaving the left atrium flows into the left ventricle through this valve; most commonly replaced due to more pressure on left side of the heart

Pitting edema grading scale

- 0+ no pitting edema - 1+ slight pitting and its hard to see(2mm indentation, disappears immediately) - 2+ mild pitting edema(4mm, disappears 10-25 sec) - 3+ moderate pitting edema(4-6mm, more than 1 minute) - 4+ severe pitting(6mm+, lasts several minutes)

Consolability

- 0: no need to console - 1: distracted or reassured by voice or touch - 2: unable to console, distract or reassure

Negative vocalization

- 0: none - 1: occasional moan or groan. Lowlevel speech with a negative or disapproving quality - 2: repeated troubled calling out. Loud moaning or groaning. Crying

Breathing independent of vocalization

- 0: normal - 1: occasional breathing. Short period of hyperventilation - 2: noisy labored breathing. Long period of hyperventilation. Cheyne Stokes respirations

Body language

- 0: relaxed - 1: tense, distressed pacing, fidgeting - 2: rigid, fists clenched, knees pulled up, pulling or pushing away, striking out

Facial expression

- 0: smiling or inexpressive - 1: sad. Frightened. Frown - 2: facial grimacing

Tonsils graded in size as follows:

- 1+ visible - 2+ halfway between tonsillar pillars and uvula - 3+ touching uvula - 4+ touching each other

Health promotion and patient teaching

- 1,3,6 program of universal newborn hearing screening - early intervention and amplification leads to better outcomes - ear protection - use good hygiene with ear devices - use unnecessary ear devices with caution and limited use - distractions from the use of headphones/electronic devices

Illicit drug statistics

- 12 years and older 10.1% current illicit drug use - marijuana most common 80% - 1-2 in 10 adolescents are illicit drug users - Impacts: legal status, healthy relationships, prospects, school

Age ranges for rectal thermometers

- 3 moths or less need rectal - Up to three years rectal is most accurate, but after use axillary

Lung fields for percussion

- 3 spots on each side of middle upper back - down intercostal spaces 4 times - curve out for the next two - 2 on each side vertical under scapula

Childhood mental disorders

- ADHD - ODD - eating disorder - autism spectrum disorder

Substance Use - standard drink

- Alcohol(one mixed drink with 1.5 fl oz of 80 proof liquor, wine is 5 fl oz, 12 fl oz of beer or wine cooler) - Drug

Environmental noise questions

- Any loud noises at home or on the job?(For example, do you live in a noise-polluted area, near an airport or busy traffic area? Now or in the past?) - Are you hearing other noises such as heavy machinery, loud persistent music, or gunshots while hunting?

Vestibular Apparatus - Romberg sign

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

Inspect with Otoscope: Insert speculum slowly and carefully along axis of canal

- Avoid touching inner "bony" section of canal wall covered by a thin epithelial layer because it is sensitive to pain. - Once in place, you may need to rotate otoscope slightly to visualize all the TM; do this gently. - Last, perform otoscopic examination before you test hearing.(Canals with impacted cerumen give the erroneous impression of pathologic hearing loss)

Pain Scales(quality) Inspection

- CRIES - FLACC - PAIN-AD

Inspect with otoscope: As you inspect external ear, note size of auditory meatus

- Choose largest speculum that will fit comfortably in ear canal. - Tilt the person's head slightly away from you to bring obliquely sloping eardrum into better view. - Pull pinna up and back on an adult or older child to straighten S-shape of canal.(Pull pinna down on an infant and a child under 3) - Hold pinna gently but firmly; do not release traction on ear until you have finished examination and removed otoscope.

To inhibit the transmission of microorganisms by vehicle

- Clean patient equipment between uses with different patients - Handle, store and prepare food properly - Careful store and draw up doses of medication from multidose medication vials.

Rinne test abnormal finding relates to:

- Conductive loss: AC = BC or even longer (AC less than BC) - Sensorineural loss: Normal ratio intact but reduced, the person hears poorly both ways

Microorganisms are transmitted in health care settings by four main routes:

- Contact - Droplet - Airborne - Common vehicle

Factors to review for headaches

- Definition, location, character, duration, quantity, and severity, and timing - aggravating symptoms or triggers, associated symptoms and relieving factors, effort to treat

Respirations(inspection)

- Do not announce this assessment - Count for at least 30 seconds, if abnormality then do full minute if possible - Often measured while still holding a person's pulse - Notice outside 10-20 respirations per minute or abnormal rising and falling of chest then do the full minute

Pain Scales(severity) interview

- FACES - VAS

What does the review of systems consist of?

- General overall health state - Skin, hair, and nails - Ears, eyes, head, nose and sinuses, mouth and throat, neck, breast, axilla, respiratory system, cardiovascular, peripheral vascular, gastrointestinal, urinary system, male genital system, female genital system, sexual health, musculoskeletal system, neurologic system, hematologic system, endocrine system

Additional History for Infants and Children Questions - Does child seem to be hearing well?

- Have you noticed that infant startles with loud noise? Did infant babble around 6 months? Does he or she talk? At what age did talking start? Was speech intelligible? Ever had child's hearing tested? If there was a hearing loss, did it follow any diseases in child or in mother during pregnancy? Does child tend to put objects in ears? Is older child or adolescent active in contact sports?

Hazardous and Harmful drinking

- Hazardous: at risk for adverse consequences - harmful: causing physical or psychological harm

Ask the person directly if there is a hearing difficulty.

- If answer is yes, perform audiometric testing or refer for audiometric testing. - If the answer is no, screen using the whispered voice test.

Pulse(palpation)

- Infant brachial(palpated) - Adult radial(palpated) - Start counting with 0

Integrity of the tympanic membrane

- Inspect TM and entire circumference of annulus for perforations. - Normal TM is intact - Some adults may show scarring, which is a dense white patch on TM, a sequela of repeated ear infections.

Assessing: Objective Data

- Inspection: patient sitting, disrobed to waist - note symmetry, size, shape - skin normally smooth and even in color - discharge, bleeding? - nipples: symmetrical?, flat?, inverted? - observe the axillary and supra clavicular areas for any bulging, discoloration or edema

How to detect skin cancer

- Learn asymmetry, border, color, diameter, evolving - new spots or moles that itch or bleed

During history, notice clues from normal conversation indicating possible hearing loss:

- Lip reading or watching your face and lips rather than your eyes - Frowning or straining forward to hear - Posturing of head to catch sounds with better ear - Misunderstands questions; frequently asks you to repeat - Irritable or shows startle reflex when you raise your voice - The person's speech sounds garbled, vowel sounds distorted - Inappropriately loud voice - Flat, monotonous tone of voice

Blood pressure(ascultation)

- Manual - Automated

Safety precautions

- NOP - fluid restriction - fall precautions - standard precautions

Weber test

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

Temperature(palpation)

- Oral: glass(3-8 minutes)/digital(20-30 sec) - Rectal: Class(2.5 minutes)/digital(30 sec) - Surface: Tympanic membrane(2-3 sec)/Temporal Artery(6 sec) - Say how you got it(oral/rectal/surface) and if it is Celsius or Fahrenheit

Objective data equipment

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

What are the four main areas of a general survey?

- Physical appearance - Body structure - Mobility - Behavior

Two types of pain assessment tools

- Self-report - Observational or behavioral

Risk factors for heart disease

- Smoking - chemicals in vessels that are causing chronic inflammation and rapid building up of plaque - diet - excessive glucose - high blood pressure - sedentary lifestyle - genetic disposition

Vascular lesions - Telangiectases

- Spider or star angioma(small red dot and then star shape around it - pregnancy, chronic liver disease) - Venous lake(purple blue dilation of venules empty or disappear when pressure applied - lips, face, ears, chest)

great vessels

- Superior and inferior vena cava - pulmonary artery - pulmonary vein - aorta

Tympanic membrane - color and characteristics

- Systematically explore landmarks - Normal TM shiny and translucent, with a pearl-gray color - Cone-shaped light reflex prominent in anteroinferior quadrant, a reflection of the otoscope light - Sections of malleus are visible through translucent drum: the umbo, manubrium, and short process. - At periphery annulus looks whiter and dense

Teaching Methods

- Teach Back - Ask me 3 - Plain Language

Electronic Health Record problems

- Technology interface can affect communication in the healthcare provider-patient relationship - doesnt always capture psychological and emotional info - do not allow the computer to become a barrier in the communication exchange process

Evidence based practice

- The conviction that all patients deserve to be treated with the most current and best practice techniques led to the development of evidence based practice. Systemic reviews and clinical trials. - Evidence shows that other assessment skills are effective for patient care.

Steps to Cultural Competence

- Understand one's own heritage-based values, beliefs, attitudes, and practices - Identify meaning of "health" to patient Understand how health care system works - Acquire knowledge about social backgrounds of patients - Become familiar with languages, interpretive services, and community resources available to nurses and patients

Developmental Adaption - Older Adults

- Use last name - Hearing impaired - speak slowly, use gestures, nodding is "friendly"

Wheal vs Urticaria/Hives

- Wheal is superficial, raised, transient, eryothema due to inflammation(scratch kind of hives) - Urticaria are larger and more of a rash and itchy

Abnormal Findings: Pediatrics - Atopic(allergic) facies

- a variety of presentation seen in children who have chronic allergies - include exhausted face, allergic shiners, morgan lines, central facial pallor and allergic gaping

Talking to a victim

- a yes response to AAS questions requires further investigation - assess when the abuse occurred - assess the seriousness of the abuse - convey concern and even distress - emphasize that it is not the persons fault - communicate that help is available red flag: noting physical findings not consistent with history(different colored bruising - still act on it)

Physical exam of someone who has experienced violence

- abrasion - avulsion - bruise - contusion - cut - exxhymosis - hematoma - hemorrhage - incision - laceration -lesion - patterned injury - pattern of injuries - petechiae - stab wound - traumatic alopecia - wound DEFINE FROM BOOK

Health effects of violence

- abuse victims have more chronic health problems/mental health problems(substance abuse, depression)/impacts brain development - physical injury is just the beginning

What type of sensory should i use?

- adhesive sensors are good for children on the earlobe, nose bridge, toe - clip sensors are good for adults

Stages of level of consiousness

- alert - lethargic: not fully alert - obtunded: difficult to arose - stupor: spontaneously unconscious - coma: completely unconscious - delirium: clouding of consciousness

Nictoine

- alert, increased systolic, increased heart rate, vascoconstriction, nausea, vomiting, ingestion, loss of appetite - withdrawal: vasodilation, headaches, anger, irrability, frustration, anxiety, nervousness, depression

Infants and children visual acuity testing

- allen test, picture card, screens children from 2 1/2 to 2 years, 11 months, and is relaible with cooperative toddlers as young as 2 - use picture chart or snellen E chart for preschooler from 3-6; normally a child achieves 20/20 acuity by age 6-7

Communication between personnel and family members

- allows communication as long as the patient hasnt objected - ask patient directly if you may disclose info to this person

Female Breast

- also known as mammary gland - reproductive organs - produce milk

Infants and children developmental competence

- always consider developmental milestones - Denver II screening test

Characteristics of eating problems

- anorexia nervosa - binge eating - bulemia nervosa

Inspection of palate

- anterior hard palate white with irregular transverse rugae - posterior soft palate is pinker, smooth, and upwardly movable

Anterior and Posterior chest in relation to lung lobes

- anteriorly is mostly upper and middle lobe - posterior chest is almost all lower lobes

Aortic aneurysms may be located in the?

- aortic arch - descending/thoracic aorta-above diaphragm - abdominal aorta - below diaphragm(AAA)

The 4 main categories of the mental status assessment

- appearance - behavior - cognition - thought processes

Ask Me 3 guidelines

- ask 3 questions - ask early - write down answers

Under the influence: interview

- ask simple direct questions - avoid confrontation - avoid scolding or disgust - use the spirit of MI and maintain professional reaction to the circumstance

Disease Causation Theories - Biomedical

- assumes cause and effect - views the body as a machine - life can be divided into parts - endorses germ theory

Malignant skin lesions - malignant melanoma

- asymmetrical, irregular boarders, dark color, diameter is larger than 6mm, elevated, looks funny

DVT clinical manifestations

- asymptomatic - pain, swelling, tenderness, redness, warmth at affected area

Diagnostic reasoning four components

- attending to initially available cues, forming diagnostic hypotheses, gathering data relative to the tentative hypotheses, and evaluating each hypothesis with the new data collected arriving at a final diagnosis.

external ear

- auricle and pinna are cartilage that help funnel sound waves - auditory canal which leads to tympanic membrane. Should have wax to protect the eardrum

Abnormal findings: red eye - vascular disorders - conjunctivitis

- bacterial, viral, and allergy related - redness in eye with injected look, different discharge depending on the type - Bacterial and viral are one sided infection - bacterial thick yellow/green, wipes away and comes back, contagious - viral has clear thick discharge and is contagious

health-related beliefs and practices

- balance and beliefs about causes of illness - biomedical or scientific theory - naturalistic or holistic theory(hot and cold, tin and yang) - magicoreligious perspective - traditional beliefs and health healers

What to do when no interpreter is available

- be polite, pronounce name correctly, unhurried, use words you may know in their language, low, moderate voice, simple words, give instructions, discuss one topic at a time, validate they understand, write them if that works for them, ask if family can interpret

homocide risk factors

- being physically abused increases the risk of being killed by the abuser - intervene to decrease the danger

Religion

- belief in a divine or superhuman power, or powers to be obeyed and worshipped as creator/ruler of universe - system of beliefs, practices, and ethical values - shared experience of spirituality

In newborn, test visual reflexes and attending behavior: test light perception using -

- blink reflex: neonate blinks in response to bright light - pupillary light reflex: shows that pupils constrict in response to light

Though process abnormalities

- blocking: interruption in train of thought - confabulation: fabricates to fill in memory gaps - circumlocution: round about expression - circumstantiality: excessive or unnecessary detail - lossening assoications: shifting from one topic to unrelated topic - flight of ideas: abrupt change - word salad: incoherent mixture of words - perserveration: persistent repeating of verbal response - exholalia: imitation - clanging: word choice based on sound

Pregnant Women developmental competence

- blood volume increases by 30-40% during pregnancy for oxygen and nutrients to baby - increases SV(more blood), HR(help move blood), murmur, bigger heart, pseudoanemia

How to use an incentive spirometer - do not do

- blow into rather than inhaling - inhale and exhale quickly

Sending: nonverbal communication

- body language helps to provide cues which may be correlated with truer feelings - recognize importance of unconscious messages

Pregnancy Changes in breasts

- breast changes occur 2nd month of pregnancy - breast enlarge - feel more nodular - nipples grow larger, darker, and erect - areolae enlarge and darken - increase venous pattern - 4th month Colostrum may be expressed

The structures and mechanisms of breathing

- breath in through noose or mouth - trachea - bronchi - acinus: functional unit of lungs(alveoli surrounded by capillaries, pulmonary artery and vein, gas exchange)

Thyroid disorders: Graves Disease

- butterfly look - eyelid retraction - exophthalmos - goiter

When is S3 normal and abnormal?

- can be normal in young adults and children, pregnancy, athletes - may signify severe mitral or tricuspid regurgitation, cardiomyopathy, or heart failure

Level of blood pressure is determined by what five factors?

- cardiac output - peripheral vascular resistance - blood volume - blood viscosity - elasticity of vessel walls

Differential diagnosis of chest pain - cardiovascular

- cardiovascular - pulmonary - gastrointestinal(reflux) - dermatologic(shingles) - musculoskeletal/neurologic(strain, injury, anxiety, depression) - psychogenic

Drugs which induce nystagmus

- central nervous system depressants - most inhalants - dissociative anesthetics - alcohol

Pulse oximetry - inspection

- check skin condition and temperature - capillary refill - make sure skin is free of nail polish, not same limb as blood pressure cuff, dont use thumb - watch waveform(consistent and regular) - check pulse to make sure matches oximeter

Head and neck vessels subjective data

- chest pain - dyspnea - orthopnea - cough - fatigue - cyanosis or pallor - edema - nocturia - past cardiac history - family cardiac history - patient centered care(cardiac risk factors)

palpation of anterior chest

- chest wall - symmetric expansion - tactile fremitus(palm of hand 4 times side to side)

Infants and young children behavorial manifestations of hearing loss

- child is inattentive in conversations - reacts more to movement and facial expression than to sound - facial expression strained or puzzled - asks to have statements repeated - confuses words that sound alike - speech problem - shy and withdrawn - complains of earaches - ears better at times when environment is more conducive

Symptoms of aging ears

- coarse hairs - eardrum is whiter and more opaque, duller, thicker - high tone frequency loss apparent for those affected with presbycusis(revealed in difficulty hearing whispered words in voice test and in difficulty hearing consonants during conversation) - feels like others mumble and feels isolated in family and friends

What makes the oxygen saturation inaccurate?

- cold finger - thick fingernail polish - acyrilic nails

What other things can affect the reading?

- cold(hypovolemia, circualtory compromise, hypothermia)

Inspection and Palpation: Skin - Lesions, if any are present note the following

- color - elevation - pattern or shape - size - location and distribution on body - any exudate: color and odor - use a wood's light(UV light) to detect fluorescing lesions

Summary Checklist - Inspection of the skin, hair, and nails

- color and pigmentation - texture and distribution - shape, contour, and consistency

Inspect the legs

- color(red, pallor) - hair distribution(thin hair or missing - lack of oxygenated blood flow) - venous pattern(varicose veins) - size/symmetry(edema) - lesions or ulcers ANTERIOR AND POSTERIOR

Summary Ear Examination - inspect tympanic membrane

- color, characteristisc, position, integrity - last do the test hearing acuity

Three functions of the middle ear

- conducts sound vibrations from outer ear to central hearing apparatus in inner ear - protects inner ear by reducing amplitude of loud sounds - eustachian tube allows equalization of air pressure on each side of TM so that it doesnt rupture

Conjuntiva and sclera test notes

- conjunctiva clear and show normal color of structure below; pink over lower lids and white over sclera - note any color change, swelling, lesions - ethnic variations

Mental status assessment involves factors such as?

- consciousness, language, mood, affect - orientation and attention - memory and abstract reasoning - though process, through content, and perception

Interpreter - family members

- convenient - may not know/understand medical language - may violate confidentiality

Research demonstrates effectiveness

- cost effectivenss - effective way to reduce drinking and substance abuse problems

Anterior Inspection - shape and configuration

- costal angle of 90 degrees if greater than may have barrel chest

Subjective data collection

- cough - shortness of breath - chest pain with breathing - history of respiratory infections - smoking history - environmental exposure - patient centered care - interrogate more if get yes answer (know highlighted terms in book)

Skin the the largest body organ

- covers 20 square feet of surface area in adults - skin is the sentry that guards body

How can we help?

- create a supportive environment - plain language vs. medical terms - use visual models to explain procedures or tests - asses ability to read and understand by using Teach Back

How many teeth do adults have

- crown, neck, root - adults have 32(16 on top and bottom)

To test pupillary light reflex

- darken room and ask person to gaze into distance; this dilates pupils; advance a light in from side and note response - in acute care setting, pupil size is measured in millimeters before and after the light reflex

For older patients, culture is likely to do the following:

- define their family responsibilities - affect their view and knowledge of health care systems used by dominant culture

Documentation of normal breast exam

- denies breast pain, lump, discharge, rash, swelling, trauma. denies past history of breast disease or surgery - Inspection: breasts symmetric. Skin smooth with even color. No dimpling or retraction elicited. No nipple discharge. No lesions - Palpation: breast contour and consistency firm and homogeneous. No masses or tenderness. No lymphadenopathy - healthy breasts bilaterally with no S/S of abnormalities

A score of 18 on the AUDIT would place a person at which use level?

- dependent use(20+) - harmful use(16-19) - at risk use(8-15) - low risk(0-7)

Modified Allen's Test

- depress radial and ulnar arteries - person opens and closes fist(skin should blanch) Keep thumb on radial artery and release ulnar artery. - normal: blood returns via ulnar artery within 7 seconds(negative) - occluded ulnar artery: no blood return(positive)

Related Organs - Spleen

- destroys old red blood cells - stores red blood cells - produces antibodies and filters the blood

Steps of ABG interpretation

- determine on PH if dealing with acidosis or alkalosis - second step is who is to blame(respiratory or metabolic?). Which one matches? - do we have compensation? is the metabolic or respiratory system trying to compensate?

Alcohol related disorders

- diabetes - liver cirrhosis - oral cancer - esophageal cancer - pharyngeal cancer - liver cancer - cardiomyopathy - atrial fibrillation - hypertension - GI bleeding - birth defects

When would you use ABG?

- diabetic ketoacidosis - renal failure - drug overdose - toxic substance ingestion - sepsis

Developmental Competence - Pregnant Women

- diaphragm is elevated 4 cm from enlarged uterus - costal angle widens 50% - respirations are deeper because fetus is increasing oxygen demands

Words with Multiple Meanings

- diet - dressing - sometimes - frequently - rarely - stool - supper - dinner

Health Promotion and Patient Teaching - Lifestyle changes

- diet - staying active - maintain healthy weight

Emerging Minority Group trends

- differences noted in age, poverty level, and household composition - emerging majority groups tend to be as follows: younger with lower median ages and higher proportions under 18 years old - all ethnic and racial minority groups exceed the national poverty level - family size and multigenerational families are more evident in minority groups

Inspection and Palpation of the Neck: Thyroid gland

- difficult to palpate; check for enlargement, consistency, symmetry, and presence of nodules - position patient for best approach(posterior approach, anterior approach) - auscultate thyroid for bruit, if enlarged

A simple, common instruction "take one teaspoon 4 times each day"

- do i take all 4 teaspoons in the morning or all at night - how long do I wait in between doses? - what could we have said to be more clear to the patient

Infants and children ear examination

- do this as later thing because it is invasive - holding othalmoscope so need barrier with finger or hand since have shorter canal - pull down and back to straighen out ear canal where as an adult you pull up and back

Additional History questions for infants and children

- does child have any birthmarks? - any change in skin color as a newborn? - does child have any rash or sores? - does child have diaper rash? - does child have any burns or bruises? - has child been exposed to contagious or communicable disease? - does child have habits such as nail biting or twisting hair? - what steps are taken to protect child from sun exposure?

Peripheral vascular disease: venous

- dull, achy pain - lower leg edema - pulse present drainage - sores with irregular borders - yellow slough or ruddy skin - location of sores on ankles

Inspect and Palpation - inspect and palpate external ear: size and shape

- ears are of equal size bilaterally with no swelling or thickening - ears of unusual size and shape may be a normal familial trait with no clinical significance

Sweat glands

- eccrine produce sweat - apocrine produce milky secretion and open into hair follicles

Jugular Venous pulse and pressure

- empty unoxygenated blood directly into superior vena cava - two jugular veins present on each side of neck(internal and external)

External factors defining the environment so as to foster communication

- ensure privacy - avoid interruptions - physical environment - dress - note taking

Developmental competence: children

- epidermis thickens, darkens, and becomes lubricated - hair growth accelerates

Skinfold thickness

- estimates body fat - 10th percentile > or < = over/under nutrition - body fat is best indication for risk factors but least convenient

What are some ways that you can garner truthful responses from your clients?

- explain condifentiality agreement - normalize the issue by telling them you screen for alc and drugs with every client - if the client is younger, have time set aside that you speak with them without their parents

Summary Ear Examination - Otoscopic examination

- external canal:redness or swelling - cerumen discharge, foreign bodies or lesions

Infants and children eye developmental competence

- eye exam often deferred at birth because a transient edema of lids from birth trauma or form the instillation of silver nitrate at birth - eyes should be examined within a few days and at every well-child visit thereafter

In adolescence

- facial hair also appears on boys at this time; first on upper lip, then on cheeks and lower lip, and last on chin - enlargement of thyroid cartilage occurs, and with it, the voice deepens

Infants and Children developmental competence

- fetal heart begins to beat after 3 weeks gestation - inflation and aeration of lungs at birth produces circulatory changes - oxygen comes from placenta so no blood to the lungs

Safety Assessment in the Care environment

- first assess the room for safety for patient and yourself - Client identification - hourly rounding

Heart sounds - S1

- first heart sound - closure of AV valves - beginning of systole LUB

Pendulous breasts

- flat sloping upper breast - nipples sit low on the breast - weight loss, age, pregnancy

Mini-mental state exam

- focuses on cognitive functioning only - takes 5-10 minutes to complete - standard set of questions

Inspect lips:

- for color, moisture, cracking, or lesions; retract lips and note inner surfaace - african americans normally may have bluish lips and a dark line on gingival margin

Disease Causation Theories - Naturalistic

- forces of nature must be kept in balance - embrances idea of opposing categories or forces - yin and yang, hot and cold

low sodium diet

- fresh food over canned - no chips - ketchup

paranasal sinuses

- frontal - ethmoid - spenoid - maxillary - amplify voice and is why sound differently when sick. Help hair get clean, moist and warm

The interview allows?

- gather complete accurate data about the persons health state - establish trust - teach the person about their health - build rapport for a continuing therapeutic relationship - discuss health promotion and disease prevention

Inspection and Palpation: Skin - Color

- general pigmentation, freckles, moles, birthmarks - widespread color change

Summary Checklist: Head, Face, and Neck, including regional lymphatics examination - inspect and palpate the skin

- general size and contour - note any deformities - palpate temporal artery and temporomandibular join(TMJ) joint

Under the influence: violence

- goal: stay safe - if you feel threatened(trust your instincts, leave door open, make a way of escape, do not raise your voice, do not argue/reason with the person, act calm, unhurried)

Developmental Competence: Aging adult

- gradual rise in SBP common with aging; widening of pulse pressure(be alert for orthostatic hypotension) - left ventricular wall thickness increase - presence of supraventricular and ventricular dysrhythmias increases with age - age related ECG changes occur due to histologic changes in conduction system

Total population passed 321 million people in 2015 in US

- greater than one third of US residents were other than non-Hispanic Whites - Minority, or emerging majority, populations total 114.5 million people - Hispanics: largest and fastest growing group - Blacks: second largest population - Asians, American Indians, Alaska natives, native hawaiians, and other Pacific Islanders make up the third largest part of the population

Methods of wound measurement

- greatest length and width method - clock method - combination method: both the above combined - photo documentation - wound traacing

health effects of violence

- gynecolic problems, depression, low birth weight, substance use, chronic pelvic pain, unintended pregnancy, STIs, UTIs, poor health, improper brain development, cerebral palsy, arrest, anxiety, chronic diseases

Perception abnormalities

- hallucinations: perceptions for which there are no external stimuli - illusion: misperception of an actual existing stimulis

Rule of nines for burns calculation

- head and neck: 4.5% - trunk: 18% - upper limbs: 4.5% - lower limbs: 9% - front groin: 1% - add the front and the back together with percentages

Inspection and Palpation of the Neck: Head and neck symmetry

- head position is centered in midline, and accessory neck muscles should be symmetric - head should be held erect and still

Subjective Data: Health History

- headache(worst headache of their life?) - head injury(recently or chronic issue?, seizures?) - dizziness(light headed ness? vertigo? history of this? fluid behind ear? nausea/vomiting? heart rate?, mobility issues? decreased hearing?) - neck pain, limitation of motion(radiating down neck? slept on it funny? meningitis? nausea? vomiting? fever?) - lumps or swelling(swollen lymph nodes? swollen head structures? radiation? problems eating/drinking?, smoke?, alcohol use? thyroid issues?) - history of head or neck surgery(many forget surgeries) Going through each of these do the PQRST

Developmental Competence: Infants

- heart rate may range from 100 to 180 bpm immediately after birth - note findings that reflect heart status(pallor, cyanosis, RR) - may hear murmurs in immediate newborn period

Subjective data for breasts

- history of breast disease and or surgery - lumps or thickening(have you noticed it before? where is it? Has there been changes?) - discharge/rash(when did you notice it? color and consistency?) - swelling/trauma(when did it occur? - pain - axillary tenderness, lumps swelling, rash

Anterior Inspection - facial expression and level of consciousness

- if have patient with acute change in LOC think oxygen status - facial expression is appropriate

Note any white patches, nodules, or ulcerations:

- if lesions are present, or with any person over 50 years old or with a positive history of smoking or alcohol use, use your gloved hand to palpate area - place your other hand under jay to stabilize tissue and to "capture" any abnormality; note any induration

Assessing the neck "Carotid Artery"

- important in middle-aged to older adults or someone with cardiac disease - auscultate for bruit and feel for contour and amplitude - angle of jaw, middle of cervical area, base of area - press lightly with bell of stethoscope

Disease Causation Theories - healing and culture

- in addition to seeking help from health care providers, patients may also seek from folk or religious healers - hispanics or american indians may believe that cure is incomplete unless healing is carried out for body, mind, and spirit

Normal occlusion:

- in back, upper teeth rest directly on lowers - in front, upper incisors slightly override lower incisors

Infants and Children - inner ear starts to develop early in fifth week of gestation

- in early development ear is posteriorly rotated and low set - if maternal rubella infection occurs during first trimesters, it can damage organ or Corti and impair hearing - infants eustachian tube is shorter and wider and more horizontal than adults, so its easier for pathogens from nasopharynx to migrate through to middle ear

Prescription drug abuse - contributing factors to Rx abuse and opioid crisis

- increase in Rx for pain medication - marketing strategies to promote medications - misrepresentation of "addictive" nature - combination addictions: drinking and taking alcohol-interactive medications

Aging adults developmental competence - Pressure/pulse changes

- increase in systolic BP due to thickening and stiffening of arteries - left ventricular wall becomes thicker - heart doesn't compensate as easily

age-related macular degeneration

- increase seen in US adults over the age of 75 - more prevalent in Caucasians - risk factors(positive family history, smoking, hyperopia, light iris color, HTN, hypercholesterolemia, and female gender)

Otitis media increased effects

- increased ambulatory visits - persistent effusion may lead to hearing loss - genetic variation with regard to cerumen development

Under the influence: risk

- increased risk for overdose - accidents(31% of driving fatalities are alc related) - injuries - complex care(body systems affected by alc use)

Harms related to bad alcohol and substance use

- injury/trauma - criminal justice involvement - social problems - mental health consequences - increased absenteeism and accidents in the workplace

Rectal, tympanic, axillary temperature

- insert inch to inch and half in adult - rapid - least accurate

Summary checklist of nose

- inspect external nose for symmetry, any deformity, or lesions - palpation: test patency of each nostril - inspect with nasal speculum nasal mucosa, septum, and turbinates - palpate the sinus area

Health Promotion and Teaching Points for peripheral vascular disorder - foot care

- inspect feet daily(sensations are decreased) - maintain exercise to improve circulation - pay attention to seated positions during the day(no leg crossing) - always wear shoes(risk of injury and delay of healing: well fitted shoes that prevent injury) - no compression socks for PAD - vascular disease is elevating legs and not keeping them hanging, compression stocking

External eye structures Infants and Children

- inspect ocular structures - a neonate holds eyes tightly shut; do not pry them open; that just increases contraction of the obicularis oculi muscle - test vestibular function reflex(Doll's eye reflex will disappear by 2 months)

Inspection and palpation - nasal turbinates

- inspect turbinates - superior turbinate may not be in view - middle and inferior turbinates appear the same light red color as nasal mucosa; note any swelling but do not try to push speculum past it

Summary checklist for mouth and throat

- inspect with penlight: mouth, teeth and gums, buccal mucosa, palate and tonsils, and pharyngeal wall - palpate when indicated(For adults bimanual palpation of the mouth. In neonate, palpate for integrity of palate and assess sucking reflex)

pleural friction rub

- inspiration and expiration - low pitched, harsh/grating sound, continuous

coarse crackles

- inspiration(can extend into expiration) - low-pitched, wet bubbling sound

Peripheral vascular disease: arterial

- intermittent claudication, pain - no edema - no pulse or weak pulse, no drainage - round smooth sores - black eschar - location of sores on toes and feet

Why is domestic and family violence important?

- intimate partner violence is another important universal screening - legal responsibility(screening and implementing) - fulfills our nursing values(social injustice - advocate)

Interpersonal violence

- intimate partner violence(IPV): physical/sexual/emotional/psychological - child/elder abuse - mandatory reporter: suspicion - do not have to have objective proof

Abnormal respiratory patterns - biots

- irregular deep respirations, shallow respirations, and periods of apnea

What are some reasons it is beneficial to screen universally?

- it can lead to early interventions - alcohol use can often go undetected

Developmental competence: newborn infants

- lanugo: fine downy hair of newborn infant - vernix casoesa: thick, cheesy substance - sebum: holding water in the skin producing milia

Galant Reflex Response

- lateral flexion of trunk on side stimulation, elongation on the opposite

CN VI

- lateral rectus

Subjective data for assessment of peripheral vasculature and lymphatic system

- leg pain or cramps(PAD - intermittent claudication) - skin changes on arms or legs(pale, sore from not enough oxygen, and colder for arterial, redish color skin, toenails, warmer legs for venous issues) - swelling(venous) - lymph node enlargement - medications - smoking history

Status of immigrants entering the health care system

- legal permanent residents - naturalized citizens - undocumented aliens - refugees, requesting asylum, and parolees - legal nonimmigrant residents

Behavior

- level of consciousness - facial expression - speech - mood and affect

How to perform breast self-examination?

- lie down. press 3 middle fingers in a circular motion and use 3 levels of pressure. Follow an up and down pattern - sit up. Examine underarm with arm slightly raised - note surface changes with hands pushed on hips, shoulders hunched.

Internal Factors specific to you as the healthcare team member

- liking others - empathy - ability to listen - self-awareness

Teach Back Points

- limit the amount of info to 2-3 key points - rephrase if a client is not able to explain the info correctly - avoid asking "do you understand" or "do you have questions" - beware of words with multiple meanings

Steps for ABI for leg

- locate pulse in dorsalis pedis - apply BP cuff to ankle and use doppler on dorsalis pedis - inflate the cuff until signal is gone and release pressure until hear return signal. - posterior tibial artery same thing. - use highest number from posterior tibial and dorsalis pedis left or right for top number - calculate each side left and right

Structure of the breast

- located between 2nd and 6th rib - nipple is below the center of the breast - areola surrounds the nipple for a 1-2 cm radius

Developmental Competence - Infants and Children - Auscultation

- loud breath sounds - fine crackles are normal AT BIRTH ONLY(amniotic fluid - more in C section from no squeeze) - may hear other sounds due to small size

bronchial breath sounds

- louder than vesicular - high-pitched - hollow sounds - normal if auscultated over trachea - inspiration and expiration almost equal in duration with distinct pause in between

Infants and Young children otoscopic examination

- mandatory for any infant or child requiring care for illness or fever - timing is best towards end - parent hold and comfort child - positioning of child to get clear view of cancal - pinna down on infant or child younger than 3; match slope of ear canal

For infants and children health history questions

- maternal alcohol or drug use? - type of delivery?(vaginal or by cesarean section? any difficulty? use of forceps?) - growth pattern?(was it on schedule?)

Critical thinking

- means by which we learn to assess and modify, if indicated, before acting. Required for sound diagnostic reasoning and clinical judgement. - The final steps to critical thinking include evaluation and planning. Make sure you are on the right track. Final step is a comprehensive plan that is kept up to date.

Fraud detection methods - automated reviews

- medical record review not required - focus on non-covered service

What might alter MSE findings?

- medications - educational level - stress - health issues

bronchovesicular breath sounds

- medium-pitched intensity - inspiratory time is equal to expiratory time - higher pitched mixed with lower pitched - throughout lung fields, upper third of chest

Skin color is derived from three sources:

- melanin: brown pigment - carotene: yellow/orange pigment - red purple tones: underlying vascular bed

At risk drinking

- men is more than 14 drinks a week or more than 4 drink/events - women is more than 7 drinks a week or more than 3 drink/event

Reference Lines

- midclavicular - midsternal - lateral clavicular - mid axillary - posterior axillary - lateral axillary - mid scapular - front clavicular

Many new immigrants have only minimal understanding of the following:

- modern health care delivery system - modern medical and nursing practices and interventions - English language

vesicular breath sounds

- most common - soft with low pitch, even softer during expiration, rustling quality - inspiratory time is longer(3:1) - heard in most areas of lungs but most prominently heard at lung bases and periphery

Alcohol statistics

- most used/abused psychoactive drug - 10% of pregnant women consume alcohol - many people have alc related problems - 56% of Americans are current alcohol drinkers(greater than 18) - of these 40% were binge drinders(more than 5 drinks/occasion) - 11% heavy drinkers(binge a least 5/30 days)

Inspect and Palpation - inspect and palpate external ear: tenderness

- move pinna and push on tragus; they should feel firm, and movement should produce no pain - palpating mastoid process should also produce no pain

How to use incentive spirometer correctly

- move yellow piece to where patient needs to get bigger yellow piece - have patient sit up and exhale completely - seal mouth around mouthpiece tightly - inhale slowly and deeply making sure yellow indicator on side within normal range - keep inhaling until cant do it anymore - hold breath for 6 seconds and exhale slowly while allowing piston to fall completely - use 10 times every 1-2 hours while awake

What does someones diet have to do with the muscles in someones body?

- muscle is made up of protein - a malnourished patient will have muscle atrophy - check protein levels to help respiratory status

Internal anatomy of breasts

- muscles - ligaments - glandular/adipose/lymphatic tissue

Victim response

- need for privacy(work around someone not wanting to leave) - delayed reporting of sexual abuse is a common, normal reaction from someone who has experienced events - sexual abuse can cause intense feelings of embarrassment, fear and humiliation - many victims continue to have a relationship with their abuser(feel like it is their fault) - a victims view of the offenders actions change over time - victims may deny the abuse theyve suffered, or misrepresent parts of their story - do not think they are lying, our job to believe and investigate even with suspicion

Anterior Inspection - color and condition and quality of respirations

- no signs of cyanosis - retraction will mean they are working harder to breath - tripod position - respiratory rate(pattern, rate)

Subjective data with violence

- nonbias and photographic evidence(have to get consent) - unrealistic to document everything - subjective statements - statements as to who perpetrated the abuse, severe threats of harm - separate patient from parent, spouse, caregiver - follow protocol

Measurement of pulmonary function status - pulse oximeter

- noninvasive - a healthy person with no lung disease and no anemia SPO2 of 97-99%

Lacrimal Apparatus - tearing

- normally puncta drain tears into lacrimal sac - presence of excessive tearing may indicate blockage of nasolacrimal duct

Where can i put the sensor to get an accurate reading?

- nose, toe, forehead, earlobe - forehead and earlobe is good for those with temors or fat fingers - children is good on the toe

Visual impairment(VI)

- not being able to see letters on the eye chart at line 20/50 or below - expected to double in the US due to aging population - highest numbers seen in Caucasian women and older adults - Ethnic groups seeing emerging trends - African Americans and Hispanics - Visual screening crucial - safety concerns

Voice sounds

- not routine - supplemental assessment if abnormality is suspected - bronchophony, egophony, whisterped pectoriloqy

Inspection and Palpation of the Neck: Range of motion

- note any limitations - test muscle strength - observe for enlargement of glands and/or pulsations

Inspection and Palpation: Skin - color, note what?

- note color change over entire body skin, such as pallor(pale - pass out), erythema(red - worked out), cyanosis(blue - poor oxygenation), or jaundice(yellow-liver issues) - Note if color change transient or due to pathology

infants and young children ear exam

- note ear position difference - top of pinna should match an imaginary line extending from corner of eye to the occiput - ear should be positioned within 10 degrees of vertical

Inspect and Palpation - inspect and palpate external ear: External auditory meatus

- note size of opening to direct choice of speculum for otoscope; no swelling, redness, or discharge should be present - some cerumen usually present with color and texture variation

Summary Checklist: Head, Face, and Neck, including regional lymphatics examination - Inspect and palpate the face

- observe facial expresssion - cranial nerve VII: symmetry of movement - observe for any abnormal movements

Nasal septum inspection

- observe nasal septum for deviation - note any perforation or bleeding in septum

Epicanthal fold differences

- occurs frequently in Asian children and in 20% of whites - in non-Asians usually disappears by 10 years of age - give false appearance of malalignment, termed pseudostrabismus; yet corneal light reflex is normal

Abnormal palpation - unequal chest expansion

- one side is not rising symmetrically like the other - pneumonia, pleural fusion, trauma to chest cavity(fractured rib), pneumothorax

Health History Questions: Headache

- onset pattern characteristics - location pattern - pain characteristics - course and duration - precipitating factors - associated factors - alleviating factors - what makes it worse - presence of comorbidities - medication history - patient-centered care

Neck pain health history questions

- onset, location, associated symptoms, limitation of ROM, precipitating factors, stress - focus on patient-centered care

Health history questions: Head injury

- onset, setting, and description of injury - changes in levels of consciousness(loss of consiousness and or fall) - history of comorbidity - location of injury - pattern of symptoms(presence of associated symptoms) - treatment plan(emergency, hospitalization, and/or medication) - HEALTH PREVENTION

Although many people take medications that are not prescribed to them, we are primarily concerned with"

- opiods - benzos - stimulants - sleep aids - other assorted(clonidine, carisoprodol)

Cognition

- orientation(time, place, person, situation)(*3,4 etc) - attention span - recent memory - remote memory - new learning

Tests for newborn hearing screening

- otoacoustic emissions test - auditory brainstem response(ABR) test

Equipment needed for nose, mouth, and throat

- otoscope with short, wide-tipped nasal speculum - penlight - two tongue babies - cotton gauze pad, 4x4 inches - gloves

Two pairs of salivary glands accessible to examination on the face:

- parotid glands are in the cheeks over mandible, anterior to and below ear: the largest of salivary glands, they are not normally palpable - submandibular glands beneath mandible at angle of jaw

Lesions caused by trauma or abuse:

- pattern injury - hematoma: collection of blood outside blood vessel - contusion(bruise): type of hematoma

Aging adult visual acuity

- perform same exam as described in adult section - central acity may decrease, particulary after 70 years of age; peripheral vision may be diminished

Developmental competence pregnant women: what are third trimester common findings?

- peripheral pitting edema - varicose veins

Risk of breast cancer

- personal history of breast, ovarian, tubal, or peritoneal cancer - family history of these cancers - ancestry(jewish) associated with BRCA1 or 2 mutations - radiotherapy to the chest between age 10 and age 30 - history of alcohol use, obesity, and smoking - known carrier of a pathogenic mutation for a hereditary breast and ovarian cancer syndrome in self or Previous breast biopsy indicating high-risk lesion(atypical hyperplasia)

Vascular lesions - purpuric lesions

- petechiae: 1-3mm round, discrete, do not go away(pressure applied constantly, bleeding disorder - conjunctiva) - ecchymosis: large bruise greater than 3mm - purpura: Worsening version of ecchymosis and petechiae greater than 3mm, flat and red(scurvy, traumas)

Thought content abnormalities

- phobia - hypochondriasis - obession - compulsion: unwanted purposeful act - delusions: firm, fixed, false beliefs

HITS

- physically hurt you - insult you or talk down to you - threaten you with harm - scream or curse at you

Opiates

- pinpoint pupils, decreased BP, pulse, repirations, lethargy, slurred speech, dysphoria, inattention, impaired memory - withdrawal: dilated pupils, pooping, runny nose, fever, elevated BP, depression, nausea, vomiting, tremor

Snellen chart positioning

- place chart in well lit spot at eye level; position the person exactly 20 feet from chart; hand the person an opaque card with which to shield one eye at a time during test - if the person wears glasses or contact lenses, leave them on; remove only reading glasses - ask the person to read through chart to smallest line of letters possible; encourage trying next smallest lime also

Let parent help position child

- place infant supine on examining table, with arms restrained - older infant and toddler may be held on parent's lap

Vascular lesions - Hemangiomas

- port-wine stain(nevus flammeus) - strawberry mark(immature hemangioma) - cavernous hemangioma(mature - spongy feel)

Preparation of objective data for nose, mouth, and throat

- position a person sitting up straight with his or her head at your eye level - is the person wears dentures, offer a paper towel and ask the person to remove them - child may sit with caregiver

Neck vessels - inspect jugular venous pulse

- position a person supine anywhere from a 30-45 degree angle, wherever you can best see pulsations - observe for distention and visible pulse(central venous pressure)

Objective data - Preparing for the assessment: Sequence

- posterior and anterior - start with posterior then anterior

Structure of nails

- posterior nail fold - cuticle - lunula - lateral nail fold - nail plate - nail matrix - nail bed

Appearance

- posture - body movements - dress - grooming and hygiene - can be noted with general survey because they match

Culture affects choices parents make for children regarding the following:

- presumed cause of illness - first treatment tried - acceptability of treatments offered by clinicians

Assess and document what?

- prior abuse - interpersonal violence - childhood physical abuse - childhood sexual abuse - prior rape

Heart and Neck Vessels - Objective Data - Preparing for the assessment

- privacy - position(sitting up, laying on back for jugular veins) - sequence - infection control

Objective data - Preparing for the assessment: Privacy

- privacy(sports bra, mention when would do sensitive areas - under breast) - if someone knocks say, patient care. Close curtain and the door

Healthcare Communication

- promoting effective interpersonal communication - impact of ineffective interpersonal communication - maintaining open lines of communication - timely updates in organized manner

Dizziness health history questions

- provide a description of "feeling" in patient's own words - associated with change of position, nausea, and/or vomiting

Communication traps

- providing false assurance or reassurance - giving unwanted advice - using authority - using avoidance language - engaging in distancing - using professional jargon - using leading or biased questions - talking too much - interrupting - using "why" questions

Thyroid disorders: hypothyroidism

- puffy edematous face - periorbital edema - coarse facial features - course hair and eyebrows

Cocaine

- pupils dilated, tachycardia, elevated or lowered BP, weight loss, vomiting - dysphoric mood, fatigue, insomia, hypersomina

Aging adult - pupils

- pupils small in old age; pupillary reflex may be slowed - lens loses transparency and looks opaque

What are three qualities to consider when assessing pulse?

- rate - rhythm - force

Precordium Auscultation note what?

- rate and rhythm - identify S1 and S2 - listen for extra heart sounds(where, what did it sound like?)

Culture and Respect

- realize you must know heritage of yourself and patient - examine patient within cultural context - select simple questions and speak slowly - pace questioning throughout exam - encourage patient to discuss meaning of health and illness with you - check patient's understanding and acceptance of recommendations - touch patient within boundaries of his or her heritage

Cannabis

- reddened eyes, tachycardia, dry mouth, euphoria, pleasant sate of relaxation - no withdrawal symptoms with occasional use, chronic is irritability, sleep disturbances, weight loss, loss of appetite

Which of the following are additional guiding principles of MI?

- resist the righting reflex - understand your client's motivations - listen to your patient

Developmental Competence: Pregnant Women

- resting pulse rate of 10-15 bpm and drop in BP from normal pre-pregnancy level - palpation of apical impulse is higher and lateral compared with normal position - heart sound changes due to increased volume and workload

Different characteristics in right and left lung

- right lung is shorter because it is displaced by the liver - left lung is narrower because of the heart

Do and dont of collecting wound culture

- rinse wound with sterile saline solution. remove gloves, hand hygiene, clean gloves. swab the wound by gently rotating a sterile calcium alginate between fingers. swab the wound from margin to margin in a 10 point zig zag fashion. Use enough pressure to express fluid within the wone tissue - dont take specimen from exudate, dont use cotton tip swab, dont let swab touch fingers or other objects

Developmental Competence - Infants - Inspection

- rounded thorax with equal AP diameter - APGAR score - nose breathers - always count for one full minute(30-40 RR - higher if crying) - irregular resp with 10-15 sec periods of apnea - use abdominal muscles more

Developmental Competence - Aging Adult

- rounder thoracic cage with kyphosis - decrease in subcut. fat = easier to palpate bony prominences - costal cartilage calcifies with age = decrease chest expansion - faint with lung sounds

Sebaceous glands

- sebum: secreted lipid substance through hair follicles - lubricate skin and form emulsion

Heart sounds - S2

- second heart sound - closure of semilunar valves - end of systole and beginning of diastole DUB

Developmental competence: adolescents

- secretions from apocrine sweat glands increase - subcutaneous fat deposits increase - secondary sex characteristics

How to prevent and detect skin cancer

- seek shade when possible - wear sun protective clothing - wear sunscreen broad spectrum and water resistance, reapply every two hours

Braden Scale for Predicting Pressure Sore Risk

- sensory perception: ability to respond meaningful to pressure discomfort - moisture: degree to which skin is exposed to moisture - activity: degree of activity(shifting in chair too) - mobility: ability to change and control body position - nutrition: usual food intake pattern - friction and shear: Do you have to pull or lift them? Sliding against sheet can cause skin tear

Summary Checklist - Note presence of lesions

- shape, configuration, and distribution

DVT complications - clinical manifestations

- shortness of beath - decreased oxygen saturation - tachycardia - hypotension - sweating - sharp chest pain(most during deep breathing) - hemoptysis

Inspection and Palpation of the Neck: Trachea

- should be midline - palpate for any tracheal shift - note any deviation from midline

Sedatives

- similar to alcohol - withdrawal: anxiety or irritabililty, nausea, vomiting, malaise, tremor of hands

Nursing process: implement and evaluation

- similar to the scientific method - determine whether you achieved the outcome desired(met, unmet, partially met)

Objective data - Preparing for the assessment: Position

- sitting up - if patient cant sit up on own then get assistance or turn on their side

Summary Ear Examination - Inspect external ear

- size and shape of auricle position and alignment on head - note skin condition - check auricle and tragus for tenderness - evaluate external auditory meatus

How to check pupils with a penlight

- size(3-5 mm) - shape(round) - direct response(shine light in one eye to see if constricts) - consenual response(opposite eye and make sure constrict together - dim light - accomodation(move the closer to face and see if eyes constrict) - PERRLA(documentation)

Three things that help venous blood return to heart

- skeletal muscle contracting - valves functioning properly - lumen(diameter) is open and patent

Why are skin, hair, nails important?

- skin assessment and management is a major role and responsibility of the RN - largest organ system - immobility is a risk for skin breakdown among other risk factors

Complete physical examination

- skin assessment integrated throughout examination all throughout body(head to toe) - scrutinize the outer skin surface first before you concentrate on underlying structures - separate intertriginous areas(areas with skinfolds) such as under large breasts, obese abdomen, and groin - always inspect feet, toenails, and between toes

Inspection of the arms

- skin color and nail beds - symmetry - lesions or scars - clubbing Look at the top and bottom of arms

Inspect and Palpation - inspect and palpate external ear: skin condition

- skin color consistent with person's facial skin color - skin intact, with no lumps or lesions

Thyroid cartilage

- small palpable notch in upper edge(adams apple in males) - cricoid cartilage or upper tracheal ring - isthmus of the thyroid gland

Barriers to treatment of intimate partner violence

- societal stressors(lack of understanding) - legal status(deported) - lack of access to culturally appropriate care(interpreters)

Condition that is culturally defined

- some have no equivalent in a biomedical, scientific perspective - anorexia nervosa and bulimia are examples of cultural aspects of illness in dominant cultural population in North America

Posterior assessment - inspection: shape and configuration

- spine is straight - thorax is symmetric - breathing is symmetrical - ribs at 45 degree angle from spine

Pressure Ulcer, Decubitus Ulcer stages

- stage 1: Non-blanchable erythema - stage 2: partial-thickness skin loss, blistering, superficial - stage III: Full thickness skin loss, ulcerated - stage IV: full thickness skin/tissue loss - deep tissue pressure injury - PI caused by medical device

Virchow's Triad for DVT?

- stasis(blood not moving) - hypercoagulability(increased risk for clotting) - vessel damage Risk factors for DVT

Reading levels

- steriods decrease inflammation and suppress the body's immune system repsosne which dilates your airway and allows more room to take in oxygen(11th grade) - steroids help decrease swelling and open your airway to help you breathe(5th grade)

When an employee in a provider's office suspects fraudulent activity and uses OIG Hotline to report it, the employee should do which of the following?

- stop filing suspicious bills and claims - pursue knowledeable legal counsel - report and return overpayments - disengage professionally with the suspected perpetrator

objective data equipment needed

- strong, direct lighting, gloves, penlight, and small centimeter ruler

CN IV

- superior oblique

CN III

- superior rectus - inferior oblique - inferior rectus

Gum hypertrophy

- surface looks smooth and stippling disappears - may occur normally at puberty or during pregnancy(pregnancy gingivitis)

Developmental Competence - Infants and Children - Palpation

- symmetric chest expansion - encircle thorax with both hands

Palpation of the legs

- temperature - tenderness(when) - inguinal lymph nodes - pulses - edema - measure calves(unequal size do it and if redness and tenderness - measure largest area)

Palpation of the arms

- temperature - texture - turgor - capillary refill - edema - pulses - epitrochlear lymph nodes

Summary Checklist - Palpation of the skin, hair, and nails

- temperature and texture - edema, mobility, and turgor

Physiologic murmur

- temporary murmur - physiologic states that increase blood flow(pregnancy, anemia, fever, hyperthyroidism) - not associated with cardiovascular disease - heard at left 2nd to 4th intercostal space, heard at apex too

Extraocular muscle function

- testing for strabismus(squint, crossed eye) is an important screening measure during early childhood - test malalignment by corneal light reflex and cover test

Thought Processes, Content, and Perceptions

- thought processes(how do they think? Should be logical, conversing with you in complete thoughts)( - thought content(what are they thinking and is it logical?) - Perceptions(assess if patient is aware of reality)

Hair

- threads of keratin: hair shaft and bulb matrix - types of hair: vellus and terminal - follicle: cyclical with active and resting phases

Pregnancy changes for HEENT

- thyroid gland enlargement - hyperpigmentation - increased fluid - more stuffy

The terms of the contract(interview) include

- time and place of the interview - introduction of yourself and explanation of your role - purpose of the interview - how long it will take - expectation of participation for each person - presence of any other people - confidentiality - costs

Heritage consistency continuum

- traditional: living within norms of traditional culture - modern: acculturated to norms of dominant society

Inspection and Palpation: Nails - Color

- translucent nail plate to pink nail bed below - note ethnic variations

Closure of fontanels

- triangle-shaped posterior fontanel closes by 1 to 2 months - diamond-shaped anterior fontanel closes between 9 months to 2 years

Innocent murmur

- turbulent blood flow - during systole as blood is ejected from ventricles

Differing views of epilepsy

- uganda: contagious, untreatable - greece: source of family shame - mexican american community: evience of physical imbalance - hutterities: evidence of having endured trial by god

Abnormal findings: extraocular muscle dysfunction - cover test

- uncovered eye - covered eye

Why is SBIRT important?

- unhealthy and unsafe alcohol and drug use are major preventable public health problems resulting in more than 100,000 dealths each year - the costs to society are more than 600 billion annually - effects of unhealthy and unsafe alcohol and drug use have far-reaching implications for the individual, family, workplace, community, and the health care system

Why is this substance use assessment important?

- universal screening - substance abuse impacts every care area - the RN functions as an advocate for the client and communicates findings related to substance use that respects client autonomy, and human dignity

Alcohol

- unsteady gait, flushed face, sedation, relief, slurred speech, irritability, depression, talkativeness - withdrawal: uncomplicated, delirium

What are the quadrants of the breasts

- upper inner quadrant - upper outer quadrant - lower inner quadrant - lower outer quadrant - axillary tail of Spence

Eyelids

- upper lids normally overlap superior part of iris, and approximate completely with lower lids when closed - palpebral fissures horizontal in non-Asians; Asians normally have an upward slant

Inspection and Palpation: Skin - temperature

- use backs of hands to palpate person - skin should be warm, and temperature equal bilaterally; warmth suggests normal circulatory status - hands and feet may be cooler in a cool environment(hypothermia, hyperthermia)

Doppler Ultrasonic Probe

- use jelly to put on skin - describe rate, rhythm, and force - use doppler for chest compressions to make sure you can hear the pulse

aging adults developmental competence

- vision and hearing checked first - easier to misdiagnose - issues come along with older age, so have to know if its just age or an issue

Subjective Data

- vision difficulty: decreased acuity, blurring, blind spots - pain - strabismus, diplopia - redness/swelling - watering, discharge - history of ocular problems - glaucoma - use of glasses or constant lenses - patient-centered care

Additional Health History Questions - Aging Adults

- what changes have you noticed in your skin in past few years? - any delay in wound healing? - any change in feet: toenails, bunions, wearing shoes? - falling: bruises, trauma? - History of diabetes or peripheral vascular disease?"

Factors in consistent wound measurement

- when measuring length, your ruler should be placed over the longest length; head is at 12:00 and feet are at 6:00 - measure widest aspect of the wound perpendicular to the length - toes are at 6:00 and heels are at 12:00 - always measure in cm L*W*D - length may be smaller than width

Findings of Raynaud phenomenon

- white: lack of arterial blood flow - blue: little blood flow - red: vasodilation and areas refilled - precursor of autoimmune disorder

What is the big deal with cultural assessment?

- who are you meeting for the first time? - where does the patient come from? what is his or her heritage? - what is their cultural background: ethnicity and religion? - does the patient understand, speak, and read English? - what language do they understand, speak read? - what are their health and illness beliefs and practices?

Trachea

- windpipe - 10-11 cm - begins at level or cricoid cartilage(cartilage that surrounds trachea) - right and left main bronchus

Sending: Verbal Communication

- words you speak: vocalization - tone used in conversation

male breast

-Chiefly small nipple and areola -Overlie thin disc of undeveloped breast tissue -May be difficult to distinguish male breast tissue from surrounding muscles of chest wall

the working phase

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

Transcultural expression of pain

-Expectations, manifestations, and management of pain are all embedded in a cultural context -Pain has been found to be a highly personal experience, depending on cultural learning, the meaning of the situation, and other factors unique to the person -Silent suffering has been identified as the most valued response to pain by health care professionals

Examples of bloodborne pathogens

-Hepatitis B virus (HBV) -Human immune deficiency virus (HIV) - Hep C

patency of nostrils

-Plug one nostril & sniff AND switch to other nostril

SA node (sinoatrial node)

-pacemaker of the heart(60-100bpm) -sets the heartbeat rate -located in the right atrium -causes atria to contract

Grading for Heart murmurs

0-6 Scale 0- can't hear 1-barely audible in quiet room 2-clearly audible but faint. 3-moderately loud/easy to hear 4-loud/palpable thrill 5-(4+)very loud/heard w/edge stethoscope off chest 6-(5+)loudest/heard w/edge stethoscope off chest.

What do rectal temperatures measure?

0.7-1 higher(0.4-0.5C) Most accurate

A score of 7 on the DAST would be considered a substantial level of risk. What additional actions need to take place?

0: no problems - none at this time 1-2: low level - monitor, reassess at a later data 3-5: moderate level - further investigation 6-8: substantial level - intensive assessment

Normal puberty - tanner stages for pubic hair men and women

1 - no pubic hair 2 - few pubic hairs 3 - too many too count 4 - full amount of pubic hair but none on thighs 5 - hair everywhere

You may normally see?

1+ or 2+ tonsils in healthy people, especially in children, because lymphoid tissue is proportionately enlarged until puberty

Blood flow through the heart

1-Superior & Inferior Vena Cava, 2-Rt Atrium, 3-Tricuspid Valve, 4- Rt Ventricle, 5-Pulmonary Valve, 6-Pulmonary Artery, 7- Lungs-pick up oxygen, 8-Pulmonary Veins, 9- Lt Atrium, 10- Mitral Valve (Bicuspid), 11-Lt Ventricle, 12- Aortic Valve, 13-Aorta, 14- Body

Nursing Process Steps

1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation

Example of Nursing Plan Interventions

1. Instruct patient to notify nurse immediately when chest pain occurs 2. Assess and Document patient response to medication

Blood pressure documentation should have the following:

1. Manual/Automatic 2. Position: Sitting, supine, standing 3. Cuff size: adult, large adult, child, thigh 4. Where you placed the cuff: Forearm, upper arm, thigh 5. Systolic/diastolic in mmHg

Nursing diagnoses

1. alteration in comfort (related to ..)(as evidenced by...) 2. alteration in respiration 4. alteration in skin integrity 5. Disturbed body image 6. Alteration in nutrition 7. potential for/acutual infection 8. Impaired oral mucus membrane 9. ineffective self-cafe

Normal respiration rate

10-20 breaths/min - watch chest rise and fall

Call your baby's healthcare provider if a baby's rectal or forehead temperature is?

100.4 or higher

--- ------ vertebra that makes up thoracic cage.

12 thoracic

The majority of adolescents have used alcohol or another drug by the?

12th grade

--- facial bones also articulate at sutures

14

the brief RCOPE

14 item assessment for use in clinical practice, helps practitioners understand the patients religious copign to enable them to integrate spirituality in treatment. Whether a patient uses positive or negative religious coping

Glandular tissue has

15-30 lobes

curved nail

160 degrees or less - christopher toenails

Adults ideal BMI range is

18.5 and 24.9

Danger Assessment Tool

19 item yes or no instrument - the more yes, the more serious the danger in the patients situation

Normally all 20 deciduous teeth are in by?

2 1/2

Cuff width should cover how much?

2/3 of the upper arm, and cuff bladder must completely encircle it.

Children have how many teeth?

20 decidious, or temporary, teeth that erupt between 6 months and 24 months of age - all 20 should appear by 2 1/2 years

Normal ABG: HCO3(metabolic)

22-26 - < 22 = acidosis - > 26 = alkalosis - bicarbonate

BMI overweight is considered

25-29.9

inspiration to expiration ratio

2:1 Inspiration may be longer, expiration may be longer, or they may be equal

Full breast development average of?

3 years - one breast may grow faster than the other(normal)

Pulse force three-point scale

3+ full, bounding 2+ normal 1+ weak, thread 0 Absent

The lung borders extend?

3-4 cm above the inner third of the clavicles. This is the apex of the lungs. Listen to lung sounds in this area

How do you know how high to pump the blood pressure cuff up to?

30 mmHg over usual systolic pressure

Obese BMI

30-39.9

Newborn's head measures about?

32-38 cm(average around 34 cm) and about 2 cm larger than chest circumference.

Normal ABG: PaCO2(respiratory)

35-45 - < 35 = alkalosis - > 45 = acidosis - carbon dioxide in the blood

Cellular metabolism requires a stable core or "deep body" temperature of a mean of

37.2C(99F)

Saliva present after ---- months of age and shows in excess with ----

3; teething children

Faces pain scale

4 y/o and older · Used in children 4-12 years · Patients point to face that represents pain · Score 0-10

What percent of people are below average health literacy?

43%, not every patient you see if going to understand the terms you are speaking. - average people speak at 6th grade level and health material is 10th grade level

Auscultation of Anterior Chest

5 spots side to side

Percussion of Anterior Chest

5 spots side to side

Nearly --- of what they do remember is recalled incorrectly

50%

Pulse in aging adults

50-95 beats/min

You cant use sunscreen in?

6 months or less

school-age child

6-12 years

Deciduous teeth lost beginning at age?

6-12; replaced by permanent, starting with central incisors

In resting adult, normal heart rate range(pulse) is?

60-100 bpm

Older adult age

61 and older

Normal ABG: PH

7.35-7.45 - PH < 7.35(acidosis) - PH > 7.45(alkalosis)

Most clients forget up to --- of their instructions as soon as you leave the room

80%

Normal ABG: PaO2

80-100 - oxygen dissolved in the blood

Height in aging adults

80s and 90s, many people shorter

Healthy person with no lung disease and no anemia normally has an SpO2 of

97% to 98%

What is the normal oral temperature in a resting person?

98.6(37C) - range of 96.4-99.1(35.8C-37.3C)

Mid upper arm circumference

< 10th percentile or > 95th = further work up

Waist/Hip circumference

> 1.0 in men > in women = increased risk for disease

Tachycardia and bradycardia

>100 bpm <60 bpm

Normal ABG: SaO2

>95% - oxygen saturation(hemoglobin binding sites)

Health Care Reform Act

A 2010 federal statute that increases the number of persons who have health care insurance in the United States and provides new protections for insured persons from abusive practices of insurance companies. - applies to all federally billed programs

Tympany

A bell-like noise when tapping the abdomen

Leukoedema

A benign lesion occurring on buccal mucosa is seen more often in blacks

Torus palatinus

A bony ridge running in middle of hard palate is seen in 20% to 35% of the US population

Fissure

A break in the skin that is a line that is a crack and can go into the dermis. Dry mouth and crack in corner of mouth

Rule of Nines for Burns

A calculation used to calculate the total body surface percentage of the body that is burned. - does the patient meet criteria to go to burn unit? patient is at risk for hypovolemic shock within first 24 hours.

A client has been diagnosed with a myocardial infarction that has damaged a part of the right atrium. The nurse monitors the client for:

A change in the rate and rhythm of the client's heartbeat - SA node

Deep Vein Thrombosis

A deep vein is occluded by a thrombus(clot) causing inflammation, decreased venous return and edema

Organic disorder

A disorder that is due to a known brain disease of a specific organic cause - alcohol and drug intoxication which is causing alteration in the brain - dementia

Orthostatic hypotension

A drop of 20 millimeters of mercury(mmHg) in your systolic blood pressure or a drop of 10 mmHg in your diastolic blood pressure within two to five minutes of standing up, or if standing causes signs and symptoms.

thyroid cartilage

A firm prominence of cartilage that forms the upper part of the larynx; the Adam's apple.

cricoid cartilage

A firm ridge of cartilage that forms the lower part of the larynx.

Epiglottis

A flap of tissue that seals off the windpipe and prevents food from entering.

A parent calls a peds office to make an appointment for her school age child. The nurse should instruct the parent to call the previous peds office and request that?

A form authorizing release of copies of the records be sent to her to sign and return

Teach Back

A method to confirm that you have explained to the client what they need to know or do, in a way the client understands - client understanding is confirmed when they explain the information back to you

Resonance

A phenomenon that occurs when two objects naturally vibrate at the same frequency

medication reconciliation

A procedure to maintain an accurate and up-to-date list of medications for all patients between all phases of health care delivery.

Wellness

an overall state of well-being or total health

Subjective

· Chief complaint · Start of the nursing process

Subjective Data

"told" by the patient and includes: · Chief complaint: direct quote(my abdominal area hurts) · History of present illness(OPQRSTU) · Family history · Patients own surgical history · Patients own medical history · Medical diagnoses · Medications · Review of systems

What does percussion do?

- Mapping out the location and size of an organ by exploring where the percussion note changes between borders of an organ and its neighbors - Signaling the density of a structure by a characteristic note - Detecting an abnormal mass if it is superficial - Eliciting a deep tendon reflex using the percussion hammer

Objective

- Physical assessment - Diagnostic findings

Disease based precautions - neutropenic

- gloves - gown - mask

Nursing process depends on our knowledge level and years of experience

- novice - competency - proficient - expert

Physical Assessment

An examination of the bodily functions and condition of an individual.

palpation: the dorsa(backs) of the hands and fingers

Best for determining temperature because the skin is thinner than on the palms

Objective

Core of the examination part of each body system chapter with skills, expected findings, and common variations for healthy people, as well as selected abnormal findings

palpation

Follows and often confirms what you noted during inspection. Applies your sense of touch to assess: texture, temperature, moisture, organ location and size, any swelling, vibration, pulsation, rigidity, presence of lumps, tenderness, pain

Needlestick Safety and Prevention Act

Revision to Bloodborne Pathogens standard that requires employers to minimize employees' exposure to blood through sharps injuries.

Objective data

The data you as the RN collect with physical exam techniques and other data from diagnostic testing - Example: · Subjective: "my throat hurts to swallow" · Objective: pharynx is erythematous and exudate is present

Nursing process: diagnosis

Uses subjective and objective data to determine a nursing diagnosis

infant

1 month to 1 year

How long does it take to develop competency?

2-3 years in which you can see actions in context of patient goals or plans of care.

Fall Risk

Based on our assessment we decide they are at risk for falls or injury. Do not want them walking without help or with device

Planning

Goals, interventions, additional diagnostic testing needed

HIPPA

Health Insurance Portability and Accountability Act of 1996. The purpose is to protect the privacy of patient health information. - privacy, security, and enforcement rule, and heath information technology for economic and clinical health eact(HITECH)

Subjective

Health history through questions(examiner asks) and explanation

What is RN practice regulated by?

NC board of nursing

What is assessment?

The foundation for the nursing process and practice. Collection of data about the patients health state.

Lab

This is where we go in hands on manikin or individual and perform assessments and will be recorded for online.

Health care language is important for what?

Your ability to act safely

Exposure can occur as the result of a

a needlestick, a cut from a sharp object, or contact of mucous membranes or broken skin with contaminated blood. Treat all human blood and body fluids as if they are infectious

Percussing over a body structure causes vibrations that produce characteristic waves that are heard as notes which are differentiated by:

amplitude(loud or soft), pitch(vibrations per second), quality, duration(time lingering) - More air(lungs) give a louder, deeper, and longer sound while denser more solid structures gives a softer, higher, shorter sound.

palpation - fingertips

best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps

Bloodborne Pathogen Standard

combined engineering and work practice controls, training, and other factors to minimize transmission of bloodborne pathogens in the workplace.

Nursing Process

five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating

Otoscope

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

Ophthalmoscope:

illuminates the internal eye structures. Its systems of lenses and mirrors enables you to look through the pupil at the fundus of the eye, much like looking through a keyhole at a room beyond.

Wash hands frequently and properly. Soap and water is preferable but,

in its absence, use an alcohol hand sanitizer that is at least 60% alcohol to clean hands. The practice of "foaming in" and "foaming out" of patients' rooms is stressed at many facilities.

chronic illness

irreversible illness that causes permanent physical impairment and requires long-term health care

Ascultation

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

Hyperresonance

lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax

Disease based precautions - droplet

mask, gown, gloves

Novice

no experience with a specified patient population and uses rules to guide performance.

What is RN practiced based on?

on Evidence(scientific and experiential) to protect our patients not necessarily just nursing professionals

Standard assessment behaviors improve what?

practice safety

What is RN practice guided by?

professional standards of practice

QSEN

quality and safety education for nurses is a national initiative to identify the competencies and knowledge, skills, and attitudes needed by all nurses to continuously improve the QS of health care.

dull

thudlike sounds are normally heard over dense areas such as the heart or liver

palpation: A grasping action of the fingers and thumb

to detect the position, shape, and consistency of an organ or mass

Shadow Health

virtual reality clinical setting, get to touch a patient with avatar, like a video game.

Anatomy of a room

· Bed/client positioning · Call system(telephone or call system) within reach · Telephone · Tv remote/lights · Bedside table · Kleenex/water

Toileting equipment

· Bedpan · Urinal · Urinary catheter · Bedside commode

Signage in room

· Bulletin board · NPO status · Fall risk

What does hourly rounding consist of?

· Care environment assessment · Client safety assessment · Client mental status/pain assessment

Assessment

· Collect Data: review of the clinical record, health history, physical examination, functional assessment, risk assessment, review of the literature · Use evidence-based assessment techniques · Document relevant data

Diagnosis

· Compare clinical findings with normal and abnormal variation and development events · Interpret data: identify clusters of clues, make hypotheses, test hypotheses, derive diagnoses · Validate diagnoses · Document diagnoses

Stages of diagnosis

· Cue recognition · Hypothesis formulation · Data gathering for hypothesis testing · Hypothesis evaluation · Critical thinking: identify assumptions and validation(reliability and accuracy)

Nursing diagnosis problems

· Include "related to" 1. The context of the problem · Include "As evidence by..." 1. The symptoms that provide the support for the selection of the problem · Actual problem already

Class 2 physical injury

· Ineffective airway clearance · Risk for aspiration · Risk for bleeding · Risk for falls · Risk for injury · Risk for thermal injury · Risk for urinary tract injury · Risk for peripheral neurovascular dysfunction · Risk for pressure ulcer · Risk for shock · Impaired skin integrity · Risk for impaired skin integrity · Risk for sudden infant death syndrome · Risk for suffocation · Impaired tissue integrity · Risk for impaired tissue integrity · Risk for trauma · Risk for vascular trauma

RN Practice State Law

· Plan and evaluating appropriate nursing acts · Teaching, assigning, delegating to our supervising other personnel · Collaborate with other health care providers in determining the appropriate health care for a patient but, subject to the provisions of G.S. 90-18.2, not prescribing a medical treatment regimen or making a medical diagnosis, except under supervision of a licensed physician · Implement the treatment and pharmaceutical regimen prescribed by any person authorized by State law to prescribe the regimen · Provide teaching and counseling about the client's health · Report and record the plan for care, nursing care given, and the client's response to that care · Supervise, teach, and evaluate those who perform or are preparing to perform nursing functions and administering nursing programs and nursing services · Provide for the maintenance of safe and effective nursing care, whether rendered directly or indirectly

Evaluation

· Progress toward outcomes · Conduct systematic, ongoing, criterion-based evaluation · Include patient and significant others · Use ongoing assessment to revise diagnoses, outcomes, plan · Disseminate results to patient ad family

Nursing diagnosis risks

· Risks for: · "Related to" 1. The context of the problem · Do not include "as evidenced by.." · Possible problem

Additional things in room

- PPE - Waste Basket - Sink - Bedside table - Chair - IV pole - Sharps container - Oxygen - Suction - Emergency equipment - emesis bags