Final Blueprint Flashcards
Respiratory assessment: focused questions
Shortness of breath (SOB) or dyspnea:
- Have you had any difficulty breathing?
- Rest, exertion, how much exertion
- Supine (orthopnea) or at night (paroxysmal nocturnal dyspnea), relieved by sitting
Cough:
- what brings on a cough?
- Hemoptysis: do you cough up blood?
– what does it look like, what brings it on, when did it start, quantity?
- do you have any allergies? What kind and what happens?
Chest pain (CP) with breathing:
- do you have any chest pain or chest discomfort?
Respiratory infection:
- have you had any respiratory infections? often?
Ears: otitis media
- infected fluid in the middle ear
- eardrum looks red and swollen
- can close off Eustachian tube
Phases of wound healing
I just added more info because I wanted to know what it was
- Stage 1: hemostasis
**- The immediate phase that begins the wound healing process- blood clot forms to prevent further blood loss. - Stage 2: inflammatory- immune cells recruited to the area
- Stage 3: proliferation*The wound contracts and new blood vessels are built to support the growth of new tissue.
- Stage 4: maturation aka: remodeling
**The wound completely closes and the new tissue develops strength and flexibility. can take up to a year.
PVD vs PAD
PAD is a specific type of PVD (PVD is umbrella)
Peripheral vascular assessment: focused questions
- chief complaint present illness
- do you have any leg pain or cramps?
- have you noticed any skin changes on your arms or legs?
- have you noticed any swelling/edema anywhere on your body?
- have you noticed any swelling/enlargement of your lymph nodes?
- medications: current and past, and reason
- smoking: PPD
Function of the respiratory system (5)
- supplies oxygen to the body
- eliminates carbon dioxide
- maintain homeostasis
- maintain heat exchange
- alveoli: exchange of oxygen and carbon dioxide
Oxygenation Depends on
What systems
- Airway system to transport air to and from lungs
- Alveolar system to exchange oxygen and carbon dioxide
- Cardiovascular system and blood supply to carry nutrients and wastes to and from body cells
Review of systems: focused questions
Why do we ask focused questions
targeted problems
Skin cancer: culture and genetics
Risk factors, Men V women, dark vs light skin
- genetic attributes of dark-skinned individuals afford protection against skin cancer due to melanin
- increased likelihood in caucasians compared to hispanic and african american populations
- women <50 at higher risk for melanoma
– at 65, men double the rate of women; tripled by 80 - risk factors:
– high exposure to UV radiation
– family history of melanoma
– atypical or high number (>50) moles
– increased risk for easy burners and natural blond/red hair - 95% of melanoma caused by UV radiation exposure
Data collection: objective data
- what the nurse observes: physical exam
- lab and diagnostic testing
- signs
Neurological assessment: abnormal findings for movement and muscle tone
Muscle Tone
- Flaccidity
- Spasticity
- Rigidity
- Cogwheel rigidity (watch-hand arm ticking)
Movement
- Paresis
- Paralysis
- Myoclonus (hiccups/epilepsy)
-** Fasciculation/Tic/Tremor
– Resting
– Intention
– Chorea (parkinsons)
– Athetoid (cerebral palsy)
Atrioventricular (AV) valves: location and function, when they open and close relating to cardiac cycle
Tricuspid valve - between RA and RV
Mitral Valve - between LA and LV
During systole - the AV valves are closed as this is pumping phase - prevents blood from backing into the aorta (regurgitation)
During diastole - the AV valves are open, filling phase as ventricles fill with blood
Respiratory assessment: developmental considerations (pregnancy)
- Diaphragm elevated 4cm
- Decreased vertical diameter thoracic cage
- Increased horizontal diameter, increased tidal volume
What is the Ankle-Brachial Index
it assesses for peripheral arterial disease (PAD); is the ratio of BP measurements in the foot and arm
- two measurements taken and then average is used as the recorded pressure
ABI = (systolic ankle pressure)/(highest systolic brachial pressure)
What happens during..Systole (AV)
valves are closed, pumping phase-prevents blood
from backing into the aorta (regurgitation)
Ears: inspection and palpation
- auricle
- tragus
- lobes
- external ear canal
– inspect piercings: healed, infections, keloids
palpate external ear
Testing cerebellar function (4)
Test through normal ROM
Testing cerebellar function
- finger to nose
- standing posture
- heel to shin
- gait pace
Assessing balance and gait/coordination
Romberg test- make sure they dont fall (Stand still for 30 seconds and not lose balance)
Finger-to-nose test
Heel to shin- to test for neurological vs weakness
Rapid alternating movements - flip hands back and forth (how fast pt can do it)
Respiratory assessment: palpation - tactile fremitus (findings: increased, decreased, crepitus, what to assess)
Decreased/absent: voice is higher pitched or soft
- something obstructs the transmission of vibration
- COPD, pleural effusion, fibrosis, pneumothorax, infiltrating tumor, emphysema
Increased:
- compression or consolidation of lung tissue
- lobar pneumonia
Crepitus:
- coarse, crackling over skin surface
- subQ emphysema (when air is in tissue and can feel it; can happen with chest tubes)
Assess:
- temperature
- lesions
- masses
- wounds
how to do it
assess for symmetry
use ball or ulnar surface of hand
ask patient to repeat words “99” or “one one one”
initially used for side-by-side comparison
both hands to palpate and compare symmetry
identify and locate any areas of increased, decreased or absent fremitus
for women: gently displace the breasts anteriorly
anteriorly: fremitus is usually decreased or absent over the precordium
Cranial Nerve 11: function and assessment
Spinal accessory
Motor
- Trapezius and sternomastoid movement
– have patient turn head and apply resistance
– assess shoulder shrug
Verbal communication
appropriate verbal communication:
- simple, recognizable and clear words
- use non-stigmatizing language; don’t them to shut down
Stridor
- high-frequency, high-pitched musical sound produced during airflow through a narrowing in the upper respiratory tract
- obstruction - foreign body
What is anosmia
loss of sense of smell
Cardiovascular assessment: palpation of the PMI (apical pulse)
represents the brief early pulsation of the LV as it moves anteriorly during systole and makes contact with the chest wall
palpable in about half of adults; not in those obese or with thick chest walls
– displaced to the left in heart failure
– if can’t find: ask person to exhale and hold; ask patient to roll partly onto left side
high cardiac output:
- apical impulse increase in amplitude and duration
- anxiety, fever, hyperthyroidism, anemia
Edema grading 1+
Barely detectable impression when finger is pressed into skin. May have mild pitting, slight indent, no perceptible swelling of legs
Mouth/tongue/lips: focused assessment
Mouth and tongue:
- mouth/gum: tenderness, pain
- mouth/gums: redness, swelling, bleeding
- mouth/gums/lips: lesions
- teeth: toothache
- tongue: lesions
Blood flow through the heart
right heart: deoxygenated blood
- enters the heart through the superior vena cava from upper body; inferior vena cava from lower body
- goes into the right atrium
- tricuspid valve opens and blood flows from RA to RV
- RV contracts and pumps blood to the lungs
- pulmonary valve opens and blood flows from RV to pulmonary artery
- pulmonary artery carries deoxygenated blood to the lungs
Left Heart: oxygenated blood
- returns to the heart through the pulmonary veins
- pulmonary veins allows blood to enter LA
- LA: oxygenated blood flows from LA to LV through mitral valve
- LV pumps the oxygenated blood to the aorta, passing through aortic SL valve
- aorta distributes oxygenated blood to the rest of the body (systemic circulation)
Assessment across the lifespan: adolescents
want to be treated as adults and to be given respect and choices
begin with client sitting on exam table
share questions or concerns w you through the use of broad open-ended questions
time alone with patient, no parent/caregiver
head-to-toe approach
Mental status - looking at memory and intellect of patient
types of memory tests
Memory:
- cerebral function
- recent vs remote memory
- immediate memory test (repeating 3 words back that were just given)
Intellectual:
- learning
- computation
- ability to read
- insight
- judgment
Edema grading 2+
Slight indentation; 15 seconds to rebound
SDOH: neighborhood and built environment
access to foods that support healthy eating, patterns, crime and violence, environmental conditions, quality of housing
Sensory and motor function: neurological assessment
Sensory assessment:
-** Superficial
– pain, temperature, light touch (cotton ball)
**- Deep Sensation
– vibration
– position (kinesthesia)
** tactile discrimination:
– stereognosis: identify item in hand
– graphesthesia: drawing number
Motor:
motor damage related to level of lesion injury
- assess muscle strength and tone
– test balance
– assess coordination and skilled movement
– test reflexes
head/neck lymph nodes: posterior cervical
along the anterior edge of the trapezius
Neck: lymph nodes (10)
Some Stupid People Purposefully Toss Out Any Puppy Dog Selfishly
- submental
- submandibular
- preauricular
- Posterior auricular
- tonsillar (jugulodigastric)
- occipital
- anterior superficial cervical
- posterior cervical
- deep cervical chain
- supraclavicular
What are the signs of infection in wounds
- Purulent and increased drainage
pain, redness, swelling - Increased body temperature
- Increased WBC
- Delayed healing
- Discoloration of granulation tissue
Cranial Nerve 5: function and assessment
Trigeminal
- Motor and Sensory
- Motor function: Chewing
– Have patient clench teeth
clench, then palpate temporal and masseter muscles
- Sensory function
– Facial sensation
– Taste at anterior tongue
What is leukoplakia (mouth abnormal assessment)
chalky white, thick raised patch on sides of tongue
precancerous
Neurological injury - Parkinson’s (has classic symptom triad)
- Damage to extrapyramidal tracts
– Dopamine loss - Classic symptom triad
– Tremor
– Rigidity
– Bradykinesia (slow walking) - Flat facial expression
- Increased Salivation (drooling)
- Decreased Eye blink (dry eyes)
- Ambulation problems (shuffling)
Eye: focused assessment
- vision difficulty: blurring, blind spots, clouding, halos, night blindness
- strabismus (one eye turning in)
- diplopia: double vision
- eye pain, redness, swelling
- wear glasses or contacts
- last vision test
- environmental factors: flying sparks, metal bits, smoke, dust, animals, etc
- vision loss
Cranial Nerve 9: function and assessment
Glossopharyngeal
Both Sensory and Motor
- Sensory: taste (posterior tongue)
- Motor: pharyngeal muscles (swallowing)
Local factors affecting wound healing
9
- pressure
- desiccation (a wound condition that occurs when a wound dries out, removing the fluids that help it heal)
- maceration- skin softens and breaks down due to prolonged exposure to moisture
- trauma
- edema
- infection (in wound)
- excessive bleeding
- necrosis
- biofilm
Internal factors
- age
- health status
- body fluid
- nutritional status
Other external factors
- medication
- temperature
- stress
Systole
AV:
- valves are closed, pumping phase-prevents blood from backing into the aorta (regurgitation)
SL:
- valves are open, pumping phase-blood is ejected from the heart
Physiologically:
Systole
- Contraction of the heart
- Blood is pumped from the ventricles and fills the pulmonary
and systemic arteries.
- Represents one third of the cardiac cycle
…..Ventricular pressure becomes higher than that in atria
- Mitral and tricuspid valves close
- Closure of AV valves contributes to first heart sound (S1)
and signals beginning of systole
- AV valves close to prevent any regurgitation of blood back
up into atria during contraction
- Brief moment, all four valves are closed and ventricular
walls contract
- Contraction against closed system; builds pressure in the
ventricles
- pressure in ventricles exceeds pressure in the aorta
Assessment across the lifespan: young and school-aged children
young: 1-4yrs
school age: 5-10 years
health history from parents
tantrums
play as a way to build rapport with child and parents
stuffed animals or drawing
use words the child understand
sitting or lying on the exam table
Ears: hearing testing
- Whisper test (CN 8 test)
– older adult: presbycusis - age related hearing loss - Rinne test- Normal result is observed when the vibrating fork positioned near the ear is louder and lasts twice as long than when placed on the mastoid bone (i.e., air conduction is better than bone conduction). AIR CONDUCTION SHOULD BE TWICE AS LONG AS BONE CONDUCTION
- Weber test- – Normal hearing is confirmed when the sound is heard midline and equally on both sides.
In healthy individuals, Rinne’s test is positive (indicating air conduct
Respiratory assessment: percussion
advanced assessment
- producing audible sound and palpable vibrations
- establish whether underlying tissues are air-filled, fluid-filled, or consolidated
- normal: resonance
- abnormal: hyperresonance (COPD); dull (pneumonia)
anteriorly:
- heart produces dullness to the left of the sternum from the 3rd-5th ICS
- gently displace the breast in women
Assessing mental status (9)
- Is change acute or gradual
- Orientation (person, place, time, situation)
- Response to pain
- Speech patterns
- Person’s appearance
- Coordination
- Thought process
- Level of consciousness (LOC)
– awake and alert
– lethargic
– stuporous: may wake to painful stimuli
– comatose - Speech patterns
– ability to communicate?
– appropriate response?
– speech rhythm
Nonverbal communication
appropriate nonverbal communication:
- body orientation toward and physical proximity to patient
- eye contact
- head nodding w facial animation
- head nodding w gestures
- posture
- tone & use of voice; use of silence
- use of touch
Assessment across the lifespan: newborns and infants
birth to 30 days; infants - 1 month-1yr
parent/caregiver presence
unable to talk
react to the emotional and physical cues
speak in a calm voice
parents can feed the baby
1-2 hours after feeding
sleeping baby best for heart/lung sounds
SDOH: economic stability
employment, food insecurity, housing instability, poverty
Cranial Nerve 10: function and assessment
Vagus
Both sensory and motor
Sensory: viscera of thorax and abdomen
motor: pharyngeal muscles (swallowing)
- consider the patient with stroke
- assess gag
Vagus is also important during the Valsalva maneuver - bearing down and the HR drops
Cataract formation: decreased visual functioning in older adults; what is it?
- lens opacity
- from clumping proteins in the lens
- expected by age of 70
OLDCARTS
Onset
Location
Duration
Character
Aggravating or Alleviating factors
Radiation
Timing
Severity
What is miosis
pinpoint pupils
can come from drug overdose, some hypertensive meds
Neurological assessment: abnormal posturing
- Decorticate rigidity: body turns in
- Decerebrate rigidity: body turns out
- Flaccid quadriplegia
- Opisthotonos: back arches
Head/neck lymph nodes: posterior auricular
superficial to the mastoid process
Superficial reflexes (5)
- Plantar
- Abdominal
- Anal
- Cremasteric: males, stroke the inner aspect of upper thigh
- Bulbocavernosus: contraction of the anal sphincter
SPICES (assessing the general care of the older client requiring nursing interventions)
Sleep disorders
Problems w eating or feeding
Incontinence
Confusion
Evidence of falls
Skin breakdown
What is the closed wound classification for wounds?
- Results from a blow, force, or strain caused by trauma
- Skin surface is not broken
- Soft tissue damage, internal injury, and hemorrhage (may occur)
Peripheral vascular disease (PVD): abnormal findings
Arms:
- Raynaud phenomenon
- lymphedema
Legs:
- arterial-ischemic ulcer
- venous (stasis) ulcer
- superficial varicose veins
- deep vein thrombophlebitis
aneurysms
occlusions
Mouth/tongue/lips: normal assessment
- Lips: smooth, moist, no lesions, edema
– pink lips can be seen in people w/ very light skin tones
– bluish and/or freckled lips can be seen in people w/ dark skin tones - 28-32 shiny, whitish teeth
- Gums are pink, moist, firm
– receding of gingivae can be normal finding related to age (can be from gingivitis too) - Buccal mucosa: smooth and moist
- dorsal/lateral tongue is pink, most, papillae (taste buds)
– size and texture of tongue including ventral/lateral surfaces - ventral tongue: smooth, shiny, pink, visible veins
- throat is pink
– no lesions, edema, odor, drainage
– positive gag reflex
— cranial nerves 9 and 10 (glossopharyngeal and vagus)
Vagus controls salivation production
Eye: assessment - pupillary light reflex
What is it and what nerves
- normal constriction of the pupils when a bright light shines on the retina
- cranial nerves 2, 3, and optic nerve
What is ptosis (eyes)
drooping of eyelids
aka lazy eye
can be both eyes
Eye: abnormal assessment
- irregular shape of the irises
- endophthalmos- sunken eyeballs
- exophthalmos- protrusion of eyeballs with retracted eyelid margins
- myxedema- edema around eyes r/t (hypothyroidism) or periorbital cellulitis
- conjunctivitis
- anisocoria- pupils of unequal size
- miosis- pinpoint pupil
- mydriasis- fixed dilated pupils
- ptosis
- exaggerated palpebral fissure
- eyelids do not close completely
- entropion- inverted lower lid (can be common in older adults)
- ectropion- everted lower lid (can be common in older adults)
- redness, swelling, lesions, discharge from eyelids
- stye
- blepharitis- infection of edges of eyelids
Deep Tissue Pressure Injury
Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration
What are the types of wound drainage?
Serous: clear watery
Sanguineous: bright red or pink
Serosanguineous: combination of blood and the clear fluid
Purulent: foul odor, white, yellow, green, pink, or brown
Frontal lobe
Personality, emotions, intellect, Broca’s area
Influences of Culture
Influences parents’ decisions
– causes of illness; healthcare and treatment
– ex. Jehovah’s witness
defines family responsibility
– care of older adult
verbal and nonverbal communication (eye contact)
views of healthcare system
increased probability of miscommunication when nurse and patient are of different cultural backgrounds
Respiratory assessment: developmental considerations (older adults) 5
- Less mobile thoracic cavity: calcified costal cartilages
- Decreased elastic properties within lungs (decreases recoil)
- Increased risk of pneumonia
- Decreased number of alveoli: less surface area available for gas exchange
- Lung bases become less ventilated as a result of closing off of a number of airways
Assessment considerations:
- Tire easily - be care to not hyperventilate them
- Typically see an increase in AP diameter
What is candidiasis (mouth abnormal assessment)
white, fuzzy, curd-like patches
Abnormal assessment findings in respiratory assessment
- Shortness of breath (SOB) or dyspnea
- Cough
– mucus, pus, blood
– allergens: dust, foreign bodies, hot or cold air - Chest pain (CP) w/ breathing
- Respiratory infection
– viral upper airway, bacterial infection
– pneumonia - Orthopnea - supine
- Cheyne-Stokes respirations
- Biot’s (Ataxic) Breathing
- Abnormal vocal sounds (advanced assessment)
– egophony, bronchophony, whispered pectoriloquy
Stage 3 pressure ulcer
Stage 3: ulcer extends to subcutaneous fat layer; full-thickness skin loss - subcutaneous fat may be visible
Cerebellum
The “auto pilot”
- Voluntary movement
- Equilibrium
- Muscle tone
- Coordination of movement
**below occipital
What is the intentional wound classification?
- Result of planned invasive therapy or treatment
- Wound edges are clean and bleeding is usually controlled
- Decreased risk for infection
- Healing is facilitated
Eyes: vision testing
- Snellen Eye chart: visual acuity
- E chart
- Jaeger chart: card held 14in from patient for them to read
- confrontation: assesses peripheral vision
- cover test: eye muscle weakness
- diagnostic positions: cardinal fields of gaze (6 fields)
- distant visual acuity: snellen or E chart
– place patient 20 feet from chart
– normal is 20/20
– worst is 20/200 - near visual acuity: jaeger card or snellen card
– place 14 inches from eye
– people over 40 have difficulty reading
– normal is 14/14 without moving card closer or further away
Fine crackles
- softer, higher pitched
- more frequent per breath than coarse
- mid to late inspiration; dependent areas of the lungs, varies with positioning - Fluid shift
Clinical reasoning
- gathering initial patient information
- health history and physical examination
- additional info:
– prior health records
– comments from fam, caregivers, providers, someone w knowledge of patient
– patient’s symptoms from history
– signed observed in exam, lab and diagnostic tests - organizing and interpreting information to synthesize the problem
- generate hypotheses
- testing hypotheses until a working diagnosis is selected
- planning diagnostic and treatment strategy
Motor pathways of the CNS
- Corticospinal (pyramidal) tract
- Motor fibers travel from motor cortex to brainstem, where they cross and go down the opposite (contralateral) side
SDOH: health and healthcare
access to healthcare, quality, access to primary care, health literacy
Signs and symptoms of a neurological issue
Headache
Mental status change - confusion, lethargy, agitation, restlessness
Dizziness, vertigo, syncope
Numbness or loss of sensation
Deficits of the 5 senses
Presbyopia: decreased visual functioning in older adults; what is it?
- decrease in near vision
- due to hardened lens resulting in inability for lens to change shape to accommodate for near vision
- occurs typically at 40 years of age
reading glasses
Contusions
- lesions caused by trauma or abuse
What happens during…Diastole (SL)
valves are closed, ventricles are relaxed, pressure
inside drops, preventing blood from flowing back into the heart
Peripheral vascular assessment: pulses and grading
Grade force (amplitude) of pulse on a three-point scale:
0: absent
+1: diminished, weak, thready
+2: brisk, normal
+3: full, bounding
What is the cerebral cortex
outer layer of brain made up of nerve cells
- controls most of the conscious processes.
- Center of functions governing though, memory, reasoning, sensation and voluntary movement.
Systemic factors affecting wound healing
- age: children and health adults heal more rapidly than older adults
- circulation and oxygenation: adequate blood flow is essential
- nutritional status: proteins, carbs, fats, vitamins and minerals
- medications and health status: corticosteroid drugs, radiation therapy, chronic illness, chemo, immunosuppression
Wheezing
- continuous musical sounds
- occur during rapid airflow when bronchial airways are narrowed
- heard throughout the lung
- inspiratory, expiratory, or biphasic
- asthma, mucous plug, tumor
Warning signs of Alzheimer’s (10)
- memory loss
- losing track
- forgetting words
- getting lost
- poor judgment
- abstract failing
- losing things
- mood swings
- personality change
- growing passive
Cranial Nerve 1: function and assessment
Olfactory
- Smell
- Non-noxious smells
- Sensory
Eyes: causes of decreased vision in the older adult (4)
- cataract formation
- glaucoma
- macular degeneration
- presbyopia -natural, age-related eye condition that makes it difficult to see objects that are close up:
S1 and where in the cardiac cycle
S1: closure of AV valves and signals beginning of systole
can hear S1 over all precordium - loudest at apex
AV valves close to prevent any regurgitation of blood back up into atria during contraction
What are examples of primary skin lesions (8)
- Macules: flat
- Papules: solid, raised
- Pustules: pus
- Vesicles/Bulla: trapped fluid under skin
- Urticaria (Hives): red, itchy welts
- Cyst: benign, round, dome-shaped encapsulated lesion containing fluid or semi-fluid material
- Nodule: solid, elevated, hard, or soft
- Wheal: superficial raised, transient and reddened, irregular shape from edema
Tools for neuro assessment
flashlight, cotton, object with sharp and dull sides, vibration (tuning) fork, reflex hammer
Heart murmurs: descriptions based on blood flow
are the result of turbulent blood flow
can be stenotic - valve opening progressively decreases in size and forward flow of blood is restricted
can be regurgitation - valve does not completely close; backflow into chamber causing overload and dilation
Locations:
aortic area: right 2nd ICS
pulmonic area: left 2nd ICS
erb’s point: 3rd left ICS
tricuspid area: 4-5th ICS left sternal border
mitral area: 5th ICS MCL
Flow of OXYGENATED blood through heart
- Pulmonary veins
- L atrium
- Mitral valve
- L ventricle
- Aortic valve
- Aorta
What are secondary skin lesions
They result from a change in a primary lesions from the passage of time; an evolutionary change
Debris on skin surface
- crust
- scales
Break in continuity of skin surface:
- fissures
- erosions
- ulcers
- excoriations: abraded skin
- scars
– atrophic scars: cannot regenerate tissue correctly
– keloids: thick raised scar
What happens during…Diastole (AV)
valves are open, filling phase-ventricles fill with
blood
Adventitious Breath Sounds
Added sounds: caused by moving air colliding with secretions in tracheobronchial passageways or by popping open of previously deflated airways
Types:
- crackles (rales)
- wheezes
- rhonchi
- stridor
- diminished/decreased, absent
- pleural friction rub
- abnormal vocal sounds
Respiratory assessment: focused questions for infants and children (directed at parents)
Any colds? Frequency? Are they severe colds?
Allergy history?
- children under 2 years old: at what age were new foods introduced? breastfed or bottle-fed? any allergies?
Cough or congested? Noisy breathing or wheezing?
- Mucus production, color, how much? What kind of cough?
Does anyone smoke in home and/or in the car with the child?
Environmental or household hazards:
- carbon monoxide monitor, pet dander, dust, mold; roaches can cause asthma attacks
Has anyone taught you emergency care measures in case of accidental choking or a hard-breathing spell?
- Heimlich; smacking infant’s back
Cranial Nerve 3: function and assessment
Oculomotor (Motor)
* Pupil dilation and constriction
* PERRLA
Stages of edema and grading
Measures the severity of pitting edema, determined by applying pressure to the affected area of skin
1+: Barely detectable impression when finger is pressed into skin. May have mild pitting, slight indent, no perceptible swelling of legs
2+: Slight indentation; 15 seconds to rebound
3+: Deeper (pitting) indentation, 30 seconds to rebound, leg looks swollen
4+: >30 seconds to rebound, leg is severely swollen
Respiratory assessment: inspection
Usually starting back and working towards the front
- symmetry, deformities
- muscle retraction: intercostal spaces during inspiration
- lag: delay
- chest shape: normally wider than it is deep
- anteroposterior diameter (AP) to the lateral chest (AP:L): want 1:2; increases with age
- patient’s position
- skin: cyanosis, pallor, clubbing of fingers
Dimensions of cultural humility
self-awareness
respectful communication
collaborative partnerships
Culture
beliefs, values, traits, social norms, communication, and behaviors of that group
characteristics of the culture are learned, shared and adapted
requires humility; continually engage in self-reflection and self-critique
examining cultural beliefs and systems of patients and providers
Neurological assessment: palpation
- superficial and deep sensation
- muscle strength and tone
- DTRs and superficial reflexes
What is anesthesia
no sensation
Cardiovascular assessment: palpation
Checking pericardium, PMI (apical pulse), and carotid artery
How to check pericardium:
- use palmar aspects of four fingers; palpate apex, left sternal border, and base
- note if any other pulsations; if present - note timing (should not be any)
- use carotid artery pulsation as your guide
Carotid artery info and palpation:
carotid artery is a central artery
- palpate pulse, carotid upstroke, amplitude and contour, presence or absence of thrills
- timing closely coincides with ventricular systole (beginning of S1)
- located in groove between trachea and SCM muscle; medial to and along side it
provides information about cardiac function (aortic valve stenosis and regurgitation)
palpate bilaterally - avoid excessive pressure and palpate one at a time
**height of pulsations unchanged by position and not affected by inspiration
**
to palpate:
- patient should be supine with head of bed at 30 degrees
- inspect for visible pulsations - often just medial to SCM muscle
- index and middle fingers in lower third of neck and palpate
- want equal bilaterally, smooth contour, brisk
– decreased pulsations: decreased stroke volume from shock or MI and local atherosclerotic narrowing or occlusion
Neck: thyroid gland
inferior to hyoid bone
check if swollen, have patient swallow
What are Cheyne-Stokes respirations?
periods of deep breathing alternating with periods of apnea
in a severe state; can be seen when a patient is dying
What is entropion
inverted lower lid (can be common in older adults)
can be irritating; eyelashes can hit eye and scratch cornea
Mouth: structure
- mouth: part of digestive and respiratory system
- tongue: functions in swallowing, chewing, cleansing teeth, forming speech
- salivary glands: moisten and lubricate food, start digestion, cleanse and protect mucosa
- teeth: deciduous and permanent
- hard palate
- soft palate
- retromolar trigone
- floor of mouth
- buccal mucosa (lip and cheek lining)
- tonsils
- uvula
- gingiva (gum)
- lips
Nose/sinuses: structure
Nose structures (document any issues in nostrils - important for NGT)
- bridge
- dorsum
- tip
- anterior naris
- vestibule
- ala nasi
- infratip lobule
- ala
- nostril floor
- nostril sill
- ala base
- footplate of medial crura
- columella
Sinuses:
- sphenoid sinus
- ethmoid sinuses
- frontal sinus
- maxillary sinus
head/neck lymph nodes: deep cervical chain
deep to the SCM muscle and often inaccessible to examination
What is mydriasis
fixed dilated pupils; not moving with light
comes from head injury/trauma
Head/neck lymph nodes: occipital
where?
at the base of the skull posteriorly
Ears: Rinne test
tests air conduction (AC) compared to bone conduction (BC)
Have patient tell you when they stop feeling vibration AND when they stop hearing the vibration
Hearing should be twice as long as compared to feeling
AC > BC = normal
BC > AC = conductive loss
head/neck lymph nodes: supraclavicular
deep in the angle formed by the clavicle and the SCM muscle
Eyes: external structure
- upper eyelid
- sclera covered by conjunctiva
- lateral canthus
- lower eyelid
- iris
- limbus
- pupil
- medial canthus
What is blepharitis
infection of edges of eyelids
can be caused by crust that isn’t cleared and gets infected
What is choanal atresia
rare; more common in children
back of nostrils constricted that cannot breathe
Head/neck lymph nodes: preauricular
in front of the ear
Eyes: diagnostic positions test
Cranial nerve 3:
- inferior oblique
- superior rectus
- inferior rectus
- medial rectus
Cranial nerve 4:
- superior oblique
Cranial nerve 6:
- lateral rectus
Spinal abnormalities
- Kyphosis- (hump) top curvature
- Lordosis (lower back curvature)
- scoliosis (spinal curvature)
Head/neck lymph nodes: submental
in the midline a few centimeters behind the tip of the mandible
Stages of bruise healing (bruising scale)
5
- red, swollen and tender: 0-2 days old
- blue, purple: 2-5 days old
- green: 5-7 days old
- yellow: 7-10 days old
- brown: 10-14 days old
after 2-4 weeks: no evidence of bruising
Neurological assessment: abnormal reflexes (pathologic)
Pathologic reflexes
- Babinski: toes fanning out
- Brudzinski: flex the neck - meningitis
- Kernig: extension of the knee - meningitis
Head/neck lymph nodes: anterior superficial cervical
superficial to the SCM muscle
What is myxedema
edema around eyes related to hypothyroidism or periorbital cellulitis
Eyes: internal structure
- lens
- iris
- cornea
- Schlemm’s canal
- ciliary body
- superior rectus muscle
- inferior rectus muscle
- macula lutea
- optic nerve
- retina
- choroid
- sclera
What is anisocoria
pupils of unequal size
head/neck lymph nodes: tonsillar (jugulodigastric)
at the angle of the mandible
Ears: structures (inner)
inner:
- three ossicles:
– malleus
– incus
– stapes
- tympanic membrane (eardrum)
- middle ear cavity
- eustachian tube
- cochlea
- CN8
- semicircular canals
- mastoid process
Ears: Structure (outer)
- helix
- antihelix
- entrance to ear canal
- tragus
- lobule
- auricle (isn’t this the entire outer ear?
- cartilage
Ears: Weber test
Using a tuning fork and seeing if the patient can hear vibration and if it is equal on both sides or heard louder on one side
If there is a side that hears vibration louder, then that SAME side has hearing loss
results (hearing louder on one eye)
- conductive loss = same ear
- sensorineural loss = opposite ear
Wound healing
- tissue normally responds to injury
- wound repair occurs by:
– primary intention
– secondary intention
– tertiary intention
What is ectropion
everted lower lid (can be common in older adults)
What is the Glasgow Coma Scale
a tool used to measure the severity of brain injury and impaired consciousness in patients
- measures eye opening response, motor response, verbal response
15 point scale
Throat: assessing tonsil size
+1: visible, but hidden within tonsil pillars
+2: halfway between pillars and uvula
+3: touching the uvula, beyond the pillars
+4: touching each other
Neck: structure
- thyroid
- trachea
- regional lymph nodes
- muscles and other connective tissues
