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
Nose/sinuses: normal assessment
- color of nose is consistent with face
- nose smooth and symmetric
- able to sniff through each nostril with other is occluded
- air flow is symmetrical
- no tenderness of nose or sinuses
Cranial Nerve 12: function and assessment
Hypoglossal
Motor
* Tongue movement
What is the chronic wound classification
- Do not move through normal sequence of repair (remains in inflammatory phase)
- Edges often not approximated (not closing or connected)
- Increased risk of infection
- Healing time delayed
What is entropion
inverted lower lid (can be common in older adults)
can be irritating; eyelashes can hit eye and scratch cornea
Respiratory assessment: focused questions - older adult
Have you noticed any SOB or fatigue with your daily activities?
Tell me about your usual amount of physical activity.
History of COPD, lung cancer, or TB
- how are you getting along each day?
- any weight change in the last 3 months? increase or decrease? how much?
How is your energy level? Do you tire more easily? How does your illness affect you at home and at work?
Do you have any chest pain with breathing?
Do you have any chest pain after a bout of coughing or after a fall?
Head/neck lymph nodes: submandibular
midway between the angle and the tip of the mandible
Complications of wounds
Infection
Hemorrhage
Dehiscence and evisceration
Fistula formation
Eyes: accommodation
- focusing on a distant object causes eyes to dilate
- shifting gaze to a near object causes pupils to constrict and converge
Diastole
AV:
- valves are open, filling phase-ventricles fill with blood
SL:
- valves are closed, ventricles are relaxed, pressure inside drops, preventing blood from flowing back into the heart
Physiologically:
- Ventricles relax and fill with blood
- Represents two-thirds of the cardiac cycle
Ventricles relaxed
- Tricuspid and mitral valves are open
- Pressure in atria higher than that in ventricles, so
blood pours rapidly into ventricles
- Toward end of diastole, atria contract and push last
amount of blood into ventricles
Cardiovascular focused questions (a bunch - combined previous flashcards)
- chief complaint present illness
- past medical/health history
- medications: current and past, and reason
- surgery or treatments
- lifestyle management
- family medical history
– cardiac history
– immediate family members: age, current health status, cause of death, age of death - nutrition
- cholesterol screenings: LDL (want low), VLDL, HDL (want higher)
- chest pain: do you have any chest pain or chest discomfort
- dyspnea: any shortness of breath?
- orthopnea: how many pillows do you sleep with? comfort or breathing?
- cough: when does it occur?
- edema: in feet or legs? socks/shoes tight?
- syncope: any LOC or dizzy getting up?
- nocturia: getting up to pee at night?
- cyanosis: changes in lips or fingertip color - blue?
Smoking:
- packs per day (PPD)
- when did you start? cough with it? what kind?
Environment:
- work
- animals
- chemicals
Medications:
- some can cause a cough
- inhaler
Allergies:
- do you have any allergies?
- reactions to allergens?
Self-care behaviors?
- mask when cleaning? fragrances?
ABCDE-EFG Lesions on skin assessment
A - asymmetry
B - border
C - color
D - diameter
E - evolving
E - elevated
F - firm to palpation
G - growing progressively over several weeks
What is the unintentional wound classification
- Result of accidental occurrence such as unexpected trauma
- Wound edges often jagged and bleeding uncontrolled
- Increased risk for infection
- Increased healing time
Interviewing people with challenging needs
- altered state or cognition: needing to decipher what is true or not
- angry, aggressive, threatening violence: getting reinforcements if needed
- flirtatious: suggest someone else be there; restating not appropriate and direct to care
- discriminatory
- under drug or alcohol influence: asking what they have taken to better care for them
- limited intelligence
- low health literacy
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
SDOH: social and community context
civic participation, discrimination, incarceration, social cohesion
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
What is conjunctivitis
red conjunctiva; pink eye
Assessment across the lifespan: adult
head-to-toe assessment
standard precautions
is it a complete or focused assessment (focused - certain problem/complete - usually first time seeing them)
explain what you are doing to the patient
basic measurements
- vitals
- height and weight
- visual and hearing acuity
Ankle-Brachial Index Values
ABI value greater than 1.4:
– calcification/vessel hardening
– refer to vascular specialist
ABI value 1.0-1.4:
– normal
– no recommendation
ABI valve 0.9-1.0:
– acceptable
– no recommendation
ABI value: 0.8-0.9:
– some arterial disease
– treat risk factors
ABI value 0.5-0.8:
– moderate arterial disease
– refer to vascular specialist
ABI value less than 0.5:
– severe arterial disease
– refer to vascular specialist
HEENT: health promotion
- annual dental assessment
- avoid heavy alcohol consumption
- avoid tobacco use, including chewing tobacco
- avoid misuse of OTC meds
- environmental carcinogens
- seatbelts
- helmets
- fire safety
Peripheral vascular assessment: pulses and arteries
Arteries of the arm:
- brachial artery
- radial artery/pulse
- ulnar artery
Peripheral arterial pulses:
- femoral artery
- popliteal
-
**pedal pulses:
– dorsalis pedis (DP) pulse
– posterior tibial (PT) pulse
Head/neck lymph nodes: occipital
where?
at the base of the skull posteriorly
Addressing SDOH at the community level
partnering with local organizations and public health agencies, getting involved in health planning, improving environments for health if possible
Assessment across the lifespan: older adults
elicit preferred way of being addressed
adjust the environment
put the patient at ease
enough space in exam room for pt to safely navigate
what assessment differences do you expect to find?
what is the patient’s functional ability?
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
Semilunar (SL) valves: location and function, when they open and close relating to cardiac cycle
Pulmonic valve - between RV and pulmonary artery
Aortic valve - between the LV and the aorta
during systole - valves are open; pumping phase – blood is ejected from the heart
during diastole - SL valves are closed, ventricles are relaxed, pressure inside drops, preventing blood from flowing back into the heart
HEENT overall
neck and eyes things to assess
Neck:
- muscles: may indicate respiratory distress
- vessels: carotid artery, jugular veins
- lymph nodes, tonsils, esophagus, trachea
- thyroid gland: bruit
Eyes:
- key areas: palpebral fissure
- assess eye movements: CN 3, 4, 6
- assess corneal light reflex, pupillary light reflex, accommodation, convergence, pupillary constriction, visual acuity
Signs and symptoms of breast cancer (8)
- irregular shape
- firm to stony hard
- poorly defined (no clear margins)
- single in number
- fixed, nonmobile
- usually nontender, but can be tender
- positive skin retraction
- constant growth
Neurological injury - stroke (types)
- “3rd most common cause of death in US”
- Men > women
- Thrombotic/embolic - clot
- Hemorrhagic - vessel ruptured/bleeding
- Often from poor control of modifiable risk factors (diabetes, obesity, HTN)
SDOH: education
early childhood education and development, enrollment in higher education, high school graduation, language and literacy
Goiter
enlarged thyroid gland
need to assess patient’s ability to breath
can be from hyperthyroidism; look for bulging eyes
can be treated or surgically removed
Eyes: external structure
- upper eyelid
- sclera covered by conjunctiva
- lateral canthus
- lower eyelid
- iris
- limbus
- pupil
- medial canthus
Mouth: abnormal assessment
- circumoral pallor, circumoral cyanosis, cyanotic lips, reddish lips, lip edema
- teeth: yellow/brown, brown dots on teeth, missing, cracked
- gums: receding, redness, edema, bleeding
- candidiasis
- lesions
- leukoplakia
- candida albicans
- black hairy tongue
Throat: uvula
- secretes saliva
- prevents food and liquid from entering the nasal cavity
- can check for the gag reflex
What is paresthesia
pins and needles
Review of systems: conducting a complete health history
- initial information
- chief complaint (s)
- history of present illness
- past medical history
- family history
- personal and social history
- review of systems (ROS)
systems:
- general survey: overall state of health, changes
- skin
- HEENT
- neck
- breast and axillae
- respiratory
- CV
- GI (abdomen)
- urinary
- genital: male and female
- psychiatric (mental health)
- hematologic
- endocrine
- lower extremities
- musculoskeletal system
- neurological
What is blepharitis
infection of edges of eyelids
can be caused by crust that isn’t cleared and gets infected
Cardiovascular assessment: Inspection
Checking for lifts or heaves
- general appearance and vital signs
- skin color, temperature
- edema
- diaphoresis
- BP: normal range or abnormal
extremities: perfusion - pulses: brisk and easily palpable
- JVP: normal range
- lower extremities for edema
Neurologic changes related to aging
- Probable decline in cranial nerve function
- Senile tremors
– Benign: intention
– Dyskinesia: no rigidity; can’t really be controlled - Grip remains intact
- Rapid alternating movements more difficulty to perform
- DTRs less brisk
- Generally, stronger stimuli may be needed to elicit response
Communicating with the hearing and visually impaired
medical interpreter if needed
Clockface if possible
SDOH
Education access and quality
Healthcare access and quality
Neighborhood and built environment
Social and Community context
Economic Stability
What is choanal atresia
rare; more common in children
back of nostrils constricted that cannot breathe
How heart murmurs can be described
- timing: systolic or diastolic
- duration: short or long
- location: where it is the loudest, radiates
- position patient: left lateral decubitis or sitting up
- shape: crescendo, decrescendo, or holosystolic
- grading and intensity
– pitch: low, medium, or high
– quality: blowing, harsh, rumbling, or musical
What are the classifications of wounds (6)
Intentional
Unintentional
Open wound
Closed wound
Acute
Chronic
Head/neck lymph nodes: preauricular
in front of the ear
Nose/sinuses: abnormal assessment
- nasal tenderness
- decreased/absent air flow via nostril(s)
- sinus tenderness
- displacement of nose cartilage or bone
- septum: deviated or perforated septum
- nasal discharges
- polyps (tags in nose that can occlude nostril)
- swollen turbinates
- mucosal discolorations
- anosmia
- choanal atresia
- epistaxis (nosebleeds)
- foreign body
- furuncle (pus or hair that gets infected)
- acute rhinitis
- allergic rhinitis
- nasal polyps
- carcinoma
HEENT: health history
- past medical history
- family history: allergies
- surgeries
- injuries, hospitalizations, allergies
- symptoms (OLDCARTS)
– location, character, or quality
– quantity or severity, timing
– aggravating or relieving factors
– associated factors
– patient’s perception
What are primary skin lesions
Not types but definition
They are the immediate result of specific causative factor; develop on previously unaltered skin
Cranial Nerve 6: function and assessment
Abducens: Eye movement (Motor)
- EOMs of cardinal gaze
– technically testing lateral eye movement
- Nystagmus? (back and forth movement)
– Unilateral or bilateral?
– Frequency?
– Plane of movement?
- Strabismus? (One eye wonky)
- Ptosis? (droopy eye lid)
Lobes of the cerebral cortex
Parietal
Occipital
Cerebellum
Frontal
Temporal
Brain stem
Risk factors for skin integrity (12)
IV drug use
Prolonged sun exposure
Body piercing
Increased age
Dehydration and Malnutrition
Reduced sensation
Diabetes
GI preparations for testing - dehydration
Bedrest - pressure ulcers
Casts - breakdown unseen; pressure
Medications
Radiation therapy
Data collection: subjective data
- what the patient says: chief complaint (CC)
- health history
- symptoms
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
What is hyperesthesia
increased sensitivity
Cranial Nerve 8: function and assessment
Acoustic / Vestibulocochlear
Sensory
- Sensory for hearing and equilibrium
– requires special equipment to full assess
– bedside assessment with conversation
- Balance
What is endophthalmos
sunken eyeballs
can come from severe dehydration
Pleural friction rub
and symptom
- inflammation of the lung tissues
- raspy breathing sound
Respiratory assessment: palpation overall
- tenderness
- intercostal tenderness: over inflamed pleurae
- crepitus: fractures
- bruising (can be from disorders, meds, injections, falls, abuse)
- sinus tract: inflammatory, tube-like structures opening onto the skin (infection)
- chest expansion
- tactile fremitus (“99”)
Respiratory assessment: developmental considerations (infants and children)
how it develops
Infant: body systems develop in utero
Respiratory system alone does not function until birth
Children: respiratory development continues throughout childhood
Cardiovascular assessment: auscultation
set up
have the patient supine
follow a “Z” pattern
- begin with diaphragm then move to bell of stethoscope
identify S1 and S2
- determine if there are abnormal heart sounds
- S3 or S4
are the sounds regular or irregular?
assess for pulse deficit - apical and radial pulses should match
– if they don’t match: not every beat is reaching the peripheral vascularization
Auscultation sites:
Identify auscultatory areas: four traditional valve areas and Erb’s point
– valve areas are not over actual anatomic locations on valves but sites on chest wall where sounds are best heard
- sound radiates with blood flow direction
- “All people eat taco meat”
– aortic valve area: 2nd right ICS; S2
– pulmonic valve area: 2nd left ICS; S2
– Erb’s point: 3rd left ICS; S1=S2
– tricuspid valve area: 4th left ICS; S1
– mitral valve area: 5th left ICS @ MCL; S1
Carotid artery:
use the bell of stethoscope: better for higher grade stenosis
- place bell near upper end of thyroid cartilage, below angle of the jaw
have client take a breath, exhale, and hold briefly while you listen for <10 seconds
- listening for bruits
Spinal abnormalities
- Kyphosis- (hump) top curvature
- Lordosis (lower back curvature)
- scoliosis (spinal curvature)
Cerebellar function - cerebellum
“auto pilot”, voluntary movement, equilibrium, coordination
Complex motor coordination for movement, equilibrium, posture
Cranial Nerve 4: function and assessment
Trochlear (Motor)
Assessed in extraocular movements (6 cardinal fields of gaze “cat whiskers”)
Head/neck lymph nodes: submental
in the midline a few centimeters behind the tip of the mandible
What happens during…Systole (SL)
valves are open, pumping phase-blood is ejected from
the heart
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
Unstageable pressure ulcer
Unstageable: base of ulcer covered by slough and/or eschar in wound bed
S2 and where in the cardiac cycle
S2 occurs when semilunar valves close
signals end of systole
heard over all of precordium - loudest at base
What does circumoral mean
around the mouth
Tanner/Lasater
Noticing
Interpreting
Responding
Reflecting
Eyes and culture
- racial differences: palpebral fissure
– Asian origin narrowed palpebral fissures - lower
– Down syndrome - fissures up
other racial differences:
- color of the iris and in retinal pigmentation
- causes of blindness
– glaucoma
– cataracts
– macular degeneration
Eyes: normal assessment findings of older adult
- loss of fat from orbit of eye, causing drooping appearance
- decreased tear production: causes dryness and/or burning of eyes
- clouding of cornea and/or deposit of white/gray-yellow material (fat) around cornea
– arcus senilis - slowing of pupillary light reflex
- pupils may be smaller in size
Cultural Humility (5 R’s)
Reflection: approach each encounter with humility & understanding
Respect: treat every person with utmost respect; strive to preserve dignity
Regard: hold every person in highest regard
Relevance: expect cultural humility to be relevant and apply this to practice
Resiliency: embody the practice of cultural humility to enhance personal resiliency
Mouth: developmental considerations
Babies:
- salivation begins 3 months
- not quite the same time as teething
- increased salivation associated with teething
Children: 20 deciduous teeth
Adults: 32 permanent teeth
Biased communication
What should you do to not be biased in communication
be nonjudgmental
safe, judgment-free, and non-discriminatory verbiage on forms
pronouns and names
Edema grading 3+
Deeper (pitting) indentation, 30 seconds to rebound, leg looks swollen
Crackles
Discontinuous nonmusical,
- early inspiratory (COPD);
- late inspiratory (pulmonary fibrosis),
- or biphasic (pneumonia)
Popping sound - inspiration
Deflated - expiration
Fine Crackles
Coarse Crackles
What is exophthalmos
protrusion of eyeballs with retracted eyelid margins
common cause is hyperthyroidism
Addressing SDOH at the practice level
offer culturally safe services, use patient navigators, ensure care is accessible to those most in need
Clinical reasoning/clinical adjustment
Recognize cues
Analyze Cues
Prioritize hypotheses
Generate Solutions
Take Actions
Evaluate outcomes
Peripheral arterial disease (PAD)
peripheral arterial disease (PAD) is form of CV disease that manifests primarily in LEs:
- deep muscle pain
- injuries often go unnoticed by patient
classic symptoms of PAD - intermittent claudication:
- ischemic muscle pain that is caused by constant level of exercise
- resolves within 10 minutes or less with rest
- reproducible
Neurological assessment: abnormal reflexes (pathologic)
Pathologic reflexes
- Babinski: toes fanning out
- Brudzinski: flex the neck - meningitis
- Kernig: extension of the knee - meningitis
Respiratory assessment: auscultation
Normal, Pediatric and infant
Normal:
Assessing air flow through the tracheobronchial tree
Listening for:
- breath sounds
- adventitious (added) sounds
- abnormalities
Diaphragm on chest wall
Listen to one full respiration; side to side
- C7 to T10
- lateral from axilla to 7th rib
Pediatric auscultation:
- Bowel sounds are easily heard in the chest
- Use smaller pediatric diaphragm end piece; or bell over infant’s interspaces and not over ribs
- Bronchovesicular breath sounds in peripheral lung fields of infant and young child up to ages 5/6 years old
- Fine crackles are commonly heard in immediate newborn period from opening of airways and clearing of fluid
Infant Auscultation
- Diaphragm is newborn’s major respiratory muscle
- count respiratory rate for 1 full minute
- normal rates 30-40 breaths (may spike up to 60)
- most accurate respiratory rate is when the infant is asleep
- Brief periods of apnea (less than 10-15 seconds) are common
– is more common in premature infants
Skin cancer: squamous cell carcinoma
- less common than basal cell; grows rapidly
- predominantly in sun-damaged skin: actinic keratosis
- can be painful, ulcerate, and bleed
- low risk for metastasis
- usually on hands or head
Ears: normal assessment
normal characteristics
- equal in size
- auricle aligns with corner of eye
- earlobes free or attached
- no lesions, discoloration or d/c
- no lumps or nodules
- no tenderness
Cranial Nerve 2: function and assessment
Optic
- Vision
- Requires ophthalmoscope
- Sensory
Using closed-ended questions
close-ended questions: yes or no answers; pertinent positives and negatives”
What is hypoesthesia
loss of sensation
Direction of blood flow (order) From arteries to veins
Arteries-Arterioles-Capillaries-Venules-Veins
Head/neck lymph nodes: anterior superficial cervical
superficial to the SCM muscle
What is black hairy tongue
papillae supposed to shed but doesn’t and debris gets stuck and turns black
OPQRST
Onset
Precipitating and Palliating factors
Quality
Region or Radiation
Severity
Timing or Temporal characteristics
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
Macular degeneration: decreased visual functioning in older adults; what is it?
- breakdown of cells in the macula of the retina
- causes loss of central vision and blindness
- women affected more than men
What is a stye
infected eyelid hair follicle
What is Biot’s (Ataxic) breathing?
severe, IRREGULAR Cheyne-Stokes
periods of apnea alternating with regular deep breaths which stop suddenly for short intervals
Shapes and configurations of lesions
Annular or circular
Confluent - growing into each other
Discrete - one area
Grouped - little groups
Target or Iris “Bulls Eye” - Lymes
Linear - common in shingles
Zosteriform - herpes
What is anisocoria
pupils of unequal size
Mini Mental Status
Tool, used with, ORNR
Screening tool
- max score is 30
- 23 or less: cognitive impairment
Used primarily with elderly
- dementia
- delirium
Example (ORNR):
- Orientation: what is today’s date?
- Registration: i’ll say three words and you say them back to me
- Naming: what is this?
- Reading: can you read this and do what it says?
What is candida albicans (mouth abnormal)
“thrush”
curd-like patches that scrape off tongue
can be seen a lot with babies
Glaucoma: decreased visual functioning in older adults; what is it?
- increased intraocular pressure
- incidence increases with age
- more common in men
What is the acute wound classification
- healing time: days to weeks
- edges well-approximated
- decreased risk of infection
- thorough healing process without delay
Occipital lobe
vision
What is a pressure ulcer
A wound with a localized area of injury to the skin and/or underlying tissue
Can be acute or chronic
Underlying cause is pressure
Most develop when soft tissue is compressed alone or in combination with shear and/or friction
AKA decubitus ulcer, pressure sore, bed sore
Edema grading 4+
> 30 seconds to rebound, leg is severely swollen
Neurological assessment: developmental considerations for elderly patients
physiologic changes and consequences
Physiologic changes:
- general atrophy of neurons
– brain usually decreases in weight
– cerebral cortex thins
- Leads to decreased CBF (cognitive brain function), CSF
- Neural connections slower
- Loss of muscle mass and tone
- Decrease in sensory abilities
Consequences:
- Dizziness
– syncope
- Tremors develop
- Strength (grip) less strong
High risk for falls!
head/neck lymph nodes: tonsillar (jugulodigastric)
at the angle of the mandible
What are clinical manifestations of peripheral arterial disease (PAD)
- paresthesia: numbness or tingling in the toes or feet
- loss of pressure and deep pain sensation
- thin, shiny, and taut skin
- loss of hair on lower legs
- diminished or absent pulses (lesion) at any point in LE circulation
– ulcers develop from inadequate circulation
– high risk for gangrene - pallor of foot with leg elevation
- pain at rest
– occurs in the foot or toes
– aggravated by limb elevation
– occurs from insufficient blood flow
– occurs more often at night
Throat: structures
Oral pharynx
- begins at the anterior tonsillar pillar
- ends at posterior pharyngeal wall
- contains tonsils (mass of lymphoid tissue)
Nasopharynx
- continuous with the oropharynx but located above it and behind nasal cavity
- contains pharyngeal tonsils (adenoids)
- contains openings of the Eustachian tubes
Afterload
afterload is the force against which the heart has to contract to EJECT THE BLOOD
afterload is the opposing pressure that the ventricle must generate to open the aortic valve -
degree of vascular resistance which the left ventricle must pump (contraction)
What are the risk factors of pressure ulcers
- Immobility
- Malnutrition and dehydration/excess fluid
- Exposure to moisture
- Altered level of consciousness
- Advancing age
- Chronic illnesses
Lesions caused by trauma or abuse
- pattern injury
- hematoma
- contusion (bruise)
Throat: abnormal assessment
- lips: dry, cracked; lesions, chelar fissures (cheilitis)
- teeth: caries, broken, severe over/under bite related to TMJ
- oral mucosa: pallor, cyanosis, lesions, bleeding gums
- salivary glands: swelling
- tongue: ulcers, CN 12 issues
- CN 9: altered taste
- CN 10: affecting uvula’s ability to rise
- CN9 and 10: loss of ability to speak or swallow
- tonsils: enlarged, thyroid enlargement
- benign or malignant growths
Neurological assessment: developmental considerations for infants
rooting, palmar grasp, tonic neck, moro, placing, stepping
- Rooting reflex: (brush cheek, infant should turn head toward side)
- Palmar Grasp (tight grasp around finger/toe)
- Tonic neck reflex (baby supine, “fencing position”
- Moro reflex- scare baby
- Placing Reflex- place foot on table
- Stepping Reflex- should alternate steps
(she didn’t have breast on blueprint but feel like i should add stuff?) Signs and symptoms of advanced breast cancer: BREAST
B: breast mass
R: retraction
E: edema
A: axillary mass
S: scaly nipple
T: tender breast
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
Addressing SDOH at the patient level
be alert to clinical flags, ask patients about social challenges in a sensitive and caring way, help them access benefits and support services
Coarse crackles
- popping sound
- are heard over any lung region
- do not vary with body position
- early inspiration and last throughout expiration
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
Normal breath sounds - description and location
Bronchial: over trachea and large bronchi; tubular sound; high pitched hollow sounds
Bronchovesicular: medium-pitched sounds
Vesicular: inspiration louder and longer than expiration, low pitched sounds
Parietal lobe
sensation
Respiratory assessment considerations with illness
- may need to roll from side to side
- limits comparison
Rate and rhythm of breathing
Normal: 10-20 breaths per minute, even pattern, normal depth (sticking to 10-20 for this class even though book says 12)
Tachypnea: >25 per minute, rapid, shallow
Bradypnea: <10 per minute
Apnea: periods of not breathing
Hyperventilation: increase rate and depth
Hypoventilation: irregular, shallow
Adventitious breath sounds
Deep tendon reflexes: types and grading
Grading
* 4+: brisk, hyperactive
with clonus
* 3+: Brisker than average
* 2+: Normal
* 1+: Diminished
* 0: No response
Areas to test
* Biceps
* Triceps
* Brachioradialis
* Quadriceps
* Achilles
Neurological assessment: inspection - still unsure on this
- cranial nerves
- A&O x3
Skin cancer: Basal cell carcinoma
- most common form of skin cancer; slow growing
- 90% presentation on sun-exposed skin
- can become painful
- rarely fatal
- starts as red or pink
Stage 4 pressure ulcer
Stage 4: ulcer extends to muscle or bone; undermining is likely; exposed bone, tendon, or muscle
PAD presentation of symptoms
-Paresthesia: numbness or tingling in the toes or feet
-Loss of pressure and deep pain sensation
-Thin, shiny, and taut skin
-Loss of hair on the lower legs
-Diminished or absent pulses (lesion) at any point in LE circulation
- Ulcers develop from inadequate circulation
- High risk for gangrene
-Pallor of foot with leg elevation
-Pain at rest
- Occurs in the foot or toes
- Aggravated by limb elevation
- Occurs from insufficient blood flow
- Occurs more often at night
What is the open wound classification for wounds
- Result of intentional or unintentional trauma
- Skin surface is broken
- Bleeding, tissue damage, infection, delayed wound healing (possible)
Nose/sinuses: inspection and palpation
Inspection:
- external nose: symmetry, lesions
- color, shape, consistency of external nose
- patency of air flow
- tenderness of nose/sinuses
Palpation:
- test patency of each nostril (occlude one and breathe through other; do both)
- palpate the sinuses for tenderness, jaw, thyroid
Mouth/tongue/lips: inspection
- mouth and throat: lips, teeth, gums, tongue, buccal mucosa for color, presence of lesions, exudate, grade tonsils
- begin with anterior structures and move posteriorly
– use tongue blade to retract structures
– bright light for optimal visualization - inspect lips for color, moisture, cracking, lesions
– retract lips and note inner surface
– african americans may have bluish lips and dark line on gingival margin - lip consistency
- number, color, condition, alignment of teeth
- color and consistency of gums and buccal mucosa
- color, moisture, size, texture of tongue (including ventral and lateral surface)
- color, integrity of posterior throat
- lesions, odor, discharge
- gag reflex
Stage 2 pressure ulcer
Stage 2: skin is broken to epidermis or dermis; partial-thickness skin loss - shallow, open ulcer
Flow of DEOXYGENATED blood through heart
- Superior/inferior vena cava
- R atrium
- Tricuspid valve
- R ventricle
- Pulmonary valve
- Pulmonary Arteries
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)
Temporal lobe
Auditory, hearing, taste, smell, Wernicke’s area
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
Rhonchi
- variant of wheezes; same mechanism
- lower in pitch
- disappear with coughing
Eye: inspection
- eyelids, lashes, eyebrows
- width/position of palpebral fissures: elliptical open space between the eyelids; how do they sit on face
- ability to close eyelids
- eyelid inversion/eversion (turn in/turn up)
- swelling/edema, lesions, discharge
- position/alignment of eyeball in socket: do they line up? how do they sit?
- color of conjunctiva: transparent protective outer covering
- color and shape of iris
- size and shape of pupil
Cardiovascular assessment: percussion
advanced - no notes in PPT (can look for stuff in book?)
Throat: focused assessment
- throat pain: sore throat
- difficulty chewing and/or swallowing
- hoarseness or voice changes
– can be puberty
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
Ears: focused assessment
- recent changes in hearing; is the change new
- ear draining: what does it look like? do you clean ears?
- ear pain/tenderness: can you describe pain?
- ringing or crackling in ears
- dizziness; what can be causing it
- spinning sensation; vertigo
Clinical judgment (steps after making a plan of care)
a decision made regarding a course of action by the nurse
- collect data
- analysis of data
- interpretation of data
- determine priority problem/concern
- apply knowledge to clinical situation
- identify appropriate nursing intervention
– problem solving
– decision making
– critical thinking
What is halitosis
bad breath
may indicate oral, digestive, metabolic or respiratory problem
Stage 1 pressure ulcer
Stage 1: skin is unbroken but inflamed; nonblanchable erythema of intact skin
Using open-ended questions
open-ended questions: patient’s own words; story of symptoms
Nose/sinuses: focused assessment
- nose/sinus pain, tenderness
- nosebleeds: often? spontaneous? how long did it last? what led to it?
- nasal stuffiness, discharge: weather? color? amount?
- postnasal drip
- recent change in ability to smell
- nasal surgery: deviated septum, trauma, cosmetic?
- sinus infections: frequency? recent?
- around any animals? allergies? pollen?
Brain stem - structure and function
Midbrain
- Thalamus/hypothalamus (actually part of diencephalon) relay center and hormone regulation, respectively
Pons
- Respiratory centers
Medulla
- Ascending and descending tracts
- Autonomic centers (respiration, heart, GI)
- regulates breathing, BP, HR, swallowing
Central core
Cranial Nerve 7: function and assessment
Facial
Motor
- Facial muscles for expression
- Have client “smile, frown, close eyes tight, lift brows, show teeth, puff cheeks
Sensory
- Taste on anterior tongue
- Tested only if injury occurs or is suspected
- Salt, lemon juice, sugar
Skin cancer: malignant skin lesions
types - 4
- basal cell carcinoma
- squamous cell carcinoma
- malignant melanoma
- metastatic malignant melanoma
Respiratory assessment: palpation - assessing chest expansion
- place thumbs at the level of the 10th ribs, fingers loosely grasping and parallel to the lateral rib cage
- position hands and slide them medially just enough to raise a loose fold of skin between thumbs over spine
- ask patient to inhale deeply
- watch distance between your thumbs as they move apart during inspiration
- feel for the range and symmetry of the rib cage as it expands and contracts
Neck: structure
- thyroid
- trachea
- regional lymph nodes
- muscles and other connective tissues
Preload
How much blood is in the ventricle before it’s pushed out. At end of diastole and before systole begins
preload is the volume of blood in the ventricles AT THE END OF DIASTOLE
preload is venous return, which build during diastole -
stretching of the cardiac cells PRIOR to contraction; how well ventricular muscle can stretch at end of diastole
the greater the stretch, the stronger the heart’s contraction
Nursing process
ADPIE
Assessment
Diagnosing
Planning
Implementation
Evaluation
Ear: abnormal assessment
Abnormal characteristics
- ears < 4 cm; tiny ear
- ears > 10 cm; huge ear (are normally 5-7cm)
- asymmetrical
- low set
- lesions
- discharge
- nodules/lumps
- tenderness
- pain
Documenting pressure ulcers
- Location
- Identification of stage
- Size: L W D
- Presence of undermining or tunneling
- Color & type of wound tissue
- Visible necrotic tissue
- Presence of exudate, drainage, or odor
- Presence of granulation tissue
- Condition of skin around wound
