NSG 500 EXAM 1 Flashcards
If a patient isn’t giving you the answers you’re looking for, what’s the best way to get it?
- Direct questions/qualifier questions
What are good ways to ask a patient their story?
- Open ended questions
- Cultural sensitivity: purpose, reason it is important, how culture may impact aspects of an exam of emotional health.
Looking at others’ lifestyles. Understanding beliefs. Ask questions.
The steps of assessment, inspection, palpation, percussion, auscultation;
What they are, how to perform; sequence used; how to palpate (what parts of the hands work best for different purposes; fine discrimination, vibration)
What are normal percussion notes, know where they are found
How to use equipment; how to apply a stethoscope, otoscope
-
-It is the process of observation. Your eyes and nose are sensitive tools for gathering data. Observe gait and stance and ease of movement.
-Info about neurological and musculoskeletal integrity.
-Patient’s emotional and mental status: make eye contact? Hygiene? Clothes?
-Color, moisture and odor…possible underlying diseases.
-Inspection -unlike palpation, percussion, and auscultation- can continue through the history taking process and physical examination.
Inspection
-Involves the use of hands and fingers to gather info through the sense of touch.
-The palmar surface of your fingers and finger pads is more sensitive than the fingertips. Use this surface whenever discriminatory touch is needed for determining position, texture, size, consistency, masses, fluid, and crepitus.
-The ulnar surface of the hand and fingers is the most sensitive for distinguishing vibration.
-The dorsal surface of the hands is best for estimating temperature.
-To palpate organs of the abdominal cavity, stand at the patient’s right side with the patient in supine position. Use warm hands and bend the patient’s knees to help relax the abdomen. Lay the palm of your hand lightly in the abdomen, with the fingers extended and held together. With the palmar surface of your fingers, depress the abdominal wall, using a light and even pressing circular motion. Start with light palpation, then moderate, and finally deep palpation.
Short fingernails are a must to perform palpation!
Palpation
-Involves striking one object against another to produce vibrations and subsequent sound waves.
-Fingers function as a hammer. Sound waves are heard as percussion tones (called resonance).
-The density of the medium through which the sound waves travel determines the degree of percussion tone. The denser the medium, the quieter the percussion tone. The percussion tone over air is loud, over fluid less loud, and over solid areas soft.
-Tympany, hyperresonance, resonance, dullness, flatness. Tympany is the loudest and flatness is the quietest.
-Because it is easier to hear the change from resonance to dullness proceed with percussion from areas of resonance to areas of dullness.
Percussion
-Immediate (direct) percussion involves striking the finger or hand directly against the body.
-To perform indirect percussion, the finger of one hand acts as a hammer (plexor) and a finger of the other hand acts as a striking surface.
-To perform it, place your non-dominant hand on the surface of the body with the fingers slightly spread. Place the distant phalanx of the middle finger firmly on the body surface with the other fingers slightly elevated off the surface. Snap the wrist of your other hand downward, and with the tip of the middle finger, sharply tap the interphalangeal joint of the finger that is on the body surface.
-Snapping downward from the elbow or shoulder is a common error.
-Percussion must be performed against bare skin.
-If you are not able to hear the percussion tone, try pressing harder against the patient’s skin with your finger that lies on the body surface.
-Tap sharply and rapidly; once the finger has struck, snap the wrist back, quickly lifting the finger to prevent dampening the sound.
-Use the tip and not the pad of the plexor finger.
-Percuss one location several times.
Percussion Technique
-Involves listening to sounds. Stethoscope.
-The environment should be quiet and free from distracting noises. Place stethoscope against naked skin. Listen for presence and characteristics of sound.
-Auscultation should be carried out last, except with the abdominal examination, after other techniques have provided information that will assist in interpreting what you hear.
Auscultation
What is the preferred order for examination of the abdomen?
The correct order for abdominal assessment is inspection, auscultation, percussion, palpation. Palpation is the last step in abdominal assessment. Percussion and palpation can alter the frequency and intensity of bowel sounds.
Equipment: pneumatic otoscope, reflex hammer, ophthalmoscope, Wood’s lamp, what they are for, how they are used, any differences with pediatrics
-
-Provides illumination for examining the external auditory canal and the tympanic membrane.
-Select the largest size speculum that will fit comfortably into the patient’s ear canal.
-You can use the otoscope for the nasal examination if a nasal speculum is not available. Use the shortest, widest otoscope speculum and insert it gently into the patient’s naris.
-The pneumatic attachment for the otoscope is used to evaluate the fluctuating capacity of the tympanic membrane. A short piece of rubber tubing is attached to the head of the otoscope. A hand bulb attached to the other end of the tubing, when squeezed, produces puffs of air that cause the tympanic membrane to move.
Otoscope
-It is used to test deep tendon reflexes.
-Hold the hammer loosely between the thumb and index finger so that the hammer moves in a swift arc and in a controlled direction.
-As you tap the tendon, use a rapid downward snap of the wrist, tap quickly and firmly, and then snap your wrist back so that the hammer does not linger on the tendon. The tap should be brisk and direct.
-You can use either the pointed or flat end of the hammer. The flat end is more comfortable when striking the patient directly; the pointed end is useful in small areas, such as on your finger placed over the patient’s biceps tendon.
-Your finger can also act as a reflex hammer; this can be particularly useful when you are examining young patients. It is less threatening to a child than a hammer.
Percussion (Reflex) hammer
-It has a system of lenses and mirrors that enable visualization of the interior structures of the eye. It has a light source that projects through various apertures while you focus on the inner eye. The large aperture, the one used most often, produces a large round beam. The various apertures are selected by rotating the selection dial.
-The lenses in varying powers of magnification are used to bring the structure under examination into focus by converging or diverging light. An illuminating lens indicator displays the lens number positioned in the viewing aperture. The system of lenses compensates for myopia or hyperopia in both the examiner and the patient. There is no compensation for astigmatism.
-The panoptic ophthalmoscope head uses an optical design that allows a larger field of view (25 degrees vs the standard 5 degrees) and increases magnification. The view of the fundus is 5X larger than the view achieved with the standard one.
Ophthalmoscope
-It contains a light with a wavelength of 360nm. This is the black light that causes certain surfaces to fluoresce.
-It is used primarily to determine the presence of fungi on skin lesions.
-To correctly use it, darken the room, turn on the Wood’s lamp, and shine it on the area or lesion you are evaluating. A yellow-green fluorescence indicates the presence of fungi. Purple color on the skin indicates no fungal infection is present.
-Darkening the room can be intimidating to children. Explain the procedure before performing it and allow them to play with the lamp.
Wood’s lamp
-
-Inappropriately laughing
-Flat affect
-Disheveled appearance
-Communication may be altered
-Patient may not be alert and oriented to person, time, place, and situation.
- Indications of cognitive impairment (history or PE findings)
Areas of the brain and their function
In the review session, the ONLY example Dr. Hall provided is… the auditory (hearing) center is in the temporal lobe of the brain.
-
- Main findings in acromegaly, Turner syndrome, Cushing syndrome, precocious puberty
-
- Main findings in acromegaly, Turner syndrome, Cushing syndrome, precocious puberty
-
- Main findings in acromegaly, Turner syndrome, Cushing syndrome, precocious puberty
-
- Main findings in acromegaly, Turner syndrome, Cushing syndrome, precocious puberty
-
- Main findings in acromegaly, Turner syndrome, Cushing syndrome, precocious puberty
-
Precocious Puberty:
- Females <7
- Males <9
-
Precocious Puberty:
- Females <7
- Males <9
-
- Exam findings indicative of nutritional deficiency, assessment of nutrition and protein status
- Vitamin B Deficiency: Fatigue/tired, headache, pale, palpitations, SOB, sores in mouth or in corners of mouth
Vitamin E: nerve and muscle function
Protein status: check prealbumin and albumin levels
-
- Growth and development milestones in children, walk, talk, use sentences.
1st milestone: smiling
12 months: speech
18 months: walking
3 years old: ask why, short phrases
-
Difference between an objective and subjective finding, know examples
-
Difference between an objective and subjective finding, know examples
-
Difference between an objective and subjective finding, know examples
-
Difference between an objective and subjective finding, know examples
-
- Skin lesions:
Description of common macule, papule, vesicle, wheal. Know examples, i.e. what is a freckle?
-
Macule
Flat, circumscribed area that is a change in the color of the skin; less than 1 cm in diameter.
Freckle, flat nevi, petechiae. Measles skin lesion.
-
Papule
An elevated, firm, circumscribed area; less than 1 cm in diameter.
Wart (verruca), lichen planus.
-
Vesicle
Elevated, circumscribed, superficial, not into dermis; filled with serous fluid; less than 1 cm in diameter.
Varicella (chickenpox), herpes zoster (shingles).
-
Wheal
Elevated, irregular-shaped area of cutaneous edema; solid, transient, variable diameter.
Insect bite, urticaria, allergic reactions.
-
What are lesions that require further investigation; what do they look like?
- Nevi. Most of them are harmless. Some of them can develop into melanoma.
- Actinic keratosis. It can progress into squamous cell carcinoma.
- Other common abnormalities; staph and strep infections
-
When to be concerned about spots on skin?
If new or recent change in appearance.
If bleeds easily.
Fixed.
Irregular
-
Actinic keratosis
- Atypical squamous cells confined to the upper layers of the epidermis as a result of sun damage.
THESE LESIONS CAN PROGRESS INTO SQUAMOUS CELL CARCINOMA OVER TIME.
-
Nevi:
Although most nevi are harmless, some may be atypical and develop into melanoma.
-
What do herpes, basal cell, malignant melanoma, and seborrheic keratosis look like?
Basal Cell Carcinoma:
- Most common type of cancer of the skin. Arises from basal layer of epidermis.
- Occurs on exposed parts of the body. It rarely metastasizes.
-
What do herpes, basal cell, malignant melanoma, and seborrheic keratosis look like?
Malignant Melanoma:
-Lethal form of cancer that develops from melanocytes.
-ABCDE.
-
What do herpes, basal cell, malignant melanoma, and seborrheic keratosis look like?
Herpes:
-Varicella-zoster viral (VAV) infection.
-Single dermatome that consists of red, swollen plaques or vesicles that become filled with purulent fluid.
-Does not cross midline.
-
- What are common normal skin lesions on an older adult
Lesions that may occur on the skin of healthy older adults (expected findings):
-Cherry angiomas are tiny, bright ruby-red to dark blue/black, round papules that may become brown with time.
-
- Seborrheic keratoses are pigmented, raised, warty lesions, usually on the trunk.
-
- Sebaceous hyperplasia: yellowish, flattened papule with a central depression that is often difficult to discern from a basal cell carcinoma.
-
- Cutaneous tags (acrochordon): small, soft, skin colored, pedunculated papules of skin, usually appearing on the neck and upper chest.
-
- Cutaneous horns: small, hard projections of the epidermis, usually occurring on the forehead and face and can be manifestation of an underlying squamous cell carcinoma or a wart.
-
- Solar lentigines (singular lentigo): irregular, gray-brown macules that occur in sun-exposed areas. AKA, age spots or liver spots.
-
- What to expect when palpating lymph nodes
- Differentiating infection from malignancy
- Normal changes in the older adult
- Where lymph nodes are palpable
- How to differentiate a lymph node from a cyst
- What does a painful enlarged node indicate v. one that is not painful?
- When does an enlarged lymph node require further investigation?
- KNOW WHERE LYMPH NODES ARE and which ones will be enlarged by infection area
-
-If a lymph node is palpable, most times it is enlarged.
-Enlarged (swollen) lymph node (lymphadenopathy)swell when the immune system is fighting an infection or illness.
-A hard, fixed, painless node suggests a malignant process.
-The more tender a node, the more likely it is an inflammatory process. Painful lymph better than nonpainful!
-Nodes do not pulsate; arteries do.
-A palpable supraclavicular node on the left (Virchow node) is a significant clue of thoracic or abdominal malignancy.
-Slow nodal enlargement over weeks and months suggests a benign process; rapid enlargement without signs of inflammation suggests malignancy.
-With bacterial infection, nodes become warm or tender to the touch, matted, and much less discrete.
-It is possible to infer the site of an infection from the pattern of lymph node enlargement. E.g., infections of the ear usually drain to the preauricular, retropharyngeal, and deep cervical nodes.
-In childhood diseases of rubella, rubeola, and varicella often present with obvious cervical nodes, usually posterior rather than anterior. Hepatitis A and B and infectious mononucleosis have the same pattern.
-In the elderly, changes in the structure of the lymph node include replacement of lymph tissue by fibrous, scar-like tissue and fatty tissue.
-
How to differentiate between lymph or cyst?
Transillumination. As a rule, nodes do not transilluminate. Fluid-filled cysts do!
-
-
-
- How to palpate the thyroid; what will you expect to feel
-Palpation of thyroid requires gentle touch. It can be palpated from the front or from the back of the patient.
-Position the patient to relax the sternocleidomastoid muscles, with the neck flexed slightly forward and laterally toward the side being examined.
-Ask the patient to swallow water while you are palpating.
-Palpation can be done using the frontal or posterior approach.
-The thyroid lobes, if felt, should be small, smooth, and free of nodules.
-At its broadest is approx. 4 cm. The right lobe is often 25% larger than the left.
-The consistency should be firm, but pliable.
- Coarse tissue or a gritty sensation suggests an inflammatory process.
-If nodules are present, they should be characterized by number, whether they are soft or hard. An enlarged, tender thyroid may indicate thyroiditis.
-If the thyroid is enlarged, auscultate for vascular sounds with the bell of the stethoscope. In a hypermetabolic state, the blood supply is dramatically increased, and a vascular bruit (a soft rushing sound) may be heard.
-Older adult: thyroid is more fibrotic, harder, not as smooth.
Note: The thyroid gland moves with swallowing. Subcutaneous fat that mimics a goiter does not.
-
-
History and physical findings suggestive of hypo and hyperthyroidism
-
- History findings suggestive of different types of headaches; migraine, tension, cluster
-
- History findings suggestive of different types of headaches; migraine, tension, cluster
-
- History findings suggestive of different types of headaches; migraine, tension, cluster
-
- History findings suggestive of different types of headaches; migraine, tension, cluster
-
- History findings suggestive of different types of headaches; migraine, tension, cluster
-
- How is pain assessed? What is the gold standard?
-A patient’s self-assessment is the gold standard. The patient’s report of pain is the most reliable indicator of pain and should be believed. Some of the most used scales in adults: numeric pain intensity scale, descriptive pain intensity scale, and visual analog scale.
How to assess pain in child?, when can a pain scale be used?
-Some children as young as 3 yo have adequate communication skills to self-report their pain perception.
-Assess the child’s ability to use a self-report pain scale by determining whether the child understands concepts of higher-lower and more-less.
-Valid and reliable self-rating pain scales for young children include the Wong-Baker Faces Rating Scale and the Oucher Scale.
-Older children and adolescents may use these pain scales or those listed for adults.
-For non-verbal children, the FLACC Behavioral Pain Assessment Scale can be used.
-
-
-
-
-
- Overall changes in the older adult to differentiate normal from abnormal
-
- Nutrition: What is normal BMI; overweight BMI, obese BMI; physical signs of nutritional deficiency
-
-
- What is physiologic jaundice in the newborn, when is it normal and what does it indicate if abnormal
-Jaundice (icterus) is a yellow pigmentation of the skin caused by an increased level of bilirubin in the blood.
-Physiologic jaundice (hyperbilirubinemia) of the newborn is a frequently encountered problem in otherwise healthy newborns caused by the lack of maturity of bilirubin uptake and conjugation by the liver.
-High bilirubin levels in the newborn period can be associated with hemolytic disease, metabolic and endocrine disorders, anatomic abnormalities of the liver, and infections.
-Pathological jaundice in the newborn period is associated with a severe illness. Risk factors for development of pathological jaundice include fetal-maternal blood type incompatibility (hemolytic disease of the newborn), premature birth, exclusive breast-feeding in some infants, maternal age greater than or equal to 25 yo, male sex, delayed meconium passage, excessive birth trauma.
-
- How to transilluminate the skull of an infant, what is seen, what is normal
-you can transilluminate the skull of an infant who have suspected intracranial lesions or a rapidly increasing head circumference (hydrocephalus).
-The procedure must be performed in a completely darkened room.
-The transilluminator is placed firmly against the infant’s scalp so that no light escapes.
-Begin at the midline frontal region and inch the transilluminator over the entire head.
-Observe the ring of illumination through the scalp and skull around the light, noting any asymmetry.
-Expected finding: A ring of 2 cm or less beyond the rim of the transilluminator with all regions of the scalp except the occiput, where the ring should be ≤ 1 cm.
-Abnormal finding: Illumination beyond these parameters suggest excess fluid or decreased brain tissue in the skull (hydrocephalus).
-
- What are normal/abnormal skin changes in pregnancy
-Striae gravidum (stretch marks) may appear over the abdomen, thighs, and breasts during the second trimester of pregnancy.
-Increase in telangiectasias. They are small, dilated blood vessels consisting of venules or arterioles. Usually resolve after delivery.
-Hemangiomas. If present before pregnancy, they may enlarge. New ones may form.
-Cutaneous tags.
-Increased pigmentation of areolae, nipples, vulvar and perineal regions, axillae, and the linea alba. Pigmentation of the linea alba is called the linea Negra.
-Preexisting pigmented nevi and freckles may darken, with some nevi increasing in size. New nevi may form.
-Melasma or “mask of pregnancy”. The darkened, blotchy skin is usually symmetric and found on the forehead, cheeks, bridge of the nose, and chin.
-Palmar erythema.
-Itching over the abdomen and breasts resulting from skin stretching.
-Growing phase of the hair is lengthened, and hair loss is decreased.
-Acne vulgaris may be aggravated during the first trimester.
-
-Melasma or “mask of pregnancy”. The darkened, blotchy skin is usually symmetric and found on the forehead, cheeks, bridge of the nose, and chin.
-
-Increase in telangiectasias. They are small, dilated blood vessels consisting of venules or arterioles. Usually resolve after delivery.
-
Cellulitis:
-Diffuse, acute, infection of the skin and subcutaneous tissue.
-Caused by Streptococcus pyogenes or Staphylococcus aureus.
-Skin is red, hot, tender, and indurated; borders are not well demarcated.
- Regional lymphadenopathy may be present.
-Rare to have bilateral cellulitis.
-
Impetigo:
-Common bacterial infection on face. Highly contagious.
-Caused by Streptococcus or Staphylococcus infection of the epidermis.
-Lesion crusts with a characteristic honey color.
-Regional lymphadenopathy may be present.
What are good ways to ask a patient their story:
Open ended questions
If a patient isn’t giving you the answers you’re looking for, what’s the best way to get it:
Direct questions/qualifier questions
Cultural sensitivity:
Looking at others lifestyles. Understanding beliefs. Ask questions.
Inspection takes place through the entire exam.
-
For abdomen, auscultate before palpation.
-
Dorsal side of hand to check for temperature.
-
Finger pads for palpation.
-
Ulnar surface for vibration.
-
Stethoscope firmly against skin.
-
Pneumatic otoscope for kids to tympanic membrane exam.
-
Percussion tones:
Dull = mass/fluid filled
Tympanic = lungs
If dull in lungs = infection/pneumonia
-
If you do not have a reflex hammer = use fingers
-
Cognitive impairment findings:
Inappropriately laughing
Flat affect
Disheveled appearance
Communication may be altered
-
Brain:
Parietal = sensation
Temporal = auditory
Frontal = behavior/speech
Cerebral = control of body/writing/drawing
-
Acromegaly – pituitary tumor
Enlarged hands and feet
Pronounced facial features
-
Turners – X,0
No periods.
Infertile.
Short.
Webbed neck.
-
Cushing - steroid
Weight gain.
Moon face.
Buffalo hump
-
Precocious Puberty
Females <7. Males <9
Breast development, pubic hair growth, enlarged testes and penis
-
Vitamin B Deficiency
Fatigue/tired, headache, pale, palpitations, SOB, sores in mouth or in corners of mouth
-
Vitamin E = nerve and muscle function
-
Protein status: check prealbumin and albumin levels
-
Milestones in kids: REMEMBER IT IS UP TO THIS AGE THAT IS NORMAL.
1st milestone: smiling
12 months: speech
18 months: walking
3 years old: ask why, short phrases
-
Subjective Data:
Patient stated.
Chest pain.
Review of Systems.
HPI
SOB
-
Objective Data:
Provider assessment.
Vital Signs
Physical exam findings
-
Skin:
Macule = freckle. Flat. <1cm
Papule = mole. Raised. <1 cm
Vesicle = fluid filled. Chicken Pox/Shingles
Wheal = hives. Edema. Red. Insect bite
-
Older adult normal skin findings:
Dryness
Skin tags
Cherry angioma
-
Malignant Melanoma
Irregular border
FIXED
-
Solar Keratosis (Actinic keratosis) – spot on skin. Scaly. NOT normal.
-
Impetigo:
Common bacterial infection on face. Highly contagious.
-
When to be concerned about spots on skin:
If new or recent change in appearance
If bleeds easily.
Fixed.
Irregular
-
KNOW PICTURES OF HERPES, BASAL CELL SKIN CANCER, MELANOMA
-
Lymph nodes:
If palpable = enlarged.
If enlarged = inflammation
Cervical chain enlarged think throat infection
KNOW WHERE LYMPH NODES ARE and which ones will be enlarged by infection area
Elderly: fibrotic or fatty is NORMAL
Painful lymph better than nonpainful.
-
How to differentiate between lymph or cyst:
Transillumination
Transillumination in a newborn/infant looks for:
hydrocephalus
Thyroid exam
Feel for movement when swallowing
Older adult: fibrotic, harder, not as smooth
-
Hypothyroid
Decreased energy, weight increased
-
Hyperthyroid
Exophthalmos, increased energy, decreased weight
-
Migraine
Unilateral or generalized.
Lasts hours to days.
Aura.
Photosensitivity and sound sensitivity.
N/V
-
Cluster Headache
Sudden, intense, one side
-
KNOW BMI CHART
<18.5 = underweight
18.5-24.9 = appropriate
25 – 29.9 – overweight
> 30 obese
-
Pain assessment
Best way to assess to ask patient. Number scale
Interactive assessment on a pediatric patient: age 3
-
Jaundice in newborn or infant
Concerned after first few weeks
Check hemolysis
-
Normal in pregnancy:
Striae (stretch marks)
Hyperpigmentation on face
Linea nigra
Be able to identify normal vs abnormal in pregnant patient
-
- Interviewing skills: how to approach patients, start the process, obtain information. open ended. Patient should tell you why they are here/clarifying questions
-
- Cultural sensitivity: purpose, reason it is important, how culture may impact aspects of an exam of emotional health— recognize and accept that there are beliefs different than the practitioner Some Asian culture don’t make eye contact
-
- The steps of assessment, inspection, palpation, percussion, auscultation (last except in abd FIRST); KNOW ORDER
What they are, how to perform; sequence used; how to palpate (what parts of the hands work best for different purposes; fine discrimination, vibration) FINE FINGER TIPS/99 ulnar surface if the hand
What are normal percussion notes, know where they are found
How to use equipment; how to apply a stethoscope, otoscope( adult pull oricle up and back) kid down and back for tympanic membrane
-
- Equipment: pneumatic otoscope ( pressure behind tympanic membrane), reflex hammer, ophthalmoscope (retina HTN/DM abnormal), Wood’s lamp(black light susp fungal infect/ corneal abrasions/foreign bodies eye), what they are for, how they are used, any differences with pediatrics
-
- Indications of cognitive impairment (history or PE findings)- inappropriate affect
-
- Areas of the brain and their function- frontal speech motor /parietal touch pressure body awareness /temporal hearing facial recognition/occipital vision color cerebellar dysfunction movt coordination
-
- Main findings in acromegaly (larger feature feet hand face), Turner syndrome ( no sexual developments), Cushing syndrome (moon face humpback lrg abdominal girth), precocious puberty(early puberty 5-11 yrs)
-
