Phys Asses #2 Flashcards
High incidence of occurrence across patient care settings
Alcohol Use and Abuse
Many patients will have significant history of ___ that has impact on their health status.
drinking
____ and ____ data reflect adverse consequences of excessive alcohol use.
Morbidity and mortality
A high number of medications are classified as ___.
alcohol interactive.
Alcohol dependence increases the risk for __, ___, and ___.
ED visits, ICU admissions, and sepsis.
Become more problematic = Binge drinking associated with __
increasing health risks
Most abused and used psychoactive drug
Alcohol
Pts use alcohol at an earlier an
earlier age
Impact of health and well-being
Alcohol
___ of meds will interact with alcohol
45%
50% of individuals over the age of __
12
Dosed dependent- the amount consumed
Alcohol
Moderate drinking associated with
hypotension, cardiomyopathy, can lead to increase in left ventricular mass, dilation of ventricles, and thinning of cardiac walls
Drinking 2.1 standard drinks in a day leads to
32% increase in developing breast cancer
__ of Americans over the age of 18 are current alcohol drinkers
56%
Defining Illicit Drug Use: Seven categories of illicit drug use
Marijuana/hashish, cocaine (including crack), heroin, hallucinogens, methamphetamines, inhalants, or prescription-type drugs used nonmedically.
___ show highest prevalence.
12 years and older
Illicit drug use has serious consequences for
health, relationships, and future jobs, school, and career.
___ percent over the age of 12 have reported using illicit drug
> 10.1
Negative impacts of numerous factors-
cancer (Comorbidities)
Most misused drug, 80% of drug users use-
Marijuana
LOC changes, Increase or decrease responsiveness to medications
Illicit Drug Use
Increased rate of deaths from drug overdose as opposed to
motor vehicle accidents
Increase in Rx for pain medication
Contributing factors to Rx abuse and Opioid crisis:
Increase Marketing strategies to promote medications
Contributing factors to Rx abuse and Opioid crisis:
Misrepresentation of “addictive” nature
Contributing factors to Rx abuse and Opioid crisis:
Combination addictions—drinking and taking alcohol-interactive medications.
Contributing factors to Rx abuse and Opioid crisis:
Monitor for signs of misuse or abuse
Prescription Drug Abuse and Opioid-Related Deaths
Very common in pts
Prescription Drug Abuse and Opioid-Related Deaths
More than __ individuals have drug abuse
1 out of 12
Alcohol releases dopamine which causes
euphoria
As pts use or misuse drugs the feeling of euphoria decreases.
The receptors are desensitized
Can help identifying drug use and abuse and help provide support to over
come addictions.
Gold standard of diagnosis is well defined in
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)
Alcohol problems underdiagnosed both in primary care settings and in hospitals
Substance Abuse
___ often unrecognized until patients develop serious complications (liver failure, kidney issues, heart issues)
Excessive alcohol use
Women who drink 8 or more alcoholic bev per week or 4 or more alcoholic bev on occasion are considered at
risk drinkers
Takes more to achieve same desired effect-
tolerance
Decreased effect with same amount of alcohol-
alcohol tolerance
Pg 88- alcohol use disorder assessment. Ask pt several questions regarding alcohol use.
Depending if yes or no to questions will determine severity
If they answer yes or no to 2-3 of the questions its considered mild
4-5 moderate, >6- severe
Effect of alcohol on developing brain
development and maturity
Associated risk between alcohol use and other high-risk behaviors leading to
sexual high-risk.
academic problems in school.
injuries from trauma.
continuation of alcohol abuse/disease in later life
Brain is not fully developed for
Developmental Competence: Adolescents
12-17 yr olds diagnosed with AUD-
3.4% are also going to have an illicit drug disorder, 2.5% will have alcohol disorder
Developmental Competence: Pregnancy
Dangers to mother as well as to fetus
Developmental Competence: Pregnancy
Development of Fetal Alcohol Syndrome spectrum
Potential adverse consequences of alcohol use to fetus are well known.
Development of Fetal Alcohol Syndrome spectrum
Physical deformities as well as learning and behavioral problems
Development of Fetal Alcohol Syndrome spectrum
____ of alcohol has been determined safe for pregnant women.
No amount
Any women contemplating pregnancy or who is pregnant should be screened for alcohol use.
Abstinence should be recommended.
An increasing number of older adults are
drinking.
- Decreased metabolic function (liver, amount of water available, and renal function). Increases bioavailability of alcohol. Increased effect for extended period of time. Can lead to injury
Characteristics that increase risks associated with alcohol use:
- Muscle mass decline. Leads to increased concentration of alcohol in pts body.
Characteristics that increase risks associated with alcohol use:
- Polypharmacy can interact with alcohol.
Characteristics that increase risks associated with alcohol use:
- Increase risk for cognitive decline.
Characteristics that increase risks associated with alcohol use:
- Increase risk for falls, incidence of depression and GI issues
Characteristics that increase risks associated with alcohol use:
Three domains: alcohol consumption, drinking behavior or dependence, and adverse consequences (Maximum score: 40)
Quantitative format uses numbers to identify a response.
Useful in primary care with adolescents and older adults
Quantitative format uses numbers to identify a response.
Relatively free of gender and cultural bias
Quantitative format uses numbers to identify a response.
AUDIT-C: shorter form for acute and critical care units (maximum score: 12)
Quantitative format uses numbers to identify a response.
___ will help detect less severe alcohol problems (hazardous and harmful drinking) as well as alcohol abuse and dependence disorders.
The AUDIT
Helpful with emergency department (ED) and trauma patients because it is sensitive to current as opposed to past alcohol problems.
The AUDIT
If currently intoxicated= information inaccurate.
The AUDIT
Refer to the AUD identification test
AUDIT Questionnaire
Helps mild to severe alcohol issues
AUDIT Questionnaire
Utilized from adolescences to older adults
AUDIT Questionnaire
Does ask a question and requires a number for an answer. Not open to interpretation.
AUDIT Questionnaire
Anything greater than 8 in a male or greater than a 4 in females or anyone over the age of 60 indicates hazardous alcohol consumption
AUDIT Questionnaire
When performing these assessment make sure private and non confrontational
AUDIT Questionnaire
Standard Clinical Diagnostic Criteria Goal:
Determine whether there is a maladaptive pattern of alcohol use causing clinically significant impairment or distress to the pt
has your drinking repeatedly caused or contributed to the following?”
Risk for bodily harm, relationship trouble, role failure, and/or run-ins with law
Ask, “In the past 12 months:
“Have you not been able to stick to drinking limits, or have you repeatedly gone over them?”- can indicate tolerance if not able to
Ask, “In the past 12 months:
Shown tolerance, signs of withdrawal, kept drinking despite problems, spent a lot of time drinking or anticipating drinking or recovering drinking and/or spent less time on other matters or activities that had been important or pleasurable
Ask, “In the past 12 months:
Screening women for alcohol problems
TWEAK questions help identify at-risk drinking in women, especially pregnant women.
TWEAK Questions
Tolerance, Worry, Eye-opener, Amnesia, Kut down
Tolerance:
how many drinks can you hold? Or how many drinks does it take to make you feel high?
Worry:
have close friends or relatives complained about your drinking?
Eye-opener:
do you sometimes take a drink in morning when you first get up?
Amnesia:
has a friend or family member told you about things you said but could not remember?
Kut down:
do you sometimes feel the need to cut down?
Scored with 1 point except for tolerance and worry bc each 2 points
TWEAK Questions
Score greater than 2 points indicates a drinking problem
TWEAK Questions
Greater than 3 indicates tolerance
TWEAK Questions
SMAST-G Questionnaire
Screening aging adults
Use the ____for older adults who report social or regular drinking of any amount of alcohol.
SMAST-G questionnaire
___ have specific emotional responses and physical reactions to alcohol.
Older adults
10 questions with yes/no responses that address these factors.
SMAST-G questionnaire
Two or more “yes” questions indicate alcohol problem
SMAST-G questionnaire
Consequences of substance abuse are so debilitating and destructive to patients and their families that a short statement of assistance and concern is given here.
Advise and Assist (Brief Intervention)
If your assessment has determined the patient to have at-risk drinking or illicit substance use, state your conclusion and recommendation clearly.
Advise and Assist (Brief Intervention)
Non confrontational, make sure they understand and what you recommend
Advise and Assist (Brief Intervention)
Drinking more that is medically safe and it is recommended that they quit drinking
Advise and Assist (Brief Intervention)
Can assist and willing to assist in achieving stop drinking goal
Advise and Assist (Brief Intervention)
Includes vital signs and oxygen saturation , N/V, tremors, Lvl of anxiety and agitation, paroxysmal sweats, auditory and tactile visual disturbances, headache and orientation status
10 measured criteria with individual scoring to arrive at a composite score
Individual subscales include 7 criteria with the exception of Orientation which includes 4 criteria
10 measured criteria with individual scoring to arrive at a composite score
Score of 0 to 7 can monitor every 4 hours.
Based on continued assessment provides trended results to determine level of monitoring that is needed.
All scores below 8 for 72 hours, you can discontinue.
Based on continued assessment provides trended results to determine level of monitoring that is needed.
Pts withdrawling from alcohol, most sensitive in order to assess objective measurements
Clinical Institute Withdrawal Assessment Scale (CIWA)
Used in monitoring progress of withdrawl
Clinical Institute Withdrawal Assessment Scale (CIWA)
Perform continued assessments
Clinical Institute Withdrawal Assessment Scale (CIWA)
Allows to avoid over medicating withdrawal pts
Clinical Institute Withdrawal Assessment Scale (CIWA)
Clinical Signs of Withdrawal- Alcohol-
Delirium tremens (DTS), anxiety, diarrhea, depression, seizures, tremors, tachycardia, headache, insomnia
Clinical Signs of Withdrawal- Sedatives-
similar to alcohol- anxiety, irritability
Clinical Signs of Withdrawal- Nicotine-
Headache, vasodilation, anger, irritability
Clinical Signs of Withdrawal- Cannabis-
Mild or occasional use- None. Heavy use- irritability, sleep disturbances, weight loss, loss of appetite or sweating
Clinical Signs of Withdrawal- Cocaine-
Anxiety, depression, fatigue, insomnia
Clinical Signs of Substance-Abuse Disorders:
“Substances” refers to non-medical agents taken to alter mood or behavior.
Clinical Signs of Withdrawal- Opiates (morphine, heroin, meperidine)-
Dilatated pupils, runny nose, excessive tears, tachycardia, sweating, hair on body to stand up. Extreme runny nose
Intoxication:
maladaptive behavioral changes due to effects on CNS from substance
Abuse:
daily or recurrent use such that impairment and decreased functioning has occurred leading to ongoing problems
Dependence:
physiological reliance
Tolerance:
requires more to get the desired effect
Withdrawal:
cessation of substance leads to physiological effects
Substance-
to alter mood or behavior
Intimate partner violence, child abuse and older people abuse is a
significant risk factor
Intimate Partner Violence: Four main categories
Physical violence, Sexual violence, Stalking, Psychological aggression
Physical violence:
force resulting in injury or death
Sexual violence:
attempted or completed acts without permission
Stalking:
repeated unwanted attention through various methods
Psychological aggression:
emotional abuse of an aggressive nature
Also includes teen dating violence is on the
rise
Can be physical, sexual, psychological, or emotional
teen dating violence
Youths who experience this are more likely to experience mental health issues and/or participate in unhealthy behaviors.
teen dating violence
Assess signs of violence in use
teen dating violence
Sexting or cyber abuse can be a
means of access.
__ women and ___ men have been abused by intimate partner
33%
25%
Defined at state and federal levels—The Child Abuse Prevention and Treatment Act
Child Abuse and Neglect
Recently amended to include sex and human trafficking
Child Abuse and Neglect
Enhance protection for infants with Fetal Alcohol Spectrum Disorder
Child Abuse and Neglect
Neglect:
failure to provide for children’s basic needs
Physical abuse:
nonaccidental injury that leads to harm of a child
Sexual abuse:
fondling, sexual acts, exploitation, and trafficking
Emotional abuse:
pattern of behavior that harms a child’s sense of self-worth or development
Be cautious when providing care to children if they experienced
child abuse
Nurses are considered mandatory reporters, report any suspected abuse and neglect to
law enforcement
When suspecting, be sure to document using exact words.
If child is able to give a description use the child’s words, verbatim
Involves both intentional and failure to act by a caregiver or trusted person. Can include abuse and neglect.
Older Adult Abuse and Neglect
Underreported with 60% performed by a family member
Older Adult Abuse and Neglect
Forms of older adult abuse
Physical abuse, Sexual abuse or abusive sexual contact, Psychological or emotional abuse, Neglect, Financial abuse or exploitation
Physical abuse:
intentionally assaulted, injured, threatened, or restrained
Sexual abuse or abusive sexual contact:
any sexual contact against one’s will
Psychological or emotional abuse:
includes verbal and nonverbal behaviors intended to humiliate, isolate, or affirm control
Neglect:
failure of caregiver to meet basic older adult needs
Financial abuse or exploitation:
unauthorized use and/or improper use of older adult’s funds/resources
Increased needs, changes in LOC
Older Adult Abuse and Neglect
If suspect abuse still report
Older Adult Abuse and Neglect
Immediate effects as well as residual effects of acts of violence leading to complications and more __
Chronic health problems
Gender r/t gynecologic and obstetrical conditions with impact on fetus
Preterm, low birth weight, and perinatal death
Violence= more likely to suffer from mental health problems
Depression, suicide, PTSD, and substance abuse
Children who are abused are more likely to experience ongoing poor health as they age.
Impact on brain development, behavioral learning delays, and higher risk for chronic disease
Rape victims More likely to use __
Marijuana
__ of rape victims to use cocaine than no rape victims
6x
child maltreatment can lead to a decreased quality of life.
can last into adulthood
Barriers to Treatment of Intimate Partner Violence
Societal stressors, Legal status, Lack of access to culturally appropriate care
Poverty level leading to increased difficulties in daily struggles and conflict in relationships
Societal stressors
Past experience with discrimination based on lack of understanding of cultural diversity
Societal stressors
Poor past experiences with understanding cultural diversities- they feel segregated.
Societal stressors
Immigration status may prevent individual from seeking care based on fear of deportation.
Legal status
Violence Against Women Act (AWA) provides legal support.
Legal status
Traditional roles foster dependency.
Lack of access to culturally appropriate care
Need for bilingual cultural interpreters in clinical practice settings
Lack of access to culturally appropriate care
Important to have interpreters
Lack of access to culturally appropriate care
When addressing care be mindful about cultural differences
Lack of access to culturally appropriate care
Ethnic and racial minorities are at greater risk for no
Treatment for Intimate Partner Violence
____ women and men are at greater risk for IPV
Multiracial American Indians, Alaskan natives and non Hispanic black
When documenting abuse, use specific words regarding the
victim
Documentation: IPV, Child Abuse, or Older Adult Abuse
Provide detail, Transcribe verbatim, Physical exam, Provide digital photographic documentation in the medical record, May have to separate
Provide detail
Non-biased progress notes, injury maps(identifying injuries, skin assessment), and photographic evidence (Further investigation)- make sure to obtain consent.
Transcribe verbatim
Information received from individual
Physical exam
Thorough documentation using forensic technology terms
Provide digital photographic documentation in the medical record
Obtain consent
May have to separate
The patient from the parent, spouse, and/or caregiver—follow protocol
All women of childbearing age (14 to 46) should be screened.
US Preventative Task Force Guidelines (USPTF)
Insufficient evidence to support screening of older adult or vulnerable adults
US Preventative Task Force Guidelines (USPTF)
No current recommendations for children
US Preventative Task Force Guidelines (USPTF)
Early detection is the key in terms of prevention of
long-term complications.
Health care providers are
mandatory reporters.
All women of child bearing age from
14-46 should be screened
Should be taken place with or without symptoms occurring
Routine Screening for Intimate Partner Violence (IPV)
How to Assess for Intimate Partner Violence
Gathering of subjective data
Use of open-ended questions to start the conversation-
to get as much info from the individual as possible
Interview the individual separately from the
perpetrator.
Listen for cues which may indicate a pattern or responses that don’t match the
“physical” injury that is present.
Be aware of state laws and requirement to
report.
Be aware of the IPV tool used in your clinical setting.
Intimate Partner Violence Screening tools
May be as simple as a single question—“Do you feel safe at home?”
Intimate Partner Violence Screening tools
USPTF prefers standardized tools
HITS and STaT
range from never to frequently.
HITS—4 item questionnaire
Can be used with teens.
HITS—4 item questionnaire
Asks how often partner physically hurt you. Insult or talk down to you. Threaten with harm. Scream or curse.
HITS—4 item questionnaire
Scored from 0-5. score greater than 10 indicates intimidate partner violence.
HITS—4 item questionnaire
Have you ever been in a relationship where partner has pushed or slapped you. Threatened you, thrown broken or punched things.
STaT—3 item questionnaire
Answering yes to any indicates positive screening for IPV.
STaT—3 item questionnaire
All adolescents should be screened for IPV.
STaT—3 item questionnaire
Ask about abuse in open needed question
STaT—3 item questionnaire
The nurse is assessing a patient who admits to being physically abused by her spouse. The patient says, “I wish I would have agreed with my husband, because then I wouldn’t have been hit.” What is the nurse’s best response?
“It is not your fault that your husband lost control. Changing your actions will not prevent him from abusing you again.” – provide reassurance
Older adult as a vulnerable population as they lose
independence
Recommended routine screening by multiple agencies but no specific tool specified
Assessment of Older Adult Abuse and Neglect
Assessment of abuse or neglect in cognitively challenged persons is complicated.
Assessment of Older Adult Abuse and Neglect
Validated in primary care
Older adult abuse suspicion index
For use with cognitively intact patients
Older adult abuse suspicion index
Includes 6 questions with 5 questions asked of the patient and the last question answered by the physician
Older adult abuse suspicion index
Can be complicated to assess in elderly population (abuse/neglect)
Older adult abuse suspicion index
Greater risk for financial abuse, theft, forcible transfer of property, corrosion to steal assets
Older adult abuse suspicion index
Dementia and Alzheimer’s cannot do this assessment
Older adult abuse suspicion index
Provide anticipatory guidance (support)
Health care providers
Ideal individual to be able to monitor, observe, and assess for potential problems
Health care providers
Developmental screening tools to identify delays
Use appropriate resources to educate caregiver/parent
Parent/caregiver teaching and education in order to seek resources for addictions, behavioral issues, etc
Use appropriate resources to educate caregiver/parent
If child is verbal, history should be obtained away from caregivers through open-ended questions or spontaneous statements. So they could understand. Need two witnesses with
child and caregiver.
Medical history is important part of examination.
Assessment of Child Abuse and Neglect
Preschool age with bruises on bony provinces =
Play
Bruising on ___ are rare and should arise concern to HC provider
Buttocks, hands, feet, and abdomen
Child who is immobile who has significant bruising or underlying illness, warrants
comprehensive assessment
Significant fractures or fracture in different stages in healing may need to have a
bone scan on radiologic bone assessment to see past injuries
Multiple injuring with multiple stages of healing=
suspicions for abuse
When documenting history and physical findings of child abuse and neglect
use words child has used to describe how his or her injury occurred.
Remember the possibility that the abuser may be accompanying the child.
If child is nonverbal, use reports of caregivers.
Know your institutional protocol for obtaining history in cases of suspected child maltreatment
Some protocols may delay a full interview until it can be done by a forensically trained interviewer.
Be aware of normal range of findings based on
developmental age.
Abuse may be hidden under clothing.
Visual examination of the entire body is required.
Atypical bruising pattern or bruise in the shape of an object (flyswatter, hand, whip)
Visual examination of the entire body is required.
Significant injury observed in non-mobile individual
Visual examination of the entire body is required.
Use appropriate terminology r/t bruising.
Maintain consistency for accurate interpretation to maintain consistency.
Include baseline laboratory testing
CBC with platelet count, basic blood chemistries, serum LFTs, coagulation panel and UA
Laceration-
produced by tearing/slitting. Blunt impact over a boney surface
Pattern injury-
Distinct shape- whip, hand, extension cord
TYPES OF INJURIES
Laceration, Contusion, Hematoma, Abrasion, Patterned
Laceration
a deep cut or tear in skin or flesh.
Contusion
Bruise, injury to soft tissue. No breakage in skin
Hematoma
Blunt force trauma, localized collection of blood, clotted in organ, tissue,
Abrasion
Rug burn
Patterned
Injury from an object
Front of body is more susceptible to bruising due to
falling forwards
This 19-item yes/no instrument is used extensively by nurses in the health care system.
Danger assessment (DA)
It starts with a calendar so women can more accurately see how frequent and severe violence has become over the past year.
Danger assessment (DA)
This is also an excellent assessment of frequency and severity of violence for health care providers.
Danger assessment (DA)
The more yes answers, the more serious the danger of the woman’s situation.
Danger assessment (DA)
Over 55% of all female homicides are related to IPV
Danger assessment (DA)
Over 11% of those victims have experienced violence of the month preceding the homicide
Danger assessment (DA)
If we fail to assess pt for risk of violence, it is a missed opportunity in order to intervene and decrease risk of danger
Danger assessment (DA)
The higher the number of yes answers is going to measure the amount of danger in the women’s situation, same tool law enforcement uses.
Danger assessment (DA)
Not going to be used in all patients.
Danger assessment (DA)
Important from first seeing them for the first time
General Survey and Measurement
Begins as soon at the pt walks into the room
General Survey and Measurement
Monitor for different areas which includes physical appearance, body structure, mobility, and behavior
General Survey and Measurement
The general survey is a study of the
whole person
Covers general health state and any obvious physical characteristics
general survey
Provides an overall impression
general survey
Includes areas of physical appearance, body structure, mobility, and behavior
general survey
Includes objective parameters that apply to the whole body
general survey
Overall impression, H to T
general survey
Observe body stature, nutritional status
general survey
Once learned = Second nature
general survey
Objective Data: Physical Appearance
Age, Sex, LOC, Skin color, Overall appearance
Age:
What age they appear to be and what age they are
Sex:
Sexual development level and age make sure its appropriate.
Level of consciousness:
Alert, oriented?
Skin color:
Pallor, Jaundice, Erythematic, Cyanosis, Pink,
Overall appearance:
Gait, symmetric movement and appropriate. General statement of pt overall appearance related to comfortable.
Objective Data: Body Structure
Stature, Nutrition, Symmetry, Posture, Position
Stature:
Nutrition is appropriate. Over weight, underweight, emaciated, cachectic.
Nutrition:
Body fat distribution. Appropriate? A lot in abdomen?
Symmetry:
Moving extremities together, same manner, and increased or decreased muscle mass on one side.
Posture:
Appropriate and appropriate their age, appear comfortable.
Position:
Kyphosis? Slumped appearance-depression s/sx, lordosis.
Tripod breathing-
COPD
HF=
Paroxysmal dyspnea
Objective Data: Mobility
Gait: normally base is as wide as shoulder width
Foot placement:
accurate; walk smooth, even, and well-balanced; and associated movements, such as symmetric arm swing, are present
Range of motion:
note full mobility for each joint, and that movement is deliberate, accurate, smooth, and coordinated.
No involuntary movement-
tics, muscle spasms- document.
Able to maintain balance without assistance- normal pt walking. If they do pay attention
Mobility
If wide base- dizziness, altered LOC
Mobility
If paralysis- unable to move extremity could be sensory, musculoskeletal or cva
Mobility
Objective Data: Behavior
Facial expression, Mood and affect, Speech, Dress, Person Hygiene
Facial expression
Note expressions both while face is at rest and while person is talking
Mood and affect
immediate expression of emotion; mood refers to the more sustained emotional makeup of the patient’s personality.
Speech:
articulation (ability to form words) clear and understandable
Stream of talking is fluent, with an even pace
Speech
Conveys ideas clearly
Speech
Word choice appropriate to culture and education
Speech
Person communicates in prevailing language easily by himself or herself or with interpreter.
Speech
Maintain eye contact if appropriate
Make sure pt is comfortable
Behavior
Dress:
Make sure the clothing fits too large- lost weight, too small- edema or more fat. More holes in belt- weight gain/edema
Amish women wear clothing from
nineteenth century.
Indian women may wear
saris.
Culturally determined dress should not be labeled as bizarre by
Western standards or by adult expectations
Personal hygiene:
Can be a sign of depression and environment they live in.
able to care for themselves and live a healthy life.
If familiar with a patient and has hygiene issues and usually does not- experiencing depression, malaise, or current illness.
Always remain unbias to people that are
not normal
Instruct person to remove his or her shoes and heavy outer clothing before standing on scale.
Objective Data: Measurements Weight
When sequence of repeated weights is necessary, aim for approximately same time of day and same type of clothing worn each time.
Objective Data: Measurements Weight
Show person how his or her weight matches up to recommended range for height.
Objective Data: Measurements Weight
Record weight in kilograms and pounds.
Objective Data: Measurements Weight
Same clothes, scale, time
Objective Data: Measurements Weight
Balnce or electronic standing scale for people that can stand
Objective Data: Measurements Weight
Always compare current and previous weight to make sure it is accurate
Objective Data: Measurements Weight
Unexplained weight loss-
short term illness
Unexplained weight gain-
edema or fluid retention
Height and Body mass index
Objective Data: Measurements
Align extended headpiece with top of the head.
Height
Use wall-mounted device or measuring pole on scale.
Height
___ is practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition.
Body mass index
Can overestimate body fat in people who are very muscular.
Body mass index
Can underestimate body fat in older adults who are lean
Body mass index
__ normal BMI
19-25
When measuring height.-
Shoeless, standing straight, looking straight ahead, and feet and shoulders up against the hard surface.
Assesses body fat distribution as indicator of health risk.
Objective Data: Waist Circumference
Excess abdominal fat is an independent risk factor for disease, over and above that of body mass index (BMI).
Objective Data: Waist Circumference
Waist circumference measured in inches at smallest circumference below rib cage and above iliac crest
Objective Data: Waist Circumference
Hip circumference measured in inches at largest circumference of buttocks
Objective Data: Waist Circumference
How and where they carry their weight.
Objective Data: Waist Circumference
Increase risk for disease- large waist circumference
Objective Data: Waist Circumference
Measure in inches at the end of expiration
Objective Data: Waist Circumference
Diseases: Heart disease and type 2 diabetes
Objective Data: Waist Circumference
Waist Circumference: A measurement ____ is increasing risk of type 2 diabetes, heart disease, dyslipidemia, and hypertension.
> 35 in women and >40 in men
Increased in pts with BMI 25-35.
Objective Data: Waist Circumference
Interpret based on age and developmental ability
General survey r/t infants and children
Behavior and parental bonding
General survey r/t infants and children
Measurement—weight and length (height)- best indicator in physical growth in infants and children.
General survey r/t infants and children
Best view of child’s general health. Compare to growth charts and watching trends
General survey r/t infants and children
Physical growth based on CDC growth charts
Head circumference and chest circumference
Up until age of 2 obtain weight measurement laying down (supine position)
using horizontal measuring board
If caregiver/parent appears to be grossed out, irritated, disgusted by the child-
raise red flags
Assess parental and child bond-
appears appropriate
Head measurement is also important
General survey r/t infants and children
At birth and then Conducted at each well child check until age 2 years.
Head meaurements
Then annually up to 6 years of age
Head measurements
Compare with expected size for age.
Head measurements
Series of measurements which gives accurate information of the pattern. 32-38 cm is normal measurement.
Head measurements
2 cm larger than the circumference of the chest.
Head measurements
Compare to head circumference
Chest measurements
Chest grows faster than the head
Chest measurements
Around the nipple line of the child
Chest measurements
Only important to compare to the head to monitor growth and appropriate.
Chest measurements
Right at their eyebrow line-measure head at
34 head measurement and chest 32= normal finding for newborn
Normal consequence of aging changes r/t posture and gait-
weakens, muscle atrophy, postural changes- kyphosis, fluctuation of knees and hips to compensate for that change.
Ambulate with a wider base to compensate for decrease balance.
General survey r/t aging adults
Measurement—weight and height
General survey r/t aging adults
Trunk appears shorter and extremities are very long-
kyphosis and losing muscle mass
Sharper features and bony landmarks may be more prominent.
Older adults enter 80 or 90s may appear shorter-
shortening and thinning of vertebrae
Dwarfism
Hypopituitary dwarfism and Achondroplastic dwarfism-
Lacking growth hormone, occurs in childhood.
Halts the growth.
Height and weight may fall into the 3rd percentile for their age. S/sx Delayed puberty, Hypothyroidism, And adrenal insufficiency.
Hypopituitary dwarfism
Halts the growth.
Hypopituitary dwarfism
Height and weight may fall into the 3rd percentile for their age.
Hypopituitary dwarfism
S/sx Delayed puberty, Hypothyroidism, And adrenal insufficiency.
Hypopituitary dwarfism
genetic disorder convert cartilage into bone.
Achondroplastic dwarfism
Result in normal trunk size and very short arms and leg.
Achondroplastic dwarfism
Short stature.
Achondroplastic dwarfism
Relatively large head, frontal bossing.
Deal with lumbar lordosis and abdominal protrusion.
Deal with lumbar lordosis and abdominal protrusion.
Deal with lumbar lordosis and abdominal protrusion.
Too much growth hormone in adulthood.
Gigantism versus acromegaly (hyperpituitarism)
Already completed normal growth.
Gigantism versus acromegaly (hyperpituitarism)
Bones in head, face, hands and feet are most effected
Gigantism versus acromegaly (hyperpituitarism)
Excessive secretion of growth hormones in adulthood after normal completion of bone growth
acromegaly
Bones in face, head, hands and feet (no changes in height)
acromegaly
Internal organs can also enlarge-
acromegaly
Metabolic disorders may be present- Diabetes mellitus, Hyperpituitarism, greater risk for diabetes
acromegaly
Skull is rigid box that protects brain.
Structure and function: Head
Made up of Cranial Bones
Structure and function: Head
Sutures- where the bones of the skull meet, immovable joints
Two pairs of salivary glands accessible to examination on the face:
Parotid glands
Submandibular glands
Parotid glands
are in cheeks over mandible, anterior to and below ear; the largest of salivary glands, they are not normally palpable. When extending head, If palpable indicates diagnosis of HIV or mumps.
Submandibular glands
beneath mandible at angle of jaw
Responsible for sensation of the face and motor function (biting + chewing)
Trigeminal nerve
Trigeminal nerve
Or Cranial nerve V (5)
Most complex cranial nerve
Trigeminal nerve
Inability to note sharp/dull sensations indicates damage to nerve
Trigeminal nerve
Assessing both sides of the face to compare
Trigeminal nerve
Neck delimited by
Base of skull and inferior border of mandible above, and by manubrium sterni, clavicle, first rib, and first thoracic vertebra below
Think of neck as conduit of many structures.
Neck
Connects respiratory, cardiovascular, lymphatics, neurovascular, digestive system-
neck function
Major neck muscles
Sternomastoid and trapezius are innervated by cranial nerve XI.
Sternomastoid enables
Head rotation and flexion and divides each side of neck into two triangles: anterior and posterior triangles
Two trapezius muscles move
shoulders and extend and turn head.
If shoulder and neck pain= damage to
cranial nerve 11
Assessing pt by- shrug shoulders against resistance
cranial nerve 11
Thyroid: Endocrine gland
Straddles trachea in middle of the neck
The gland has two lobes
Should not have significant pain and should shrug shoulders with resistance
cranial nerve 11
Synthesizes and secretes
Thyroxine (T4) and triiodothyronine (T3), which are hormones that stimulate rate of cellular metabolism
Thyroid: Endocrine gland
If thyroid is enlarged-
listen for a bruit using the bell of the stethoscope. Bruit- Increased blood flow or hyperplasia.
Highly vascular.
If hyperthyroidism do not press on thyroid bc it can release more hormones
Thyroid: Endocrine gland
Men thyroid -
in small palpable v within upper edge of thyroid cartilage- Adams apple
Hugs the second and third tracheal reeves
Thyroid gland
Major part of immune system
Lymphatic System
Rich supply of lymph nodes- head and neck contains 60-70 lymph nodes
Lymphatic Systematic System
Be aware of lymphatic drainage takes place.
Lymphatic Systematic System
If enlarged lymph node, assess above it.
Lymphatic Systematic System
Lymphatic Purpose-
detect and eliminate foreign substances from the body
Leads to Lymphatic drainage.
Lymphatic Systematic System
Proximal to enlarged lymph nodes-
swollen lymph nodes
Normal, should be movable discrete and can have varying levels of firmness but should be soft
lymph nodes
Should not be tender
lymph nodes
Firm lymph nodes-
cancer
If swollen check source up stream
lymph nodes
Separate from the cardiovascular system but work together
Lymphatic Systematic System
Only area able to access examination of lymph nodes, are the
head, neck, arms, inguinal area, axilla area
Located like beads on a string
Lymphatic Systematic System
Bones of neonatal skull are separated by sutures and fontanels, spaces where the sutures intersect.
These membrane-covered “soft spots” allow growth of brain during first year; gradually ossify. For childbirth and growth
Posterior Closure of fontanels-
1-2 months will close and be triangular shaped
Anterior Closure of fontanels-
diamond shaped, will close 9 months- 2 years of age
Well developed at birth and grows to adult size when the child is
6 years old
facial hair also appears on boys : first on upper lip, then on cheeks and lower lip, and last on the chin.
In adolescence
noticeable enlargement of the thyroid cartilage occurs, and with it, the voice deepens.
In adolescence
Facial bones and orbits appear more prominent.- lose fat, muscle, decreased elasticity, decreased moisture(water). If lost teeth the facial features change even more
Older Adults
During fetal period the head growth will be
fast
When assessing lymph nodes may be palpable in children up until they reach puberty,
can be a normal finding even if no s/sx of illness.
Grows rapidly at 10-11. Puberty it starts to atrophy,
lymph nodes.
Leading cause of acute pain and lost productivity
Headache
Classified by etiology and often misdiagnosed,
Headache
Headache classified by location and etiology.
tension, migraine, cluster headache.
Headache Health History
Determine surgeries, hx of headaches, recent infection, radiation, smoking.
Complain of acute onset of headache, neck stiffness/pain, and fever-
suspect meningeal infection
Severe headache with no Hx of headache-
Hemorrhage, CVA
Note facial expression and appropriateness to behavior or reported mood.
Inspection of the Face
Goal in headache’s-
prevent neurological dysfunction, address asap.
Facial structures
Always should be symmetric.
Note any involuntary movements (tics) in facial muscles; normally none occur. Gather more info and document.
Inspection of the Face
Asymmetry- stroke, bells palsy- damage to cranial nerve 7.
Inspection of the Face
Head and neck symmetry
Inspection and Palpation-Neck
Range of motion- not pain/discomfort
Inspection and Palpation-Neck
Observe for enlargement of glands and/or pulsations.
Inspection and Palpation-Neck
Thyroid gland-enlargement
Difficult to palpate; check for enlargement, consistency, symmetry, and presence of nodules
Position patient for best approach (posterior)
Palpate nodes noting location, size, shape, delimitation, mobility, consistency, and tenderness.
Inspection and Palpation-Neck
Gentle palpation in neck and lymph nodes
Inspection and Palpation-Neck
Trachea- midline
Inspection and Palpation-Neck
Palpate both sides to compare
Inspection and Palpation-Neck
Using a gentle (esp. pain and discomfort) circular motion of finger pads, palpate lymph nodes.
Examining Lymph Nodes
Do not vary sequence or you may miss some small nodes.
Examining Lymph Nodes
Up to 1 cm in size
Examining Lymph Nodes
If palpable, note location, size, shape, and if discrete or matted together.
Examining Lymph Nodes
Measure infant’s head at each visit up to age
2 years and yearly up to age 6 years.
Note infant’s head posture and head control; infant can turn head side to side by
2 weeks.
Two common variations in newborn cause shape of skull to look markedly asymmetric due to birth trauma:
Caput succedaneum
Cephalohematoma
Caput succedaneum:
Swelling across suture lines in newborns. Self limiting- swelling will go down.
Cephalohematoma:
Trauma occurring hours after birth and gradually increase in size. Bleeding. Periosteum holds the blood.
Molding- for child birth and growth
Skull
Positional molding (positional plagiocephaly)
flat spot from laying down. common
Fontanels
Observe anterior and posterior fontanel. Depressed or sunken in= dehydrated or malnourished.
Head and neck control
Observe for appearance of tonic neck reflex which disappears between 3 and 4 months of age.
By age of ___ infants should maintain head control.
4 months
Should hold head up when erect and steady themselves if pulled up.
Physical Examination: Infants and Children
While crying lying down or vomiting may notice bulge in fontanels- increased intercranial pressure.-
Physical Examination: Infants and Children
Physical Examination: Pregnant Female- During second trimester- chloasma may show on face.
A blotchy, hyperpigmented area over cheeks and forehead that fades after delivery
Physical Examination: Aging Adult: Temporal arteries
may look twisted and prominent.- esp. losing muscle tone to face or body fat
Thyroid gland may be palpable normally during pregnancy.
bc highly vascular and has increased blood flow. Increase in hyperplasia
In some aging adults, a mild rhythmic tremor of head may be normal.
Benign finding
Older adult: Neck may show an increased concave curve
to compensate for kyphosis.
Maintain patient safety by indicating patient perform ROM and position changes slowly
minimize potential for dizziness.
Decreased elasticity loss of sub fat and decreased moisture
Older adult
Changing positions slowly- avoid falls and dizziness.
Older adult
Types of headaches:
Tension, Migraine, Cluster
Tension Headache definition
HA of musculoskeletal origin; may be a mild-to-moderate, less disabling form of migraine
Tension Headache location
Usually both sides, across frontal, temporal, and/or occipital region of head: forehead, sides, and back of head
Tension Headache character
Band-like tightness, viselike, nonthrobbing, nonpulsatile
Tension Headache duration
Gradual onset, lasts 30 mins to days
Tension Headache quantity/severity
Diffuse, dull aching pain
Mild to moderate pain
Tension Headache timing
Situational, in response to overwork, posture
Tension Headache aggravating symptoms or triggers
Stress, anxiety, depression, poor posture.
Not worsened by physical activity
Tension Headache associated symptoms
Fatigue, anxiety, stress.
Sensation of band tightening around head, of being gripped like a vise.
Sometimes photophobia or phonophobia
Tension Headache relieving factors, effort to treat
Rest, massaging muscles in area, NSAID meds
Migraine Headache definition
HA of genetically transmitted vascular and trigeminal nerve origin. HA plus prodrome, aura, other symptoms: 2-3 times as common in women as in men
Migraine Headache location
Commonly one sided but may occur on both sides. Pain is often behind the eyes, the temples, or forehead
Migraine Headache duration
Rapid onset, peaks 1-2 hrs, lasts 4-72 hrs, sometimes longer
Migraine Headache character
Throbbing, pulsating
Migraine Headache quantity/severity
Moderate to severe pain
Migraine Headache aggravating symptoms or triggers
Hormonal fluctuations (premenstrual)
Foods (alcohol, caffeine, MSG, nitrates, chocolate, cheese)
Hunger, letdown after stress, sleep deprivation, sensory stimuli (flashing lights or perfumes), changes in weather, and physical activity
Migraine Headache timing
=2 per month, lasts 1-3 days
=1 in 10 patients have weekly headaches
Migraine Headache associated symptoms
Aura (visual changes as blind spots or flashes of light, tingling in an arm or leg vertigo)
Prodrome (change in mood, behavior, hunger, cravings, yawning)
N/V photophobia, phonophobia, abdominal pain
Person looks sick
Family hx of migraine
Migraine Headache relieving factors, effort to treat
Lie down, darken room, use eyeshade, sleep, NSAID early, avoid opioid
Cluster Headache definition
Rare HA that is intermittent, excruciating, unilateral, with autonomic signs
Cluster Headache location
Always one sided. Often behind or around the eye, temple, forehead, cheek
Cluster Headache character
Continuous, burning, piercing, excruciating
Cluster Headache duration
Abrupt, onset, peaks in minutes, lasts 45-90 mins
Cluster Headache quantity/severity
can occur multiple times a day
Cluster Headache timing
1-2/day, each lasting 1/2 to 2 hrs for 1 to 2 months; then remission for months or years
Cluster Headache aggravating symptoms or triggers
Exacerbated by alcohol, stress, daytime napping, wind or heat exposure
Cluster Headache associated symptoms
Ipsilateral autonomic signs: nasal congestion, runny nose, watery or reddened eye, eyelid drooping, miosis
Feelings of agitation
Cluster Headache relieving factors, effort to treat
Need to move, pace floor
Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head.
Hydrocephalus
Dilated scalp veins.
Hydrocephalus
Face looks small in relation to their head. Setting sun eyes-sign.
Hydrocephalus
Most common chromosomal abnormality with characteristic facial abnormalities.
Down syndrome
Facial features: flat nasal bridge, small broad nose, up slanting to the eyes, inner epicanthal folds, thicker tongue that may protrude and broad neck and webbing small hand with palmar crease
Down syndrome
Plagiocephaly
Positional or deformational due to sleeping position. Laying on one side, flattened head
Abnormal Findings: Pediatrics
Craniosynostosis, Atopic (allergic) facies, Fetal alcohol spectrum disorders (FASD), Allergic salute and crease
Craniosynostosis
Premature closing of one or more cranial sutures that leads to head malformation. Does not allow growth
A variety of presentations seen in children who have chronic allergies
Atopic (allergic) facies
Include exhausted face, allergic shiners, morgan lines, central facial pallor, and allergic gapping, which can lead to can lead to malocclusion of the teeth and malformed jaw bc its still forming.
Atopic (allergic) facies
- blue shadows below the eyes from sluggish venous return,
allergic shiners
double or single crease on the lower eyelids
morgan lines
open mouth breathing
allergic gapping,
Narrow palpebral fissures, epicanthal folds, thin upper lip, and midfacial hypoplasia
Fetal alcohol spectrum disorders (FASD)
Allergic salute and crease
Appearance of transverse line on the nose in response to chronically repeated use of hand to push the nose up and back
Not possible to palpate adult
thyroid gland
If painless or rapidly growing nodule it can be cancerous esp. present in a
young person
Hard and fixed, not mobile-
cancerous nodules
Physical presentation neck and face
Thyroid Disorders: Graves Disease
Goiter
Thyroid Disorders: Graves Disease
Eyelid retraction
Thyroid Disorders: Graves Disease
Exophthalmos- protruding of the eyes
Thyroid Disorders: Graves Disease
Carotid gland inflammation-
hiv and mumps
Intolerance to heat
fine-straight hair
bulging eyes
facial flushing
enlarged thyroid
tachycardia,
systolic BP increase,
breast enlargement,
Hyperthyroidism
weight loss,
muscle wasting,
flinger clubbing,
tremors,
increased diarrhea,
menstrual changes (amenorrhea)
localized edema
Hyperthyroidism
Physical presentation neck and face
Hypothyroidism
Puffy edematous face
Hypothyroidism
Periorbital edema
Hypothyroidism
Coarse facial features
Hypothyroidism
Coarse hair and eyebrows
Hypothyroidism
Decrease in thyroid hormone
Hypothyroidism
Decreasd metabolic rate
Hypothyroidism
Cause; hashimoto thyroiditis
Hypothyroidism
Severe non pitting edema
Hypothyroidism
S/sx: fatigues, cold intolerance, puffy, swollen face, hands, feet.
Hypothyroidism
Coarse facial features and slow refexes. Cold-thyroid furnace
Hypothyroidism
Intolerance to cold
receding hairline
facial & eyelid edema
dull-blank expression
extreme fatigue
thick tongue-slow speech
Hypothyroidism
anorexia
brittle nails & hair
menstrual disturbances
hair loss
apathy
lethargy
dry skin (coarse & scaly)
muscle aches & weakness
constipation
Hypothyroidism
Late manifestations of Hypothyroidism
Subnormal temp
Bradycardia
Weight gain
Decreased LOC
Thickened skin
Cardiac Complications
