Bachelor Degree in Nursing - University "La Sapienza" of Rome PDF

Bachelor degree in Nursing University «La Sapienza» of Rome NURSING PRACTICE Prof. Matteo Bonifazi RN, MsN 2024/202 5  NURSING PRACTICE The objective of this course is to impart essential cultural and professional knowledge to...

Bachelor degree in Nursing University «La Sapienza» of Rome NURSING PRACTICE Prof. Matteo Bonifazi RN, MsN 2024/202 5  NURSING PRACTICE The objective of this course is to impart essential cultural and professional knowledge to students, empowering them to contribute meaningfully to healthcare processes within the domains of general clinical and pediatric nursing science. Upon course completion, students will demonstrate a thorough understanding of the nursing process and its practical application in clinical contexts. Suggested Book: Kozier & Erb’s (2022). Fundamentals of nursing, Global Edition. Concepts, Process and Practice. 11th Edition.  Contacts For any questions and doubts, do not hesitate to contact me at: [email protected] VITAL SIGNS  VITAL SIGNS Vital signs are measurements of the body's most basic functions Which vital signs do you know? Traditional vital signs are: - Body temperature - Pulse - Respiration - Blood pressure There are two more parameters that are normally measured with the traditional vital signs, that can be considered vital signs too: - Pain - Oxygen saturation Monitoring a client’s vital signs should; it should be a thoughtful, scientific assessment. Vital signs should be evaluated with reference to clients’ present and prior health status, their usual vital sign results (if known), and accepted standards. A nurse should assess vital signs more often if the client’s health status requires it.  TIMES TO ASSESS VITAL SIGNS On admission to a healthcare agency to obtain baseline data When a client has a change in health status or reports symptoms such as chest pain or feeling hot or faint Before and after surgery or an invasive procedure Before and after the administration of a medication that could affect the respiratory or cardiovascular systems; for example, before giving a digitalis preparation Before and after any nursing intervention that could affect the vital signs (e.g., ambulating a client who has been on bedrest)  Body Temperature Body temperature reflects the balance between the heat produced and the heat lost from the body, and is measured in heat units called degrees. There are two kinds of body temperature: core temperature and surface temperature. - Core temperature is the temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity. - The surface temperature is the temperature of the skin, the subcutaneous tissue, and fat. It, by contrast, rises and falls in response to the environment. The body continually produces heat as a by-product of metabolism. When the amount of heat produced by the body equals the amount of heat lost, the client is in heat balance.  Factors affecting the body heat production 1. Basal metabolic rate  The basal metabolic rate (BMR) is the rate of energy utilization in the body required to maintain essential activities such as breathing. Metabolic rates decrease with age. In general, the younger the client, the higher the BMR. 2. Muscle activity  Muscle activity, including shivering, increases the metabolic rate. 3. Thyroxine output  Increased thyroxine output increases the rate of cellular metabolism throughout the body. 4. Epinephrine and norepinephrine and sympathetic nervous system stimulation (such as with stress)  Epinephrine and norepinephrine immediately increase the rate of cellular metabolism in many body tissues. 5. Fever  Fever increases the cellular metabolic rate and thus increases the body’s temperature further.  How heat can be lost? - Radiation is the transfer of heat from the surface of one object to the surface of another without contact between the two objects, mostly in the form of infrared rays. - Conduction is the transfer of heat from one molecule to a molecule of lower temperature: conductive transfer cannot take place without contact. The amount of heat transferred depends on the temperature difference and the amount and duration of the contact. - Convection is the dispersion of heat by air currents. The body usually has a small amount of warm air adjacent to it. This warm air rises and is replaced by cooler air, so people always lose a small amount of heat through convection. - Evaporation is continuous vaporization of moisture from the respiratory tract and from the mucosa of the mouth and from the skin. This continuous and unnoticed water loss is called insensible water loss, and the accompanying heat loss is called insensible heat loss (accounts for about 10% of basal heat loss).  Regulation of body temperature The system that regulates body temperature has three main parts: 1 - sensors in the periphery and in the core 2 - an integrator in the hypothalamus 3 - an effector system that adjusts the production and loss of heat. 1 - Most sensors or sensory receptors are in the skin. The skin has more receptors for cold than warmth. Therefore, skin sensors detect cold more efficiently than warmth. When the skin becomes chilled over the entire body, three physiologic processes to increase the body temperature take place: a) Shivering increases heat production. b) Sweating is inhibited to decrease heat loss. c) Vasoconstriction decreases heat loss 2 - The hypothalamic integrator is the center that controls the core temperature. When the integrator detects heat, it sends out signals intended to reduce the temperature, that is, to decrease heat production and increase heat loss. In contrast, when the cold sensors are stimulated, the integrator sends out signals to increase heat production and decrease heat loss 3 - The signals from the cold-sensitive receptors of the hypothalamus initiate effectors, such as vasoconstriction, shivering, and the release of epinephrine, which increases cellular metabolism and hence heat production. When the warmth-sensitive receptors in the hypothalamus are stimulated, the effector system sends out signals that initiate sweating and peripheral vasodilation. Also, when this system is stimulated, the individual consciously makes appropriate adjustments, such as putting on additional clothing in response to cold or turning on a fan in response to heat.  Factors affecting the body temperature 1 – Age  infants are greatly influenced by the temperature of the environment and must be protected from extreme changes. 2 – Circadian rhythms  body temperature change throughout the day: the lowest point is reached during the night. 3 – Exercise  exercise can increase body temperature 4 – Hormones  in women, progesterone secretion at the time of ovulation raises body temperature by about 0,3 to 0,6 °C. 5 – Stress  Stimulation of the sympathetic nervous system can increase metabolic activity and heat production. 6 – Environment  Extremes in environmental temperatures can affect a client’s temperature regulatory systems  Alterations Pyrexia Body temperature above the usual range. It’s also called hypertermia (or fever). A temperature around 41 °C is called iperpyrexia. A patient who has fever is referred to as febrile, the one who does not is afebrile.  Pyrexia There are 4 common type of pyrexia (or fever): - Intermittent = the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures (e.g. malaria) - Remittent = a wide range of temperature fluctuations (more than 2 °C) over a 24 hrs period (e.g. cold or influenza) - Relapsing = short febrile periods of a few days are fragmented with afebrile periods - Costant = body temperature fluctuates minimally, always above normal. - Spike = rapid rise and back to normal in a few hrs (e.g. bacterial blood infections)  Other anormalities Heat Exhaustion Excessive heat and dehydration. Signs are: paleness, dizziness, nausea, vomiting, fainting, a moderately increased temperature (max 39 °C) Heat Stroke A temperature above 40 °C or higher Signs are: warm and flushed skin, may be delirious, unconscious, or having seizures  Pyrexia phases 1 – Onset (chill phase) Hypothalamic set point changes to a higher than normal value: however, the core body temperature reaches the new set point after several hours. The body heat production responses take place: chills, feeling of coldness, cold skin due to vasoconstriction, shivering. 2 – Course (plateau phase) When the core temperature reaches the one of the hypothalamic set point, the patient won’t experience chills anymore. Very high temperature (41-42 °C) can cause brain damage or to other organs. Patiente will have an increased pulse and respiratory rate, mild to severe dehydration, drowsiness or delirium, loss of appetite 3 – Defervescence (or flush phase) When the cause of the high temperature is removed, the set point is reduced to a lower value, so the hypothalamus try to lower the body temperature with heat loss responses as: excessive sweating, flushed skin due to vadilation.  Hypothermia It is a core body temperature below the lower limit of normal. There are three physiologic mechanisms: a) excessive heat loss b) inadequate heat production to counteract heat loss c) impaired hypothalamic thermoregulation  Hypothermia Clinical signs - Decreased body temperature, pulse, and respirations - Severe shivering (initially) - Feelings of cold and chills - Pale, cool, waxy skin - Frostbite (discolored, blistered nose, fingers, toes) - Hypotension - Decreased urinary output - Lack of muscle coordination - Disorientation - Drowsiness progressing to coma  Hypothermia Two types: - Induced H. = deliberate lowering of the body temperature to decrease oxygen need by the body tissues (e.g. surgery) - Accidental H. = can occur as a results of a) exposure to a cold environment b) immersion in cold water c) lack of adequate clothing, shelter or heat In older adults, a decreased metabolic rate or the use sedative medication can be the causes.  Hypothermia Nurse must remove the patient from the cold and rewarming him/her up. With mild hypothermia, the body is rewarmed applying blankets. With severe hypothermia, a hypothermia blanket (electronically controlled blanket) is applied, and warm IV fluids are given  Assessing body temperature Oral = wait 30 minutes if the patient has been taking cold or hot food, drinks or smoking. Rectal = very accurate. Not indicated for who is udergoing rectal surgery, suffer of hemorrhoids, have diarrhea. Axilla = preferred site in newborns ‘cause is accessible and safe. Axillary temperatures are lower than rectal Tympanyc = reflects the core temperature, can be uncomfortable especially for children Forehead = measured at the temporal artery level; useful in infants and children when a more invasive measurement is not necessary  Types of thermometers - Mercury-in-glass  used in the past, no longer used in the hospitals. Now, can be made in plastic and with gallium instead of mercury. - Electronic temperature  quite fast, cna provide a reading in 2 to 60 seconds - Chemical disposable temp.  have liquids crystal dots or bars that change color to indicate temperature. - Temperature-sensitive tape  contains liquid crystal that change color according to temperature (useful for infants) - Infrared temperature  sense body heat in the form of infrared energy given off by a heat source - Temporal artery temper.  compare the scanned temperature of the temporal artery to the one of the room and calculates the heat balance to approximate the core temperature.  Temperature scales Temperature can be measures on a Celsius (centigrade) or Fahreneit scale. In case you need to convert from one to another, these are the formulas: C = (Fahrenheit temperature – 32) x 5/9 For example, with a Fahrenheit reading of 100: C = (100-32) x 5/9 = (68) x 5/9 = 37,8 F = (Celsius temperature x 5/9) + 32 For example, if the Celsius reading is 40: F = (40 x 5/9) + 32 = (72) + 32 = 104  Pulse The pulse is a wave of blood created by contraction of the left ventricle of the heart. Generally, the pulse wave represents the stroke volume output or the amount of blood that enters the arteries with each ventricular contraction. Compliance of the arteries is their ability to contract and expand. When an individual’s arteries lose their distensibility, as can happen with age, greater pressure is required to pump the blood into the arteries. Cardiac output is the volume of blood pumped into the arteries by the heart and equals the result of the stroke volume (SV) times the heart rate (HR) per minute. For example, 65 mL * 70 beats per minute = 4.55 L per minute. When an adult is resting, the heart pumps about 5 liters of blood each minute. In a healthy individual, the pulse reflects the heartbeat; that is, the pulse rate is the same as the rate of the ventricular contractions of the heart. However, in some conditions, the heartbeat and pulse rates can differ. In these instances, the nurse should assess both the heartbeat (apical pulse) and the peripheral pulse. A peripheral pulse is a pulse located away from the heart, for example, in the foot or wrist. The apical pulse, in contrast, is a central pulse; that is, it is located at the apex of the heart. It is also referred to as the point of maximal impulse (PMI).  Factors affecting the pulse The rate of the pulse is expressed in beats per minute (bpm). It can vary due to: - Age = the pulse gradually decrease with age - Sex = the average male’s pulse is slower than female’s - Exercise - Fever = increased due to vasodilation and increased metabolic rate - Medication - Hypovolemia or dehydration - Stress - Position - Pathology  Pulse sites Pulse can be measured in nine sites: 1- temporal 2 – carotid (never press both carotid at the same time!) 3 – apical = at the apex of the heart (5° interc. space.) 4 – brachial = antecubital fossa 5 – radial 6 – femoral = alongside the inguinal ligament 7 – popliteal = behind the knee 8 – posterior tibial = on the medial surface of the ankle 9 – dorsalis pedis = over the bones of the foot  Assessing pulses A pulse is commonly assessed by palpation (feeling) or auscultation (hearing). The middle three fingertips are used for palpating all pulse sites except the apex of the heart. A stethoscope is used for assessing apical pulses. The nurse should also be aware of the following: Any medication that could affect the heart rate. Whether the client has been physically active. If so, wait 10 to 15 minutes until the client has rested and the pulse has slowed to its usual rate. Any baseline data about the normal heart rate for the client. For example, a physically fit athlete may have a resting heart rate below 60 beats/min. Whether the client should assume a particular position (e.g., sitting). In some clients, the rate changes with the position because of changes in blood flow volume and autonomic nervous system activity. When assessing the pulse, the nurse collects the following data: the rate, rhythm, volume, arterial wall elasticity, and presence or absence of bilateral equality. Pulse characteristics: - Tachicardia  An excessively fast heart rate - Bradycardia  A heart rate in an adult of less than 60 beats/min - Pulse rhythm  is the pattern of the beats and the intervals between the beats. Equal time elapses between beats of a normal pulse. - Dysrhythmia/arrhythmia  A pulse with an irregular. It may consist of random, irregular beats or a predictable pattern of irregular beats (documented as “regularly irregular”). When a dysrhythmia is detected, the apical pulse should be assessed. An electrocardiogram (ECG or EKG) is necessary to define the dysrhythmia further. - Pulse volume  or pulse strength or amplitude, refers to the force of blood with each beat. Usually, the pulse volume is the same with each beat. It can range from absent to bounding. When assessing a peripheral pulse. the nurse should also assess the corresponding pulse on the other side of the body. When a peripheral pulse is located, it indicates that pulses more proximal to that location will also be present. Peripheral pulses  Respirations Respiration is the act of breathing. Inhalation or inspiration refers to the intake of air into the lungs. Exhalation or expiration refers to breathing out or the movement of gases from the lungs to the atmosphere. Ventilation is also used to refer to the movement of air into and out of the lungs. There are basically two types of breathing: costal (thoracic) breathing and diaphragmatic (abdominal) breathing. - Costal breathing involves the external intercostal muscles and other accessory muscles, such as the sternocleidomastoid muscles. It can be observed by the movement of the chest upward and outward. - Diaphragmatic breathing involves the contraction and relaxation of the diaphragm, and it is observed by the movement of the abdomen, which occurs as a result of the diaphragm’s contraction and downward movement.  Mechanics and Regulation of Breathing During inhalation: - The diaphragm contracts (flattens) - The ribs move upward and outward - The sternum moves outward, thus enlarging the thorax and permitting the lungs to expand. During exhalation: - Diaphragm relaxes - The ribs move downward and inward - The sternum moves inward, thus decreasing the size of the thorax as the lungs are compressed. Normal breathing is automatic and effortless. Respiration is controlled by: a) respiratory centers in the medulla oblongata and the pons of the brain b) chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies. These centers and receptors respond to changes in the concentrations of oxygen (O2 ), carbon dioxide (CO2 ), and hydrogen (H+ ) in the arterial blood.  Assessing Respirations Resting respirations should be assessed when the client is relaxed because exercise affects respirations, increasing their rate and depth. Before assessing a client’s respirations, a nurse should be aware of the following: The client’s normal breathing pattern The influence of the client’s health problems on respirations Any medications or therapies that might affect respirations The relationship of the client’s respirations to cardiovascular function. The rate, depth, rhythm, quality, and effectiveness of respirations should be assessed. The respiratory rate is normally described in breaths per minute. Breathing that is normal in rate and depth is called eupnea. Abnormally slow respirations are referred to as bradypnea, and abnormally fast respirations are called tachypnea or polypnea. Apnea is the absence of breathing.  Factors Affecting Respirations Increase resp. rate  exercise, stress, increased environmental temperature, and lowered oxygen concentration at increased altitudes. Decrease resp. rate  decreased environmental temperature, certain medications (e.g., morphine), and increased intracranial pressure. The depth of an individual’s respirations can be established by observing the movement of the chest: is generally described as normal, deep, or shallow. - Deep respirations are those in which a large volume of air is inhaled and exhaled, inflating most of the lungs. - Shallow respirations involve the exchange of a small volume of air and often the minimal use of lung tissue. During a normal inspiration and expiration, an adult takes in about 500 mL of air. This volume is called the tidal volume. Hyperventilation refers to very deep, rapid respirations; hypoventilation refers to very shallow respirations. Respiratory rhythm refers to the regularity of the expirations and the inspirations; respiratory rhythm can be described as regular or irregular. Respiratory quality refers to those aspects of breathing that are different from normal, effortless breathing. Two of these aspects are the amount of effort a client must exert to breathe and the sound of breathing. The sound of breathing is significant: normal breathing is silent, but a number of abnormal sounds such as a wheeze are obvious to the nurse’s ear. Many sounds occur as a result of the presence of fluid in the lungs and are most clearly heard with a stethoscope. The effectiveness of respirations is measured in part by the uptake of oxygen from the air into the blood and the release of carbon dioxide from the blood into expired air. The amount of hemoglobin in arterial blood that is saturated with oxygen can be measured indirectly through pulse oximetry, that provides a digital readout of both the client’s pulse rate and the oxygen saturation.  Blood Pressure Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arteries. Because the blood moves in waves, there are two blood pressure measurements. - The systolic pressure is the pressure of the blood as a result of contraction of the ventricles, that is, the pressure of the height of the blood wave. - The diastolic pressure is the pressure when the ventricles are at rest. Diastolic pressure, then, is the lower pressure, present at all times within the arteries. The difference between the diastolic and the systolic pressures is called the pulse pressure. A normal pulse pressure is about 40 mmHg but can be as high as 100 mmHg during exercise. A consistently elevated pulse pressure occurs in arteriosclerosis. A low pulse pressure (e.g., less than 25 mmHg) occurs in conditions such as severe heart failure. Sometimes, it is useful to also determine the mean arterial pressure (MAP) because this represents the pressure actually delivered to the body’s organs. The MAP can be calculated in several different ways, one of which is to add two-thirds of the diastolic pressure to one-third of the systolic pressure. A normal MAP is 70 to 110 mmHg. Determinants of Blood Pressure Arterial blood pressure is the results of several factors: - pumping action of the heart - peripheral vascular resistance - blood volume - viscosity  Factors Affecting Blood Pressure - Age  the pressure rises with age: newborns have a systolic pressure of about 75 mmHg - Exercise  physical activity increase the cardiac output and hence the BP(wait 30 min before measuring) - Stress  stimulation of sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles too - Race  African American older than 35 yrs tend to have higher BP - Sex  women have usually lower BP than men - Medications  can increase or decrease BP - Obesity  predispose to hypertension - Diurnal variation  BP in usually lower in the morning, when the metabolic rate is at his lowest - Medical condition  any condition affecting cardiac output, blood volume, blood viscosity, or compliance of the arteries has a direct effect on the bloodpressure - Temperature  cold increase BP, hot decrease BP. Fever increase BP (increased metabolic rate)  Hypertension A blood pressure that is persistently above normal is called hypertension. A single elevated blood pressure reading indicates the need for reassessment. Hypertension cannot be diagnosed unless an elevated blood pressure is found when measured twice at different times. It is usually asymptomatic and is often a contributing factor to myocardial infarctions (heart attacks). An elevated blood pressure of unknown cause is called primary hypertension. An elevated blood pressure of known cause is called secondary hypertension. Factors associated with hypertension include: - thickening of the arterial walls, which reduces the size of the arterial lumen, and inelasticity of the arteries - cigarette smoking - obesity - heavy alcohol consumption - lack of physical exercise - high blood cholesterol levels -continued exposure to stress  Hypotension Hypotension is a blood pressure that is below normal, that is, a systolic reading consistently between 85 and 110 mmHg in an adult whose normal pressure is higher than this. Orthostatic hypotension (or postural hypotension) is a blood pressure that decreases when the client changes from a supine to a sitting or standing position. It is usually the result of peripheral vasodilation in which blood leaves the central body organs and moves to the periphery, often causing the client to feel faint. Hypotension can also be caused by analgesics, bleeding, severe burns, and dehydration.  Assessing Blood Pressure Manual blood pressure measurement is performed with a blood pressure cuff, a sphygmomanometer, and a stethoscope. The blood pressure cuff consists of a bag, called a bladder, that can be inflated with air. It has two tubes attached to it. One tube connects to a bulb that inflates the bladder. A small valve on the side of this bulb traps and releases the air in the bladder. The other tube is attached to a sphygmomanometer. The sphygmomanometer indicates the pressure of the air within the bladder.  Blood Pressure Assessment Sites The blood pressure is commonly assessed in the client’s upper arm. In some settings, blood pressure may be routinely measured on the forearm or wrist. Assessing the blood pressure on a client’s thigh is indicated in these situations: The blood pressure cannot be measured on either arm (e.g., because of burns or other trauma). The blood pressure in one thigh is to be compared with the blood pressure in the other thigh. Blood pressure is not measured on a particular client’s limb in the following situations: The shoulder, arm, or hand (or the hip, knee, or ankle) is injured or diseased. A cast or bulky bandage is on any part of the limb. The client has had surgical removal of breast or axillary (or inguinal) lymph nodes on that side The client has an IV infusion or blood transfusion in that limb. The client has an arteriovenous fistula (e.g., for renal dialysis) in that limb.  Methods Blood pressure can be assessed directly or indirectly. Direct (invasive monitoring) measurement involves the insertion of a catheter into the brachial, radial, or femoral artery; is represented as wavelike forms displayed on a monitor. Two noninvasive indirect methods of measuring blood pressure are the auscultatory and palpatory methods. The auscultatory method is most commonly used in hospitals, clinics, and homes. When taking a blood pressure using a stethoscope, the nurse identifies phases in the series of sounds called Korotkoff sounds. The systolic pressure is the point where the first tapping sound is heard (phase 1). In adults, the diastolic pressure is the point where the sounds become inaudible (phase 5). The palpatory method is sometimes used when Korotkoff sounds cannot be heard. In this method, instead of listening for the blood flow sounds, the nurse uses light to moderate pressure to palpate the pulsations of the artery as the pressure in the cuff is released. The pressure is read from the sphygmomanometer when the first pulsation is felt. This vibration is no longer felt when the cuff pressure is below the diastolic pressure Korotkoff Sounds  Oxygen Saturation A pulse oximeter is a noninvasive device that estimates a client’s blood oxygen saturation (SpO2 ) by means of a sensor attached to the client’s finger, toe, nose, earlobe, or forehead (or around the hand or foot of a neonate). The oxygen saturation value is the percent of all hemoglobin binding sites that are occupied by oxygen. The pulse oximeter can detect hypoxemia (low oxygen saturation) before clinical signs and symptoms develop.  Factors Affecting Oxygen Saturation Readings - Hemoglobin  if the hemoglobin is fully saturated with oxygen, the SpO2 will appear normal, even if the hemoglobin level is low. - Circulation  if circulation is impaired, reading is not accurate - Activity  shivering or movement may interfere - Carbon monoxide poisoning  pulse oximeter cannot discriminate between hemoglobin saturated with carbon monoxide vs oxygen.  HEALTH ASSESSMENT  Health Assessment Assessing a client’s health status is a major component of nursing care. A physical examination can be any of several types: 1) a comprehensive initial assessment 2) a focused examination of a body system or body area 3) a functional assessment that examines one or more aspects of the client’s abilities Assessing is considered the first phase or step of the nursing process. Performing the health history and physical examination is part of assessing, which includes data collection, organization, validation, and documentation.  Physical Health Assessment These are some purposes of the physical examination: To obtain baseline data about the client’s functional abilities To supplement, confirm, or refute data obtained in the nursing history To obtain data that will help establish nursing diagnoses and plans of care To evaluate the physiologic outcomes of healthcare and thus the progress of a client’s health problem To make clinical judgments about a client’s health status To identify areas for health promotion and disease prevention. Assessments are conducted using a framework or approach to gathering the data. The most common framework for a comprehensive assessment is the head-to-toe assessment. Head-to-Toe Framework With hospitalized clients, a quick assessment is done at the beginning of the shift to use as a baseline. One possible structure for this shift assessment is the following: 1 – Observe a. Level of consciousness b. Skin color c. Respiratory effort d. Nutritional status e. Body position (e.g. does the client appear in pain?) f. Speech g. Hygiene and grooming 2 – Check vital signs including pain; include pedal pulses 3 - Auscultate lungs and apical pulse 4 - Check capillary refill and peripheral edema 5 - Auscultate bowel sounds 6 - Observe skin turgor and surfaces for lesions (anterior and posterior, especially bony prominences) 7 - Observe mobility (all four extremities, weight bearing) 8 - Examine drains, catheters, wound dressings or tubes: location, patency, and description of drainage, if any.  Preparing the patient Most people need an explanation of the physical examination. Often clients are anxious about what the nurse will find. The nurse should explain when and where the examination will take place, why it is important, and what will happen. Health examinations are usually painless. Clients should empty their bladders before the examination: doing so helps them feel more relaxed and facilitates palpation of the abdomen and pubic area. The sequence of the assessment differs with children and adults. With children, always proceed from the least invasive or uncomfortable aspect of the exam to the more invasive. Examination of the head and neck, heart and lungs, and range of motion can be done early in the process, with the ears, mouth, abdomen, and genitals being left for the end of the exam.  Preparing The Environment The environment needs to be well lighted and the equipment should be organized for efficient use. The room should be warm enough to be comfortable for the client. Providing privacy is important. Family and friends should not be present unless the client asks for someone. Drapes should be arranged so that the area to be assessed is exposed and other body areas are covered. Exposure of the body is frequently embarrassing to clients. All equipment required for the health assessment should be clean, in good working order, and readily accessible. Instrumentation  Positioning Several positions are required during the physical assessment. The client’s physical condition, energy level, and age should be considered. The assessment is organized so several body areas can be assessed in one position, thus minimizing the number of position changes needed.  Methods of Examining Four primary techniques are used in the physical examination: 1 - inspection 2 - palpation 3 - percussion 4 - auscultation  Inspection Inspection is the visual examination, which is assessing by using the sense of sight. The nurse inspects with the naked eye and with a lighted instrument such as an otoscope. In addition to visual observations, olfactory (smell) and auditory (hearing) cues are noted. Nurses frequently use visual inspection to assess moisture, color, and texture of body surfaces, as well as shape, position, size, color, and symmetry of the body.  Palpation Palpation is the examination of the body using the sense of touch. Palpation is used to determine: (a) texture (e.g., of the hair); (b) temperature (e.g., of a skin area); (c) vibration (e.g., of a joint); (d) position, size, consistency, and mobility of organs or masses; (e) distention (e.g., of the urinary bladder); (f) pulsation; (g) tenderness or pain.  Light and Deep Palpation There are two types of palpation: light and deep. Light (superficial) palpation should always precede deep palpation because heavy pressure on the fingertips can dull the sense of touch. For light palpation, the nurse extends the dominant hand’s fingers parallel to the skin surface and presses gently while moving the hand in a circle. Deep palpation is usually not done during a routine examination and requires significant practitioner skill. It is performed with extreme caution because pressure can damage internal organs. It is usually not indicated in clients who have acute abdominal pain or pain that is not yet diagnosed. Deep palpation is done with two hands (bimanually) or one hand. The top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensations.  Percussion Percussion is the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt. There are two types of percussion: direct and indirect. In direct percussion, the nurse strikes the area to be percussed directly with the pads of two, three, or four fingers or with the pad of the middle finger Indirect percussion is the striking of an object (e.g., a finger) held against the body area to be examined. In this technique, the middle finger of the nondominant hand, referred to as the pleximeter, is placed firmly on the client’s skin. Only the distal phalanx and joint of this finger should be in contact with the skin. Using the tip of the flexed middle finger of the other hand, called the plexor, the nurse strikes the pleximeter, usually at the distal interphalangeal joint or a point between the distal and proximal joints. Percussion is used to determine the size and shape of internal organs by establishing their borders. It indicates whether tissue is fluid filled, air filled, or solid. Percussion elicits five types of sound: flatness, dullness, resonance, hyperresonance, and tympany. 1- Flatness is an extremely dull sound produced by very dense tissue, such as muscle or bone. 2 - Dullness is a thudlike sound produced by dense tissue such as the liver, spleen, or heart. 3 - Resonance is a hollow sound such as that produced by lungs filled with air. 4 - Hyperresonance is not produced in the normal body. It is described as booming and can be heard over an emphysematous lung. 5 - Tympany is a musical or drumlike sound produced from an air- filled stomach. On a continuum, flatness reflects the most dense tissue (the least amount of air) and tympany the least dense tissue (the greatest amount of air).  Auscultation Auscultation is the process of listening to sounds produced within the body. Auscultation may be direct or indirect. Direct auscultation is performed using the unaided ear, for example, to listen to a respiratory wheeze. Indirect auscultation is performed using a stethoscope, which transmits sounds to the nurse’s ears. A stethoscope is used primarily to listen to sounds from within the body, such as bowel sounds or valve sounds of the heart and blood pressure. Auscultated sounds are described according to their pitch, intensity, duration, and quality. The pitch is the frequency of the vibrations (the number of vibrations per second). Low-pitched sounds, such as some heart sounds, have fewer vibrations per second than high-pitched sounds, such as bronchial sounds. The intensity (amplitude) refers to the loudness or softness of a sound. The duration of a sound is its length (long or short). The quality of sound is a subjective description of a sound, for example, whistling, gurgling, or snapping.  Health Assessment: Integument Health Assessment Integument The integument includes the skin, hair, and nails. The examination begins with a generalized inspection  Skin Assessment of the skin involves inspection and palpation. The entire skin surface may be assessed at one time or as each aspect of the body is assessed. Possible findings: - Pallor is the result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation. r in all people is usually most evident in areas with the least pigmentation such as the conjunctiva, oral mucous membranes, nail beds, palms of the hand, and soles of the feet. - Cyanosis (a bluish tinge) is most evident in the nail beds, lips, and buccal mucosa. - Jaundice (a yellowish tinge) may first be evident in the sclera of the eyes and then in the mucous membranes and the skin. - Erythema is skin redness associated with a variety of rashes and other conditions. - Albinism is the complete or partial lack of melanin in the skin, hair, and eyes. -Edema is the presence of excess interstitial fluid. An area of edema appears swollen, shiny, and taut and tends to blanch the skin color or, if accompanied by inflammation, may redden the skin.  Skin Lesion A skin lesion is an alteration in a client’s normal skin appearance. Primary skin lesions are those that appear initially in response to some change in the external or internal environment of the skin. Secondary skin lesions are those that do not appear initially but result from modifications such as chronicity, trauma, or infection of the primary lesion. Nurses are responsible for describing skin lesions accurately in terms of location, distribution, and configuration (the arrangement or position of several lesions) as well as color, shape, size, firmness, texture, and characteristics of individual lesions.  Hair Assessing a client’s hair includes inspecting the hair and the head. Normal hair is resilient and evenly distributed. In people with severe protein deficiency (kwashiorkor), the hair color is faded and appears reddish or bleached. Some therapies cause alopecia (hair loss).  Nails Nails are inspected for nail plate shape, angle between the fingernail and the nail bed, nail texture, nail bed color, and the intactness of the tissues around the nails. The nail plate is normally colorless and has a convex curve. Abnormalities - “Spoon shape” = the nail curves upward from the nail bed; this condition (called koilonychia) may be seen in clients with iron deficiency anemia - Clubbing = condition in which the angle between the nail and the nail bed is 180 degrees, or greater (normally is 160°); may be caused by a long-term lack of oxygen. A blanch test can be carried out to test the capillary refill, that is, peripheral circulation. Normal nail bed capillaries. blanch when pressed, but quickly turn pink or their usual color when pressure is released. A slow rate of capillary refill may indicate circulatory problems.  Health Assessment: Head  Health Assessment: Head During assessment of the head, the nurse inspects and palpates simultaneously and also auscultates. The nurse examines the skull, face, eyes, ears, nose, sinuses, mouth, and pharynx.  Skull and Face A normal head size is referred to as normocephalic. Names of areas of the head are derived from names of the underlying bones: frontal, parietal, occipital, mastoid process, mandible, maxilla, and zygomatic.  Eye and Vision Examination of the eyes includes: - assessment of the external structures - visual acuity (the degree of detail the eye can discern in an image) - ocular movement - visual fields (the area an individual can see when looking straight ahead). Most eye assessment procedures involve inspection. Many people wear eyeglasses or contact lenses to correct common refractive errors of the lens of the eye. These errors include: - myopia (nearsightedness) - hyperopia (farsightedness) - presbyopia (loss of elasticity of the lens and thus loss of ability to see close objects). - Astigmatism, an uneven curvature of the cornea that prevents horizontal and vertical rays from focusing on the retina, is a common problem that may occur in conjunction with myopia and hyperopia; may be corrected with glasses or surgery. Three types of eye charts are available to test visual acuity: Common inflammatory visual problems that nurses may encounter in clients include: - conjunctivitis = inflammation of the bulbar and palpebral conjunctiva. Redness, itching, tearing, and mucopurulent discharge occur - dacryocystitis = inflammation of the lacrimal sac. Is manifested by tearing and a discharge from the nasolacrimal duct. - iritis = inflammation of the iris. Results in pain, tearing, and photophobia - contusions or hematomas = “black eyes” resulting from injury Other eye problems: - cataract = opacity of the lens or its capsule, which blocks light rays, is frequently removed and replaced by a lens implant - glaucoma = a disturbance in the circulation of aqueous fluid, which causes an increase in intraocular pressure. Danger signs of glaucoma include blurred or foggy vision, loss of peripheral vision, difficulty focusing on close objects, difficulty adjusting to dark rooms, and seeing rainbow-colored rings around lights. Pupils are normally black, are equal in size (about 3 to 7 mm in diameter), and have round, smooth borders. Mydriasis (enlarged pupils) may indicate injury or glaucoma, or result from certain drugs (e.g., atropine, cocaine, amphetamines). Miosis (constricted pupils) may indicate an inflammation of the iris or result from such drugs as morphine or heroin and other narcotics, barbiturates, or pilocarpine. It is also an age-related change in older adults. Anisocoria (unequal pupils) may result from a central nervous system disorder; however, slight variations may be normal.  Ears and Hearing Assessment of the ear includes direct inspection and palpation of the external ear, inspection of the internal parts of the ear by an otoscope and determination of auditory acuity. The ear is divided into three parts: external ear, middle ear, and inner ear. The external ear includes the auricle or pinna, the external auditory canal, and the tympanic membrane. The external ear canal is curved, is about 2.5 cm long in the adult, and ends at the tympanic membrane; the glands secrete cerumen (earwax), which lubricates and protects the canal. The middle ear is an air-filled cavity that starts at the tympanic membrane and contains three ossicles (bones of sound transmission): the malleus (hammer), the incus (anvil), and the stapes (stirrups). The eustachian tube connects the middle ear to the nasopharynx, and stabilizes the air pressure between the external atmosphere and the middle ear, thus preventing rupture of the tympanic membrane. The inner ear contains the cochlea, a seashell-shaped structure essential for sound transmission and hearing, and the vestibule and semicircular canals, which contain the organs of equilibrium. Sound transmission and hearing are complex processes. In brief, sound can be transmitted by air conduction or bone conduction. Air-conducted transmission occurs by this process: 1. A sound stimulus enters the external canal and reaches the tympanic membrane. 2. The sound waves vibrate the tympanic membrane and reach the ossicles. 3. The sound waves travel from the ossicles to the opening in the inner ear (oval window). 4. The cochlea receives the sound vibrations. 5. The stimulus travels to the auditory nerve (the eighth cranial nerve) and the cerebral cortex. Bone-conducted sound transmission occurs when skull bones transport the sound directly to the auditory nerve.  Nose and Sinuses Assessment of the nose includes inspection and palpation of the external nose and patency of the nasal cavities using a penlight  Mouth and Oropharynx The mouth and oropharynx are composed of a number of structures: lips, oral mucosa, the tongue and floor of the mouth, teeth and gums, hard and soft palate, uvula, salivary glands, tonsillar pillars, and tonsils. three pairs of salivary glands empty into the oral cavity: the parotid, submandibular, and sublingual glands. Problems: - Dental caries (cavities) - Periodontal disease (or pyorrhea) - Plaque = is an invisible soft film that adheres to the enamel surface of teeth; it consists of bacteria, molecules of saliva, and leukocytes. - Tartar = dental calculus, is a visible, hard deposit of plaque and dead bacteria that forms at the gum lines. - gingivitis = red, swollen gingiva, bleeding - glossitis = inflammation of the tongue - stomatitis = inflammation of the oral mucosa - parotitis = inflammation of the parotid salivary gland  Neck Examination of the neck includes the muscles, lymph nodes, trachea, thyroid gland, carotid arteries, and jugular veins. Areas of the neck are defined by the sternocleidomastoid muscles, which divide each side of the neck into two triangles: the anterior and posterior Lymph nodes in the neck that collect lymph from the head and neck structures are grouped serially and referred to as chains  Thorax and Lungs Assessing the thorax and lungs is frequently critical to assessing the client’s oxygenation status. Changes in the respiratory system can occur slowly or quickly. In clients with chronic obstructive pulmonary disease (COPD), such as chronic bronchitis, emphysema, and asthma, changes are frequently gradual. The onset of conditions such as pneumonia or pulmonary embolus is generally more acute or sudden. Before beginning the assessment, the nurse must be familiar with a series of imaginary lines on the chest wall and be able to locate the position of each rib and some spinous processes. A) The midsternal line is a vertical line running through the center of the sternum. The midclavicular lines (right and left) are vertical lines from the midpoints of the clavicles. B) The anterior axillary lines (right and left) are vertical lines from the anterior axillary folds. The posterior axillary line is a vertical line from the posterior axillary fold. The midaxillary line is a vertical line from the apex of the axilla. C) The vertebral line is a vertical line along the spinous processes. The scapular lines (right and left) are vertical lines from the inferior angles of the scapulae. Each lung is first divided into the upper and lower lobes; the right lung is further divided by a minor fissure into the right upper lobe and right middle lobe (RML). The starting point for locating the ribs anteriorly is the angle of Louis, the junction between the body of the sternum (breastbone) and the manubrium. The superior border of the second rib attaches to the sternum at this manubrio-sternal junction. The superior border of the second rib attaches to the sternum at this manubrio-sternal junction. Only the first seven ribs attach directly to the sternum.  Chest Shape and Size In healthy adults, the thorax is oval. Its antero-posterior diameter is half its transverse diameter. The overall shape of the thorax is elliptical. In older adults, kyphosis and osteoporosis alter the size of the chest cavity as the ribs move downward and forward. Chest abnormalities: - Pigeon chest (pectus carinatum) = prominent sternum - Funnel chest (pectus excavatum) = depressed sternum - Barrel chest = ratio of antero-posterior to transverse diameter is 1:1  Breath Sounds Abnormal breath sounds, called adventitious breath sounds, occur when air passes through narrowed airways or airways filled with fluid or mucus, or when pleural linings are inflamed. Absence of breath sounds over some lung areas is also a significant finding that is associated with collapsed and surgically removed lobes or severe pneumonia. Assessment of the lungs and thorax includes all methods of examination: inspection, palpation, percussion, and auscultation.  Assessment Start with the posterior thorax, in a sitting position (maximizes expansion). We are checking: symmetry, spinal alignement, avoid deep palpation if pain, check thoracic expansion. Palpate the thorax for fremitus, the vibration felt through the chest wall when the patient speaks (tactile fremitus). Percuss the thorax and auscultate it at the end. Then assess the anterior thorax. Inspect breathing patterns (respiratory rate and rhythm), palpate to check expansion e for tactile fremitus; percuss and then auscultate. Cardiovascular and Peripheral Vascular Systems  Cardiovascular and Peripheral Vascular Systems The cardiovascular system consists of the heart and the central blood vessels (primarily the pulmonary, coronary, and neck arteries and veins). The peripheral vascular system includes those arteries and veins distal to the central vessels.  Heart Nurses assess the heart through inspection, palpation, and auscultation. In the average adult, most of the heart lies behind and to the left of the sternum. A small portion (the right atrium) extends to the right of the sternum. The point where the apex touches the anterior chest wall and heart movements are most easily observed and palpated is known as the point of maximal impulse (PMI). The precordium, the area of the chest overlying the heart, is inspected and palpated for the presence of abnormal pulsations or lifts or heaves. The terms lift and heave, often used interchangeably, refer to a rising along the sternal border with each heartbeat. Heart sounds can be heard by auscultation. The normal first two heart sounds are produced by closure of the valves of the heart. The first heart sound, S1 , occurs when the atrioventricular (AV) valves close. S1 is a dull, low-pitched sound described as “lub.” After the ventricles empty the blood into the aorta and pulmonary arteries, the semilunar valves close, producing the second heart sound, S2 , described as “dub.” S2 has a higher pitch than S1 and is shorter in duration. These two sounds, S1 and S2 (“lub-dub”), occur within 1 second or less.  Central Vessels The carotid arteries supply oxygenated blood to the head and neck. Because they are the only source of blood to the brain, prolonged occlusion of these arteries can result in serious brain damage The carotid is also auscultated for a bruit. A bruit (a blowing or swishing sound) is created by turbulence of blood flow due either to a narrowed arterial lumen (a common development in older people) or to a condition, such as anemia or hyperthyroidism, that elevates cardiac output. If a bruit is found, the carotid artery is then palpated for a thrill. A thrill, is a vibrating sensation like the purring of a cat or water running. The jugular veins drain blood from the head and neck directly into the superior vena cava and right side of the heart. The external jugular veins are superficial and may be visible above the clavicle. The internal jugular veins lie deeper along the carotid artery. By inspecting the jugular veins for pulsations and distention, the nurse can assess the adequacy of function of the right side of the heart and venous pressure. Bilateral jugular venous distention (JVD) may indicate right-sided heart failure.  Peripheral Vascular System Assessing the peripheral vascular system includes measuring the blood pressure, palpating peripheral pulses, and inspecting the skin and tissues to determine perfusion to the extremities. Palpate the peripheral pulses on both sides of the client’s body individually, simultaneously (except the carotid pulse), and systematically to determine the symmetry of pulse volume. Inspect the peripheral veins in the arms and legs for the presence or appearance of superficial veins when limbs are dependent and when limbs are elevated. Assess the peripheral leg veins for signs of phlebitis. Inspect the skin of the hands and feet to check peripheral perfusion (color, temperature, edema, skin changes). Execute the capillary refill test.  Breast and Axillae The breasts of males and females need to be inspected and palpated. Males have some glandular tissue beneath each nipple, a potential site for malignancy, whereas mature females have glandular tissue throughout the breast. During assessment, the nurse can localize specific findings by dividing the breast into quadrants and the axillary tail. Inspect the breasts for size, symmetry, and contour or shape while the client is in a sitting position. - Females: rounded shape; slightly unequal in size; generally symmetric - Males: breasts even with the chest wall; if obese, may be similar in shape to female breasts Inspect the skin of the breast for localized discolorations or hyperpigmentation, retraction or dimpling, localized hypervascular areas, swelling or edema. Palpate the axillary, subclavicular, and supraclavicular lymph nodes. Palpate the breast for masses, tenderness, and any discharge from the nipples Abdomen  Abdomen Assessment of the abdomen involves all four methods of examination (inspection, auscultation, palpation, and percussion). When assessing the abdomen, the nurse performs inspection first, followed by auscultation, percussion, and/or palpation. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results. The abdomen can be divide using two common methods: quadrant and regions. To divide the abdomen into quadrants, the nurse imagines two lines: a vertical line from the xiphoid process to the pubic symphysis, and a horizontal line across the umbilicus. Using the second method, division into nine regions, the nurse imagines two vertical lines that extend superiorly from the midpoints of the inguinal ligaments, and two horizontal lines, one at the level of the edge of the lower ribs and the other at the level of the iliac crests.  Ispection of the Abdomen Prior to inspection, ask if the patient has any past medical history, as abdominal pain and quality, associated symptoms (nausea, diarrhea, vomiting…), change in appetite, food intolerances… Inspect the abdomen for contour and symmetry. Ask the client to take a deep breath and to hold it: this makes an enlarged liver or spleen more obvious. Observe abdominal movements associated with respiration, peristalsis, or aortic pulsations.  Auscultation of the Abdomen Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs. Ask when the client last ate: hortly after or long after eating, bowel sounds may normally increase. Four to seven hours after a meal, bowel sounds may be heard continuously. Listen for active bowel sounds—irregular gurgling noises occurring about every 5 to 20 seconds. For vascular sounds, listen for bruits: normally the nurse should not hear any. The presence of bruit over the aortic area may indicate a possible aneurysm.  Percussion of the abdomen Percuss several areas in each of the four quadrants to determine presence of tympany (sound indicating gas in stomach and intestines) and dullness (decrease, absence, or flatness of resonance over solid masses or fluid). What the nurse expect to hear is tympany over the stomach and gas- filled bowels, and dullness, especially over the liver and spleen, or a full bladder. Large dull areas may be associated with presence of fluid or a tumor)  Palpation of the abdomen Perform light palpation to detect areas of tenderness and/or muscle guarding. Systematically explore all four quadrants. Note areas of tenderness or superficial pain, masses, and muscle guarding. To determine areas of tenderness, ask the client to tell you about them and watch for changes in the client’s facial expressions.  Musculoskeletal System The musculoskeletal system encompasses the muscles, bones, and joints. The nurse usually assesses the musculoskeletal system for muscle strength, tone, size, and symmetry of muscle development, and for tremors. A tremor is an involuntary trembling of a limb or body part. An intention tremor becomes more apparent when an individual attempts a voluntary movement. A resting tremor is more apparent when the client is relaxed. Bones are assessed for normal form. Joints are assessed for tenderness, swelling, thickening, crepitation and range of motion. Neurologic System  Neurologic System Examination of the neurologic system includes assessment of: a) mental status including level of consciousness b) the cranial nerves c) reflexes d) motor function e) sensory function Three major considerations determine the extent of a neurologic exam: 1) the client’s chief complaints 2) the client’s physical condition (i.e., level of consciousness and ability to ambulate)  Mental Status Assessment of mental status reveals the client’s general cerebral function. These functions include intellectual (cognitive) as well as emotional (affective) functions. Major areas of mental status assessment include language, orientation, memory, and attention span and calculation  Language Any defects in or loss of the power to express oneself by speech, writing, or signs, or to comprehend spoken or written language due to disease or injury of the cerebral cortex, is called aphasia. Sensory or receptive aphasia is the loss of the ability to comprehend written or spoken words. Motor or expressive aphasia involves loss of the power to express oneself by writing, making signs, or speaking.  Orientation This aspect of the assessment determines the client’s ability to recognize other people (person), awareness of when and where they presently are (time and place), and who they, themselves, are (self). Memory The nurse assesses the client’s recall of information presented seconds previously (immediate recall), events or information from earlier in the day or examination (recent memory), and knowledge recalled from months or years ago (remote or long-term memory).  Level of Consciousness Level of consciousness (LOC) can lie anywhere along a continuum from a state of alertness to coma. A fully alert client responds to questions spontaneously; a comatose client may not respond to verbal stimuli. The Glasgow Coma Scale was originally developed to predict recovery from a head injury, but is now largely used to assess level of consciousness. It tests in three major areas: eye response, motor response, and verbal response. A comatose client scores 7 or less.  Sensory Function Sensory functions include touch, pain, temperature, position, and tactile discrimination. The first three are routinely tested. Abnormal responses to touch stimuli include: - loss of sensation (anesthesia); - more than normal sensation (hyperesthesia); - less than normal sensation (hypoesthesia); - abnormal sensation such as burning, pain, or an electric shock (paresthesia). Female Genitals and Inguinal Area The examination of the genitals and reproductive tract of females includes assessment of the inguinal lymph nodes and inspection and palpation of the external genitals. For sexually active adolescent and adult females, a Papanicolaou test (Pap test) is used to detect cancer of the cervix. If there is an increased or abnormal vaginal discharge, specimens should be taken. Examination of the genitals usually creates uncertainty and apprehension. The nurse must explain each part of the examination in advance and perform the examination in an objective, supportive, and efficient manner. - Inspect the skin of the pubic area for parasites, inflammation, swelling, and lesions. - Inspect the clitoris, urethral orifice, and vaginal orifice when separating the labia minora; report the presence of lesions. - Palpate the inguinal lymph nodes. Examination of the internal genitals involves: a) palpating Skene’s and Bartholin’s glands b) assessing the pelvic musculature c) inserting a vaginal speculum to inspect the cervix and vagina d) obtaining a Papanicolaou smear.  Male genital and Inguinal Area In adult males, a complete examination includes assessment of the external genitals and prostate gland, and for the presence of any hernias. The techniques of inspection and palpation are used to examine the male genitals. The male reproductive and urinary systems share the urethra. All male clients should be screened for the presence of inguinal or femoral hernias. A hernia is a protrusion of the intestine through the inguinal wall or canal. Cancer of the prostate gland is the most common cancer in adult males. Examination of the prostate gland is performed with the examination of the rectum and anus.  Anus Inspect the anus and surrounding tissue for color, integrity, and skin lesions. Then, ask the client to bear down as though defecating. Bearing down creates slight pressure on the skin that may accentuate rectal fissures, rectal prolapse, polyps, or internal hemorrhoids.