Chap 13 Common Conditions of the Skin PDF

Chap 13 Common Conditions of the Skin Benign lesions like acne, psoriasis, and seborrheic keratoses. Psoriasis causes red, scaly plaques often on knees, elbows, and scalp due to an autoimmune reaction. Inflammatory conditions like eczema and dermatitis, presenting with itchy, red, irritated skin....

Chap 13 Common Conditions of the Skin Benign lesions like acne, psoriasis, and seborrheic keratoses. Psoriasis causes red, scaly plaques often on knees, elbows, and scalp due to an autoimmune reaction. Inflammatory conditions like eczema and dermatitis, presenting with itchy, red, irritated skin. Skin infections - bacterial (e.g. impetigo, cellulitis), viral (e.g. warts, herpes), and fungal (e.g. ringworm). Age-related changes like wrinkles, age spots, thinning skin, and senile purpura (bruising). Proper assessment of skin lesions by appearance, distribution, and morphology is key for nurses to recognize and document skin pathologies.  - Chap 13 Medication Side Effects/Skin - Rashes and skin eruptions from antibiotics like sulfonamides, penicillins, and anticonvulsants. These can range from mild rashes to severe conditions like toxic epidermal necrolysis. - Photosensitivity reactions causing exaggerated sunburn when exposed to UV light, seen with some antibiotics, NSAIDs, and diuretics. - Acne or oily skin from corticosteroids, anabolic steroids, and some psychiatric medications.   - Dry skin and pruritus from diuretics, cholesterol medications, and retinoids - Skin discoloration like darkening from antimalarials, phenytoin, or amiodarone. - Drugs, especially antibiotics, may cause allergic skin eruption. Drugs may increase sunlight sensitivity and give burn response: sulfonamides, thiazide diuretics, oral hypoglycemic agents, tetracycline. Drugs can cause hyperpigmentation: antimalarials, anticancer agents, hormones, metals, and tetracycline. - Chap 13 Primary/Secondary Skin Lesions - A diagram of several different types of skin Description automatically generated - Macule- flat - mole,etc - Papule- elevated, solid- warts, moles - Bulla \>1cm (blister)  - Pustules- acne  - Plague- scaly lesions, seen in psoriasis  - Chap 13 Shapes and Configurations of Lesions - Macules - Flat, non-raised discolored areas less than 1 cm. - Patches - Flat areas greater than 1 cm. - Papules - Solid, raised lesions less than 0.5 cm.  - Nodules - Solid, raised lesions greater than 0.5 cm. - Plaques - Raised, flat-topped solid lesions greater than 1 cm. - Vesicles - Small, fluid-filled lesions less than 0.5 cm. - Bullae - Large, fluid-filled lesions greater than 0.5 cm. - Lesions can be solitary or occur in clusters, lines, or generalized patterns across the body. Describing the configuration, such as annular (ring-shaped) or serpiginous (snake-like), provides additional diagnostic clues. Proper identification of lesion morphology is crucial for accurate assessment and diagnosis of skin conditions. - Chap 13 Signs of Skin Cancer - ABCDE - Basal cell carcinoma often appears as a pearly or waxy bump, or a flat, flesh-colored lesion. Squamous cell carcinoma may look like a firm, red nodule or a rough, scaly patch. Melanoma lesions are often irregularly shaped, contain multiple colors, and have uneven borders. Any concerning skin changes should be evaluated promptly by a dermatologist. - A: These lesions are asymmetric meaning one half does not match the other half of the lesion. - B: The borders are irregular, ragged, or blurred.   - C: The color varies and may contain shades of blue, black, or tan but can also be red. - D: The diameter is 6 mm or greater, approximately the size of a pencil eraser.   - E: These lesions are evolving or changing. They are usually different than other lesions, the ugly duckling sign. The lesions may be changing in size, shape, or color. They also may itch or bleed.   - The EFG is a new addition to recognize nodular melanomas. This includes elevation, firmness, and growing. A diagram of different stages of development Description automatically generated - Chap 18 Normal Findings in Adolescent Breast Exam - 1\. Preadolescent: There is only a small elevated nipple. - 2\. Breast bud stage: A small mound of breast and nipple develops; the areola widens. - 3\. The breast and areola enlarge; the nipple is flush with the breast surface. - 4\. The areola and nipple form a secondary mound over the breast. - 5\. Mature breast: Only the nipple protrudes; the areola is flush with the breast contour (the areola may continue as a secondary mound in some normal women).15 - During adolescence, normal breast development follows the Tanner stages of sexual maturation. Early signs include breast budding and growth of the duct system. Temporary asymmetry between breasts is common. Breast tenderness and nodularity that increases around menstruation are also normal. Full breast development from initial budding to maturity takes an average of 3 years, with a range of 1.5 to 6 years. Breast changes typically precede the first menstrual period (menarche) by about 2 years. - Chap 18 Assessment for Retraction of the Breast - When assessing for breast retraction, look for dimpling, puckering, or inward pulling of the breast skin or nipple. This can indicate an underlying breast mass or malignancy tethered to the skin or chest wall. Have the patient raise their arms overhead to better visualize any subtle skin changes. Palpate the breast thoroughly for any underlying masses or thickening. Retraction is an important sign that warrants further diagnostic evaluation. - Chap 18 Developmental Competence/Aging Adult Female - As women age, normal breast changes occur due to hormonal shifts and loss of tissue elasticity. The breasts may become smaller, less dense, and more pendulous. Glandular tissue atrophies while fat deposits increase, making lumps easier to palpate. Encourage older women to perform regular breast self-exams and have annual clinical exams to detect any abnormalities. Provide education on age-appropriate breast cancer screening guidelines. Assess functional status, comorbidities, and life expectancy when considering treatment options if breast cancer is diagnosed. Tailor care to promote dignity, comfort, and quality of life for the aging adult female. - Chap 18 Documenting Breast Lump Findings - Location - Quadrant of the breast and distance from the nipple - Size - Measurements of length, width, and depth  - Characteristics - Shape, borders, consistency (hard, soft, etc.), mobility, tenderness - Skin changes - Dimpling, retraction, redness, etc. - Nipple discharge - Color, consistency, from one or both breasts - Lymph nodes - Location and description of any palpable axillary nodes - Chap 18 Case Study Abnormal Breast Findings  - Objective Inspection --- Breasts asymmetric when sitting, arms down. Right breast appears fixed with dimpling at 9 o\'clock position. Leaning forward, left breast falls free while right breast flattens. Palpation --- Left breast soft and granular, no masses. Right breast with large, stony hard 5 cm x 4 cm x 2 cm mass in outer quadrant at 9 o\'clock, 3 cm from nipple. Mass borders irregular, fixed, no pain. One firm, palpable right axillary lymph node.  - These findings are concerning for a possible breast malignancy on the right side. The dimpling, fixation, large irregular mass, and palpable lymph node warrant prompt further diagnostic evaluation such as imaging studies and biopsy. Thorough documentation of exam findings guides appropriate next steps in care. - Chap 23 Skeletal Muscle ROM - When assessing range of motion (ROM) for skeletal muscles, perform both active and passive movements of the major joints. Active ROM involves the patient moving the joint through its full range without assistance. Passive ROM is when you move the joint through its complete range for the patient. Compare sides for symmetry and note any limitations, pain, crepitus, or muscle spasms. Use a goniometer to precisely measure joint angles if indicated. Evaluate functional ROM by observing the patient perform activities of daily living that require joint mobility. Impaired skeletal muscle ROM can result from injury, arthritis, contractures, neurological deficits, and other musculoskeletal conditions. - Chap 23 Patient History Musculoskeletal System - Pain - location, duration, characteristics (dull, sharp, etc.), aggravating/relieving factors - \- Weakness or loss of strength - \- Stiffness or decreased range of motion in joints - \- Swelling, redness, or warmth around joints - \- Deformities like bunions, muscle wasting, or postural abnormalities - \- History of injuries, fractures, or dislocations - \- Chronic conditions like arthritis, gout, osteoporosis - \- Difficulty with mobility or activities of daily living - \- Occupational or recreational activities impacting the musculoskeletal system - Chap 23 Objective Data/ Normal and Abnormal Findings for Musculoskeletal System  - Joints and muscles symmetric, no swelling, masses, or deformities. Normal spinal curvature. No tenderness on palpation of joints, no heat or swelling. Full, smooth range of motion without crepitus or tenderness. Able to maintain muscle flexion against resistance without pain. - Abnormal findings may include: - Swelling, redness, warmth around joints indicating inflammation. Limited or painful range of motion. Muscle weakness or atrophy. Crepitus on joint movement. Deformities like bunions or muscle contractures. Abnormal gait or posture. Palpable joint effusions, nodules, or masses. Spinal curvature abnormalities like kyphosis or scoliosis. - Chap 23 Assessment of Subject/Objective Data for Musculoskeletal System  - When assessing the musculoskeletal system, collect both subjective and objective data. Subjective data includes the patient\'s reported symptoms like pain, weakness, stiffness, or limitations in movement or activities. Ask about the location, duration, characteristics, and aggravating/relieving factors for any musculoskeletal complaints. - Objective data is gathered through inspection, palpation, range of motion testing, and strength assessments. Inspect for swelling, deformities, muscle wasting, and gait abnormalities. Palpate for tenderness, warmth, effusions, crepitus, or abnormal masses around joints and muscles. Test active and passive range of motion, noting any limitations or pain. Evaluate muscle strength by having the patient move against resistance. Document symmetry and compare bilateral findings. Thorough assessment helps identify musculoskeletal issues requiring further evaluation or treatment. - Chap 23 Normal Range of Findings Pregnancy - First Trimester: - \- Amenorrhea (missed periods) - \- Breast tenderness and enlargement  - \- Nausea and vomiting - \- Fatigue - \- Frequent urination - Second Trimester:  - \- Fetal movement felt around 18-20 weeks - \- Continued breast enlargement with colostrum production - \- Darkening of areolas and linea nigra line on abdomen - Possible dizziness from drop in blood pressure around 20 weeks - Third Trimester: - \- Increased blood volume peaking around 45% above pre-pregnancy levels - \- Shortness of breath from elevated diaphragm  - \- Edema in lower extremities - \- Palpable fetal movements - \- Cardiac output and heart rate increase - Close monitoring of vital signs, weight gain, fetal growth, and any deviations from the expected course is important throughout pregnancy. Documenting all findings guides appropriate prenatal care. - Chap 23 Objective Data Muscle Testing - When testing skeletal muscle strength objectively, grade individual muscles or muscle groups on a 5-point scale during contraction. Grade 5/5 as normal strength with full resistance against your applied force. Have the patient push or pull against your resistance to flex and extend major joints like shoulders, elbows, wrists, hips, knees, and ankles. Note any asymmetry between sides. Test pronator drift by having the patient hold arms outstretched with palms up for 30 seconds - downward drift indicates weakness. Assess reflexes like biceps, triceps, brachioradialis, patellar, and Achilles by tapping the tendon and grading the contraction 0-5. Document any abnormal findings like weakness, atrophy, fasciculations, or abnormal reflexes. - Chap 25 Male Genital Lesions - When assessing male genital lesions, it\'s important to obtain a detailed history including onset, progression, associated symptoms like pain or discharge, and any potential risk factors. Perform a thorough visual inspection and palpation, noting the location, size, appearance, and texture of any lesions. Penile cancers often present as painless growths or ulcerative lesions on the glans, foreskin, or shaft. Other concerning findings may include indurated nodules, bleeding, or signs of infection. Prompt biopsy is crucial for any suspicious lesions to rule out malignancy and guide appropriate treatment. Maintaining an open, sensitive approach when discussing intimate areas is key to a comprehensive evaluation. - Chap 25 TSE - TSE, or Testicular Self-Examination, is a technique for men to check their testicles for any abnormalities like lumps, swelling, or changes in size or shape. It should be performed monthly after a warm bath or shower when the scrotal skin is relaxed. Using the palm and fingers, gently roll each testicle between the thumb and fingers to feel for any irregularities. It\'s important to be familiar with the normal size and texture to detect any changes that could indicate conditions like testicular cancer. Any concerning findings should be promptly reported to a healthcare provider for further evaluation. - Chap 25 Inspect & Palpate Scrotum - To inspect and palpate the scrotum, first visually examine for any swelling, redness, lesions, or abnormalities in the scrotal skin. Gently lift and palpate each testicle between your fingers to assess for any masses, tenderness, or changes in size or consistency. Note if one testicle hangs lower than the other. Retract the foreskin if present to inspect the glans penis for discharge, irritation, or lesions. Palpate along the spermatic cord for any tenderness or abnormal thickening. Document any concerning findings that require further evaluation or treatment. - Chap 25 Penis Abnormalities - When inspecting the penis, look for any abnormalities such as hypospadias, where the urethral opening is misplaced on the underside of the penis. Note the presence and severity of chordee, a downward curvature during erection. Inspect for phimosis, where the foreskin cannot be retracted, or paraphimosis, where the foreskin is stuck in a retracted position. Check for penile lesions, discharge, swelling, or signs of infection. Palpate along the shaft for any masses or tenderness. Penile torsion, or rotation of the shaft, may also be present. Prompt evaluation is needed for any concerning findings to rule out congenital anomalies or other conditions requiring treatment. - Chap 25 Tanner's SMR - Tanner\'s Sexual Maturity Ratings (SMRs) are a standardized scale used to document the stages of puberty and sexual development in children and adolescents. The scale rates the development of secondary sexual characteristics like breast development in girls, genital growth in boys, and pubic hair distribution. Each characteristic is rated on a scale from 1 (pre-pubertal) to 5 (fully mature adult stage). Tanner SMRs provide an objective way for healthcare providers to assess and monitor normal pubertal progression. - Chap 25 Preparation for Assessment of Male GU - When preparing to assess the male genitourinary system, ensure privacy and a comfortable environment for the patient. Explain the procedure and obtain consent. Have the patient undress from the waist down and provide a drape or gown. Position the patient standing or lying supine with legs spread. Proper lighting is important for visualization. Wear clean gloves and use lubricant if needed for palpation. Maintain a professional, sensitive approach throughout the exam. Document any abnormal findings thoroughly. - Chap 26 Meconium - Meconium is a dark greenish substance that accumulates in the fetal intestines before birth. It consists of desquamated cells, mucus, bile, and other materials. Normally, meconium is expelled within the first 12-48 hours after delivery. However, issues can arise if meconium is abnormally thick and sticky, leading to intestinal obstruction (meconium ileus) or if it contaminates amniotic fluid and is aspirated by the infant (meconium aspiration syndrome). Prompt recognition and management of meconium-related conditions is crucial to prevent complications in newborns. - Chap 26 Abnormal Findings Anal Region Abnormalities - When inspecting the anal region, be alert for the following potential abnormalities: - \- Hemorrhoids - swollen, bulging veins around the anus that may bleed - \- Fissures - linear tears in the anal mucosa causing pain with bowel movements   - \- Fistulas - abnormal tracts or openings connecting the anus to surrounding tissues - \- Abscesses - painful, swollen collections of pus  - \- Skin tags - small, benign growths of excess skin - \- Condylomas - wart-like growths caused by HPV infection - \- Rectal prolapse - protrusion of rectal lining through the anus - \- Anal stenosis - abnormal narrowing of the anal canal - Palpate for any masses, tenderness, or irregularities. Note any discharge, bleeding, or changes in sphincter tone. Prompt evaluation is needed for any concerning findings. - Chap 26 Documentation of Sub/Obj Data - Proper documentation of subjective and objective data is crucial for effective communication and continuity of care. Subjective data should be documented using the patient\'s own words, enclosed in quotation marks. For example, \"The patient states \'I have a sharp pain in my lower abdomen.\'\" Objective data should be documented factually and objectively, without interpretation. For instance, \"The patient is grimacing and holding their lower abdomen.\" Clearly separate subjective from objective data, and include relevant details like timing, location, and descriptors. Thorough, accurate documentation allows the healthcare team to properly assess and treat the patient\'s condition. - Chap 26 Colorectal Cancer - Colorectal cancer is a serious health concern, being the third most common cancer and second leading cause of cancer deaths in the United States. Early detection through regular screening starting at age 45 is crucial, as it often allows for curative treatment when found early. Colonoscopy screening can detect precancerous polyps which can be removed, further reducing cancer risk. Lifestyle modifications like maintaining a healthy weight, exercising regularly, eating a high-fiber diet low in red/processed meats, and not smoking can also help reduce colorectal cancer risk. Knowing the early warning signs like blood in stool, anemia, and changes in bowel habits is important for promptly seeking medical evaluation. Through a combination of preventive measures, screening, and early treatment, the death rate from colorectal cancer can be significantly reduced. - Chap 26 Subjective Data Infants & Children - When collecting subjective data from infants and young children, the caregiver is the primary source of information. Infants cannot verbalize their symptoms, so caregivers report details like crying patterns, feeding issues, or behavior changes. For toddlers and young children with limited verbal skills, caregivers interpret nonverbal cues and describe symptoms. Open-ended questions allow caregivers to fully explain observations without feeling defensive. Maintaining a supportive, non-judgmental approach facilitates open communication from caregivers about the child\'s condition. - Chap 26 Developmental Competence/Children & Adolescent - Assessing developmental competence is crucial when caring for children and adolescents. Key areas to evaluate include physical growth and motor skills, cognitive abilities, psychosocial and emotional maturity, and moral reasoning. Use age-appropriate interview techniques and allow time for the child to feel comfortable. Observe the child\'s interactions, play, and responses to assess developmental milestones. Involve parents/caregivers to gain insight into the child\'s typical behaviors and abilities. Tailor your approach based on the child\'s developmental stage, as their understanding and coping mechanisms evolve over time. Providing developmentally-appropriate care promotes trust, cooperation, and optimal outcomes for pediatric patients. - Chap 27 STI Health History Questions - When obtaining a sexual health history, it\'s important to ask open-ended, non-judgmental questions to encourage honest disclosure. Some key questions include: \"Are you currently sexually active? If so, with what gender(s)?\" \"How many sexual partners have you had in the past year?\" \"Do you use barrier protection like condoms?\" \"Have you ever been diagnosed with a sexually transmitted infection before?\" \"Do you have any concerns about your sexual health?\" Approach the conversation with sensitivity, respect patient privacy, and tailor counseling based on the patient\'s responses. Creating a safe, compassionate environment is crucial for patients to feel comfortable discussing this personal topic. - Chap 27 Documenting Subjective Obstetric History - When documenting the subjective obstetric history, it\'s important to obtain detailed information about the current and previous pregnancies. Key details to document include: Current Pregnancy: - \- Last menstrual period and estimated due date - \- Whether the pregnancy was planned or unplanned  - \- The patient\'s attitude and feelings towards the pregnancy - \- Any complications experienced so far like bleeding, nausea, etc. - \- Use of medications, alcohol, tobacco, or other substances Previous Pregnancies: - \- Number of previous pregnancies, live births, preterm births, miscarriages/abortions - \- Details about the course of each previous pregnancy and delivery - \- Any complications that occurred like gestational diabetes, preeclampsia, etc.  - \- Mode of delivery (vaginal, cesarean) - \- Birth details like gestational age, birth weight, complications - Thoroughly documenting the subjective obstetric history provides critical information to monitor the current pregnancy, identify potential risk factors, and guide the plan of care. Using open-ended questions and a non-judgmental approach facilitates open communication - Chap 27 Female Anatomy/Speculum Exam Normal Findings - \- Cervix appears smooth, pink, and round (nulliparous) or slightly irregular (parous) - \- Small amount of clear or slightly white, non-odorous cervical discharge - \- Vaginal walls appear pink and rugated (ridged) - \- No lesions, growths, or abnormal discharge in the vaginal vault - \- Cervical os (opening) is closed and round - \- No areas of acetowhitening when applying acetic acid, indicating no precancerous changes - The bimanual exam should reveal a midline, smooth, mobile uterus of normal size with no palpable masses or tenderness. The ovaries should not be enlarged or tender. Overall, the exam findings should be within normal limits for the patient\'s age and reproductive status - Chap 27 Subjective Data/Urinary Symptoms in Aging Woman - Changes in urinary frequency, urgency, or incontinence - \- Presence of nocturia (waking at night to urinate) - \- Any pain, burning, or difficulty with urination - \- Changes in urine color, odor, or appearance - \- History of urinary tract infections or other urological conditions - \- Impact of symptoms on daily activities and quality of life - It\'s important to use open-ended questions and a non-judgmental approach. Older women may feel embarrassed discussing incontinence, so creating a supportive environment is crucial. Inquire about potential contributing factors like pelvic floor weakness, hormonal changes, obesity, or neurological conditions. Thoroughly assessing subjective urinary symptoms guides further evaluation and management. - Chap 27 Genetics and Environment/HPV Vaccine - The HPV vaccine is highly recommended for preventing cervical cancer and other HPV-related cancers in both females and males. It protects against the HPV strains responsible for 90% of cervical cancers. The vaccine is given in two doses to those starting before age 15, providing full protection. Widespread use of the HPV vaccine, along with continued cervical cancer screening, can significantly reduce cervical cancer rates, especially in underserved populations with limited access to preventive care. Promoting HPV vaccination is crucial for improving women\'s health outcomes globally. - Chap 27 Health Promotion Adolescent Girl/Tanner Staging - Tanner staging is a system used to track and describe the physical development of adolescents during puberty. It assesses the maturation of secondary sexual characteristics like breast development in girls and pubic hair growth in both sexes. Discussing Tanner staging with an adolescent girl provides an opportunity to educate her on the normal pubertal changes she can expect. It validates her experiences as normal and allows you to address any concerns. Emphasizing that individual variation in the timing and rate of development is normal can help ease anxiety about being an \"early\" or \"late\" bloomer compared to peers. Tanner staging is a valuable tool for monitoring healthy pubertal progression. - Chap 28 Objective Data Heart - Heart Rate and Rhythm: Auscultate the apical pulse for 1 full minute to determine rate and regularity. Note any abnormalities like tachycardia, bradycardia, or arrhythmias. - Heart Sounds: Listen carefully for S1 (lub) and S2 (dub) sounds. Note any extra sounds like murmurs, rubs, gallops, or clicks that may indicate valve issues or other pathology.  - Jugular Venous Pulse: Inspect for jugular vein distention at 45 degrees, which can indicate increased central venous pressure from heart failure. - Peripheral Pulses: Palpate radial, femoral, dorsalis pedis, and posterior tibial pulses bilaterally. Note rate, rhythm, amplitude, and equality. - Edema: Assess for pitting edema in the extremities which may signal right-sided heart failure. - Chest Inspection: Look for precordial bulges, heaves, or lifts that can indicate enlargement. - Palpation: Feel for thrills, heaves, or displaced apical impulse suggesting cardiac pathology - Chap 28 Respiratory Assessment - Respiratory Rate: Count rate and pattern (normal 12-20 breaths/min for adults). Note if bradypneic, tachypneic, irregular, or abnormal patterns like Kussmaul or Cheyne-Stokes respirations. - Work of Breathing: Observe for use of accessory muscles, nasal flaring, pursed lip breathing indicating increased effort. - Breath Sounds: Auscultate anterior and posterior lung fields. Note any adventitious sounds like wheezes, crackles, or diminished breath sounds. - Oxygen Saturation: Assess SpO2 levels using pulse oximetry. Levels below 90% may indicate impaired gas exchange. - Sputum: Inspect any expectorated sputum for color, amount, odor, and consistency which can signify underlying conditions. - Subjective Report: Ask about dyspnea, cough, sputum production, chest tightness or pain to identify symptoms. - A comprehensive respiratory exam evaluates the ability to ventilate and perfuse effectively, guiding appropriate nursing interventions. - Chap 28 Documenting History & Physical Assessment - Accurate and timely documentation of the patient history and physical assessment is essential for providing high-quality nursing care. Record data as soon as possible after the interaction, while details are fresh. Use clear, concise language and objective descriptions. Chart relevant positive and negative findings to support clinical decision-making. Avoid redundancies and excessive detail. Simple sketches can effectively illustrate certain findings. Follow your institution\'s approved documentation method, whether paper-based or electronic charting. Remember that undocumented information is considered not done from a legal standpoint. Comprehensive documentation promotes continuity of care and meets professional standards. - Chap 28 Health History - The health history is a crucial component of the nursing assessment process. It provides valuable insight into the patient\'s past and present health status, risk factors, and potential areas of concern. Key elements to gather include: - - \- Past medical history (illnesses, injuries, surgeries, hospitalizations) - \- Medication history (prescribed, over-the-counter, supplements) - \- Allergies and adverse reactions - \- Family history (genetic risks, inherited conditions) - \- Social history (lifestyle, habits like smoking/alcohol use) - \- Review of systems (any current symptoms across body systems) - Chap 28 Documentation of Complete Health Assess. - Documenting a complete health assessment is vital for communicating patient data and ensuring continuity of care. Start by recording the patient\'s demographic information and chief complaint. Document the comprehensive health history, including past medical issues, medications, allergies, family and social history. Objectively describe the patient\'s general appearance, behavior, and any pertinent findings from the review of systems. Thoroughly document the physical exam, noting any abnormalities across each body system assessed. Include results from diagnostic tests or procedures performed. Summarize your clinical impressions, nursing diagnoses, and plan of care. Use clear, concise language and approved medical terminology. Timely, accurate, and detailed documentation promotes patient safety and quality care. - Chap 29 Reflex Assessment Newborn - Rooting and Sucking Reflexes: Stroke the corner of the newborn\'s mouth to elicit rooting (turning head towards stimulus) and sucking motions. - Moro Reflex: Support the infant\'s head and allow it to fall back slightly to trigger extension of the arms and legs followed by flexion, as if embracing. - Grasp Reflex: Stroke the palms to observe the fingers curling inward to grasp. - Plantar Grasp: Run a finger along the outer edge of the foot to see the toes flex inward. - Stepping Reflex: Hold the infant upright and allow the feet to touch a flat surface, observing stepping motions. - Assessing these primitive reflexes provides insight into the neurological integrity and development of the newborn. Asymmetric or absent reflexes may indicate an underlying issue requiring further evaluation. - Chap 29 APGAR Scoring - The APGAR score is a rapid assessment performed on newborns at 1 and 5 minutes after birth to evaluate their physiological condition. It consists of 5 components scored 0-2: - Appearance (skin color) - Pulse (heart rate)  - Grimace (reflex irritability) - Activity (muscle tone) - Respiration Each component is scored 0, 1, or 2, with 2 being the best score. The scores are summed for a total between 0-10. A score of 7-10 is reassuring, while lower scores may indicate the need for medical intervention. The APGAR provides a standardized approach to quickly identify newborns requiring resuscitation or ongoing monitoring. - Chap 29 Assessment of the Adolescent - Assessing the adolescent patient requires an approach tailored to their unique developmental stage. Build rapport by showing interest in them as an individual first, asking about school, activities, and friends. Explain procedures thoroughly and encourage questions. Be prepared for limited health knowledge. Conduct a comprehensive review of systems, as adolescents may not volunteer all relevant information. Assess physical and psychosocial development, including puberty changes, body image, and identity formation. Involve the adolescent in the assessment process to promote engagement. Maintain a non-judgmental, respectful attitude to facilitate open communication. Providing privacy can help the adolescent feel more comfortable discussing sensitive topics. - Chap 29 Order of Assessment for Neonate - Assessing the adolescent patient requires an approach tailored to their unique developmental stage. Build rapport by showing interest in them as an individual first, asking about school, activities, and friends. Explain procedures thoroughly and encourage questions. Be prepared for limited health knowledge. Conduct a comprehensive review of systems, as adolescents may not volunteer all relevant information. Assess physical and psychosocial development, including puberty changes, body image, and identity formation. Involve the adolescent in the assessment process to promote engagement. Maintain a non-judgmental, respectful attitude to facilitate open communication. Providing privacy can help the adolescent feel more comfortable discussing sensitive topics - Chap 29 Assessment Position for the Young Child - 1\. Immediate assessment at birth (Apgar scoring) - 2\. Stabilize physiological functioning (airway, temperature, infection prevention) - 3\. Comprehensive physical exam within first few hours  - 4\. Measure vital signs, weight, length, head/chest circumference - 5\. Evaluate gestational age  - 6\. Observe parent-infant interactions and bonding - 7\. Assess primitive reflexes This systematic approach allows for timely interventions, establishing baselines, identifying any abnormalities, and promoting successful transition to extrauterine life. Ongoing monitoring continues throughout the neonatal period. - Chap 30 Patient Initial Assessment - The initial patient assessment establishes the foundation for the nursing plan of care. Begin by introducing yourself and confirming the patient\'s identity. Observe the patient\'s general appearance, behavior, and ability to communicate. Obtain the chief complaint and history of present illness. Conduct a focused review of systems related to the presenting problem. Assess vital signs, pain level, and pertinent physical exam findings. Gather information on allergies, medications, past medical history, and social/family background. Throughout the assessment, maintain therapeutic communication to build rapport and make the patient feel comfortable. Document all findings thoroughly using approved terminology. The initial assessment data guides further evaluation and management. - Chap 30 Head to Toe Assessment Frequency - The frequency of complete head-to-toe assessments varies based on the clinical setting and patient acuity. Upon admission, a comprehensive head-to-toe exam is performed. Subsequent assessments focus on specific areas of concern rather than repeating the full exam daily. In high-acuity units like the ICU, focused assessments may occur every 4 hours. On general medical-surgical floors, focused assessments are typically done every 8-12 hours. Certain measurements like weight and circumferences require strict technique consistency between nurses for accurate monitoring. Always follow your facility\'s policies regarding assessment frequencies for different patient populations. - Chap 30 Initial Patient Assessment - The initial patient assessment establishes the foundation for the nursing plan of care. Begin by introducing yourself and confirming the patient\'s identity. Observe the patient\'s general appearance, behavior, and ability to communicate. Obtain the chief complaint and history of present illness. Conduct a focused review of systems related to the presenting problem. Assess vital signs, pain level, and pertinent physical exam findings. Gather information on allergies, medications, past medical history, and social/family background. Throughout the assessment, maintain therapeutic communication to build rapport and make the patient feel comfortable. Document all findings thoroughly using approved terminology. The initial assessment data guides further evaluation and management. - Chap 30 SBAR - Situation  - Background  - Assesment  - Reccomedation  - Chap 30 Assessment Findings - When documenting assessment findings, clearly describe your objective observations and the patient\'s subjective reports. Note the patient\'s general appearance, level of distress, and any pertinent non-verbal cues. Document vital signs, including any abnormalities. Describe assessment findings for each body system in a head-to-toe format, noting any areas of concern. Include the patient\'s account of symptoms, allergies, and medical history. Summarize the patient\'s functional status and any factors impacting care. Use approved medical terminology and avoid personal opinions or judgments. Thorough, accurate documentation of assessment data is crucial for communicating clinical information to the healthcare team.