HA Complete Notes PDF - Nursing Process

PRELIM TRANSES  INTRODUCTION TO THE NURSING PROCESS WHAT IS HEALTH ASSESSMENT? Rise of integrated clinical practice for surgical care. Plan of care that identifies specific needs of clients...

PRELIM TRANSES  INTRODUCTION TO THE NURSING PROCESS WHAT IS HEALTH ASSESSMENT? Rise of integrated clinical practice for surgical care. Plan of care that identifies specific needs of clients - Nurse follows a client’s care from preoperative care, to a How these needs will be addressed by the health care multidiscipinary outpatient clinic, and into the home organization, or skilled nursing facility through remote technology. Evolution of the nurse’s role in health assessment - The Nurse in the Late 1800s to Early 1900s REASONS FOR THIS TREND - The Nurse in the 1930s Rising educational costs and focus on primary care (affects - The Nurse in the 1950s number of medical students) - The Nurse in the 1970s Increasing complexity of acute care - The Nurse in the 1990s - Present Expanding health care needs of single parents - The Nurse in the 1990s - Present Increasing impact of children and the homeless in - The Nurse in the 1990s - Present communities - The Nurse in the 1990s - Present Intensifying mental health issues Expanding health service networks RAPID EXPANSION IN THE NURSE ROLE Increasing reimbursement for health promotion and More prevalent today than in previous decades preventive care services New fields are emerging necessitating the development of their own related nursing diagnoses WHAT IS THE SIGNIFICANCE OF HEALTH ASSESSMENT? Home health nursing Significance - Independent nursing diagnosis, referrals, and Allows the nurse to formulate the Nursing Diagnosis that collaborative care as needed require: - Median salary $78,983 ($34 - $41/hour) - Nursing care Public Health nursing - Identification of collaborative problems (interdisciplinary - Needs of communities and monitor growth and health of care) children - Identification of problems requiring immediate referral - Median salary $56,111 ($24 - $29/hour) Not just about gathering information about the health status School nursing of a patient, but also: - Needs of communities and monitor growth and health of - Analyzing and synthesizing data children - Making judgments about the effectiveness of nursing - Median salary $49,168 ($21 - $25/hour) interventions Hospice nursing - Evaluating client care outcomes - Assess the needs of terminally ill clients and their families - Median salary $71,654 ($31-$37/hour) OVERVIEW OF THE NURSING PROCESS Acute Care nursing The Nursing Process - Extensive focused assessments Systemic and rational method of planning and providing - Median salary $73,500 ($31-$38/hour) nursing care. Forensic nursing It is cyclical, logical, and more than one component (or - Extensive focused assessments (reversed process) phase) may be involved at one time. - Median salary $81,800 ($35-$42/hour) Critical care outreach nursing Responsibilities of the Nurse - Enhance assessment skills to safely assess clients outside Conduct and document a nursing assessment of the health the structured intensive care environment status of the client - Median salary $62,822 ($27-$32/hour) Collect subjective and objective data Ambulatory care nursing Modify the assessment as the client’s status changes - Assess and screen clients to determine need for referrals Report assessment as needed to the other members of the - Median salary $78, 983 ($34-$41/hour) health team - Test in forensic/legal nursing FUNCTIONS OF THE NURSE ACROSS ALL FIELDS OF NURSING 1. Independent Nurses nowadays increasingly document and retrieve Licensed to initiate on the basis of knowledge and skills assessment data through computerized information systems. Do not require an order from another professional Warrants why courses with Informatics content are include physical care, ongoing assessment, emotional becoming the norm in baccalaureate programs. support, teaching, counseling, environmental management, and making referrals FUTURE TREND AS PREDICTED Examples of Independent Functions Continuing increased specialization and diversity of assessment skills of nurses.  - Identify patterns of human responses to actual or Focuses on how client’s health status affects activities of potential health problems daily living, and how those ADLs affect the client’s health. - Assess health status Assesses how clients interact within their family and - Select, perform, manage, and evaluate nursing actions community, and how client’s health status affects the family - Provide health counselling/teaching and community. Also, how the family and community affect - Teach, administer, supervise, delegate, and evaluate the client’s health status. nursing practice NURSING VS OTHER PROFESSIONS ON ASSESSMENT 2. Dependent NHA vs Other Health Professionals Under orders or supervision of a licensed physician or Nursing another health care provider authorized to write orders for - Includes subjective and objective data nursing care (CPA, NP) - Physiologic, sociocultural, psychological, and spiritual Include providing medications, intravenous therapy, data diagnostic tests, treatments, diet, and activity Other Examinations/Professions Nurse is responsible for assessing need for, explaining, and - Focuses on one aspect only (MD, PT, and RT) administering medical orders (with client) - Framework used is different Examples of Dependent Functions - Administering medications HOW ABOUT NHA VS MD ASSESSMENT? - Giving treatment According to Dillon: - Execute regimens prescribed by physicians - Very similar but there are important differences - Differences are defined by the focus and scope of a 3. Interdependent/Collaborative medical vs nursing practice Implemented in collaboration or consultation with another - Questions may be similar but the underlying rationale professional (PT, social workers, dietitians, and primary differs care providers) - Physicians diagnose and treat illnesses. Includes physical therapy to teach crutch-walking. (Nurse - Nurses diagnose and treat the patient’s response to a coordinates with physical therapy department, including PT health problem. sessions) o This is How Collaboration Looks Like Examples of Interdependent Functions o Complete Blood Count: Diagnosis? - Administration of oxygen o Comparison of Diagnoses - Referral to registered social workers o Chest Radiograph: Diagnosis? - Physical therapy sessions o NHA vs Other Health Professionals o Medical Management CRITERIA FOR CHOOSING INTERVENTIONS o Nursing Management Safe and appropriate for individual age, health and condition Achievable with available resources SKILLS OF ASSESSMENT Congruent with client’s values, beliefs, and culture (as well as Cognitive skills other therapies) - Considered to be a “thinking” process Based on nursing knowledge and experience from relevant - Needed for critical and creative thinking, and clinical sciences decision making Within established standards of care as determined by state - Theoretical knowledge base enables you to holistically laws and organizations assess patients, differentiate normal from abnormal, as well as identify and prioritize actual and potential BEGINNING THE NURSING PROCESS problems Assessment Phase - Reflective, and reasonable thinking It is a systemic, and deliberate process. - Not just doing, but asking “why” The nurse collects and analyzes data about the patient. - Involves inquiry, interpretation, analysis, and synthesis Continuous process carried out during all phases of the o Critical Thinking Skills Nursing Process Most critical and crucial TYPES OF ASSESSMENT According to Weber Collection of data 1. Initial Comprehensive 2. Ongoing or Partial FOCUS OF HEALTH ASSESSMENT 3. Focused or Problem-oriented Consists of a health history and a physical examination 4. Emergency Purpose? - To collect holistic subjective and objective data to 1. Initial Comprehensive determine a client’s overall functioning Total or complete assessment - In order to make a professional clinica Other members of the health team may also participate - Includes physiological, psychological, developmental, and (hospital → physician, PT, dietitian) spiritual data Collection of Data - Subjective (client’s perception of his condition)  - Objective (physical examination) d. Self-awareness (reflect on own feelings) regarding first encounter with the client 2. Ongoing or Partial - Case: 22-year old with drug addiction, but you do not Occurs after comprehensive database is established drink, smoke, take illegal drugs, or drink caffeine Mini-overview of body systems and health patterns - To avoid biases, judgment, and projecting those Functions as a follow-up on the health status judgments (be objective and open) Problems initially detected are reassessed to determine Client Preparation changes (deterioration/improvement) Self-awareness (reflect on own feelings) regarding first Brief reassessment to detect new problems encounter with the client Usually done by another nurse or health professional - Other cases: STDs, amputation, paralysis, HIV/AIDS, Can be done in hospital, community, or at home abortion, sexual preferences, PWDs who are cognitively Frequency is determined by acuity of client challenged Client Preparation 3. Focused or Problem-Oriented Prepare all materials needed Does not replace comprehensive assessment - Equipment (stethoscope, thermometer, etc) Done after database is established (OPOC, OPNC) - Interview tools/questions/forms Thorough assessment of a particular problem Does not cover areas not related to the complaint WHAT IS DATA COLLECTION? WHAT IS A DATABASE? Definitions to Know 4. Emergency Data collection Very rapid assessment during life-threatening situations - Process of gathering information about a client’s health (choking, cardiac arrest, drowning) status Immediate assessment to provide prompt treatments Database Major and only concern is determine status of client’s life- - All the information (pooled) about the client. sustaining physical functions - Nursing health history, physician’s history and PE, results of laboratory and diagnostic tests, and other material STEPS OF THE HEALTH ASSESSMENT contributed by members of the health team Steps in Nursing Assessment Collecting subjective data The steps are: Subjective data - Collection of Subjective Data - Collection of Objective Data Sensations or Symptoms (pain, hunger) - Validation of Data Feelings (happiness, sadness) - Documentation of Data Perceptions Tend to overlap Desires May perform 2 or 3 steps concurrently Beliefs and Ideas Values PREPARING FOR THE ASSESSMENT Personal Information elicited and verified only by the client Client Preparation himself a. Review the client’s medical record Major areas: - Familiarize biographical data (age, sex, religion, - Biographical information (name, age, religion, educational level, and occupation) occupation, etc) - Provides background of chronic diseases and clues how - History of Present Health Concern (physical symptoms the present illness impacts ADLs related to each body part) - Awareness of past and current health status guides - Personal and Family Health History interactions with client - Health and Lifestyle practices (risky, nutrition, activity, - Info can also be procured from other members of health relationships, cultural beliefs, practices, family structure team, and significant others and function, community environment) b. Keep an open mind and avoid premature judgments (decreases accuracy of data) COLLECTING OBJECTIVE DATA - Do not assume a 30-year old female client, an RN, knows Objective Data everything about hospital routine and medical care Directly observed by the examiner: - Nor assume a 60-year old male client with DM needs - Physical characteristics (skin color, posture) client teaching regarding diet. - Body functions (heart rate, respiratory rate) - Do validate information and be prepared to collect - Appearance (dress and hygiene) additional data - Behavior (mood, affect) c. Use time to educate self about diagnosis and tests - Measurements (BP, height, weight, temperature) performed - Laboratory test results (complete blood count, x-ray - Unfamiliar medical diagnosis findings) - Special blood tests (abnormal results) Obtained by general observation and PE techniques (inspect, - Consult available resources (laboratory manual, textbook, auscultate, palpate, percuss) or electronic references)  Taken from EMHR (another source), through the entries of a. Directive other health care professionals - Highly structured and elicits specific information Can also be from patient’s family members - Nurse establishes purpose of and controls interview Obtained to validate subjective data and to complete the (close-ended questions) assessment phase of the nursing process b. Non-Directive - Client controls the purpose, subject matter, and Validation of data pace Crucial part - Builds rapport (open-ended questions, empathy) Occurs along with collection of data The Interview Questions Ensures the assessment process is not ended prematurely (all relevant data is collected) Observation Method Helps prevent documenting inaccurate data Gathering data with the use of senses: Process of confirming or verifying that data collected are a. Vision (body size, skin color and lesions) reliable and accurate b. Smell (body and breath odors) Steps: c. Hearing (lung and heart sounds) - Decide which data need validation d. Touch (skin temperature and moisture) - Determine ways to validate data - Identify areas which data are missing Physical Assessment Method Inspection → careful and critical observation Do All Data Require Validation? Auscultation → listening through a stethoscope No, do validate instead: Palpation → touching and feeling - Discrepancies → gaps in the information Percussion → touching, tapping, and listening Subjective vs Objective data (happy vs cancer) - Obsolete Way of Auscultation What client says at different times (history of childbirth) - Who Invented the Stethoscope? Abnormal findings (inconsistencies in pain/fever - The Story Behind the Stethoscope presentation) Medical Records Review Method Methods of Validation Go through the medical record to add to the comprehensive Recheck own data (repeat assessment) assessment Clarify data by asking additional questions - Verify data with another health professional Organizing the data Compare objective with subjective findings Use of written (or computerized) format that organizes the assessment data systematically Identifying Areas of Missing Data Organized according to different models Go through the database established - Nursing Conceptual models (Gordon’s functional health Consider areas you may have overlooked: patterns, Orem’s self-care model, Roy’s adaptation - 98 lbs patient (lost vs usual weight over time?) model) - Lives alone (existence of support system, ability for - Wellness models independent function/self-care, and degree of social - Non-nursing models (Body systems model, Maslow’s involvement) hierarchy of needs, developmental theories) Sources of data What Models Do We Use? Primary → client Maslow’s Hierarchy of Needs - Unless too ill, young, or unable to communicate clearly Gordon’s 11 Functional Patterns - Emphasis on subjective data only he can provide Secondary → all sources other than the client DOCUMENTING THE DATA - Support system (family members, friends, caregivers) Documentation - Client records (medical records, lab results, therapy Record in a factual manner (do not interpret) records) Documentation - Health care professionals (members of health team which Consider this nurse recording a client’s breakfast: have had previous or current contact with the client) - “coffee 240 mL, juice 120 mL” - Literature (nursing and other professional journals) - “1 egg, 1 slice of toast” - “appetite good” (wrong) Data collection methods 1. Interview Increasing Accuracy in Documentation 2. Observation Record subjective data in the client’s own words 3. Physical Assessment 4. Medical Records Review Interview Method Planned and purposeful conversation:  PATIENT POSITIONS SUPINE SITTING ACCORDING TO DILLON If client has trouble breathing, the head of the bed may be Areas Assessed Pros/Cons elevated. Head and neck Provides good visualization This position allows: Anterior and posterior chest Allows full lung expansion - Allows abdominal muscles to relax (respiratory, cardiac, and and respiratory assessment - Provides easy access to peripheral pulse sites breast exams) Areas that can be assessed in this position: Vital signs and upper Patients with weakness or - Head and neck extremities paralysis may have - Chest and lungs difficulty assuming position - Breast and axillae and need assistance. - Heart - Abdomen - All extremities SUPINE ACCORDING TO DILLON DORSAL RECUMBENT ACCORDING TO DILLON Areas Assessed Pros/Cons Areas Assessed Pros/Cons Anterior chest for respiratory, If patient has trouble Abdomen: basically supine If patient has abdominal cardiac, and breast exams breathing in supine position, position with knees slightly pain, flexing knees is more use semi-Fowler’s flexed to relax abdominal comfortable Pulses and extremities Semi-Fowler’s muscles semi-sitting with knees Female pelvic area if patient is Older patients may have flexed, and supported by unable to assume lithotomy difficulty assuming pillows or Sim’s position lithotomy position Lithotomy position (female) essentially same but legs and feet on stirrups PRONE Client lies down on abdomen with head to the side. Used primarily to assess the hip joint. The back can also be assessed. Position cannot be tolerated by patients with problems in: SIM’S ACCORDING TO DILLON - Cardiac systems Areas Assessed Pros/Cons - Respiratory system Female pelvic and rectal May be difficult to assume if areas patient has arthritis Best alternative if patient is Contraindicated if the unable to assume lithotomy patient has had a total hip position replacement PRONE ACCORDING TO DILLON Areas Assessed Pros/Cons Musculoskeletal system Difficult position for many patients. Especially those with respiratory diseases  LEFT LATERAL ACCORDING TO DILLON LITHOTOMY Areas Assessed Pros/Cons May require assistance to get into this position Chest: best for cardiac Patients with respiratory An exposed position embarrassment auscultation, particularly of problems may have trouble Examination of the: S3, S4, and some murmurs. assuming this position - Female genitalia - Reproductive tracts - Rectum May not be well-tolerated by elderly clients Keep the client well-draped Perform the examination as q KNEE-CHEST ACCORDING TO DILLON Areas Assessed Pros/Cons Male rectal and prostate This position and its areas best position for alternative (bending over a these exams table) are very difficult and embarrassing for most patients. STANDING ACCORDING TO DILLON Areas Assessed Pros/Cons Spine and joints (ROM): best Patients who are weak, for these musculoskeletal disabled, or paralyzed, may areas need assistance or may not be able to assume this position. Used for both neurological exam and to assess gait and cerebellar function  PATIENT GUIDELINES WHAT IS PHYSICAL ASSESSMENT? 4. Explain what you are doing every step of the way (as Systematic, comprehensive, and continuous collection, you go along) validation, and communication of client’s data using a variety Consider the Age: of methods 1. Neonate 2. Infant GENERAL CONSIDERATIONS 3. Toddler Physical assessment is correlated with the patient’s health 4. School-age history 5. Adolescent 1. History of Present Illness (HPI) 6. Young Adult 2. Past Medical History 7. Middle Aged Adult 3. Family History 8. Older Adult Empty the Bladder (check for need to void) GENERAL CONSIDERATIONS Examiner should follow a certain sequence in doing physical Determine the status of the patient assessment 1. Pregnant Include only findings with medical significance a) Assess both woman and fetus - You should not include a small scar on the foot in a case b) Include fundal height and fetal heart tone (FHT) of cataract c) Assess for normal changes occurring in pregnancy Findings should not only focus on symptoms that are present d) Pay special attention to nutritional assessment but also pertinent negatives e) Last trimester may have difficulty switching positions 1. In a case of dengue fever, having no abdominal f) Hormonal swings may exaggerate patient’s responses pain/tenderness or epistaxis is significant 2. In a case of stroke, having no neurologic deficit is 2. Disabled significant as well a) Identify the disability Result should be objective, and have no examiner variance b) Focus on ability (functional, and mental capacity) Neurologic exam is always a part of the physical exam. c) Modify assessment based on patient’s needs (deaf When examining a patient of the opposite sex, always have written instructions or sign language) a companion of the same sex as the patient with you d) Be alert and sensitive to patient’s needs especially in throughout the assessment. unable to communicate verbally. Always maintain patient privacy. Remember the patient has the right to refuse to be PREPARING THE EQUIPMENT examined, despite being an essential part of the history. ▪ Clean Physical findings may change from time to time. ▪ In working order Begin at the patient’s right side, then moving to the opposite ▪ Readily accessible side of the patient, or foot of the bed as needed. (recommended) PREPARING THE ENVIRONMENT Advantages: Right JVP more reliable (right) Make sure room is quiet, private, warm, and well-lit. Consider positioning. Right kidney more palpable Consider draping. APPROACH TO PATIENT DURING PA PATIENT’S RIGHTS INCLUDE When possible, begin with patient at sitting position. Asking to see and get a copy of health records. Completely expose part to be examined, but drape the rest Have corrections added to health information. of the body. (maintains privacy) Receive a notice informing him how health information is Conduct the examination from head to toe (cephalocaudal) used or shared. Compare findings on both sides Get a report on when and why health information is shared. Explain all procedures to avoid alarming the patient, and Ask to be contacted somewhere other than at home. this encourages cooperation Ask that information not be shared. Make patient as comfortable as possible File complaints. PREPARING THE CLIENT REMEMBER Explanation Be responsible and accountable for your practice. 1. Introduce yourself. Be a patient advocate. 2. Tell the patient what you are going to do and why. Respect patient’s rights. 3. Tell the patient the examination normally takes some Assure confidentiality of information/patient’s data. time.  PATIENT EQUIPMENT BASIC EQUIPMENT Cover card Rosenbaum Pocket Tuning Fork Gloves Stethoscope Sphygmomanometer Screener Thermometers Watch with Swift Skinfold Calipers Second Hand Tongue Depressor Piece of Small Gauze Pillows Flexible tape measure Penlight Platform scale with Vaginal Speculum Lubricant Cotton-tipped Height attachment Applicator Small cup of water Magnifying glass Ruler with Centimeter Specimen containers Reflex Hammer markings Snellen Chart Otoscope Ophthalmoscope  CULTURE, SPIRITUALITY, AND FAMILY CULTURE, SPIRITUALITY, AND FAMILY Are all systems Difficult to separate the three (3) systems - Constantly interact with each other - Change based on their interactions WHAT IS CULTURE? From Latin, “competere” → to strive together Totality of transmitted behavioral patterns, values, and all other products of human work and thought Characteristic of a population that guide their world view and decision-making Frame of reference in interpreting and understanding the world Values and norms - All verbal and behavioral systems that transmit meaning CHARACTERISTICS OF CULTURE 1. Learned 2. Shared 3. Associated with Adaptation to Environment 4. Universal Culture is Learned Through life’s experiences and contact with other cultural groups Transmitted from generation to another - How? Socialization CULTURE IS SHARED Norms for behavior, values, and beliefs Shared by a group to a great extent CULTURE IS ASSOCIATED WITH ADAPTATION TO ENVIRONMENT As the environment changes, groups also change to improve its ability to survive - Hunter and gatherer phase - Agricultural phase - Industrial phase - Information phase CULTURE IS UNIVERSAL Cultures may vary between groups Humans cannot exist without it  CONSTRUCTS OF CULTURAL COMPETENCE DEFINITIONS TO KNOW Conscious Incompetence Cultural Assessment - Aware that one lacks knowledge about another culture - Systematic appraisal of individual beliefs, values, and - Aware that cultural difference exists practices - Doesn’t know how to communicate with a client from a Cultural Competence different culture - Complex integration of knowledge, attitudes, and skills - Enhance cross-cultural communication Conscious Competence - Promote meaningful interactions with patients - Consciously (actively) learning about a client’s culture - Enable one to provide culturally appropriate, congruent, Providing culturally relevant interventions and relevant health care - Aware of differences between cultures - Able to interact effectively (despite this) PURNELL AND PAULANKA PROCESS Unconscious Competence - Able to automatically provide culturally congruent care to clients from different cultures - Experienced with a variety of cultural groups Cultural Skill - Ability to collect relevant cultural data regarding client’s health history and presenting problem - Accurately performing a physical assessment - Application of cultural knowledge o Efficient in PA and collecting of further information Cultural Knowledge - Process of seeking and obtaining sound educational Components: foundation 1. Cultural Awareness - Concerning the various world views of different cultures 3. Cultural Skill o Immersion vs reading 4. Cultural Knowledge 5. Cultural Encounters Cultural Encounters 6. Cultural Desire - Process that allows healthcare provider to engage directly in cross-cultural interactions CULTURAL AWARENESS o Actual experience → knowledge and awareness Deliberate, cognitive process in which the healthcare provider becomes: Cultural Desire - Appreciative and sensitive to the values, beliefs, life ways, - Motivation: and practices of a client’s culture o To engage in intercultural encounters o To acquire cultural competence STAGES OF CULTURAL AWARENESS: SUMMARY: Unconscious Incompetence - Not aware that one lacks cultural knowledge - Not aware that cultural difference exists  CULTURE AND ILNESS CAUSES OF ILLNESS: Rootwork Biomedical - Belief that illnesses are supernatural in origin (witchcraft, Naturalistic voodoo, evil spirits, or evil person? Anxiety, - (Yin/yang theory, Hot/cold theory of illness) gastrointestinal complaints, fear of being poisoned or Magico-Religious killed? - (faith healing, witchcraft, healing rituals) Spell - Communicates with dead relatives or spirits? Often with CULTURE-BASED SYNDROMES distinct personality changes? Not considered pathologic in Perceived to be separate illnesses within cultures culture of origin? Illnesses defined by a specific cultural group, but interpreted High blood differently or not even perceived as illnesses by other groups - Slang term for high blood pressure? Also for thick or - Latin (American/Mediterranean) excessive that rises in the body? Often believed to be - Africa and African Origin in Americas caused by overly blood rich foods? - Native American Low blood - Middle Eastern - Not enough or weak blood caused by diet? - Asian (South or East) Bad blood - North American/Western Europe - Blood contaminated? Often refers to sexually transmitted infections? LATIN (AMERICAN/MEDITERRANEAN) Boufee deliriante (Haiti) Ataque de nervios - Panic disorder with sudden agitated outbursts? Aggressive - Results from stressful event and build up of anger over behavior? Confusion? Excitement? May have hallucinations time? Shouting, crying, trembling, verbal or physical or paranoia? aggression, sense of heat in chest rising to head? Empacho NATIVE AMERICAN - Especially in young children? Soft foods believed to adhere Ghost sickness (Navajo) to stomach wall? Abdominal fullness, stomachache, - Feelings of danger, confusion, futility, suffocation, bad diarrhea with pain, vomiting? Confirmed by rolling egg over dreams, fainting, dizziness, hallucinations, loss of stomach and egg appears to stick to an area? consciousness? Possible preoccupation with death or Mal de ojo (Evil Eye) someone who died? - Children, infants, at greatest risk? Women more at risk Hi-Wa itck (Mohave) than men? Cause often thought to be a stranger’s touch or - Unwanted separation from a loved one? Insomnia, attention? Sudden onset of fitful sleep, crying without depression, loss of appetite, suicide? apparent cause, diarrhea, vomiting, and fever? Pibloktoq or Arctic hysteria (Greenland Eskimos) Mal puesto/Brujeria - Abrupt onset? Extreme excitement of up to 30 minutes? - Belief that illnesses are supernatural in origin (witchcraft, Followed by convulsive seizures and coma lasting 12 hours voodoo, evil spirits, or evil person? Anxiety, with amnesia of event? Withdrawn or mildly irritable for gastrointestinal complaints, fear of being poisoned or hours or days before attack? During attack may tear off killed? clothing, break furniture, shout obscenities, eat feces, run Susto out into snow, do other irrational or dangerous acts? - Spanish for “fright”? Caused by natural (cultural stressors) Wacinko (Oglala Sioux) or supernatural (sorcery or witnessing supernatural - Often reaction to disappointment or interpersonal phenomenon) means? Nervousness, anorexia, insomnia, problems? Anger, withdrawal, mutism, immobility, often listlessness, fatigue, muscle tics, diarrhea? leads to attempted suicide? Caida de la mollera - Mexican term for “fallen fontanel”? Caused by midwife MIDDLE EASTERN failing to press on palate after delivery? Falling on the Zar head? Removing the nipple from baby’s mouth - Experience of spirit possession? Laughing, shouting, inappropriately? Failing to put on a cap on newborn’s weeping, singing, hitting head against wall? May be head? Crying, fever, vomiting, diarrhea are indicators of apathetic, withdrawn, refuse food, unable to carry out this condition? Similarity to dehydration? daily tasks? May develop long-term relationship with possessing spirit? Not considered pathologic in the culture? AFRICA AND AFRICAN ORIGIN (AMERICAS) Falling out/Blacking out ASIAN (SOUTH OR EAST) - Sudden collapse preceded by dizziness, spinning sensation? Amok (Malaysia) Eyes may remain open but unable to see? May hear and - Occurs among males (20-45 years old) after perceived or understand what is happening around them but unable to slight insult? Aggressive outbursts, violent or homicidal, interact? aimed at people or objects, often with ideas of  persecution? Amnesia, exhaustion, finally returns to previous state? Koro (Malaysia, Southeast Asia) - Fear that genitalia will retract into the body? Possibly leading to death? Causes vary, including inappropriate sex, mass cases from belief that eating swine flu-vaccinated pork is a cause? Similar to conditions in China, Thailand, and other areas? Latah (Malaysia) - Occurs after traumatic episode or surprise? Exaggerated startle response (usually in women)? Screaming, cursing, dancing, hysterical laughter, may imitate people, hypersuggestibility? Shen kui (China) Dhat (India) - Similar conditions that result from belief that semen (or “vital essence”) is being lost? Anxiety, panic, sexual complaints, fatigue, weakness, loss of appetite, guilt, sexual dysfunction, with no physical findings? Taijin kyofusho (Japan) - Dread of offending or hurting others? By behavior or physical condition such as body odor? Social phobia? Wind illness (Asia) - Fear of wind or cold exposure? Causing loss of YANG energy? NORTH AMERICA OR WESTERN EUROPE Anorexia nervosa 1. Associated with intense fear of obesity? Severely restricted food and calorie intake? → ANOREXIA NERVOSA Bulimia nervosa 2. Associated with intense fear of obesity? Bingeeating and self-induced vomiting? Use of laxatives, or diuretics? → BULIMIA NERVOSA  DIAGNOSIS (QUIPPER) Reticulocyte Maturation Urine and Hydration Status Complete Blood Count Tonsillopharyngitis Lipid Profile Gastrointestinal Visualization Phenylketonuria  Thoracentesis/Pleural Tap Ultrasonography  DIAGNOSIS PROCEDURE PHASES OF DIAGNOSTIC TESTING 4. Arterial Blood Gases (ABG) 1. Pretest - Diagnosis: chronic and restrictive lung disease, adult - Preparing the client respiratory failure, acid-base disturbance, pulmonary - Knowing about the test ordered emboli, sleep disorders, CNS dysfunction, cardiovascular - Gathering equipment and supplies disorders, mgmt. of patients in mech. Vent. And during the weaning process from the mech. Vent. 2. Intratest Phase - provides the ph, partial pressure of carbon and oxygen, - Collecting the specimen bicarbonate, O2 saturation, and base excess and deficits - Performing or assisting levels - Providing emotional and physical support - ph of human blood = 7.35-7.45 - Monitoring - Correct labeling, storage, and transportation of specimen 5. Blood Chemistry 5.1 Liver Function Test 3. Post test - Serum Bilirubin - Nursing care of client - evaluate liver function; dx and monitor progression of - Performing follow-up activities and observations jaundice - Comparing the previous and current test results - Direct and Indirect – identify the underlying cause of - Modifying nursing interventions as needed elevations - Reporting the results 5.2 Cardiac Markers - diagnose acute myocardial infarction COMMON BLOOD TESTS (AMI) 1. Complete Blood Count (CBC) - CK (creatinine kinase) MB – enzyme found in heart - Assess the patient for anemia, infection, inflammation, - Troponin 1 – found only in cardiac muscle polycythemia, hemolytic disease, and effects of ABO - LDH1 & 2 isoenzymes – used to assess degree of incompatibility, leukemia and dehydration status myocardial damage - Components: - Normal Values: o Hemoglobin (Hgb) o CK Male: 14-17.5g/dL or 140-175g/L Adult male: 38- 174 units/L Female: 12.3-15.3g/dL or 123-153g/L Adult female: 26-140 units/L o Hematocrit (Hct) Newborn: 50-525 units/L Male: 41.5-50.4% or 0.415-0.504 o CK-MB = 0%-6% of total CK Female: 35.9-44.6% or 0.359-0.446 o Cardiac Troponin 1 = < 0.35mcg/L o Red blood cell count o LDH Isoenzymes Male: 4.5-5.9 x 1,000,000 ul 1 = 14%-26% Female: 4.5-5.1 x 1,000,000 ul 2 = 29%-39% o Red cell indices – help diagnose, classify and evaluate different types of anemia 5.3 Lipoprotein profile (lipid profile or lipid panel) o White blood cell - used to determine individual at risk for CAD and as an 4.4-11 x 1,000 evaluation tool for the effectiveness of “healthy heart” (leukocytosis and leukopenia) changes in lifestyles o Platelet count - Values: 150,000-450,000 cells/ul o Total lipids: 4 – 8 g/L (thrombocytosis and thrombocytopenia) o Total Cholesterol: 120-200mg/dl o Reticulocyte count o LDL: < 130 mg/dl Evaluate erythropoiesis; they are immature o HDL: Male – 44-45mg/dl erythrocytes Female – 55mg/dl o Triglycerides: Male – 75-313 mg/dl 2. Serum Osmolarity – measure solute concentration in the Female – 52-200 mg/dl blood 5.4 Glucose - Capillary Bedside Glucose Monitoring (CBGM) assess 3. Blood Urea Nitrogen (BUN) and Creatinine and manage patients with diabetes Values: 60-110 - used to evaluate renal function; with serum creatinine level mg/dl or 3.3-6.1 mmol/L it is used to monitor patients in renal failure or those - Fasting Blood Sugar (FBS) receiving dialysis therapy o Is an evaluation to diagnose and manage patient - urea → end product of protein metabolism with diabetes mellitus - creatinine → produced my muscles o Values: 60-110 mg/dl NURSING RESPONSIBILITY FOR FBS: - Dip a sterile swab in to the specimen - Instruct patient to fast for 12 hours before the blood is - Using sterile technique, place the swab in a sterile test tub drawn. - Instruct to withhold any medication until after the blood is URINE SPECIMEN drawn. Clean voided specimens for routine analysis (First Morning Specimen) - is the specimen of choice for urinalysis and 5.5 Metabolic Screening microscopic analysis, since the urine is generally more - henylketonuria (PKU) Test concentrated o is to detect an inherited disorder of amino acid Clean-catch or midstream urine specimen for urine culture metabolism characterized by elevated are strongly recommended for microbiological culture and phenylalanine and phenylpyruvic acid antibiotic susceptibility testing because of the reduced o An elevated level will cause CNS damage and mental incidence of cellular and microbial contamination. retardation o ideal time to test is 2 days old onwards Sterile specimen - Guthrie Test 1 cm manipulated primary skin lesions Psoriasis, Ringworm - Primary Secondary Macules Scales Patches Crusts Papules Excoriations Plaques Fissures Nodules Erosions Cyst Ulcers NODULES Wheals Scars Palpable Vesicles Firmer and deeper (than papule) Bullae Round to spheroid shape (marble like) Pustules Center may be at dermis or subcutaneous tissue - PRIMARY SKIN LESIONS MACULES Flat Variable size and shape Differs from surrounding skin (color) < 1 cm CYST eg. Freckles, petechiae in Dengue → Tourniquet Test: A blood pressure cuff is applied and inflated to the midpoint Epithelial cell-lined sac between the systolic and diastolic blood pressures for five Contains liquid or semi solid material (fluid, cells, and cell minutes. The test is positive if there are more than 10 to 20 products) petechiae per square inch. Mosquito bite, skin test PATCHES WHEALS Very large macules Irregular Coalescence of macules Transient (relatively) ≥ 1 cm Superficial  Localized edema Impetigo Flat-topped papule Epithelial cell-lined sac, contains liquid or semi-solid material (fluid, cells, and cell products) eg. Sebaceous cyst, ganglion cyst EXCORIATIONS Superficial excavations of epidermis May be linear or punctuate Results from scratching VESICLES Filled with serous fluid Elevated ≤ 1 cm Shingles FISSURES Linear crack on the skin Athlete’s foot, fissure-in-ano BULLAE Larger than vesicle (≥ 1 cm) Second degree burn EROSIONS Loss of superficial epidermis Surface is moist (but does not bleed) PUSTULES Elevated Filled with pus (exudate) Acne, Psoriasis ULCERS Deeper loss of epidermis and dermis May bleed and scar Pressure ulcer SECONDARY SKIN LESIONS SCALES Thin flake of exfoliated epidermis Dandruff, Psoriasis SCARS New connective tissue (fibrous) that has replaced lost substance (in the dermis or deeper) Results from injury or disease Part of normal reparative process CRUSTS Dried residue: - Serum - Pus - Blood May be mixed with epithelial and bacterial debris SKIN CONDITIONS SKIN MOISTURE  Dryness Where: - Consider hypothyroidism or dehydration - Child/Adult → forehead, chest, abdomen, and Oiliness (prone to acne) extremities Sweating (degree) - Elderly →chest and abdomen only - Consider hyperthermia or hyperthyroidism Findings: - If the sweating can be attributed to an underlying - Pinched easily and immediately returns to its original medical condition, it's called secondary hyperhidrosis position - Diaphoresis is a medical term for perspiration or - Older patients → decreased elasticity and collagen fibers sweating. The term usually refers to unusually heavy (sagging/wrinkled skin in the face, breast, and scrotal perspiration. area) - Hyperhidrosis pertains to sweating excessively and - Decreased mobility → edema unpredictably, usually - Decreased turgor (or >30 seconds) → dehydration SKIN INTEGRITY Assess skin over pressure point areas (sacrum, hips, and elbows) → prone to decubitus ulcers/bed sores N: intact, no redness AbN: (+) skin breakdown, redness, warmer than Note any rough, flaky, or dry skin (hypothyroidism) Obese clients may report dry, or itchy skin SKIN TEXTURE Note any rough, flakey, or dry skin (hypothyroidism) Obese clients may report dry, or itchy skin SKIN THICKNESS Note for presence/absence of calluses: DOCUMENTATION FOR SKIN FINDINGS - Rough, thickened sections of epidermis DIAGRAM - Commonly seen in parts exposed to constant pressure Draw the location, size, and describe skin lesions on the body - Thin skin without calluses (N) surface diagram - Very thin skin (arterial insufficient/steroid therapy → AbN) LIFESPAN CONSIDERATIONS Neonates/Newborns SKIN TEMPERATURE Infants Compare hands and feet bilaterally (using dorsal aspect of Elderly hand) N: uniform and within normal range NEONATES/NEWBORNS AbN: generalized hyperthermia (fever) Physiologic jaundice may manifest at 2-3 days after birth generalized hypothermia (shock) (usually last 1 week) localized hyperthermia (infection) localized hypothermia (arteriosclerosis) Pathologic jaundice appears within 24 hours (usually lasts more than 8 days) WHICH PARTS OF THE HAND TO USE IN CHECKING Note for the presence of: TEMPERATURE? - Millia (whiteheads) - Small nodules over the nose and face Factored to be assessed Parts of the hand to use - Vernix caseosa (white, cheesy, and greasy material) find discrimination: plus size, If premature: texture, size, consistency, shape, Finger pads - Lanugo (fine, downy hair over the shoulders and back) and crepitus If dark-skinned: - May have areas of hyperpigmentation on the back (sacral Vibration? Thrills? Fremitus? Ulnar and palmar surface area) Temperature? Dorsal surface - Mongolian spots SKIN TURGOR INFANTS Refers to the skin’s elasticity Note for presence/absence: - And how quickly it returns to its original shape after - Diaper rash (diaper dermatitis) being pinched o Inquire about details of immunization history Refers to skin mobility Also assess skin turgor (abdomen) - How easily the skin can be pinched Assessed by: CHILDREN - Lifting fold of skin Usually have minor skin lesions (bruising or abrasions) on - Note its ease with which it lifts up arms and legs  Lesions on other parts of the body may be signs of disease or HAIR CONDITIONS abuse (take thorough history, e.g. glove/stalking injury, ALOPECIA cigarette burns) Male-pattern hair loss (normally) Secondary skin lesions may occur frequently as children Loss of hair which may be: scratch or expose a primary lesion to microbes (staph. Spp) - Diffuse Oil glands may become more productive and consequently - Patchy develop acne (puberty) - Total ELDERLY ALOPECIA AREATA Changes in fairer skin occur earlier than dark-skinned Clearly demarcated round or oval patches of hair loss individuals Usually affects children and young adults Wrinkles first appear on skin or face and neck (abundant in No visible scarring or inflammation collagen and elastic fibers) Skin appears thin and translucent due to loss of dermis and subcutaneous tissue Skin may be dry and flaky (less active sebaceous and sweat glands) - More prominent over extremities Decreased skin turgor - Assess for hydration instead over sternum or clavicle Senile lentigines (melanotic freckles) TRICHOTILLOMANIA - Flat, tan-brown, macules areas exposed to the sun Hair loss due to pulling, plucking, or twisting hair (apparent on back of hands and other skin areas) Hair shafts are broken at varying lengths - May be as large as 1-2 cm More common in children (in setting of family or psychosocial stress) ASSESSMENT ON THE HAIR AND SCALP - Occasionally may lead to hair being consumed Assess for: INFECTION - Growth Ring worm → Tinea capitis - Texture - Oiliness NUTRITIONAL DEFICIENCIES (KWASHIORKOR) - Infection - Infestation 1. Wear gloves 2. Inspect hair (natural color) 3. Inspect evenness of growth over the scalp 4. Inspect hair texture and oiliness 5. Note presence of infection of infestation (part the hair several areas and check behind ears, along hairline, and neck) CANCER TREATMENT 6. Inspect amount of body hair 7. Note presence of infection/infestation by parting the hair N: scalp free from flaking No signs of nits or lice AbN: excessive scaliness (dermatitis) Raised lesions (tumor/inflammation) 8. Inspect amount of body hair N: characteristic hair distribution on body (biologic sex and physiologic function) ADRENAL IMBALANCE (HIRSUTISM) AbN: excessive hairiness in females Hirsutism can be caused by: Polycystic ovary syndrome. This (may be due to imbalance in adrenals) most common cause of hirsutism is caused by an imbalance Note that excessive hair loss may be caused by: of sex hormones that can result in irregular periods, obesity, - Infaction infertility and sometimes multiple cysts on your ovaries - Nutritional deficiencies - Hormonal disorders - Thyroid or liver disease - Drug toxicity - Hepatic or renal failure - Radiation or chemotherapy  THYROID DISORDERS Hyperthyroidism - Fine, silky hair Hypothyroidism - Sparse hair LIFESPAN CONSIDERATIONS Neonates/Newborns (and Infants) Children Elderly NEONATES/NEWBORNS (AND INFANTS) Normal to have very little or a great deal of body and scalp hair CHILDREN Axillary and pubic hair begin to appear as puberty approaches Measured by Tanner scale/staging TANNER STAGES Stage I Stage II Stage III Stage IV Stage V No sexual Pubic hair Coarsening Coarse hair Coarse hair hair appears of pubic across pubis, across pubis hair sparring thigh and medial Flat Testicular thigh appearing enlargeme Increase Penis chest with nt Penis width/glans Penis and raised size/length increases testis nipples Breast bud enlarge to forms Breast Breast adult size Pre- 8-11.5 enlarges, enlarges, pubertal years mound raised areola, Adult breast forms mound on contour, 11-15 mound areola years 13-15 years flattens >15 years ELDERLY Possible loss of scalp, pubic, and axillary hair Hair on eyebrows, ears, and nostrils may become bristle-like, and coarse  SKIN, HAIR, AND SCALP (ADDITIONAL INFORMATION) THE SKIN Circulates in the red blood cells and carries oxygen of the Major function is to keep body in homeostasis (Despite daily blood assaults from the environment) Exist in two forms Synthesizes vitamin D - Oxyhemoglobin Body temperature modulation/adaptation - Deoxyhemoglobin Protects underlying tissue against: - Microorganisms OXYHEMOGLOBIN - Harmful substances Bright red pigment - Radiation Arteries and capillaries (concentrated) Provides boundaries for fluid Increase blood flow reddens skin Single heaviest single organ in the body Decreased blood flow produces pallor - 16% of total body weight - 1.2 to 1.3 square meters in area LIGHTER-SKINNED PEOPLE Contains three (3) layers Some areas are normally redder on: - Epidermis - Palms - Dermis - Soles - Subcutaneous tissue - Face - Neck EPIDERMIS - Upper chest Most superficial layer Devoid of blood vessels DEOXYHEMOGLOBIN Further divided into two (2) layers Darker and bluer pigment - Outer keratinized cells Produce when oxyhemoglobin passes through capillaries and - Inner cellular layer (site of melanin and keratin loses its oxygen formation) Increased concentration in the tissue leads to a bluish cast → Cell migration from the inner to outer layer takes cyanosis approximately one month This layer depends on the dermis for nutrition (diffusion) PROPENSITY OF SKIN TO TAN AND BURN DERMIS Rich in blood vessels (blood supply) Merges with the subcutaneous layer below Contains: - Connective tissue - Sebaceous glands - Sweat glands - Hair follicles SKIN COLOR HAIR Relies on four (4) pigments: Adults have two types of hair: - Melanin - Vellus - Carotene - Terminal - Hemoglobin (Oxyhemoglobin and Deoxyhemoglobin forms) VELLUS HAIR Short MELANIN Fine Amount is genetically determined Inconspicuous Increased by exposure to sunlight Unpigmented (relatively) CAROTENE TERMINAL HAIR Golden-yellow pigment Coarser Found in: Thicker - Subcutaneous fat More conspicuous - Heavily keratinized areas (palms and soles) More pigmented Scalp and eyebrows HEMOGLOBIN  HAIR (SPLIT END) NAILS Protect the distal ends of fingers and toes Fingernails grow 0.1 mm daily - Toenails are slower Parts: - Lunula (whitish moon) - Nail plate (firm, rectangular, and curving; site of attachment of nail bed) - Cuticle (extends from nail fold, functions as a seal, protects space between fold and plate from external moisture) - Lateral nail fold (cover sides of nail plate) - Proximal nail fold (covers 1/4 of the nail plate [nail root]) - Free edge (0.1 mm day or slower if toenails) SCALP IS A MNEMONIC SEBACEOUS GLANDS Produce a fatty substance secreted onto skin surface (through hair follicles) Not found on: - Palms - Soles Eccrine - Widely distributed - Open directly onto skin surface - Health control body temperature (sweat) Apocrine - Axillary and genitalia regions - Open into hair follicles - Stimulated by emotional stress - Responsible for body odor (bacterial decomposition of apocrine sweat)  THE NAILS NAIL ASSESSMENT Equipment Needed Acetone Cotton Ball NAILS Nails are assessed through inspection and palpation. Condition of the nails often provides important clues about the patient’s overall health status. Inspect the color and shape of the nails. Color beneath the nails should be similar to the overall skin coloring, although somewhat rosier. There should be no hemorrhage. NAIL TEXTURE Nail texture should uniform and not brittle. Note any grooves Present and smooth (normal) or lines in the nails. May be thickened and yellowish due to decreased circulation normal skin varies from light pink in light skinned patient and (elderly) light brown in dark skinned patients color change may Excessive thickness due to hypoxia (clubbing) indicate local or systemic problem Beau’s lines - Transverse linear depression (associated with an acute, 1. Inspect fingernail plate shape severe illness) Determine its curvature and angle - Bilateral (usually) 2. Inspect fingernail and toenail texture - Due to temporary disruption of proximal nail growth 3. Inspect fingernail and toenail color, lesions, and obvious (systemic illness) deformities - Timing of illness may be estimated by measuring distance from line to the nail bed. NAIL GROOMING - Serious illness that causes nail growth to slow or halt Normal: - It is believed that there is a temporary cessation of cell - Clean, manicured division in the nail matrix Abnormal: - Dirty, jagged, or broken (poor hygiene or related to client’s occupation) NAIL COLOR Normal: - Pink with some longitudinal ridging - May have freckles/pigments (dark-skinned) KOILONYCHIA Abnormal: - Spooning or concave nail - - Pale or cyanotic (hypoxia or anemia) o severe iron deficiency anemia thyroid and - Splinter hemorrhages (trauma) circulatory disease or in response to some disease - Yellow discoloration (fungal infection or psoriasis) and local trauma - Spoon-shaped nails NAIL SHAPE - Loss of convexity - Consider iron-deficiency Schamroth’s technique - Put ring fingernails together - Locate diamond-shaped space in between the fingernails (normal finding) - No diamond shape (clubbing of the fingers) Angles formed between the nail base and skin - 160 degrees (normal) - 180 degrees (early clubbing + spongy sensation) MEES’ LINES - >180 degrees (late clubbing) - Transverse lines similar to the lunula (closes the nail) - Occur following an acute or severe illness - Vary in width - Moves distally as nail grows out - Arsenic poisoning - Heart failure - Hodgkin’s disease - Chemotherapy - Carbon monoxide poisoning - N: intact epidermis - Leprosy - AbN: presence of hangnails o Dry skin is a major cause of hang nails. Other reasons include frequent nail biting, cutting a cuticle too closely or from previous injury to the nail. Therefore, in order to prevent hang nails, depending on your situation, it is important to address the cause. ONYCHOLYSIS - Painless separation of the nail plate from the nailbed - Starts distally and progress proximally enlarging the free edge of the nail. - May be due to trauma from manicuring, psoriasis fungal - Perform blanch or capillary refill test infection and allergic reactions to nail cosmetics. - N: 2-3 seconds Capillary Refill Test (CRT) - Systemic causes include diabetes, anemia o Capillary refill test- gently press on nail and note hyperthyroidism peripheral ischemia and syphilis. blanching then release and note speed of refill return of color → poor refill indicates cardiopulmonary problems or anemia. Note that positive capillary refill may be affected by cold temperatures. - Document findings LEUKONYCHIA - White spots that grow slowly out with the nail following LIFESPAN CONSIDERATIONS trauma to the nails INFANTS - Typical od vigorous and repeated manicuring Newborns nails grow very quickly, are extremely thin, and tear easily CHILDREN Bent, bruised or ingrown toenails may indicate shoes that are too tight Nail biting should be discussed with a family member. PARONYCHIA - Superficial infection of the proximal and lateral nail folds ELDERS adjacent to the nail plate usually from staphylococcus The nails grow more slowly and thickened aureus or streptococcus. Longitudinal bands commonly develop, and the nails tends to split Bands across the nails may indicate protein deficiency; white spots; zinc deficiency; and spoon-shaped nails; iron deficiency Toenail fungus is more common and difficult to eliminate - Indicates local inflammation of proximal and lateral nail (although not dangerous to health) folds (superficial infection) - Nail folds are red, swollen, and tender - Most common infection of the hand (Staph and Strep spp) - May spread until completely surrounds nail plate - Local trauma (nail biting, manicuring, or frequent hand immersion in water) - May create felon (painful sbscession fingertips) if extends into pulp space of fingers - Inspect surrounding tissue  THE SKULL AND FACE ASSESSMENT OF THE SKILL AND FACE Leonine Facies (Leprosy/Hansen’s Disease) 1. Inspect skill for shape and symmetry 2. Inspect facial features 3. Inspect eyes for edema and hollowness 4. Inspect facial symmetry and movements - Elevate eyebrows - Frown/lower eyebrows - Close eyes tightly - Puff cheeks - Smile - Show teeth 5. Palpate the skull for nodule, masses, or depression - Include the fontanels for pediatric patients ASSESSING THE SKULL Asses for the size, shape, and symmetry of the skull Normal: - Rounded, smooth (normocephalic) Abnormal: - Enlarged (hydrocephalus) - Lack symmetry - Increases size with prominent nose and forehead ASSESSING FACIAL FEATURES Normal: - Symmetrical facial features (round, oval, square, elongated) - Palpebral fissures equal - Symmetric nasolabial folds Abnormal: - Asymmetrical facial features - Prominent facial hair (hypertrichosis or werewolf syndrome) - Exophthalmia - Proptosis - In the case of thyroid eye disease, the immune system attacks the muscles and fatty tissues around and behind the eye, causing them to become EYES ASSESSMENT inflamed (swollen). Inspect the eyes for edema and hollowness - Facies (a distinctive facial expression associated with a Normally, there should be none clinical condition) Abnormal o Periorbital edema Bird facies Eye bags o Lack of sleep increases venous congestion; fluid build- up leads to pooled blood in those superficial blood vessels, making dark circles look even darker when you’re tired. Hollow Eyes or Sunken Eyes ▪ Aging o Dramatic Weight Loss o Lack of Sleep o Dehydration Moon Facies (Cushingoid syndrome) FACIAL SYMMETRY ASSESSMENT Ask patient to: 1. Elevate eyebrows 2. Frown 3. Lower eyebrows 4. Close lids tightly 5. Puff the cheeks  6. Smile 7. Show teeth OTHER ASSESSMENTS OF THE FACE Palpate for any nodules, masses, or depressions Normal: Smooth, uniform, no nodules/masses noted Abnormal: Indicate which area has abnormalities such as a depression from local trauma (Le Fort Fractures) Le Fort Fractures Le Fort III LIFESPAN CONSIDERATIONS NEONATES/NEWBORNS Shape of the head can be different - Depends on the type of delivery (vaginal vs caesarian section) Vaginal delivery: - Can sometimes lead to elongated, molded heads - Normal shape of the head becomes more rounded after 1-2 weeks (molding) Cesarean Section: - Tend to have smooth, rounded heads Head movement: - Can slightly lift their heads and move side to side - Voluntary control is established at approximately 4-6 months Fontanel Shape Size Time of Closure Anterior Diamond 2-3cm 18 months Posterior Triangle 1 cm 8 weeks  EYES EYE STRUCTURES/VISUAL ACUITY CONJUNCTIVA (PALPEBRAL AND BULBAR) Eyebrows: hair distribution and alignment and for skin quality and movement o Let pt. raise and lower eyebrow - N: symmetrical, equal eyebrow movement and hair distribution - AbN: scaling (seborrheic dermatitis), lateral sparseness (hypothyroidism), and asymmetrical eyebrow movement or distribution Eyelashes: evenness and curl direction - N: evenly distributed and turned outward - No crusting and infestations - Absence of eyelashes- alopecia universalis BULBAR CONJUNCTIVA - Inflammation → called BLEPHARITIS Lower palpebral: ask patient to look up, depress lower lids o inflammation at the edge of the eyelids involving hair with thumbs follicles and meibomian glands of the eyelids Bulbar: rest thumb and finger on the bones of the cheek and - Inverted eyelashes - entropion can scratch the cornea brow and spread the lids, let patient look to each side and - Everted eyelashes - ectropion can lead to excessive down drying of the eyes - clear with few underlying blood vessels and white sclera Eyelids for surface characteristics etc. visible - Elevate brows with thumb and index and let pt. close - N: transparent and with red blood vessels eyes - AbN: red blood vessels are dilated (bloodshot eyes) - N: skin intact, no discharge /discoloration - 15-20 blinks/min; bilateral PALPEBRAL CONJUNCTIVA - N: palpebral fissures should be equal in size when eyes Upper palpebral: ask pt. to look down, relax the eyes, raise are open upper lid slightly so eyelashes protrude, grasp upper Eye Lids eyelashes pull gently forward and down - upper lid: covers small portion of the iris and cornea Place small stick (applicator/tongue blade) 1 cm above the - lower lid: margin just below the junction of the cornea lid margin, push down the stick as you raise the edge of the and sclera lid then evert - lid margins: are clear, lacrimal duct openings (puncta) - Note for the color and foreign objects. Palpebral evident at nasal ends of upper and lower lids conjunctiva is smooth glistening pinkish peach color with - AbN: rapid, monocular, infrequent or absent blinking minimal blood vessels visible - Ptosis: drooping of upper eyelid may be d/t myasthenia Secure upper lashes against the eyebrow with your thumb gravis, damage to oculomotor, senile ptosis and inspect the palpebral conjunctiva o Ptosis can be due to damage of cranial nerve 3 or After: grasp upper lashes and pull forward gently, ask patient stroke if both eyelids affected- myasthenia gravis to look up, lid will return to normal position Normal: should be pink and clear AbN: Conjunctivitis → inflamed conjunctival surface - Entropion: more in elderly : inward turning of the lid Lacrimal Ducts and Glands margin - Ectropion: margin of lower lid is turned outward, ex