Health Assessment Lecture Notes PDF (NCM101LC, 2024-2025)

HEALTH ASSESSMENT – LECTURE NCM101LC NU LIPA A.Y. 2024-2025 TERM 2 HEALTH ASSESSMENT A. Overview of the Nursing Process (ADPIE) Assessment - Collecting subjective and objective data Diagnosis - Analyzing subjective and objective data to make a professional...

HEALTH ASSESSMENT – LECTURE NCM101LC NU LIPA A.Y. 2024-2025 TERM 2 HEALTH ASSESSMENT A. Overview of the Nursing Process (ADPIE) Assessment - Collecting subjective and objective data Diagnosis - Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral) Planning - Determining outcome criteria and developing a plan Implementation - Carrying out the plan Evaluation- Assessing whether outcome criteria have been met and revising the plan as necessary B. 4 Basic Types of Assessment 1. Initial Assessment - involves collection of subjective data about the client’s perception of her health of all body parts or system, past health history, family history, and lifestyle and health practices as well as objective data gathered during a step-by-step physical examination. 2. Ongoing or Partial Assessment - occurs after the comprehensive database is established. It is usually performed whenever the nurse or another health care professional has an encounter with the client. 3. Focused or Problem-Oriented Assessment - it is performed when a comprehensive database exists for a client and she comes to the health care agency with the specific concern. 4. Emergency Assessment - very rapid assessment performed in life-threatening situations. C. Steps of Health Assessment 1. Collection of Subjective Data Subjective Data: Sensation or Symptoms, Feelings, Perception, Desires, Preference, Belief, Ideas, Values, Personal information Phases of Interview: Introductory phase - the nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client that confidential information will remain confidential Working phase - the nurse elicits the client’s comments about major biographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level. Summary and closing phase - the nurse summarizes information obtained during the working phase and validates problems and goals with the client 2. Collection of objective data Objective Data - obtained by general observation and by using the four physical examination techniques Physical examination techniques: Inspection, Palpation, Percussion, Auscultation 3. Validating Data Purpose: to confirm or verify that the subjective and objective data you have collected is reliable and accurate. It serves to ensure that the assessment process is not ended before all relevant data has been collected and helps to prevent documentation of inaccurate data. Methods of Validation: Recheck, Clarify, Verify, Compare Niña Jane P. Lualhati NUR245  4. Documenting Data Purpose: to provide the health care team with a database that becomes the foundation for care of the client. Thorough and accurate documentation is vital to ensure that valid conclusions are made when the data are analyzed in the second step of the nursing process. PAIN Pain - is an unpleasant sensory and emotional experience, which we primarily associate with tissue damage or describe in terms of such damage, or both. The pathophysiologic phenomena of pain are associated with the central and peripheral nervous systems. The source of pain stimulates peripheral nerve endings (nociceptors), which transmit the sensations to the central nervous system (CNS). Pathophysiologic Phenomenon of Pain: 1. Transduction - begins when a mechanical, thermal or chemical stimulus result in tissue injury or damage stimulating the nociceptors, which are the primary afferent nerves for receiving painful stimuli. 2. Transmission - is initiated by this inflammatory process, resulting in the conduction of an impulse in the primary afferent neurons to the dorsal horn of the spinal cord. 3. Modulation - a difficult phenomenon. It inhibits the pain message and involves the body’s own endogenous neurotransmitters in the course of processing the pain stimuli. 4. Perception - still poorly understood. Studies have shown that emotional status affects directly the level of pain perceived and thus reported by patients. Classification of Pain: 1. Acute Pain - usually associated with an injury with a recent onset and duration of less than 6 months and usually less than a month. 2. Chronic/non-malignant pain - usually associated with a specific cause or injury and is described as a constant pain that persists more than 6 months. 3. Cancer Pain - often due to the compression of peripheral nerves or meninges or from the damage to these structures following surgery, chemotherapy, radiation, or tumor growth and infiltration. COLDSPA: Characteristic, Onset, Location, Severity, Pattern, Associated factors PQRST: Provocation/Paliation, Quality, Region/Radiation, Severity/Symptoms, Time PAIN: Pattern, Area, Intensity, Nature Numerical Rating Scale – 0-10 Verbal Rating Scale – description Wong-Bake Faces Pain Rating Scale - six faces are used that are numbered 0 to 5 underneath Visual Analogue Scales - vertical or horizontal line with words that convey “no pain” at one end and “worst pain” at opposite end ASSESSING THE VITAL SIGNS Vital signs reflect the body’s physiologic status and provide information critical to evaluating homeostatic balance. The term “vital” is used because the information gathered is the clearest indicator of overall health status. Niña Jane P. Lualhati NUR245 Primary Vital Signs: Blood Pressure, Body Temperature, Respiratory Rate, Pulse Rate Secondary Vital Signs: Pain level, Level of consciousness, Blood glucose, Skin color, Pupillary assessment, Capillary refill time, Height and weight (BMI), Urine output, Mental status Orthostatic vital signs - measurements of blood pressure and heart rate that are taken in different body positions, typically lying down and standing up. BODY TEMPERATURE 2 Kinds 1. Core Temperature - deep tissues of the body, such as the cranium, thorax, abdominal cavity, and pelvic cavity. Remains relatively constant. (Oral, Rectal) 2. Surface Temperature - temperature of the skin, the subcutaneous tissue and fat Rectal – 37-37.8 ° (most accurate) Oral – 36.4 - 37.2° (most convenient /accessible) Axillary – 35.8 - 36.6° (infants and children) Tympanic – 35.8 - 38° (fastest) Temporal - 35.8 - 37.8° Types of Fever 1. Intermittent fever: regular intervals between periods of fever and periods of normal or subnormal temperature. 2. Remittent fever: wide range of temperature fluctuation occurs over the 24 hr period, all of which are above normal 3. Relapsing fever: short febrile periods of a few days then periods of 1 or 2 days of normal temperature. 4. Constant fever: body temperature fluctuates minimally but always remains above normal Factors Affecting Body Temperature Age Diurnal variations (circadian rhythms) Exercise Hormones Stress Environment Factors Affecting Heat Exchange Conduction - transfer of heat by two objects that are in direct contact with one another. Convection - transfer of heat to the air surrounding the skin. Radiation - transfer of heat via infrared waves. Evaporation - transfer of heat by the evaporation of water. Types of Thermometers Oral thermometer: Has long slender tips. Rectal thermometer: Short, rounded tips. 1.5 – 4 cm into the anus. For an infant 2.5cm, for a child 3.7 cm – for an adults 4 cm. Axillary: Long and slender tip. Tympanic: infrared sensor to ear drum. Digital: electronic Niña Jane P. Lualhati NUR245  HYPERTHERMIA – body temperature rises above normal levels HYPOTHERMIA – body's core temperature drops below normal (also febrile/pyrexia) PULSE RATE Wave of blood created by contraction of the left ventricle of the heart. i.e. the pulse reflects the heartbeat or is the same as the rate of ventricular contractions of the heart – in a healthy person. Normal Rate: 60 – 100 BPM (adult), 80 – 180 (newborn) Doppler Ultrasound – used for pulses that are difficult to assess. Types of Pulses Peripheral Pulse: is a pulse located in the periphery of the body e.g. in the foot, and or neck Apical Pulse (central pulse): it is located at the apex of the heart. Pulse Deficit - difference between the apical and radial pulse Factors Affecting Pulse Rate Age Sex Exercise Fever Medications Heat Stress Position changes Pulse Sites 1. Temporal 2. Carotid 3. Brachial 4. Radial 5. Apical 6. Femoral 7. Popliteal 8. Dorsalis Pedis 9. Posterior Tibial Rate - beats per minute Rhythm - pattern and interval between the beats, random (regular or irregular) Volume - force of blood with each beat (weak or bounding). Graded by: 0 (absent), 1 (thready or weak, diff to feel), 2 (normal, detected readily), 3 (bounding, diff to obliterate) Elasticity of the arterial wall – straight, smooth, soft, pliable DYSRHYTHMIA - irregular beats TACHYCARDIA – greater than 100 bpm BRADYCARDIA – less than 60 bpm ARRHYTHMIA - abnormal heart rhythm that can be too fast, too slow, or irregular. RESPIRATORY RATE Respiration - breathing (includes intake of oxygen removal of carbon dioxide) Ventilation - movement of air in and out of the lungs. Niña Jane P. Lualhati NUR245 Hyperventilation: very deep, rapid respiration. Hypoventilation: very shallow respiration. 2 Types of Breathing 1. Costal (thoracic) - external muscles and other accessory muscles (sternoclodio mastoid). Observed by the movement of the chest upward and downward. Commonly used for adults. 2. Diaphragmatic (abdominal) - contraction and relaxation of the diaphragm, observed by the movement of abdomen. Commonly used for children. Rate - rate per minute (RPM)/breaths per minute (BPM). Healthy adult RR = 15- 20/ min. As the age decreases the respiratory rate increases. Rhythm – pattern/regularity of expiration and inspiration. Normal breathing is automatic & effortless. Depth - normal, deep, or shallow. Deep - a large volume of air inhaled & exhaled, inflates most of the lungs. Shallow - exchange of a small volume of air minimal use of lung tissue. Tidal Volume – normal inspiration and expiration Types of Respiration 1. External – exchange of O2 and CO2 between the alveoli and pulmonary blood 2. Internal – exchange of gases between the circulating blood and the cells of body tissues Types of Breathing Pattern 1. Cheyne-Stoke – waxy and waning rapid breathing followed by apnea 2. Blot – shallow and period of apnea 3. Kussmaul – type of hyperventilation that is the lung’s response to acidosis Control Center for Respiration 1. Medulla Oblongata – cardio-resp center 2. Pons – rhythm 3. Chemoreceptors EUPNEA- normal breathing rate and depth BRADYPNEA- slow respiration TACHYPNEA - fast breathing APNEA - cessation of breathing DYSPNEA – difficulty of breathing ORTHOPNEA – ability to breathe in an upright position HYPERVENTILATION – very deep and rapid ventilation HYPOVENTILATION – very shallow respiration BLOOD PRESSURE Blood pressure - pressure exerted by blood against the wall of blood vessels. It includes arterial, venous, and capillary pressures. Arterial BP- pressure exerted by the blood as it flows through the arteries. Arterial blood pressure (BP) = cardiac output (CO) x total peripheral resistance (TPR). Systolic pressure - contraction of the ventricle. Maximum pressure developed on the ejection of blood from left ventricles into the arteries. Niña Jane P. Lualhati NUR245 Diastolic blood pressure - ventricles are at rest. Lowest pressure and a measure of peripheral resistance. Pulse pressure - difference between the systolic and diastolic pressure. Normal Rate: 12-20 bpm (adult), 30-60 bpm (newborn) Heart Sounds First sound – ventricular systole. Caused by the closure of the mitral and tricuspid valves. Second sound – ventricular diastole. Caused by the closure of aortic and pulmonary valves. Third heart sound (S3) - “ventricular gallop,” occurs just after S2 when the mitral valve opens, allowing passive filling of the left ventricle Fourth heart sound (S4) - “atrial gallop,” occurs just before S1 when the atria contracts to force blood into the left ventricle. Conditions Affecting Blood Pressure Fever: Increase Stress: Increase Arteriosclerosis: Increase Obesity: Increase Exposure to cold: Increase Hemorrhage: Decrease Low hematocrit: Decrease External heat: Decrease Sites for Measuring Blood Pressure Upper arm using brachial artery (commonest) Thigh around popliteal artery Forearm using radial artery Leg using posterior tibial or dorsal pedis 2 Methods 1. Direct (invasive monitoring) - insertion of catheter into the brachial, radial, or femoral artery. The physician inserts the catheter, and the nurse monitors the pressure reading. With the use of correct placement, it is highly accurate. 2. Indirect (non-invasive methods) - auscultatory & palpatory 5 Phases of Auscultatory Phase 1: 1st joint clear tapping sound is heard, these sounds gradually become more intense. Phase 2: The period during deflation when the sound has a swishing quality Phase 3: The period during which the sounds are crisper and more intense (forceful and powerful) Phase 4: The time when the sounds become muffled and have a soft blowing quality (less bounding) Phase 5: The pressure level when the sounds disappear Sphygmomanometer Two types: mercury and aneroid Too narrow = erroneously elevated reading Too wide = erroneously low reading Niña Jane P. Lualhati NUR245 Hypertension stages are classified as follows: Normal: SBP < 120 mm Hg and DBP < 80 mm Hg Elevated: SBP 120-129 mm Hg and DBP < 80 mm Hg Stage 1: SBP 130-139 mm Hg or DBP 80-89 mm Hg Stage 2: SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg. HYPERTENSION - elevated blood pressure above normal limits HYPOTENSION - abnormally low blood pressure ASSESSING THE SKIN, HAIR, AND NAIL SKIN Pallor - loss of color caused by arterial insufficiency, decreased blood supply, and anemia. Cyanosis - bluish cyanotic skin is associated with oxygen deficiency. Central cyanosis results from a cardiopulmonary problem, whereas peripheral cyanosis may be a local problem resulting from vasoconstriction. Jaundice - yellow skin tones, from pale to pumpkin, particularly in the sclera, oral mucosa, palms, and soles associated with hepatic dysfunction. Erythema - redness of the skin caused by increased blood flow to the skin's blood vessels. Diaphoresis - excessive sweating Edema – Fluid accumulation in the intercellular spaces Turgor Test/Pinch Test - Pinch up a large fold of skin (should return to normal position rapidly) Primary lesions - arise from normal skin due to irritation or disease. Secondary lesions - arise from changes in primary lesions. ABCDE of Lesions Asymmetry, Border irregularity, Color variation, Diameter, Elevation, Enlargement PRIMARY LESIONS SECONDARY LESIONS VASCULAR LESIONS MACULES - small, flat, EROSION - loss of superficial PETECHIA (PL. PETECHIAE) - nonpalpable. Less than 1 cm epidermis that does not extend round red or purple macule that with a circumscribed border to the dermis. It is a depressed, is 1–2 mm in size. It is Examples: freckles, flat moles, moist area. secondary to blood petechiae, rubella, vitiligo, port Examples: rupture vesicle, extravasation and associated wine stains, and ecchymosis scratch mark, and aphthous with bleeding tendencies or ulcer (aphthous stomatitis, emboli to skin. commonly called a canker sore). PATCHES - small, flat, ULCER - skin loss extending ECCHYMOSIS (PL. nonpalpable. Greater than 1 cm, past epidermis, with necrotic ECCHYMOSES) - round or and may have an irregular border. tissue loss. Bleeding and irregular macular lesion that is scarring are possible. larger than petechial lesion. The Examples: stasis ulcer of color varies and changes: black, venous insufficiency (stasis yellow, and green hues. It is dermatitis with venous stasis secondary to blood ulcer) and pressure ulcer. extravasation and associated with trauma and bleeding tendencies. PAPULES - elevated, palpable, SCAR (CICATRIX) - skin mark HEMATOMA - localized solid mass. Circumscribed left after healing of wound or collection of blood creating an border and are less than 0.5 cm. lesion that represents elevated ecchymosis. It is Examples: elevated nevi, warts, replacement by connective associated with trauma. and lichen planus. tissue of the injured tissue. Young scars are red or purple, Niña Jane P. Lualhati NUR245  whereas mature scars are white or glistening. Examples: healed wound and healed surgical incision. PLAQUES - elevated, palpable, FISSURE - linear crack in the CHERRY ANGIOMA - papular solid mass. Greater than 0.5 cm skin that may extend to the and round, red or purple lesion and may be coalesced papules dermis and may be painful. found on the trunk or with a flat top. Examples: chapped lips or extremities. It may blanch with Examples: psoriasis, and actinic hands and athlete’s foot. pressure. It is a normal age- keratosis. Interdigital tinea pedis with related skin alteration and fissures and maceration usually not clinically significant. NODULES - elevated, solid, SPIDER ANGIOMA - red palpable mass that extends arteriole lesion with a central deeper into dermis than a body with radiating branches. It papule. 0.5–2 cm and is usually noted on the face, circumscribed. neck, arms, and trunk. It is rare Examples: keloid, lipoma, below the waist. Compression squamous cell carcinoma, poorly of the center of the arteriole absorbed injection, and completely blanches the lesion. dermatofibroma It is associated with liver disease, pregnancy, and vitamin B deficiency. TUMORS - elevated, solid, TELANGIECTASIS (VENOUS palpable mass that extends STAR) - bluish or red lesion with deeper into dermis than a varying shape (spider-like or papule. Greater than 1–2 cm and linear) found on the legs and do not always have sharp anterior chest. It does not borders. blanch when pressure is Examples: larger lipoma and applied. It is secondary to carcinoma superficial dilation of venous vessels and capillaries and associated with increased venous pressure states (varicosities). VESICLES - circumscribed elevated, palpable mass containing serous fluid. Less than 0.5 cm. Examples: e herpes simplex/ zoster, varicella (chickenpox, pictured below), poison ivy, and second-degree burn BULLA - circumscribed elevated, palpable mass containing serous fluid. Greater than 0.5 cm. Examples: pemphigus, contact dermatitis, large burn blisters, poison ivy, and bullous impetigo WHEAL - elevated mass with transient borders that is often irregular. Size and color vary. Caused by movement of serous fluid into the dermis; it does not contain free fluid in a cavity (e.g., vesicle). Niña Jane P. Lualhati NUR245  Examples: urticaria (hives) and insect bites. PUSTULE - pus-filled vesicle or bulla. Examples: acne, impetigo, furuncles, and carbuncles. CYST - Encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis. Examples: sebaceous cyst and epidermoid cyst Other Common Lesions Folliculitis - superficial infection of hair follicle r/t shaving Psoriasis - Scaly red patches /c silvery scales Herpes Simplex - Cold sore-vesicle then pustule which erupts Herpes Zoster (Shingles) - small, groped vesicles then pustules then crust- develops along nerve path Contact dermatitis - Local reaction to irritant- redness followed by swelling, wheals or urticaria. Allergic drug reaction - red macular rash, generalized. May proceed to urticaria Common Skin Variations 1. Freckles—flat, small macules of pigment that appear following sun exposure. 2. Vitiligo - depigmentation of the skin. 3. Striae (sometimes called stretch marks). 4. Seborrheic keratosis, a warty or crusty pigmented lesion. 5. Scar. 6. Mole (also called nevus), a flat or raised tan/ brownish marking up to 6 mm wide. 7. Cutaneous tag, raised papule with a depressed center. 8. Cutaneous horn. 9. Cherry angiomas, small raised spots (1–5 mm wide) typically seen with aging Infant and Children Mongolian Spots - Blue, Black and Purple spots on buttocks or sacrum- common if AA, Native American, Hispanic and Asia newborns. Bruising - Common following injuries from rapid, traumatic, or breech births Congenital birth marks - Port wine stains, angiomas, Strawberry mark, Cavernous Hemangioma Petechiae and Hematoma may be present on face r/t prolonged violent crying or coughing Diaper Dermatitis - red moist diffuse macular Candidiasis(yeast)- fiery red moist patches with clear borders Impetigo - red vesicles rupture to form honey colored crust-contagious bacterial infection Chickenpox (Varicella) - small vesicles evolving to pustules on trunk spreading to face, and limbs Ringworm - fungal infection produces scales and can cause permanent hair loss Measles (Rubeola)- red macular/papular rash behind ears and spreads to body German Measles (Rubella)- paler lesions than rubeola Atopic Dermatitis (eczema) – red papules and vesicles /c weeping, oozing and crusts (Family hx of allergies) Seborrheic Dermatitis (Cradle Cap) – greasy yellow-pink lesions on scalp and forehead (No family hx of allergies) Niña Jane P. Lualhati NUR245 Pregnant Women Striae- Stretch marks. Initially pink then silver Linea Nigra- Brownish black line abdominal midline Chloasma- Irregular brown patches on face- aslo /c oral contraceptives-disappears /p pregnancy ends Vascular Spider Veins- Capillaries on skin surface break Malignancies Basal Cell carcinoma – most common. Starts as skin colored papule. Develops pearly borders with red center. (Slow growing) Squamous Cell Carcinoma – red scaly patch /c sharp margins.1 cm or more. Develops central ulcer /c surrounding redness. (Less common but grows rapidly) Malignant Myeloma – ½ of lesions are preexisting nevi – Brown, tan, black. Red, or purple. Irregular borders. May scale, flake or ooze. (Metastasizes quicker than other forms) Epidemic Kaposi’s Sarcoma – 3 stages. Multiple pink patches. Lesions develop into raised papules, oval and vary in color. Advances are widely disseminated involving skin, mucus membranes, and visceral organs. NAILS Capillary Refill Test/Blanch Test - Blanching of nail bed lasts 1-2 seconds. Longer may indicate cardiovascular or respiratory disorder. Clubbing - congenital or chronic CO2 retention Jagged Nails - chronic anxiety Transverse grooves - nutrient deficiency Longitudinal grooves - normal Nail adhered to bed - spongy bed accompanies clubbing Pitting - often seen with psoriasis Lindsay Nails (Half-and-Half Nails) - half white on the upper proximal half and pink on the distal half. May be seen in chronic renal disease. Yellow Nail Syndrome - grow slow and are curved. May be seen in AIDS and respiratory syndromes. Koilonychia (Spooning) - concave curves associated with Fe deficiency Paronychia- swollen tender nail folds-fungal or bacterial infection HAIR Patchy gray hair - nutritional deficiencies Dermatitis - excessive scaliness Infections or tumor growth – raised lesions Hypothyroidism and malnutrition - dull, dry hair Tinea capitis - pustules with hair loss in patches Folliculitis - infections of the hair follicle Hirsutism (facial hair on females) - characteristic of Cushing’s disease and results from an imbalance of adrenal hormones or it may be a side effect of steroids Dandruff Baldness Ticks Pediculosis Capitis – head louse (scalp) Niña Jane P. Lualhati NUR245  Pediculosis Corporis – body louse (clothing) Pediculus Pubis – crab louse (pubic hair) Lanugo (down or wooly hair) - fine hair on the body of a fetus ASSESSING THE HEAD AND NECK Crepitus - popping or crackling /c movement Normocephalic - normal round, symmetrical skull Microcephalic - abnormally small Macrocephalic - abnormally large Flat affect - unmoving expression (depression, anger, neuro) Drooping, weakness, or paralysis on one side of the face may result from a stroke (cerebrovascular accident, CVA) and usually is seen with paralysis or weakness of other parts on that side of the body. Drooping, weakness, or paralysis on one side of the face may also result from a neurologic condition known as Bell’s palsy Parkinson’s disease - “mask-like” face Cachexia (emaciation or wasting) - “sunken” face with depressed eyes and hollow cheeks Nephrotic syndrome - pale, swollen face TMJ syndrome - limited range of motion, swelling, tenderness, or crepitation ACROMEGALY - enlargement of the facial features (nose, ears) and the hands and feet caused by increased production of growth hormone after the skeleton and other organs finish growing. Acromegaly is often due to a noncancerous (benign) tumor of the pituitary gland and is also seen in Paget’s disease. CUSHING’S SYNDROME - moon-shaped face with reddened cheeks and increased facial hair. SCLERODERMA - tightened-hard face with thinning facial skin HYPERTHYROIDISM - exophthalmos BELL’S PALSY - one-sided facial paralysis Lymph Node Positions Pre and post auricular - in front and behind ear Occipital Jugulodigastric - below ear lobe Superficial cervical - Along upper SCM muscle Posterior Cervical - base of lateral neck Supraclavicular - above clavicle – Submandibular-under jaw Submental - under chin Deep cervical - jaw line along SCM to clavicle Lymphadenopathy Acute infection – nodes are bilateral, enlarged, warm, tender and firm but moveable Chronic inflammation – nodes clumped. May be asymmetrical Cancerous – nodes are hard, unilateral, non-tender and fixed ASSESSING THE EYES Os = left eye Od = right eye Vision Charts/Tests 1. Snellen Chart - test distant visual acuity. The client stands 20 feet from the chart and covers one eye with an opaque card. Record as a fraction (20/20). Numerator is the of feet from chart, denominator is the distance at which normal eye can read a line. Niña Jane P. Lualhati NUR245  2. Jaeger Test - near vision is assessed by holding the pocket screener (Jaeger test) or newspaper print 14 inches from the eye. 3. Ishihara Test - color vision test used to detect red-green color deficiencies/color blindness 4. Confrontation test - assess visual fields/peripheral vision (2 feet away) 5. Cover test - assessing eye alignment issues/extraocular muscle movements (detects strabismus) 6. Position test – assessing eye movement for jerky movements (detects nystagmus) Ophthalmoscope - a hand-held instrument that allows the examiner to view the fundus of the eye by the projection of light through a prism that bends the light 90 degrees. Cataract - opacity of lens Arcus senilis - white line on top of lens-normal in elderly PERRLA (pupils are equally round, reactive to light and accommodation) Infants Absent pupillary light reflex esp after 3 weeks indicates blindness Strabismus ie crossed eyes can lead to permanent vision damage if not treated May have an epicanthal fold - excess skin fold extending over the inner corner of eye. Disappears later. Mongolian slant - seen with down’s syndrome Elderly Arcus Senilis normal – Sparse eyebrows Lower lid droop r/t decreased skin elasticity Decreased orbital fat r/t sunken eye appearance Decreased tear production Pinguiculae - yellow nodules on sclera normal Xanthelasma - soft raised plaques at tear ducts Drusen - yellow spots on retina Other abnormalities Myopia (impaired far vision) - the second number in the Snellen test result is larger than the first (20/40) Presbyopia (impaired near vision) - when the client moves the chart away from the eyes to focus on the print. It is caused by decreased accommodation. Phoria - misalignment that occurs only when fusion reflex is blocked. Strabismus - constant malalignment of the eyes. Tropia - specific type of misalignment: esotropia is an inward turn of the eye, and exotropia is an outward turn of the eye Nystagmus — an oscillating (shaking) movement of the eye Ptosis - drooping of the upper lid Entropion - inverted lower lid Ectropion - everted lower eyelid Staphylococcus aureus - redness and crusting along the lid margins suggest seborrhea or blepharitis, an infection Exophthalmos - protrusion of the eyeballs accompanied by retracted eyelid margins Conjunctivitis (pink eye) - generalized redness of the conjunctiva Episcleritis - a local, noninfectious inflammation of the sclera. Niña Jane P. Lualhati NUR245  Miosis (pinpoint pupils) - constricted and fixed pupils—possibly a result of narcotic drugs or brain damage Anisocoria - pupils of unequal size Mydriasis - dilated and fixed pupils, typically resulting from central nervous system injury, circulatory collapse, or deep anesthesia Papilledema - swollen optic disc Glaucoma - enlarged physiologic cup occupying more than half of the disc’s diameter Optic atrophy - white optic disc, lack of disc vessel ASSESSING THE EARS Tests 1. Whisper test - detects high tone loss 2. Weber test- evaluate the conduction of sound waves through bone to help distinguish between conductive hearing (sound waves transmitted by the external and middle ear) and sensorineural hearing 3. Rinne test - compares air and bone conduction sounds (air conduction is longer) conductive hearing loss - bone conduction (BC) sound is heard longer than or equally as long as air conduction (AC) sound (BC ≥ AC) sensorineural hearing loss - air conduction sound is heard longer than bone conduction sound (AC > BC) if anything is heard at all. Otoscope - flashlight-type viewer used to visualize the eardrum and external ear canal. Some guidelines for using it effectively follow. Pull up on pinna (auricle) to straighten canal on adult (on child pull down). OTORRHEA – drainage OTALGIA – earache TINNITUS – ringing in the ears VERTIGO - true spinning motion OTITIS EXTERNA (infection of ear canal) - sticky yellow discharge OTITIS MEDIA (infection of middle ear) ASSESSING THE MOUTH, THROAT, NOSE, AND SINUSES Nose and Paranasal Sinuses – first part of the respiratory system and are responsible for receiving, filtering, warming, and moistening air to be transported to the lungs Tonsil gradings: 1+ Tonsils are visible. 2+ Tonsils are midway between tonsillar pillars and uvula. 3+ Tonsils touch the uvula. 4+ Tonsils touch each other Acute Sinusitis - pain, tenderness, swelling and pressure around the eyes, cheeks, nose or forehead Chronic sinusitis - sinuses become inflamed and swollen Dull sound of Sinus on percussion - Thickening or fullness of sinus Rhinorrhea - thin, watery, clear nasal drainage Epistaxis – bleeding Perforated Septum – hole in the septum Nasal Polyps – soft, painless, noncancerous growths on the lining of nasal passages or sinuses Niña Jane P. Lualhati NUR245  Gingivitis - red, swollen gums that bleed easily Periodontitis - destruction of the gums with tooth loss occurs in more advanced gum disease Dysphagia - difficulty swallowing Odynophagia - painful swallowing Bilateral cross bite – open bite Bruxism – grinding the teeth Pallor around the lips (circumoral pallor) - anemia and shock. Bluish (cyanotic) lips - cold or hypoxia. Reddish lips - ketoacidosis, carbon monoxide poisoning, and chronic obstructive pulmonary disease (COPD) with polycythemia. Swelling of the lips (edema) Caries – tooth decay Scurvy - vitamin C deficiency Hyperplasia - enlarged reddened gums Lead poisoning - bluish-black or grey-white line along the gum line Koplik’s spots - tiny whitish spots that lie over reddened mucosa Canker sores - brown patches inside the cheeks of clients with adrenocortical insufficiency Candida infection – whitish curd-like Leukoplakia – chalky, white patch or plaque in the mouth Niacin or Vit B12 Deficiency - smooth, reddish, shiny tongue without papillae Kaposi’s sarcoma - deep purple, raised, or flat lesions (AIDS patient) Pharyngitis - bright red throat with white or yellow exudate indicates Yellow Teeth – tobacco use, excessive intake of coffee/tea Malocclusion – misalignment of upper and lower teeth Brown stain or white spot – antibiotic therapy Periodontal Disease – mouth full of infection, tartar, and recession Meth Mouth – only when the patient becomes clean and sober do they realize that they have toothaches Baby bottle decay – prolong bottle feeding Gingival Hyperplasia – associated with dilantin ASSESSING THE THORAX AND LUNGS Inhalation - diaphragm presses the abdominal organs downward and forward. T9-chest should expand evenly during inspiration. Exhalation - diaphragm rises and recoils to the resting position. Chest percussion – apices to base, 5cm interval. Resonance is heard over healthy lung tissue. Heavily muscled or obese pt may sound duller. Dullness is heard over bone or abnormal lung. Normal diaphragmatic excursion is 3 to 5 cm but may be as high as 8 in athletes. Excursion will be decreased in COPD, pleural effusion and Atelectasis. Three normal breath sounds: 1. Vesicular sounds – low, breezy, soft, long in inspiration, short in expiration, found in peripheral lung fields (heard over lung periphery) 2. Bronchial sounds (aka tracheal or tubular) – high, harsh or hollow, loud, short during inspiration, long in expiration, found in trachea and thorax (heard close to larger airways) Niña Jane P. Lualhati NUR245 3. Bronchovesicular sounds – moderate, mixed, moderate, same during inspiration and expiration, found over the major bronchi—posterior: between the scapulae; anterior: around the upper sternum in the first and second intercostal spaces (heard over medium sized airways) Adventitious sound/Abnormal sounds: Fine crackles/Fine rales - High-pitched, short, popping sounds heard during inspiration and not cleared with coughing; sounds are discontinuous and can be simulated by rolling a strand of hair between your fingers near your ear. [pneumonia, CHF, Atelectasis] Course crackles - Low-pitched, bubbling, moist sounds that may persist from early inspiration to early expiration; also described as softly separating Velcro. (fluid/secretions) Pleural friction rib - Low-pitched, dry, grating sound; sound is much like crackles, only more superficial and occurring during both inspiration and expiration Wheeze (sibilant) - High-pitched, musical sounds heard primarily during expiration but may also be heard on inspiration. [asthma, emphysema, bronchitis or bronchospasm] Wheeze (sonorous) - Low-pitched snoring or moaning sounds heard primarily during expiration but may be heard throughout the respiratory cycle. These wheezes may clear with coughing. Stridor - harsh, honking wheeze with severe broncholaryngospasm, such as occurs with croup. Rhonchi - continuous, low-pitched lung sounds that resemble snoring during expiration (buildup of fluid on bronchial tree) Bronchophony: Ask the client to repeat the phrase “ninety-nine” while you auscultate the chest wall. (sound of the voice may be heard but the actual phrase cannot be distinguished) Egophony: Ask the client to repeat the letter “E” while you listen over the chest wall. (soft and muffled but the letter “E” should be distinguishable) Whispered pectoriloquy: Ask the client to whisper the phrase “one–two–three” while you auscultate the chest wall. (sound is very faint and muffled. It may be inaudible) Tactile fremitus - palpable vibration, vibrations should be equal bilaterally. Repeats phrase “99 or blue moon.” Palpate over apices to bases Decreased fremitus = pleural effusion, thickened chest wall (Pnuemothorax, emphysema) Increased fremitus= consolidation of lung tissue (pneumonia, tumor, fibrosis) Crepitus = crackling sensation over skin surface (emphysema) Normal findings: Scapulae are symmetric and nonprotruding. Shoulders and scapulae are at equal horizontal positions. The ratio of anteroposterior to transverse diameter is 1:2. Spinous processes appear straight, and thorax appears symmetric. The client does not use accessory (trapezius/ shoulder) muscles to assist breathing. No tenderness, pain, or unusual sensations. The examiner finds no palpable crepitus. Fremitus is symmetric and easily identified in the upper regions of the lungs. Chest expansion - client takes a deep breath, the examiner’s thumbs should move 5 to 10 cm apart symmetrically. Resonance is the percussion tone elicited over normal lung tissue. Percussion elicits flat tones over the scapula. No sternal retractions. Ribs slope downward with symmetric intercostal spaces. Costal angle is within 90 degrees. Niña Jane P. Lualhati NUR245  Will hear vesicular lung sounds over most of anterior chest. Abnormal findings: Dyspnea (difficulty breathing) can indicate congestive heart failure (CHF), coronary heart disease (CHD), myocardial ischemia, and myocardial infarction (MI), chronic obstructive pulmonary disease (COPD) Continuous coughs - associated with acute infections Coughs only early in the morning - associated with chronic bronchial inflammation or smoking Coughs late in the evening - exposure to irritants during the day. Coughs occurring at night - related to postnasal drip or sinusitis. Smoker’s cough - continuous coughing Orthopnea - difficulty breathing when lying supine Paroxysmal nocturnal dyspnea - severe dyspnea that awakens the person from sleep Sleep apnea - periods of breathing cessation during sleep (snoring) White or mucoid sputum is often seen with common colds, viral infections, or bronchitis. Yellow or green sputum is often associated with bacterial infections. Blood in the sputum (hemoptysis) is seen with more serious respiratory conditions. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia. Pink, frothy sputum may be indicative of pulmonary edema. Nasal flaring - labored respirations (especially in small children) and is indicative of hypoxia. Pursed lip breathing - asthma, emphysema, or CHF. Barrel Chest - chest appears rounded or puffed up like a barrel. Increased ratio between the anteroposterior–transverse diameter, diameter equal to transverse diameter /c horizontal ribs and costal angles greater than 90 degrees. Funnel Chest - sunken sternum and adjacent cartilages (Pectus excavatum) Pigeon Chest - forward protrusion of the sternum causing the adjacent ribs to slope backward (Pectus carinatum) Scoliosis - s shaped curve Kyphosis - an increased curve of the thoracic spine (outward curvature) Tripod Position - client leans forward and uses arms to support weight and lift chest to increase breathing capacity Pneumothorax - air in the pleural space Atelectasis - collapse or incomplete expansion Emphysema - abnormal enlargement of airspaces in the lungs, leading to the destruction of alveolar walls without fibrosis. Fibrosis - excessive accumulation of connective tissue components in response to tissue damage or chronic inflammation (leads to scarring, loss of organ function, and can be life-threatening) Bronchitis - inflammation of the bronchial tubes Bronchospasm - sudden tightening of the muscles surrounding the airways in the lungs, leading to a constriction of the airways Consolidation - the air-filled spaces in the lungs are filled with fluid, pus, blood, or other materials, leading to a solid or opaque appearance on imaging tests like X-rays or CT scans Hyperresonance of diaphragmatic excursion - trapped air such (emphysema or pneumothorax) Dullness of diaphragmatic excursion - fluid or solid tissue replaces air in the lung or occupies the pleural space (lobar pneumonia, pleural effusion, or tumor) Decreased/ Diminished Breath Sounds - bronchial tree is obstructed by secretions, mucous plug or foreign body Niña Jane P. Lualhati NUR245  Bronchophony - words are easily understood and louder over areas of increased density Egophony - sound is louder and sounds like “A.” Whispered pectoriloquy - sound is transmitted clearly and distinctly Tachypnea - More than 24 breaths/min and shallow Bradypnea - Less than 10 breaths/min and regular Hyperventilation – Increased rate and increased depth Hypoventilation - Decreased rate, decreased depth, irregular pattern Kussmaul - Rapid, deep, labored breathing Cheyne-Stokes respiration - Regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea Biot’s respiration - Irregular pattern characterized by varying depth and rate of respirations followed by periods of apnea Ataxic - Significant disorganization with irregular and varying depths of respiration Air tapping - Increasing difficulty in getting breath out Age specific considerations: Infants and Children Resp rate will be irreg during feeding or sleeping in neonate. Broncho vesicular sounds heard over entire lung field r/t thin chest wall Crackles heard in upper fields /c cystic fibrosis. Stridor Pregnant Women Thoracic cage widens Apical pulse displaced laterally Orthopnea may be present Change in resp character Elderly Kyphosis Barrel chest Marked bony prominences r/t decreased subcutaneous fat. May fatigue during exam or hyperventilate More likely to have disease present (Pneumonia, Atelectasis, etc) ASSESSING THE BREASTS AND AXILLA Clinical Breast Exam – 20’s-30’s (every 3 years), after 40s (every year) Mammography – radiological diagnostic method that uses low-dose X-rays to examine breast tissue for abnormalities like breast cancer. Every Year Beginning at age 40. MRI yearly for high-risk women – BRCA gene (1st degree relative) Monthly self breast exam - optional Retraction of Breast Ask pt to bend at the waist Ask to lift arms – should move symmetrically Ask to put hands on hips – observe position Ask to press hands together – should move together Niña Jane P. Lualhati NUR245 Breast Palpation Patient should be supine (lying down) Place a small towel under shoulder on side to be assessed Raise pt arm over her head Use pads of 1st three finger to palpate in a rotary motion Assess entire breast using light, medium and then deep palpation Cover entire breast - any pattern acceptable. Work your way around the breast in a clockwise fashion, using small circles of the hand as you go. Make sure the entire breast is felt. Nullaparus (haven’t given birth yet) - breasts feel firm and elastic Post parus (gave birth already) - breasts feel softer and looser Premenstrual tenderness - increased progesterone levels Heat, Redness, and swelling in non-lactating breasts indicate inflammation Patterns of palpation: Circular, Wedge, Vertical strip Normal findings: One breast may normally be larger than the other. Linear stretch marks may be seen during and after pregnancy or with significant weight gain or loss. Areolas vary from dark pink to dark brown, depending on the client’s skin tones. They are round and may vary in size. Small Montgomery tubercles are present. Nipples are nearly equal bilaterally in size and are in the same location on each breast. Nipples are usually everted, but they may be inverted or flat No discharge should be present. The client’s breasts should rise symmetrically, with no sign of dimpling or retraction. Lactating women often have chaffed or sore nipples Normal male breasts have flat disk of undeveloped breast tissue beneath nipple A milky discharge is usually normal only during pregnancy and lactation. However, some women may normally have a clear discharge. Montgomery's glands/Montgomery's tubercles or areolar glands - sebaceous glands around the dark area of the nipple. They produce an oily secretion that lubricates and protects the nipple and areola. Abnormal findings: Peau d’orange - pigskin-like or orange-peel appearance (from edema) Edema - caused by blocked lymphatic drainage Paget’s disease - red, scaly, crusty areola Dimpling or retraction (ask the client to raise her arms overhead then press her hands against her hips. Next ask her to press her hands together.) Mastitis – infections Lipomas - collection of fatty tissue that may also appear as a lump. Benign - movable lumps in the upper outer quadrant of tail of spence Cancerous - immovable lumps in the upper outer quadrant of tail of spence Malignant – regular distinctness, nontender Benign– irregular distinctness, tender Gynecomastia - enlargement of male breast tissue, often unilateral Intraductal papilloma - small growth inside a milk duct of the breast, often near the areola. It is harmless and occurs in women ages 35 to 50. Niña Jane P. Lualhati NUR245  Retracted nipple suggests malignancy. Dimpling suggests malignancy. Retracted breast tissue suggests malignancy. Cancerous tumors - irregular, firm, hard, not defined masses that may be fixed or mobile. They are not usually tender and usually occur after age 50. Fibroadenomas - lesions are lobular, ovoid, or round. They are firm, well defined, seldom tender, and usually singular and mobile. They occur more commonly between puberty and menopause. Benign breast disease/ fibrocystic breast disease - round, elastic, defined, tender, and mobile cysts. The condition is most common from age 30 to menopause, after which it decreases. Age Specific Considerations Witch’s Milk- infants, may be secreted in 1st weeks of life Pregnant Females Breasts and nipples Increase in size Vascularity may become more visible Striae may appear Nipples become darker and more erect Areola widen and contain small scattered Montgomery’s glands May express thick yell colostrum /p 1st trimester (Colostrum – first milk produced after giving birth) Lactating Females Colostrum changes to milk approx 3rd day post partum Breasts become engorged, reddened and shinny May feel warm Nipples sore and may crack Frequent nursing is best treatment for engorged and sore breasts Aging Breasts May become pendulous and flattened Nipples may retract but should be easily pulled outward Feels granular with prominent milk ducts Women over 50 have increased risk of breast cancer Stress Self breast exam Niña Jane P. Lualhati NUR245