NURS 305 Exam 1 Study Guide PDF

NURS 305 Exam 1 Study Guide Topics # of Questions Subtopics SBAR, SOAP, QSEN, priority problems, types of databases,...

NURS 305 Exam 1 Study Guide Topics # of Questions Subtopics SBAR, SOAP, QSEN, priority problems, types of databases, subjective vs. objective findings and Evidence-based Practice & data, examples of stages of the Assessment nursing process, palpating for 4-6 temperature, technique for palpation, Healthy People 2030 auscultation technique, inspection, percussion, assessment equipment proper use, stethoscope components Culture-related concepts, language Cultural Assessment 3-5 barriers Communication: Verbal, nonverbal, communication traps, empathy, positioning for the interview, components of the health Interview and Complete Health 8 - 11 history, review of systems, signs vs. History symptoms, accurate documentation of past health and childhood illnesses, open-ended and close- ended questions Components of a general survey, normal range of findings, stature, General Survey and Measurement 3-5 build, contour, proportion, mobility, BMI ranges, changes in the older adult Vital signs interpretation, vital signs assessment methods, appropriate BP Vital Signs 7 - 10 cuff size, procedures for obtaining vital signs, abnormal and normal findings. Tools to assess pain, pain in older adults, pain scales, assessing pain Pain 4-6 quality, sources of pain, physiologic changes due to pain. Normal versus abnormal findings, terminology, expected and unexpected findings, developmental changes, shapes and configuration of lesions, patient teaching, functions Skin, Hair, and Nails 8 - 12 of the skin, classification of skin lesions, subjective data, documenting subjective and objective findings, terms for common skin symptoms, color changes in light and dark skin Terminology, Lymph node assessment, names and locations, range of findings, lifespan changes, Head, Neck, and Regional assessment of the thyroid, abnormal 8 -12 Lymphatics thyroid findings, subjective data, objective data/rationale, normal range of findings, abnormal findings, bruits Metric, household, fractions, decimals, apothecary, conversions Unit Conversions 3 -5 between and within systems of measure.  objective data/rationale, normal range of findings, abnormal findings, bruits Metric, household, fractions, decimals, apothecary, conversions Unit Conversions 3 -5 between and within systems of measure. Evidence-Based Practice/Assessment SBAR – verbal/written communication tool that helps sum up essential/concise information to relay to other healthcare providers. Often used in critical situations. Situation – brief description of pertinent patient variables, demographics, clinical diagnosis and location Background – provide pertinent history as it directly relates to the patient Assessment – state pertinent assessment findings obtained with interpretation of data Recommendation – state what you need or want for the patient in terms of medical treatment and/or assistance SOAP Subjective – history/information obtained from patient, their explanation for why they’re seeking care Objective – exam findings/vital signs Assessment – diagnoses Plan – plan of care/interventions QSEN – quality and safety education for nurses project designed to prepare future nurses with the knowledge and skills necessary to improve patient care and health care environments in which they work Patient-centered care Teamwork and collaboration Safety Evidence-based practice Quality improvement Informatics Priority problems First-level priority problems – emergent, life-threatening, immediate (like establishing airway) Second-level priority problems – next in urgency, require prompt intervention to forestall further deterioration (mental status change/acute pain/risk to safety/etc.) Third-level priority problems – important to the patient’s health but can be handled after more urgent health problems are addressed first. May require collaboration between patient and healthcare professionals. Types of Databases Complete or Total Health Complete health history and full physical examination Described current and past health state and forms baseline for all future changes Usually collected in primary care setting Also collected upon admission to the hospital Focused or Problem-Centered Limited or short-term problems Smaller database and more targeted to main concern/issue at presentation Used in all settings – hospital, primary, long-term, etc. Follow-Up Status of formerly identified issue is evaluated, any changes are noted Used in all setting to follow up both short-term and chronic health concerns Emergency Urgent/rapid collection of crucial information and is usually combined with lifesaving measures Used primarily in ED or field settings, can come from patient or family/friends/caretakers as needed After patient is stabilized a more thorough database is collected Subjective vs. Objective Findings and Data Subjective = information obtained from the patient/caretaker Think “subject” you need to learn Includes ROS, patient’s history/chief complaint Descriptions of pain (headache/ear ache/abdominal pain etc) Objective = information that you can interact with (see/smell/taste/touch/hear/palpate) Think “object” you can interact with Includes physical exam findings and vital signs Tenderness Nursing Process Assessment Recognizing cues Diagnosis Analyzing cutes Planning Prioritizing hypothesis Generating solutions Implementation Taking action Evaluation Evaluating the outcomes of your interventions Palpation Technique Fingertips – best for fine discrimination like skin texture/edema/presence of lumps Grasping with fingers and thumb – detecting position, shape and consistency of organ/mass Dorsa – best used for temperature discernment by placing dorsal surface of hands on forehead or extremities Base of fingers/ulnar surface of hand – best for vibration Auscultation Technique/Stethoscope Components Use stethoscope to listen to sounds produced by the body like lungs, abdomen, heart, blood vessels Diaphragm – large, flat edge. Best for high pitched sounds like breath, bowel and normal heart sounds. Press diaphragm firmly to person’s skin. Bell – smaller end piece that is deep, hollow and cuplike. Best for soft, low-pitched sounds like extra heart sounds/murmurs. Hold lightly against the skin to make a seal. Holding too tight makes it act like diaphragm. Quality – subjective difference caused by the overtone of a sound Pitch – frequency or number of vibrations per second Amplitude – intensity or how loud/soft the sound Inspection Concentrated watching. Close, careful scrutiny of patient as a whole and then of each body system. It starts the moment you first see the patient. Look for things like gait, facial expression, symmetry, skin concerns and then later in exam use in conjunction with tools like otoscope, ophthalmoscope, penlight, etc to look for any abnormalities. Percussion – tapping the patient’s skin with short, sharp strokes to assess underlying structures. The strokes yield audible vibrations with characteristic sounds that depict the location, size and density of the underlying organ. Keep one hand over area to percuss and lift all digits except middle finger off the patient. Use striking hand to tap the middle finger of resting hand. Percuss each area 2x and listen for sound produced. assessment equipment proper use Assessment Equipment Stethoscope – use to listen for body sounds Penlight – used to assess pupils or gain closer inspection of skin or ear/nose Platform scale with height attachment – get patient height and weight Sphygmomanometer – blood pressure cuff Thermometer Tympanic – ear, uses infrared scanning Temporal – take across forehead, uses infrared scanning Oral Rectal Disposable Pulse oximeter – obtain oxygen saturation and heart rate Otoscope/ophthalmoscope Tools for evaluating ears and eyes Culture Related Concepts Culture is a complex phenomenon that include attitudes, beliefs, self-definitions, norms, roles and values  Basic characteristics: Learned from birth through process of language acquisition and socialization Shared by all members of the same cultured group Adapted to specific conditions related to environmental and technical factors and to the availability of natural resources Dynamic and always changing Acculturation - is the process of adopting the culture and behavior of the majority culture Assimilation – immigrant taking on the characteristics of the dominant culture Religion and Spirituality Spirituality – connection/belief in something larger than ones self Religion – organized system of beliefs concerning the cause, nature and purpose of the universe and attendance of regular services Healing and Culture Biomedical / Scientific – all events in life have cause and effect; germ theory is the process of adopting the culture and behavior of the majority culture Naturalistic / Holistic – most frequently in Native Americans, Asians and others that believe that human life is only one aspect of nature and a part of the general order of the cosmos. Yin/Yang theory – health exists when all aspects of the person are in perfect balance Hot/cold theory – explanatory model with origins in the ancient Greek humoral theory (4 humors = blood, black bile, yellow bile and phlegm) regulate basic bodily functions and are described in terms of temperature, dryness and moisture and treatment is determined by adding/subtracting those things as needed. Magicoreligious – belief in the supernatural or spiritual cause of illness Language Barriers Use of medical interpreters required for any language barrier Cannot use lay people or non-medical people for interpretation Do not rely of family to translate Communication: Verbal: Words spoken, vocalizations, tone of voice Non-Verbal: Body language, posture, gestures, facial expression, eye contact, foot tapping, touch, chair placement etc. Communication Traps – nonproductive verbal and nonverbal messages. Providing false assurance/reassurance: Don’t provide comfort you’re not sure is factual. Instead, acknowledge the patient’s feelings and give them a safe place to communicate. Example: Patient – “I haven’t felt my baby kick in hours. I just know that I’m miscarrying.” You – “Don’t worry – I’m sure everything will be okay.” Instead try - “You’re really worried about your baby aren’t you? It must be hard waiting for the doctor. Is there anything I can get you or anything you’d like to talk about while you’re waiting?” Giving Unwanted Advice: Don’t provide unwanted to unwarranted advice with it should be avoided. If advice you’re about to give is based on a hunch or a feeling – don’t. Example: You – “If I were you… I would do what the doctor recommended.” Any “If I were you” statements are likely unwanted advice. You are not that person, so you cannot make decisions for them. Using Authority: “Your doctor/nurse knows best.” – promotes dependency and inferiority. Downplays client’s concerns. Invalidates feelings. Using Avoidance Language: Use of euphemisms to avoid tough topics like “he’s in a better place” instead of stating “he has died.” – Approach difficult topics like this head-on, with clear language. Distancing: Use of impersonal speech to put space between a threat/negative thing and yourself. “There is a lump in the left breast.” vs “There is a lump in YOUR left breast.” This can communicate fear of the procedure or the disease so the patient rather than comfort them. Using Professional Jargon: Use of medical terminology can be scary, intimidating or come across as rude for patients, so use words that they will understand. It can also cause misunderstandings which may interfere with care.  Example: “Hypertensive” – can be taken to mean tense or stressed by a patient who is not familiar. Say “high blood pressure” instead. Using Leading or Biased Questions: Don’t phrase questions in a way that makes the patient believe one answer is better than another. Phrase things in an open and unbiased manner to encourage them to respond truthfully. Example: “You don’t smoke do you?” – this implies that smoking is bad and you’re far more likely to get a lie from the patient rather than phrasing it like “Do you smoke?” which is unbiased and may lead to a more truthful response. Talking Too Much: Don’t spend more time talking than you do listening. Your patient should have ample time to speak and provide you with material and questions for further conversation. Interrupting: Even if you feel you know what the patient is going to say next, make it a point to not interrupt them. Let them speak. Interrupting is rude and may make the patient believe that you are in a rush or that speaking to them is not your current priority. Using Why Questions: Do not use why questions because it tends to imply blame. Example: “Why did you wait so long before seeking medical care?” – implies that they were wrong in waiting. Try: “I see that this pain started several hours ago. What was happening between the time the pain started and the time that you arrived in the ER?” – this not only gives you a better picture of the timeline of events but also does not make the patient feel as though you are blaming them/shaming them for waiting to seek care. Empathy – means viewing the world from the other person’s inner frame of reference while remaining you. It’s recognizing and accepting the other person’s feelings without criticism. The ability to understand and be sensitive to the feelings of others and understand how they perceived the world. Positioning for the Interview Make sure the room temperature is comfortable Have sufficient lighting Make sure the room is private and secure. Have the room be quiet and without distractions. Remove unnecessary equipment from the room. You and the client should be 4-5 feet apart. Set up equal-status seating – you should be eye-to-eye with the patient; no desk or barrier between you and the patient Avoid standing over the patient whenever possible Dress professionally and appropriately Weight the pros/cons of note-taking during the exam and only write down the necessary information during the interview, fill in the rest later Questions: Open-ended: asks for narrative information; allows the patient to freely answer any question; these are unbiased questions and allow for full expression. Make eye contact, encourage the patient to keep speaking by nodding your head or saying things like “mhm – keep going”; use body language to convey your interest in what the patient is saying Close-ended: also called direct questions, allow the patient to provide 1-2 word answers. This is good when specific questions need to be answered in an emergency or when time is an issue so that you can keep the interview concise. Ask only 1 direct question at a time Use language that the client understands Components of the Health History Biographic data – basic information like name, address, number, age, DOB; birthplace, gender and pronouns, relationship status, race, ethnic origin and occupation. Source of history – record who is giving the information, judge how reliable the information is that is given, note whether the person appears well or ill Reason for seeking care – chief complaint and usually a brief  description in the patient’s own words of the reason for their visit History of present illness (HPI) – can be a short statement about general state of health but if the patient is ill or inured it should be a more detailed telling of what brought them to the ED and should include: Location – location of symptoms, injury, illness etc Character or Quality – description of the complaints, is pain sharp, dull, aching, throbbing, does the pain radiate, is it worse with movement or inspiration, etc. Quantity or severity – attempt to quantify the symptom, can use the pain scale (chest pain 6/10) or describe in words like moderate, severe, mild, minimal or descriptions of how it affects their ADL’s like unable to walk because I’m doubled over in pain, unable to weight bear Timing (Onset, Duration, Frequency) – when did the symptoms start, how long do they last, are the constant or intermittent, do they wax and wane, have they been presents for minutes or hours or days or years, how often do the symptoms occur, do they ever fully resolve Setting – what were they doing at onset of symptoms Aggravating or Relieving Factors – does anything make the symptoms better or worse? Does weather affect the symptoms? Are there any foods that make it worse or medications that make it better? Associated Factors – these are symptoms that may be related to the chief complaints, for example if a patient is complaining of chest pain they might have associated dizziness, lightheadedness, arm pain, neck pain, nausea or vomiting Patient’s perception – you can find out the meaning of the patient’s symptoms by asking how it affects their ADL’s and what it means to them Can organize pain questioning with the PQRSTU method if you want, especially when it pertains to pain P – Provocative or Palliative – what brings it on, what were you doing when it started? What makes it better or worse? Q – Quality or Quantity – describe the pain? R – Region or Radiation – where is the pain and does it radiate? S – Severity Scale – on a scale of 0-10 how bad is it? Has it changed? T – Timing – how did it first occur? How long does it last? How often does it occur? U – Understanding – what do you think it means? Past history – events important because they may have residual effect on the current health of the patient, previous experience with illness may also help you see how a patient responds to illness Include: Childhood illness, accidents/injuries, serious or chronic illnesses, hospitalizations, surgeries, OBGYN history, immunizations, date of last exam, list of allergies. Medication reconciliation – this should also be done. Compile a list of patient’s current medications and compare to previous list (done at every hospitalization and clinic visit). Document the name, dose and schedule for each medication Check for patient compliance Ask about non-prescription meds like any OTC medications they take regularly or natural remedies/supplements/vitamins You can ask about substances here (alcohol/tobacco use/vaping/illicit drug use) Family history – an accurate family history highlights disease and conditions for which a patient may be at increased risk genetically A pedigree or genogram can be completed Record medical condition of each relative and their relationship to the patient Age, cause of death, chronic illness, tobacco use/alcohol use - addictions, mental health history Ask about specific diseases such as: strokes, CAD, breast/ovarian cancer, colon cancer, kidney disease, sickle cell, HTN, obesity, arthritis, allergies, diabetes, seizures, TB, etc. ROS – evaluate past and present health state of each body system, double-check in case any significant data was admitted from present illness section, evaluate health promotion practices Usually done in head-to-toe order, only most common symptoms of each body system are listed Medical terms used here but should be voiced to patient in non-medical terms  Record presence or absence of findings – not “negative” This is SUBJECTIVE only – do not include objective data or physical exam findings here General overall health Skin, hair, nails Head Eyes Ears Nose/sinuses Mouth/throat Neck Breasts Axilla Respiratory system Cardiovascular system Peripheral vascular system GI Urinary system Genital Male or Genital Female Sexual health Musculoskeletal System Neurologic System Hematologic System Neurologic System Endocrine System Signs vs Symptoms Signs – objective abnormality that you as the examiner could detect on physical examination or through diagnostic testing Tachycardia, tachypnea, fever Symptoms – subjective sensation that the patient feels from whatever their disorder is Chest pain for 2 hours, sinus pressure for 3 days, tugging at her ears last night, etc. General Survey: The study of the whole person, their general health state and any obvious physical characteristics. Components of a general survey: Physical appearance Age – appears stated age Abnormal finding – appears older than stated age or delayed/precocious puberty Sex - sexual development appropriate for sex and age, if transgender note the stage of transformation Level of consciousness - Person should be alert, oriented to person, place, time and situation. Should respond appropriately to questions. Abnormal finding – confused, drowsy, lethargic, not fully oriented, doesn’t answer questions appropriately Skin color – color tone should be even, pigment may vary with genetic background, skin should be intact with no obvious lesions, note any tattoos/piercings and their stage of healing Abnormal finding – pallor, cyanosis, jaundice, erythema, presence of lesions Facial features – symmetric at rest and with movement Abnormal finding – immobile, masklike, asymmetric, drooping, etc. Overall appearance – no signs of acute distress Abnormal finding - Cardiac or respiratory signs— Diaphoresis, rubbing or clutching the chest, short- ness of breath, wheezing. Pain, indicated by facial grimace, holding body part. Body structure  Stature – height appears WNL for age, genetic heritage Abnormal finding – overly tall or short, abnormalities in body height or proportion Nutrition status – weight appears WNL for height and body build, fat distributed evenly Abnormal finding – cachectic/emaciated, simple obesity – with even fat distribution, centripetal obesity – fat concentrated in face, neck, trunk with thin extremities Symmetry – body parts look = bilaterally and are in proportion to each other Abnormal finding – unilateral atrophy or hypertrophy, asymmetric location of body part Posture – should stand comfortably erect for age, “plumb line” connecting ear through anterior shoulder, hip, knee and ankle. Exceptions – toddler, lordosis (protuberant abdomen) or elderly – stooped with kyphosis Abnormal finding – rigid spine/neck; moves as one unit (pain/arthritic). Stiff and tense, ready to spring from chair/fidgety (anxiety). Shoulder slumped – looks deflated (depression). Position – person should sit comfortably with arms relaxed at sides and head turned to examiner Abnormal finding - Tripod – leaning forward with arms braced on chair arms or thighs (chronic pulmonary disease), Sits straight up and resists lying down (heart failure). Curled up in fetal position (abdominal pain). Body build/contour – proportions are 1. Arm span = height, 2. Body length from crown to pubis roughly = length from pubis to sole Abnormal finding – elongated arm span (Marfan syndrome) Obvious physical deformities – note any congenital or acquired defects Abnormal finding – missing extremities or digits, webbed digits, shortened limbs Mobility Gait – feet approximately shoulder width apart, steady, accurate foot placement, can maintain balance without assistance, associated movements like arm swing present and symmetric Abnormal finding – wide base, staggering, stumbling, shuffling, dragging, nonfunctional leg, limping due to injury, propulsion issues – difficult stop/start of ambulation Range of motion – note full mobility for each joint and that the movement is deliberate, accurate, smooth and coordinated. No involuntary movements. Abnormal findings – limited joint ROM, paralysis – absence of movement, jerky/ uncoordinated movement, unintentional movement – tics, tremors, seizures Behavior Facial expression - The person maintains eye contact (if culturally appropriate); expressions are appropriate to the situation (e.g., thoughtful, serious, or smiling). Note expressions both while the face is at rest and while the person is talking. Abnormal finding – flat, depressed, angry, sad, anxious (although this can be common at the doctor) Mood and affect - The person is comfortable and cooperative with the examiner and interacts pleasantly. Abnormal finding – hostile, distrustful, suspicious, crying Speech - Articulation (the ability to form words) is clear and understandable Abnormal finding – dysarthria/dysphagia, speech defect, monotone, garbled speech. Speech pattern - The stream of talking is fluent with an even pace. The person conveys ideas clearly. Word choice is appropriate for culture and education. Communicates in prevailing language easily with the provider or an interpreter. Abnormal finding - Extremes – speaking few words or nonstop talking. Dress - Clothing is appropriate to the climate, looks clean and fits the body, and is appropriate to the person’s culture and age-group (e.g., Indian women may wear saris). Culturally determined dress should not be labeled as inappropriate by Western standards or adult expectations. Abnormal finding – clothing too large/held up by belt (new holes in belt) suggesting weight- loss, clothing too tight may suggest weight gain or ascites, consistent wear of clothing may give clues – like long sleeves to hide tracks or self-harm or thin arms from anorexia, velcro instead of buttons may show motor dysfunction Personal hygiene - The person appears clean and groomed appropriately for age, occupation, and socioeconomic group. (Note that a wide variation of dress and hygiene is “normal.” Many cultures do not include use of deodorant or women shaving legs.) Hair is groomed, brushed. Makeup is appropriate for age and culture.  Abnormal finding – body odor/alcohol smell, unkempt appearance in person who had previously good hygiene may mean depression/malaise/illness BMI – practical marker of health weight for height and an indicator of obesity or malnutrition; used to guide patient progress toward healthy weight. Calculation: Ranges: Changes in the Older Adult: Expect body contour to be sharper, with more angular facial features Body proportions redistributed – fat redistributed to waist, muscle loss especially in extremities Kyphosis (humpback) is an expected finding Gait – usually a wider base due to decreased balance, arms may be held out to increase balance and steps may be shorter or uneven Vital Signs Temperature Body maintains a steady temp through feedback mechanism regulated by the hypothalamus of the brain Average body temperature is 97.7F, anything over 100.4F is considered a fever. On Celsius scale 37C is normal and 37.8C is considered a fever. Temp affected by: Time of day Menstruation cycle in women Exercise Age Temp Measuring Techniques: Oral – most convenient/commonly used. Sublingual pocket has rich blood supply from carotids. Place thermometer at base of the tongue in either posterior sublingual pockets and have patient close lips around thermometer. If patient has eaten recently, wait at least 15 minutes before taking a reading. If patient has smoked recently, wait t least 30 minutes. If patient has drank cold liquids, wait 10-15 minutes and if they’ve drank hot liquids, wait 25 minutes. Rectal – most accurate route, results is closest to core temperature. More invasive than other methods. Position patient in left lateral decubitus, wear gloves, use thermometer cover, apply lubricant to probe, insert 2-3 cm into rectum directed toward umbilicus. In infants, insert probe about 0.5 inches. Do not let go of probe while it is in the rectum. Remove after reading is complete. Clean patient and reposition for comfort. Tympanic Membrane – shares same blood supply as hypothalamus so it is an accurate measurement of core temperature. Minimally invasive and easily accessible. Uses infrared reading of the ear drum. For adults, pull pinna up and back and place probe tip in ear. Leave in place until it beeps. For children, pull pinna down and place probe tip in ear. Leave in place until it beeps. Ear infections can alter results. Temporal Artery – Easily accessible and minimally invasive. Least accurate. Uses infrared  emissions. Slide the probe across the forehead and behind the ear. It takes multiple infrared readings and then provides the temperatures. Pulse Every heart beat pumps an amount of blood (stroke volume) into the aorta. The force flares the arterial walls and generates a pressure wave that is felt as the pulse. Feeling the pulse gives information on rate and rhythm of heartbeat and local data on condition of artery. Use the pads of 1-3 fingers on a pulse point, like radial pulse. If rhythm feels regular, count for 30 seconds and multiply by 2. If rhythm is irregular count for full 60 seconds. Adult pulse should be 50-95 BPM; below 50 BPM = bradycardia, above 95 BPM = tachycardia. Well-trained athletes have naturally lower heart rates so less than 50 BPM may be normal for them, it may also be normal for people taking certain heart medications. Tachycardia can occur with fever/illness. Children’s normal heart rates -> Rhythm – should be regular, even tempo. Abnormal rhythms are called arrythmias. Force – shows the strength of the hearts stroke volume. Rated 0 to 3+. Respirations Normal breathing is relaxed, regular, automatic and silent. Do not mention that you’re counting respirations as patients may alter their breathing when awareness is brought to it. Recommend that you keep acting like you’re counting the pulse and when finished start counting the respirations. Should count respirations for at least 60 seconds. If having a hard time seeing chest rise, you can place a hand on their chest/back/shoulder or watch their abdomen. Adult respiration range is 16-25 RPM. Tachypnea is rapid respiratory rate, any rate above 25/min. Bradypnea is a slow respiratory rate, any rate below 8-12/min depending on source. Children respiration range is higher than adults. Newborns 30-50 RPM. It slows as they age and after 8 years old should have more similar range to an adult. Blood Pressure BP is the force of the blood pushing against the side of the cell walls. The strength of the push changes with the event in the cardiac cycle. Systolic BP – maximum pressure felt on the artery during left ventricular contraction (systole) Diastolic BP – elastic recoil or resting pressure that the blood exerts constantly between each contraction Pulse pressure – difference between the SBP and the DBP and reflects the stroke volume. Mean Arterial Pressure (MAP) – the pressure forcing blood into the tissues averaged over the cardiac cycle. Measuring BP: Manual: BP measured using sphygmomanometer and stethoscope. Choose appropriately sized cuff (too loose – false low BP reading, too tight – false high BP reading). Make sure the patient has rested at least 5 minutes. Have patient either seated with feet flat on the ground and arm resting on flat surface, or patient lying flat with legs uncrossed and with arm resting beside them or patient standing with arm at rest. Feel for brachial artery. Keep fingers on brachial artery, pump up cuff until you no longer feel the brachial artery and note the mmHg that happened. Release pressure. Wait at least 30 seconds. Place stethoscope at location you felt brachial artery. Pump up cuff to 20-30 mmHg above where you lost palpation of the brachial artery. Then slowly release the valve. Note where you heart first return of beat (SBP). Continue listening until you hear loss of beat (DBP). Automatic: Place appropriately sized cuff and let machine run until it provides you with readings. Review for apparent accuracy. Always double check with manual reading if there is any abnormality noted. BP varies with many factors: Age – normally a gradual rise occurs through childhood into adulthood Sex – before puberty, no difference. After puberty, females usually have a lower BP reading than males. After menopause, BP is normally higher than males in their age group. Race – Black people have higher prevalence of HTN, as do Hispanic males. Social determinants – those with lower socioeconomic status tend to have higher BP’s  Diurnal rhythm – BP highest in late afternoon/early evening and declines to early morning low Weight – BP higher in overweight individuals Exercise – increasing activity = proportionate BP increase Emotions – stress, anger, pain can raise BP Stress – people who feel continual tension have higher BP BP Determined by these 5 factors -> Orthostatic vital signs may be requested if you suspect volume depletion, when person is taking antihypertensives, when person reports syncope or near syncope. Collect these by having patient rest supine for 3 minutes – take a BP reading. Help them sit up and assess BP and pulse. Then have the patient stand, and assess BP and pulse. After standing for 3 minutes, again assess BP and pulse. A slight decrease in SBP when going from sitting to standing is expected (6 mm Mole (nevus) – clump of E – elevation/evolution if melanocytes, tan to brown changes appearance color, flat or raised, single F – “funny looking” stands uniform pigmentation. out as looking different from rest of lesions Birthmarks – may be tan to brown in color Absence of luster of Pallor – red-pink tones underlying red tones. from oxygenated Brown-skinned people Widespread color changes hemoglobin is lost and show yellowish-brown – should not have any Generalized pallor skin looks more like color and black-skinned significant color change connective tissue (mostly people appear ashen or over entire body. Mottling or localized white). Common in high- grey. Look at mucous pallor stress states, cold membranes, lips and nail environment, cigarette beds. smoking and edema. Cool to touch. Erythema – redness of the skin from excess blood in the dilated superficial Unable to visualize capillaries. Expected with erythema in dark-skinned Red or bright pink. fever, local inflammation people, need to palpate for or emotional reactions. heat and swelling. Associated with increased temperature in the area. Can be normal to have bluish tone on lips of dark- skinned Mediterranean Cyanosis – bluish mottling people color from decreased  or emotional reactions. heat and swelling. Associated with increased temperature in the area. Can be normal to have bluish tone on lips of dark- skinned Mediterranean Cyanosis – bluish mottling people color from decreased perfusion. Tissues have Difficult to observe in deoxygenated blood. Best Dusky blue color darkly pigmented people, seen in lips, nose, cheeks, check conjunctiva, oral ears and oral mucous Nail beds dusky mucosa. membranes. May need to look for associated signs like change in level of consciousness and respiratory distress. Jaundice – yellowish skin Check sclera for yellow all color indicates rising the way to iris, don’t Jaundice is normal in levels of bilirubin in the Yellow sclera, hard palate, mistake normal fat newborn at roughly 3 days blood. First noted in mucous membranes and deposits for jaundice. of life. junction of hard and soft then skin Check hard and soft palate palate in mouth and sclera, and palms. then eyes appear yellow. Temperature – skin should be warm to touch and equal bilaterally. Hands and feet may be slightly cooler in cold environment. Diaphoresis – profuse Moisture – appears perspiration normally on face, hands, May appear dry and flaky axillae and skinfolds in Dehydration – can be but does not necessarily response to activity, heat found in the oral mucous indicate dehydration. or anxiety membranes. Normally they look smooth and moist. Smooth and soft like velvet – likely Texture – smooth and firm hyperthyroidism with even surface Rough, dry, flaky – can be hypothyroidism Thickness – should be uniform across skin Very thin and shiny – although thickened callus usually occurs with arterial areas are normal on palms insufficiency and soles. Edema – fluid accumulation in interstitial spaces. Check by pushing thumb into skin and looking for retention of the dent. Masks normal skin Makes skin appear paler. color. Obscures pathologic conditions like jaundice/ cyanosis because fluid lies between the surface and pigmented/vascular layers. Mobility decreased with  although thickened callus usually occurs with arterial areas are normal on palms insufficiency and soles. Edema – fluid accumulation in interstitial spaces. Check by pushing thumb into skin and looking for retention of the dent. Masks normal skin Makes skin appear paler. color. Obscures pathologic conditions like jaundice/ cyanosis because fluid lies between the surface and pigmented/vascular layers. Mobility decreased with edema – won’t lift easily. Mobility and Turgor – pinch large fold of skin Turgor decreased if under clavicle. Should lift “tenting” occurs and skin easily and return to place does not return to normal promptly. quickly. Evident in severe dehydration. Developmental Changes Infants General Coloration/Pigmentation Black newborns typically born with lighter-toned skin than parents that later develops Mongolian spot – common variation of hyperpigmentation in Black, Asian, Native American and Latino newborns Blue to black to purple macular area at sacrum/buttocks and occasionally abdomen, thighs, shoulders or arms. Gradually fades. Café au lait spot – large round or oval patch of light brown pigment, normally present at birth. Normal finding unless 6+ of them are found and are more than 1.5 cm in diameter, then they can be diagnostic of neurofibromatosis. At birth – normally beefy red flush for 24 hrs Harlequin color change – distinct line of red/pale color down midline or horizontal. ½ body red and blanches. Transient and self-resolves. Erythema toxicum – common rash appears in first 3-4 days of life. AKA flea bite rash or new born rash. Tiny punctate red macules and papules on cheeks, trunk, chest, back and buttocks. No treatment needed. Acrocyanosis – bluish color around lips, hands, fingernails, feet and toenails. May last few hours and disappear on its own. Cutis marmorata – transient mottling of the trunk and extremities in response to cooler room temperatures. Forms reticulated red or blue pattern over skin. Disappear on own. Physiologic jaundice – normal in about ½ of all newborns. Yellowing of skin, sclera and rd th mucous membranes that develops at 3 -4 day of life. Carotenemia – yellow-orange color in light-skinned person but no yellowing of sclera or mucous membranes due to ingesting large amounts of carotene. Infants Moisture Vernix caseosa – moist, white, cream cheese-like substance that covers part of skin in all newborns. If green-tinged, meconium staining. Infants Texture Milia – tiny white papules on the forehead, eyelids, cheeks, nose, chin caused by sebum. Resolves on its own.  Infants Thickness/Mobility/Turgor Normally thin epidermis with some well-defined areas of SQ fat. Skin dimples over joints but no breaks in skin are normal. Test mobility and turgor over the abdomen (poor turgor or tenting = dehydration) Vascularity or Bruising Nevus simplex – aka salmon patch or stork bite – flat, irregularly shaped red or pink vascular patch on forehead, eyelid or upper lip but most common on face and back of next. Present at birth and normally fades in first year. Infant Hair Skin covered in fine hair called lanugo. Darker skin = more lanugo. Scalp hair may be lost in a few weeks after birth, especially at temples and occiput. Grows back slowly. Infant Nails Nail beds may be blue for first few hours, then turn pink. Adolescents Skin Acne – most common skin issue in adolescence. Most teens have at least a mild form of closed comedones (whiteheads) and open comedones (blackheads). Severe acne includes papules, pustules and nodules. Normally appear on face and sometimes chest, back, abdomen and shoulders. Show after start of puberty. Pregnancy Striae (stretchmarks) – jagged linear marks of silver-to-pink color that appears during the nd 2 trimester on the abdomen, breasts and sometimes thighs. Fade after delivery but do not disappear. Change in hormones may cause color changes. Linea nigra – brownish-black line down the midline of the abdomen. Chloasma – irregular brown patch of hyperpigmentation on the face. Vascular spiders – tiny red centers with radiating branches that occur on the face, neck, upper chest and arms. Aging Adult Skin Color/Pigmentation Solar lentigines – aka liver spots – common circumscribed clusters of melanocytes due to chronic sun exposure. Small, flat, brown macules that appear on dorsa of hands, forearms, face, upper trunk and skins. Lesions benign. Keratoses – raised, thickened areas of pigmentation that look crusted/scaly and warty. Seborrheic keratosis – looks dark, greasy and stuck on. Develop mostly on trunk but also face, hands and sun exposed areas. Do not become cancerous but may be irritated by friction/trauma. Actinic keratosis – most frequent pre-malignant skin lesion in White people. Caused by sun/artificial UV. Red-tan, scaly plaques that increase over the years to become raised and roughened. Occur on sun exposed areas and may develop into squamous cell carcinoma. Aging Adult Moisture Dry skin (xerosis) common in the aging person because of a decline in the number and output of the sweat glands and sebaceous glands. Skin is itchy and looks flaky/loose. Aging Adult Texture Acrochordons – aka skin tags – are overgrowths of normal skin that form a stalk and are polyp-like. They occur frequently on eyelids, cheeks, neck, axillae and trunk. Sebaceous hyperplasia – raised yellow papules with central depression, more common in men. Occur on forehead, nose or cheeks. Pebbly appearance. Aging Adult Thickness/Hair/Nails/Mobility/Turgor Skin thins, SQ fat decreases. Loss of collage leads to tears or other injury. Amount of hair decreases in axilla and pubic areas. After menopause women may develop hairs on chin/ upper lip. Men develop hair in the ears, nose and eyebrows. Male pattern balding/alopecia occurs – usually starts as receding hairline. Scalp hair gradually turns gray. Nail growth decreases and local injuries to the nail matrix make longitudinal ridges. Surface may be  prattle or peeling/sometimes yellow. Toe nails thicken and may grow misshapen. Skin turgor decreases and skin tents more easily. Common Shapes and Configurations of Lesions Primary Skin Lesions Secondary Skin Lesions Pressure Injuries (PI) Pressure Injuries – typically appear on the skin over bony prominences when circulation is impaired like when patient is immobile. Risk factors: Impaired mobility, impaired level of consciousness, impaired sensation, moisture secondary to incontinence/excessive sweating/wound drainage, shearing injuries, poor nutrition, infection and use of vasopressors. Common Abnormal Skin Findings - Hemangiomas Common Abnormal Skin Findings – Vascular Lesions Common Abnormal Skin Findings – Lesions in Children Common Abnormal Skin Findings – Lesions  Malignant Skin Lesions Abnormal Hair Conditions Abnormal Conditions of the Nails Patient Teaching Patient should be educated on the importance of health promotion in skin care. Advise patient to use sunscreen and protect selves from the sun with clothing during outdoor activities. Discourage need for tanning, especially use of tanning beds. Teach self-skin-examinations (SSE). Teach patients the ABCDEF rule. The Head, Face, Neck and Regional Lymphatics Skull -rigid bony structure that protects the brin and special sensory organs Skull includes bones of the cranium: Frontal Parietal Occipital Temporal Cranial bones joined together by sutures (coronal, parietal, sagittal, lambdoid) There are 14 facial bones – aid the face in making expressions with muscles and facial nerves Eyebrows, eyes, ears, nose and mouth should appear symmetric at rest and move symmetrically Cranium supported by cervical vertebrae, axis (C2) and atlas (C1) Inside the skull the brain is held by membranous meninges – they support the brain and act as shock absorption There are two pairs of salivary glands, parotid glands, sublingual glands and submandibular glands. Infants Neonatal skull is separated by sutures and fontanels where sutures intersect. Soft spots allow for st growth and gradually ossify over the 1 year. Fontanels should be soft and flat. If they’re depressed or bulging it can mean dehydration or infection. Note infant head posture and head control as well as tonic neck reflex. During fetal period, head growth predominates. Head size is greater than chest circumference at birth. Head measures 32-38 cm at birth and should be 2 cm larger than chest circumference. Caput succedaneum – edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma that gradually resolves in a few days.  Cephalhematoma – subperiosteal hemorrhage which is also the result of birth trauma. Soft, fluctuant and well-defined over one cranial bone because it holds the bleeding in place. Appears hours after birth and increases in size and may take months to dissipate. Aging Adult Facial bones and orbits appear more prominent in the face, SQ fat decreases, skin sags due to decreased elasticity Objective Findings Assess shape by placing fingers along scalp. Should be no tenderness. No bogginess. No lumps, depressions or abnormal protrusions. Head normocephalic = round symmetric shape, no abnormalities noted Microcephaly = small head Macrocephaly = large head Palpate temporal artery. Should be no tenderness. Palpate TMJ. Should be no crepitus with normal ROM and no tenderness. Facial structures should be even with a calm and relaxed expression. Note any abnormalities. Pediatric Head Abnormalities Facial Abnormalities Neck Supports the skull and houses a number of blood vessels, muscles, nerves, lymphatics, respiratory and digestive organs. Blood vessels include the common and internal carotid arteries and their associated veins. Internal and external jugular veins. Major neck muscles include the sternomastoid (which rotates and flexes the head) and the trapezius (which moves the shoulders and extends and turns the head) which are innervated by cranial nerve XI. The sternomastoid divides the side of the neck into the anterior triangle and the posterior triangle. Anterior triangle – lives in front, between the sternomastoid and the midline of the body with its base along the lower border of the mandible and its apex down to the suprasternal notch. Posterior triangle – behind the sternomastoid muscle, with the trapezius muscle on the other side and its base long the clavicle below. Thyroid gland – endocrine gland with rich blood supply. Straddles the trachea in the middle of the neck. Synthesizes T4 and T3, which stimulate cellular metabolism. Gland as 2 lobes, conical in shape. Evaluate for swelling. Tilt head back to stretch the skin against thyroid and look at neck as person swallows Thyroid tissue should move up with swallow and fall into resting place. Look for diffuse enlargement. Posterior approach: Stand behind patient. Bend head slightly forward and to the right. Palpate the thyroid gland by lightly displacing it with the left hand and palpating along the right side and ask them to swallow. Palpate looking for asymmetry, palpable nodes or swelling. Then repeat the opposite way. Anterior approach: Stand facing the patient. Place the thumb 3 cm below the thyroid cartilage prominence as patient swallows. Then ask them to tip the head forward and to the right. Use your right thumb to displace the trachea slightly to the persons right. Hook your left thumb and fingers around the sternomastoid muscle. Feel for lobe enlargement or nodes as person swallows. If thyroid gland is enlarged, auscultate for a bruit. Bruit = soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope. Bruit is not a normal finding.  Thyroid Disorders Pregnancy Thyroid gland grows as a result of hyperplasia of the tissue and increased vascularity. Aging Adult May see isolated head tremors Forward curvature of the cervical spine Low lying thyroid glands that are impossible to palpate Objective Findings of the Neck Head position should be centered/midline. Palpate neck muscles for spasm or asymmetry. Check ROM and strength of cervical muscles. There should be no pain, tenderness or palpable spasm. Thyroid should be palpated and checked for enlargement or presence of nodes. Trachea should be midline – palpate for shift. Should be symmetric on both sides. Swelling on Head and Neck Lymphatics 60-70 lymph nodes present in head/neck Drainage patterns of lymph nodes is key for understanding why some are enlarged while others are not Lymphatic system = separate vessel system from the cardiovascular system. Key part of the immune system. Vessels gather lymph from the tissue and return it to circulation. Lymph nodes slowly filter the lymph and engulf pathogens, preventing harmful substances from entering circulation. Infants Lymph tissue is well developed at birth and grows to adult size by 6 yo, lymphatic tissue continues to grow until 10-11 yo, then slowly atrophies with age. Objective Findings of Lymphatic System Use gentle circular motions with fingertips to palpate lymph nodes and glands. Compare both sides at the same time for symmetry, aside from submental which should be 1 handed. If any nodes are palpable document their location, size, shape, delimitation, mobility, consistency and tenderness. Normal nodes are freely movable, discrete, soft and nontender. If they are enlarged check the area that they drain into for other enlarged lymph nodes and attempt to find cause of enlargement. Lymphadenopathy = enlargement of a lymph node >1 cm Headache  Medical Math Cheats Intake and Output Calculations Liquids we eat (Liquid at room temperature) Liquids we drink Jell-o Ice cream Coffee Popsicles (counts as full volume; 4 oz of Juice a popsicle is 4 oz of liquid) Water Ice chips (counts as half the volume; 4 oz Meal supplements (Boost/Ensure) of ice is 2 oz of liquid) Soup only if listed as broth Military Time For your reference, here is a standard time-to-military-time conversion chart: Midnight – 0000 (or 2400) 1:00 a.m. – 0100 2:00 a.m. – 0200 3:00 a.m. – 0300 4:00 a.m. – 0400 5:00 a.m. – 0500 6:00 a.m. – 0600 7:00 a.m. – 0700 8:00 a.m. – 0800 9:00 a.m. – 0900 10:00 a.m. – 1000 11:00 a.m. – 1100 12:00 p.m. – 1200 1:00 p.m. – 1300 2:00 p.m. – 1400 3:00 p.m. – 1500 4:00 p.m. – 1600 5:00 p.m. – 1700 6:00 p.m. – 1800 7:00 p.m. – 1900 8:00 p.m. – 2000 9:00 p.m. – 2100 10:00 p.m. – 2200 11:00 p.m. – 2300