MNU health assessment book final 2023-2024 (1).pdf

Prepared by Medical Surgical Nursing Department Teaching Staff Faculty Members Faculty of Nursing Menoufia University  )23( ‫نًىرج سقى‬...

Prepared by Medical Surgical Nursing Department Teaching Staff Faculty Members Faculty of Nursing Menoufia University  )23( ‫نًىرج سقى‬ ً‫تىصُف يقشس دساس‬ ‫تناء عهً انًعاَُش االكادًَُه انًثنُه عهً انكفاَاخ‬ 3122 ‫اتشَم‬ Menoufia University ‫ انًنىفُح‬:‫جايعح‬ Faculty of Nursing ‫ انتًشَض‬:‫كهُح‬ Medical Surgical Nursing ٍ‫ انتًشَض انثاطنٍ انجشاح‬: ‫قسى‬ :‫تاسَخ اعتًاد انتىصُف‬ : ‫ تُاناخ انًقشس‬-1 1st level/Second semester : ‫ انًستىي‬/ ‫انفشقح‬ : ٌ‫انشيز انكىد‬ Health assessment : ‫اسى انًقشس‬ AHN 1117 --- ً‫تطثُق‬ --- ً‫عًه‬ 2 ‫نظشي‬ :‫عذد انساعاخ انًعتًذج‬ : ‫انتخصص‬ ‫تانًعايم‬ ٍ‫ ساعح) فٍ انفصم انذساس‬----( ٍ‫ تطثُق‬- )‫ ساعح‬----( ً‫ ساعح)– عًه‬41( ‫ نظشي‬:‫عذد انساعاخ انكهُح نهفشقح انثانُح‬ - Aim of the course: 3 Health assessment is a comprehensive course designed to provide the undergraduate nursing students with the knowledge needed in assessing the physical and mental health status of the clients with different age groups. Specific attention is given to bio-psychological and spiritual aspects of the adult clients. Normal and abnormal variations are also addressed. 1  No. of No. of Practical/ : ‫ يحتىٌ انًقشس‬-4 Topic hours lecture tutorial Course Content (theory) (theory) (Hours No.) Introduction to the course  Definition of health assessment 2 1 --- ---  Tools for data collection techniques Eye, ear and nose assessment  Assessment parameters 2 1 --- ---  Interpretation of data Skin, hair and nails assessment  Assessment parameters 2 1 --- ---  Interpretation of data Neurological assessment  Assessment parameters 4 2 --- ---  Interpretation of data Quiz 1 1 --- --- --- Cardiovascular assessment  Assessment parameters 4 2 --- ---  Interpretation of data Respiratory assessment  Assessment parameters 4 2 --- ---  Interpretation of data Gastrointestinal assessment  Assessment parameters 2   Interpretation of data 4 1 --- --- Midterm examination 1 --- --- --- Urinary assessment  Assessment parameters 2 1 --- ---  Interpretation of data Musculoskeletal assessment  Assessment parameters 2 1 --- ---  Interpretation of data Breast assessment  Assessment parameters 2 1 --- ---  Interpretation of data Final exam. 1 Total 30 hours 15 week --- --- 3  Competencies :‫ انًعاَُش االكادًَُه انًثنُه عهً انكفاَاخ‬-4 Domain Competency Key elements Course objectives Course Teaching Media Assessment Outline Methods used or Evaluation 1 1.1 Demonstrate 1.1.1 Demonstrate  Explain the knowledge, utilizing of the legal and ethical understanding, legislative framework Modified and responsibility and and the role of the considerations Applied for Traditional - Powerpoints accountability of the nurse and its in performing a all content lectures presentation legal obligations for regulatory functions. health ethical nursing practice Simulation and - Written assessment. case studies exam  Define health - Simulation assessment and its importance in patients care. 1.1.3 Practice nursing  Explain the based on policies and legal and ethical Applied for procedural guidelines all content Modified and - Powerpoints considering patient/ considerations Traditional presentation client rights. in performing a lectures health - Videos Group assessment. discussion  Explore the main components of the 4  comprehensive health assessment techniques successfully.  Differentiate between subjective and objective data collected during a health assessment. 2 2.1 Provide holistic 2.1.2 Provide holistic  Identify the and evidence-based nursing care that structure and - Powerpoints - Written nursing care in addresses the needs of Simulation and presentation exam different practice individuals, families function of body case studies. settings. and communities systems and Applied for - Class across the life span. all content - Simulation activities changes to detect deviation from normal. Videos  Analyze adult's clinical data, history and examinations 5  which facilitate diagnosis. 3 3.1 Demonstrate 3.1.3 Organize own Modified and effective managerial and  Communicate workload and apply Traditional - Powerpoints leadership skills in the time-management effectively with Applied for lectures presentation provision of quality principles for meeting all health care all content - Written nursing care responsibilities. team members in Group exam inter-professional discussion context timely - Simulation and effectively. Seminars. Class activity. Videos 3 3.2 Provide a safe 3-2-2. Act to protect - -  Communicate working environment patients and their Group Powerpoints that prevents harm for families from unsafe, effectively with Applied presentation - Written discussion patients and workers. illegal, or unethical all health care for all exam care team members in content Simulation inter-professional Class activity. - Class context timely Videos activities and effectively. 6  4 4.1 Utilize information 4.1.1 Use different -  Documents and technology to sources of data related underpin health care to advanced standards how to obtain an - Simulation - Simulation delivery, of practice and patient accurate, and Case communicate, manage care. comprehensive Applied for studies - Written knowledge and support history and findings all content - Role play exam decision making for of a health patient care. assessment to adult - Class activities patients 5 5.1 Collaborate with 5.1.2 Interact within -  Communicate colleagues and behavioral norms - members of the health related to the effectively with all Simulation - Simulation - Written care team to facilitate interdisciplinary health care team General skill exam members in inter- applied for and Case and coordinate care communication and provided for the health care professional context all studies - Class individuals, families organizations. curriculum activities timely and and communities. effectively. 5.1.3 Apply -  Communicate standardized - communication effectively with all Simulation - Simulation - Written approach to transfer health care team General skill exam members in inter- applied for and Case care responsibilities to other professionals to professional context all studies - Class facilitate experience curriculum activities timely and transitions across effectively. different healthcare settings. 7  Students assessment :‫ تقىَى انطالب‬-5 5. a. 1- Mid-term exam. :‫ األسالية المسحخدمة‬-‫أ‬ 5.a.2- Semester work Methods used 5.a.3- Final written exam. Assessment Schedule Assessment 1 Quiz 4th Week Assessment 2 Mid-term written exam 11th Week Assessment 3 Quiz 8th Week Time : ‫ الحوقيث‬-‫ب‬ Assessment 4 Cass work periodically th Assessment 3 Final written exam end of semester 16 week Weighting of Assessments (for each semester) Mid term exam 10 % Final written exam 70 % : ‫جوزيع الدرجات‬-‫ج‬ Quizzes 10 % Mark Distribution Class work, attendance and participation 10 % Total 100 % List of References ‫ قائًح انكتة انذساسُح وانًشاجع‬-6 6. a.1- Course Notes: teacher notes in health assessment Course note ‫ يزكشاخ‬-‫أ‬ 8  6.b.1- Recommended Books ‫ كتة يقتشحح‬-‫ب‬ - Weber, R.J, Kelley. H.J (2018): Health Assessment in Nursing, 6th ed. Philadelphia: Lippincott Recommended Books Williams & Wilkins - KOZIER & ERB’S. (2022). FUNDAMENTALS OF NURSING, Concepts, Process, and Practice.10th Ed. - Perry. A. G, and Potter, P.A. (2016). Clinical Nursing Skills and Technique. 3rd ed. St Louise, Missouri. Mosby. ‫سئُس انقسى‬ ‫ينسق انًقشس‬ ‫ أيال ايُن انشُخ‬/‫د‬.‫أ‬ ‫ وفاء حسن عثذ هللا‬/‫د‬.‫أ‬ ‫ سهاو دمحم عثذ انعهُى‬/‫و‬.‫أ‬ ‫ سًاح انجاسحً يصشي‬/‫و‬.‫أ‬ 9 Outlines No. Lecture name Page no. 1. Introduction to the health assessment 11 2. Eye, ear and nose assessment 21 3. Integumentary assessment (Skin, hair and nails) 38 4. Neurological assessment 51 5. Cardiovascular assessment 65 6. Respiratory assessment 75 7. Gastrointestinal assessment 85 8. Urinary assessment 94 9. Musculoskeletal assessment 103 10. Breast assessment 113 11  Overview of a Holistic Health Assessment Health: As defined by World Health Organization it defined as a state of complete physical, mental & social Wellbeing, not merely the absence of disease. The new definition, considers health as a dynamic state of well-being with different levels of functional abilities at different point in time. So a diabetic patient no doubt has a disease, but there are times when the client feels well and can be called healthy Health assessment: It is a dynamic and continuous process involving the collection, verification, and organization of information about a client within a specific healthcare context. Or it is a systematic method of collecting data about a patient. Purpose of the health assessment:  To establish a database about the client’s perceived needs, health problems, and responses to these problems.  To determine the patients' current and ongoing health status.  To predict risks to health.  To identify health promoting activities.  To provide an updated baseline for a healthy client Principles of health assessment An appropriate and timely assessment provides a better establishment of nursing care and intervention.  The health assessment process should include certain data collection, documentation, and evaluation of the patient's physical condition.  The documents should be objective, accurate, concise, specific, and most up-to-date.  This needs to be performed in all types of settings whenever the interaction between a client and a nurse occurs.  Gathered or collected pieces of information are needed to be discussed with professional caregivers and specialists. 11   Confidentiality is needed to be maintained. Types of assessment  Initial Comprehensive assessment: Also called an admission assessment, it is performed when client enter health care system. Involves collection of subjective data about the client's perception of health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the client's overall function) as well as objective data gathered during a step-by-step physical examination.  Ongoing or Partial assessment: Consists of data collection that occurs after the comprehensive database is established. This consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on his health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed in less depth to determine any major changes (deterioration or improvement) from the baseline data.  Focus or Problem Oriented assessment: It is performed when a comprehensive database exists for a client and he/she comes to the health care agency with a specific health concern. Consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem. For example, if the client tells that he has ear pain, nurse would ask him questions about the pain, possible hearing loss, dizziness, ringing in his ears, and personal ear care. Sexual functioning & bowel habits would be unnecessary and inappropriate.  Emergency assessment: An emergency assessment is a very rapid assessment performed in life-threatening situations. In such situations (choking, cardiac arrest, drowning), an immediate diagnosis is needed to provide prompt treatment. 12  Components of health assessment: Health assessment Health history Physical examination History of present illness, Past, present medical history Inspection, Palpation, Family history Percussion, Auscultation Social history A comprehensive patient assessment harvests both subjective and objective findings.  Subjective findings are obtained from the health history and body systems review.  Objective findings are collected from the physical examination. The Interview: The interview, in which subjective data are gathered, includes the health history and focused interview. The data collected will come from primary and secondary sources. The primary source from which data are collected is the patient, and the patient is the direct source. An indirect or secondary source would include a significant other, family members, caregivers, other members of the health team, and medical records. Comparing subjective and objective data: Subjective Objective Description Data elicited and verified Data directly or indirectly by the client observed through measurement Sources Client Observations and physical Family and significant assessment findings of the nurse others or other health care professionals. Client record Documentation of assessments Other health care made in client record. professionals Observations made by the client's family or significant others. Methods used to Client interview Observation and physical 13 obtain data examination Skills needed to Interview and therapeutic Inspection obtain data communication skills Palpation Caring ability and empathy Percussion Listening skills Auscultation Examples "I have a headache." Respirations 16 per minute "It frightens me." BP 180/100, "I am not hungry." apical pulse 80 and irregular X-ray reveals fractured pelvis Interviewing and Communication Techniques: A. Health History Information about the patient's health in his or her own words and based on the patient's own perceptions. Includes biographic data, perceptions about health, past and present history of illness and injury, family history, a review of systems, and health. Skills needed for taking effective health history Communication Skills……. is the exchange of information between individuals. Interactional Skills….. are actions that are used during the encoding ‖ is the process of formulating a message for transmission to another person/decoding ―the process of searching through one's memory, experience, and knowledge base to determine the meaning of the intended message‖ process to obtain and disseminate information, develop relationships, and promote understanding of self and others. Listening….is paying undivided attention to what the patient says and does. Attending…. Giving full attention. to verbal and nonverbal messages Paraphrasing, Leading, Questioning, Reflecting and Summarizing The Health History ”Interview” The nurse uses the health history and interview in various healthcare settings to create a comprehensive account of the patient's past and present health. The nurse can use this database, which provides a total picture of the patient's past and present physical, psychological, social, cultural, and spiritual health, to formulate nursing diagnoses and plan the patient's care. 14 Preparing the Client: Health examinations are usually painless; however, it is important to determine in advance any positions that are contraindicated for a particular client. The nurse assists the client as needed to undress and put on a gown. Clients should empty their bladders before the examination. Doing so helps them feel more relaxed and facilitates palpation of the abdomen and pubic area. If a urinalysis is required, the urine should be collected in a container for that purpose. Preparing the Environment Providing privacy is important The time for the physical assessment should be convenient to both the client and the nurse. The environment needs to be well lighted, and the equipment should be organized for efficient use. A client who is physically relaxed will usually experience little discomfort. The room should be warm enough to be comfortable for the client. Positioning Several positions are frequently required during the physical assessment. It is important to consider the client’s ability to assume a position. The client’s physical condition, energy level, and age should also be taken into consideration. Draping Drapes should be arranged so that the area to be assessed is exposed and other body areas are covered. Exposure of the body is frequently embarrassing to clients. Drapes provide not only a degree of privacy but also warmth. 15  Drapes are made of paper, cloth, or bed linen. Instrumentation All equipment required for the health assessment should be clean, in good working order, and readily accessible. Equipment is frequently set up on trays, ready for use. B. Physical Assessment: The physical examination can be general or particular due to a specific problem. It can be frequent if serious health issues are involved. It is performed head to toe and generally lasts for 25-30 minutes. It measures vital signs like body temperature, blood pressure, breathing rate, oxygen pressure, and heart rate. The evaluation process goes through some particular stages. It includes four techniques: Inspection, palpation, percussion, and auscultation. Use these techniques in this sequence except when perform an abdominal assessment. Because palpation and percussion can alter bowel sounds, the sequence for assessing the abdomen is inspection, auscultation, percussion, and palpation. Basic techniques of physical assessment Inspection: It is the skill of observing the patient in a deliberate, systematic manner. It begins the moment the nurse meets the patient and continues until the end of the patient-nurse interaction. Inspect each body system using vision, smell, and hearing to assess normal conditions and deviations. Observe for color, size, location, movement, texture, symmetry, odors, drainage and sounds as assess each body system. Inspection begins with a survey of the patient’s appearance and a comparison of the right and left sides of the patient's body, which should be nearly symmetric. As the nurse assesses each body system or region, he or she inspects for color, size, shape, or region, he or she inspects for color, size, shape, contour, symmetry, movement, or drainage. When inspecting a large body region, the nurse should proceed from general overview to specific detail. 16  For example, when inspecting the leg, the nurse surveys the entire leg first and then focuses on each part, including the thigh, knee, calf, ankle, foot, and toes in succession. Although the nurse will perform most of the inspection without the help of instruments, some special tools for visualizing certain body organs or regions are important. For example, the ophthalmoscope is used to inspect the inner aspect of the eye. Palpation: Palpation requires touching the patient with different parts of hands, using varying degrees of pressure. Because hands are the nurse tools, keep the fingernails short and hands warm. Wear gloves when palpating mucous membranes or areas in contact with body fluids. Palpate tender areas last. Percussion: Percussion involves tapping fingers or hands quickly and sharply against parts of the patient’s body to locate organ borders, identifies organ shape and position, and determines if an organ is solid or filled with fluid or gas. 17 Types of palpation Light palpation Use this technique to feel for surface abnormalities. Depress the skin 1/2 to 3/4 (1.5 to 2 cm) with finger pads, using the lightest touch possible. Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, superficial organs, and masses. Deep palpation Use this technique to feel internal organs and masses for size, shape, tenderness, symmetry, and mobility. Depress the skin 11/2 to 2 (4 to 5 cm) with firm, deep pressure. Use one hand on top of the other to exert firmer pressure, if needed. 18 Types of percussion: Direct percussion This technique reveals tenderness; It’s commonly used to assess an adult patient’s sinuses. Here’s how to do it: Using one or two fingers, tap directly on the body part. Ask the patient to tell which areas are painful and watch his face for signs of discomfort. Indirect percussion: This technique elicits sounds that give clues to the makeup of the underlying tissue. Press the distal part of the middle finger of non-dominant hand firmly on the body part. Keep the rest of the hand off in the body surface. Flex the wrist of the dominant hand. Using the middle finger of the dominant hand, tap quickly and directly over the point where the other middle finger touches the patient’s skin. Listen to the sounds produced Auscultation: Auscultation involves listening for various breaths, heart, and bowel sounds with a stethoscope. Provide a quiet environment. Make sure the area to be auscultated is exposed (Auscultating over a gown or bed linens can interfere with sounds) 19  Warm the stethoscope head in hand. Close eyes to help focus the attention.  How to auscultate use the diaphragm to pick up high-pitched sounds, such as first (S1) and second (S2) heart sounds. Hold the diaphragm firmly against the patient’s skin, enough to leave a slight ring on the skin afterward.  Use the bell to pick up low-pitched sounds, such as third (S3) and fourth (S4) heart sounds. Hold the bell lightly against the patient’s skin, just enough to form a seal. Holding the bell too firmly causes the skin to act as a diaphragm, obliterating low- pitched sounds.  Listen to and try to identify the characteristics of one sound at a time. 21  Health assessment of eyes, ear and nose EYES Anatomy of the eye: The eyes are delicate sensory organs equipped with many extra-ocular and intra- ocular structures. Some structures are easily visible, whereas others can only be viewed with special instruments, such as an ophthalmoscope Ciliary body – part of the eye that Sclera – the tough outer coat that protects produces the aqueous humor. the entire eyeball. Aqueous Humor the watery fluid that Choroid – layer of the eye containing blood produced in the eye and fill anterior and vessels that nourish the retina. posterior chamber. Retina: Innermost layer of the eye, it lines Trabecular Meshwork – aqueous humor the back of the eye and composed of light flows out of the eye through this spongy sensitive cells which pick up the images tissue located near the cornea seen by the eye. Cornea: Front part or "window" of the eye. Lens: Part of the eye that focuses images Iris: "Colored" part of the eye. onto the retina. Pupil: Regulate amount of light that Macula: That sensitive part of the retina entering the eye. responsible for central or "Eagle eye" vision. Anterior chamber: the region of the eye Optic Nerve: Collection of nerve endings 21 between the cornea and the iris. attached to the retina connecting the eyeball Posterior chamber: the region of the eye to the "seeing" centers of the brain. between the iris and the lens. Vitreous: clear jelly-like substance that fills the eye from the lens on back. Performing the Eye Assessment Assessment of the eye includes taking a thorough health history and performing a physical examination. Data obtained are combined and analyzed to determine the patient’s existing health status and to identify potential health risks and disorders of the eye.  Health History The health history addresses the patient’s personal and family history of eye diseases and diseases that affect the eye. A comprehensive health history also allows the nurse to identify areas of the physical examination that require more or less depth. The health history will include biographical data, current health status, past health history, family history, a review of systems, a psychosocial profile, and a detailed eye history. Current Health Status Begin by asking about the person’s chief complaint, asking him or her to describe the problem in his or her own words. If time is an issue and you are unable to perform a complete health history, perform a focused eye history by asking these questions: - Have you noticed any changes in your vision? - Do you wear glasses or contact lenses? - Have you ever had an eye injury? - Have you ever had eye surgery? - Have you ever had blurred vision? - Have you ever seen spots or floaters, flashes of light, or halos around lights? 22  - Do you have a history of frequent or recurring eye infections, tearing, or dryness? - When was your last eye examination? - Have you had any redness, swelling, watering, or discharge from the eyes? - Have you ever been diagnosed with an eye condition such as cataracts, glaucoma, or macular degeneration? - Do you have a history of diabetes or high BP? - What medications are you currently taking eye drops, or supplements for your eyes? - Do you use any prescription or eye drops? PHYSICAL EXAMINATION Approach to assess the eye; use the techniques of inspection and palpation begin by testing visual acuity. For visual acuity, test and record the findings for each eye separately and then together. To perform the physical assessment, you’ll need the following tools: visual acuity charts (Snellen and Snellen E chart, Allen cards, Jaeger chart), color vision chart (Ishihara’s cards), ophthalmoscope, penlight, cotton swab, and cotton ball. Inspecting the eyes With the scalp line as the starting point, determine whether the eyes are in a normal position. They should be about one-third of the way down the face and about one eye’s width apart from each other 1. Identify external structures & landmarks for assessment. Eyelid- Each upper eyelid should cover the top quarter of the iris so the eyes look alike. Look for redness, edema, inflammation, or lesions on the lids.  Eyelashes  Canthus – corner of the eye, angle where lids meet  Conjunctiva – transparent protective covering, exposed part of the eye  Lacrimal – upper outer corner over the eye 23  Cornea: The corneas should be clear and without lesions and should appear convex. Examine the corneas by shining a penlight first from both sides and then from straight ahead. Test corneal sensitivity by lightly touching the cornea with a wisp of cotton. Irises: The irises should appear flat and should be the same size, color, and shape. Conjunctivae and sclera: The conjunctivae should be clear and shiny. Note excessive redness or exudate. The sclera should be white or buff. To inspect the bulbar conjunctiva, ask the patient to look up and gently pull the lower eyelid down. Then have the patient look down and lift the upper lid to examine the palpebral conjunctiva. Pupils Pupils should occupy about one-fourth the size of the iris in normal room light. "PERRLA" revealed that P- Pupils Clear E- Equal & between 3-7 mm in diameter R- Round RL- Reactive to light A- Accommodation of the pupils when they dilate to look at an object far away & then coverage & constrict to focus on a near object 24 Primary technique for examination of the eyes is inspection, with limited amount of palpitation that require gloves Visual Acuity assessment: Measure the client’s ability to see small details  If the client can read, use a Snellen chart, Rosenbaum chart, or newspaper to measure visual acuity.  If the client has eyeglasses or contact lenses, have the client use them during the test  Ensure reading material is in the client’s language  Near Vision: hand-held card Measure the client’s ability to see small details. Note: The Snellen (E) chart is used for clients who cannot read.  Distant Vision: Snellen & Rosenbaum charts.  If the client has eyeglasses or contact lenses, have the client use them during the test  Ensure reading material is in the client’s language Note: Snellen chart is used to screen for myopia (impaired far vision). Rosenbaum eye chart: it holds 14 inches from the client’s face to screen for presbyopia (impaired near vision or farsightedness 25 Test cranial nerves during the eye examination  CN II (optic): visual acuity, visual fields  CN III (oculomotor), CN IV (trochlear), CN VI (abducens): External movements  CN III (oculomotor): pupillary reaction to light  CN VI (abducens): External movements  CN V corneal light reflexes Examining intraocular structures: The ophthalmoscope allows to directly observing the eye’s internal structures 26 Unexpected abnormal finding of the eye include: 1- Conjunctivitis: his condition is characterized by hyperemia of the conjunctiva with predominate redness in the eye periphery. 2- Acute angle-closure glaucoma is characterized by a rapid onset of unilateral inflammation, severe eye pain and pressure, and photophobia. It also causes decreased vision, moderate pupil dilation, nonreactive Pupillary response, and clouding of the cornea but no eye discharge 3- Ptosis, or a drooping upper eyelid, may be caused by an interruption in sympathetic innervation to the eyelid, muscle weakness, or damage to the oculomotor nerve 4- Cataract: A common cause of vision loss, a cataract is a clouding of the lens or lens capsule of the eye that can result from trauma, diabetes, and some medications. 5- Macular degeneration: atrophy or deterioration of the macular disk—is a cause of severe irreversible loss of central vision in people older than age 50. Dry macular degeneration, in which tissue deterioration isn't accompanied by bleeding, is the most common form. 27 Other findings as:  Asymmetric corneal light reflex  Periorbital edema  Corneal abrasion  Diabetic retinopathy  Exophthalmos Disorders of visual acuity:  Myopia  Hyperopia  Astigmatism  Familial condition  Refraction of light spread over a wide area rather than a distinct point on the retina  Presbyopia Disorders of Visual fields  Damage to the retina  Lesions in the optic nerve or chiasm  Increased intraocular pressure  Retinal vascular damage  Cardinal fields of gaze  Strabismus  Esophoria  Exophoria 28  EARS Structures and Functions of the Ear The three parts of the ear external, middle, and inner contain anatomical structures that work together to allow us to hear. External ear The flexible external ear consists mainly of elastic cartilage. It contains the ear flap, also known as the auricle or pinna, and the auditory canal. This part of the ear collects and transmits sound to the middle ear. Middle ear The tympanic membrane separates the external and middle ear. The center, or umbo, is attached to the tip of the long process of the malleus on the other side of the tympanic membrane. The eustachian tube connects the middle ear with the nasopharynx, equalizing air pressure on either side of the tympanic membrane. The middle ear conducts sound vibrations to the inner ear. Inner ear The inner ear consists of closed, fluid-filled spaces within the temporal bone. It contains the bony labyrinth, which includes three connected structures: the vestibule, the semicircular canals, and the cochlea. The inner ear receives vibrations from the middle ear that stimulate nerve impulses. These impulses travel to the brain, and the cerebral cortex interprets the sound. 29  Performing the Ear Assessment Assessment of the ear involves obtaining a complete health history and performing a physical examination. As you perform the assessment, be alert for signs and symptoms of actual or potential problems in the various structures of the ear.  Health History The health history identifies any related symptoms or risk factors and the presence of diseases involving the ear. It must also detect any other disorders that may affect the ear. History will include obtaining biographical data and asking questions about the patient’s current health, past health, and family and psychosocial history. It also includes a review of systems and an ear history. If a detailed history is not feasible or appropriate, focus only on the most essential questions. Focused ear history ask these questions:  Do you have problems with your ears such as ringing?  Do you have hearing problems? If so, do you wear hearing aids?  Do you have balance problems (Do you ever feel dizzy, off-balance, or like the room are spinning)?  Do you have drainage from your ears? If yes, how much and what color?  Have you had recent head trauma?  Do you have any health problems?  Are you exposed to noise pollution at work or in your home environment?  Are you on any prescribed medications?  Do you have allergies? External observation 1. Observe the ears for position and symmetry. 31  2. The top of the ear should line up with the outer corner of the eye, and the ears should look symmetrical, 3. Inspect the auricle for lesions, drainage, nodules, or redness. Pull the helix back and note if it’s tender, which may indicate otitis externa. 4. Inspect and palpate the mastoid area behind each auricle, noting tenderness, redness, or warmth. 5. Finally, inspect the opening of the ear canal, noting discharge, redness, odor, or the presence of nodules or cysts. 6. Patients normally have varying amounts of hair and cerumen (earwax) Otoscopic examination (discussed in the clinical) It used to examine internal structure as the tympanic membrane, pars flaccida, and the bony structures, as shown. The tympanic membrane should be pearl, gray, glistening, and transparent. Inspect the membrane for bulging, retraction, bleeding, lesions, and perforations. Abnormal finding of the ear 1- Earache: Earaches usually result from disorders of the external and middle ear and are associated with infection, hearing loss, and otorrhea. 2- Hearing loss: Several factors can interfere with the ear’s ability to conduct sound waves. Cerumen (wax), a foreign body, or a polyp may obstruct the ear canal. Otitis media may thicken the fluid in the middle ear, which interferes with the vibrations that transmit sound. Otosclerosis (a hardening of the bones in the middle ear), also interferes with the transmission of sound vibrations. Trauma can disrupt the middle ear’s bony chain. 3- Otitis media: Otitis media, inflammation of the middle ear, results from disruption of eustachian tube patency. It can be suppurative or secretory, acute or chronic. In Acute 31  otitis media there is characterized by rapid onset and short duration and presence of infected fluid in middle ear. Signs & Symptoms of otitis media: Signs and symptoms common in children include:  Ear pain, especially when lying down, tugging or pulling at an ear, trouble sleeping, crying more than usual (Fussiness).  Trouble hearing or responding to sounds  Loss of balance  Fever of 100 F (38 C) or higher  Drainage of fluid from the ear  Headache  Loss of appetite Signs and symptoms common in Adults include:  Ear pain  Drainage of fluid from the ear  Trouble hearing 32  NOSE Anatomy The lower two-thirds of the external nose consist of flexible cartilage, and the upper one-third is rigid bone. Posteriorly, the internal nose merges with the pharynx, which is divided into the nasopharynx, oropharynx, an laryngopharynx. Anteriorly, it merges with the external nose. The parts of the nose  Bone: The hard bridge at the top of nose is made of bone.  Hair and cilia: Hair and cilia (tiny, hair like structures) inside nose trap dirt and particles. Then they move those particles toward nostrils, where they can be sneezed out or wiped away.  Lateral walls (outer walls): The outer walls of nose are made of cartilage and covered in skin. The walls form nasal cavities and nostrils. 33  Nasal cavities: Nose has two nasal cavities, hollow spaces where air flows in and out. They are lined with mucous membranes.  Nerve cells: These cells communicate with your brain to provide a sense of smell.  Nostrils (nares): These are the openings to the nasal cavities that are on the face.  Septum: The septum is made of bone and firm cartilage. It runs down the center of nose and separates the two nasal cavities.  Sinuses: there are four pairs of sinuses. These air-filled pockets are connected to nasal cavities. They produce the mucus that keeps nose moist.  Turbinates (conchae): There are three pairs of turbinates located along the sides of both nasal cavities. These folds inside nose help warm and moisten air after breathe it in and help with nasal drainage. Physical examination:  Health history:  How long you've had the symptoms?  What treatments you've used?  What makes the symptoms get better and what makes them get worse?  What are the other health problems you have?  Ask if the patient take any medicines?  Ask about signs of common problems of the sinuses. These can include:  Signs of a sinus infection. These can include long-term (chronic) yellow or greenish drainage, decreased sense of smell, facial pain or pressure, runny nose, and headache.  Signs of nasal allergies. These can include runny nose, sneezing, and red or itchy eyes or nose.  Signs of nasal blockage (obstruction). This can include needing to breathe through your mouth or nose on 1 side only. 34 Inspection:  Observe the patient’s nose for position, Observe the size, shape, symmetry, and color. Note variations, such as discoloration, swelling, or deformity.  Observe for nasal discharge or flaring. If discharge is present, note the color, quantity, and consistency. If notice flaring, observe for other signs of respiratory distress.  Inspect the nasal cavity: Check patency, examine the nostrils by direct inspection using a nasal speculum, or an otoscope, check for exudate. The mucosa should be moist, pink to light red, and free from lesions and polyps. Nasal speculum Palpating the nose  Palpate the patient’s nose with your thumb and forefinger, assessing for pain, tenderness, swelling Examining the sinuses  Checking for swelling around the eyes, especially over the sinus area. Then palpate the sinuses, checking for tenderness and deformity. 35 Nose abnormalities: 36  Integumentary (skin, hair and nails) assessment The integumentary system, consisting of the skin, hair, and nails, is the largest organ of the body and the easiest of all systems to assess. It provides invaluable information about all other bodily systems. The skin, hair, and nails provide clues about general health, reflect changes in environment, and signal internal ailments stemming from other organs. Because integumentary system cells reproduce rapidly, changes in the skin, hair, and nails may be an early warning of a developing health problem. The skin covers and protects the internal structures of the body. It consists of two distinct layers: the epidermis and the dermis. Subcutaneous tissue lies beneath these layers.  Epidermis: Outer layer made of squamous epithelial tissue  Dermis: Thick, deeper layer consists of connective tissue and an extracellular Material (matrix), which contributes to the skin’s strength and pliability. Location of blood vessels, lymphatic vessels, nerves, hair follicles, and sweat and sebaceous glands  Subcutaneous tissue: Beneath dermis and epidermis consists mostly of adipose and other connective tissues. Performing assessment of integumentary system:  Assessment of the integumentary system includes a comprehensive health history and physical examination.  The examination begins with a generalized inspection using a good source of lighting, preferably indirect natural daylight.  Assessment of the skin involves inspection and palpation. 37   The entire skin surface may be assessed at one time or as each aspect of the body is assessed. In some instances, the nurse may also use the olfactory sense to detect unusual skin odors; these are usually most evident in the skinfolds or in the axillae.  Pungent body odor is frequently related to poor hygiene, hyperhidrosis (excessive perspiration), or bromhidrosis (foul-smelling perspiration).  The history identifies any symptoms related to the integumentary system, risk factors for skin problems, and the presence of diseases in other systems that could contribute to skin problems. Health History The health history includes obtaining biographical data and asking questions about the patient’s current health, past health, and family and psychosocial history. It also involves a review of systems. If patient’s condition or time prohibits a detailed integumentary history, ask the following questions:  Do you have any changes in your skin, hair, or nails?  Are you currently experiencing any skin symptoms such as itching, rashes, or an unusual mole, lump, bump, or nodule?  Do you have any food, drug, or environmental allergies?  Do you have any medical problems?  Are you on any medications, prescribed or over-the counter? Physical examination Inspection: Color  Inspect the color of the patient’s skin and compare findings to what is expected for their skin tone. 38   Note a change in color such as pallor (paleness), cyanosis (blueness), jaundice (yellowness), or erythema (redness). Note if there is any bruising (ecchymosis) present. Scalp If the patient reports itching of the scalp, inspect the scalp for lice and/or nits. Lesion and skin breakdown  Note any lesions, skin breakdown, or unusual findings, such as rashes, petechia, unusual moles, or burns. Be aware that unusual patterns of bruising or burns can be signs of abuse that warrant further investigation and reporting according to agency policy and state regulations. Palpation: Palpation of the skin includes assessing temperature, moisture, texture, skin turgor, capillary refill, and edema. If erythema or rashes are present, it is helpful to apply pressure with a gloved finger to further assess for blanching (whitening with pressure). Temperature, moister, and texture Fever, decreased perfusion of the extremities, and local inflammation in tissues can cause changes in skin temperature. For example,  A fever can cause a patient’s skin to feel warm and sweaty (diaphoretic).  Decreased perfusion of the extremities can cause the patient’s hands and feet to feel cool.  Local tissue infection or inflammation can make the localized area feel warmer than the surrounding skin. 39 For accurate palpation of skin temperature,  Do not hold anything warm or cold in hands for several minutes prior to palpation.  Use the palmar surface of dominant hand to assess temperature.  While assessing skin temperature, also assess if the skin feels dry or moist and the texture of the skin. Skin that appears or feels sweaty is referred to as being diaphoretic. Capillary refill The capillary refill test is a test done on the nail beds to monitor perfusion, the amount of blood flow to tissue.  Pressure is applied to a fingernail or toenail until it turns white, indicating that the blood has been forced from the tissue under the nail. This whiteness is called blanching. Once the tissue has blanched, remove pressure.  Capillary refill is defined as the time it takes for color to return to the tissue after pressure has been removed that caused blanching.  If there is sufficient blood flow to the area, a pink color should return within 2 seconds after the pressure is removed. Skin turgor Skin turgor may be included when assessing a patient’s hydration status, but has shown it is not a good indicator.  Skin turgor is the skin’s elasticity. Its ability to change shape and return to normal may be decreased when the patient is dehydrated.  To check for skin turgor, gently grasp skin on the patient’s lower arm between two fingers so that it is tented upwards, and then release.  Skin with normal turgor snaps rapidly back to its normal position, but skin with poor turgor takes additional time to return to its normal position. 41   Skin turgor is not a reliable method to assess for dehydration in older adults because they have decreased skin elasticity, so other assessments for dehydration should be included. Edema It is excessive accumulation of fluid in body tissues. If edema is present on inspection, palpate the area to determine if the edema is pitting or non-pitting.  Press on the skin to assess for indentation, ideally over a bony structure, such as the tibia.  If no indentation occurs, it is referred to as non-pitting edema.  If indentation occurs, it is referred to as pitting edema.  If pitting edema is present, document the depth of the indention and how long it takes for the skin to rebound back to its original position.  The indentation and time required to rebound to the original position are graded on a scale from 1 to 4, where 1+ indicates a barely detectable depression with immediate rebound, and 4+ indicates a deep depression with a time lapse of over 20 seconds required to rebound. 41  Pallor: It is the result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation. Pallor in all people is usually most evident in areas with the least pigmentation such as the conjunctiva, oral mucous membranes, nail beds, palms of the hand, and soles of the feet. Jaundice (a yellowish tinge) may first be evident in the sclera of the eyes and then in the mucous membranes and the skin. Nurses should take care not to confuse jaundice with the normal yellow pigmentation in the sclera of a dark-skinned client. Cyanosis: Cyanosis (a bluish tinge) is most evident in the nail beds, lips, and buccal mucosa. In dark-skinned clients, close inspection of the palpebral conjunctiva (the lining of the eyelids) and palms and soles may also show evidence of cyanosis. 42 Erythema: It is skin redness associated with a variety of rashes and other conditions. Localized areas of hyperpigmentation (increased pigmentation) and hypopigmentation (decreased pigmentation) may occur because of changes in the distribution of melanin (the dark pigment) or in the function of the melanocytes in the epidermis. Skin Color Uniformity Normal Generally uniform except in areas exposed to sun; areas of lighter pigmentation in dark skinned Deviations Hyperpigmentation Birthmarks – abnormal distribution of the melanin 43 Deviations Hypopigmentation Vitiligo due to destruction of melanocytes in the area Albinism – complete or partial lack of melanin Vitiligo: It is a patch of hypo-pigmented skin, caused by the destruction of melanocytes in the area. Albinism is the complete or partial lack of melanin in the skin, hair, and eyes. Other localized color changes may indicate a problem such as edema or a localized infection. Dark-skinned clients normally have areas of lighter pigmentation, such as the palms, lips, and nail beds. 44  Nails Nails are inspected for nail plate shape, angle between the fingernail and the nail bed, nail texture, nail bed color, and the intactness of the tissues around the nails. The nail plate is normally colorless and has a convex curve. Inspect fingernail plate shape, curvature & angle Normally nails are:  Colorless and a convex curve.  Angle between nail and  Nail bed: usually, 160o Deviations from Normal are:  Concave  Clubbed fingernails (>180 o) due to chronic tissue hypoxia 45 Inspect and palpate finger & toenail bed color Normally:  Highly vascular and pink in light  Skinned; dark skinned may be brown or black Deviations from Normal:  Bluish or purplish tinges;  Pale Inspect tissues surrounding nails Normally:  Intact epidermis Deviations from Normal:  Hangnails (paronychia = ingrown nail)  Inflammation of surrounding tissues 46 Perform Blanch Test/Capillary refill test Normally Prompt return or pink or usual color, less than 2-4 seconds Deviations Delayed return of pink or usual color, usually >4 seconds Hair Assessing a client’s hair includes inspecting the hair, considering developmental changes and ethnic differences, and determining the individual’s hair care practices and factors influencing them. Much of the information about hair can be obtained by questioning the client. Normal hair is resilient and evenly distributed. In people with severe protein deficiency (kwashiorkor), the hair color is faded and appears reddish or bleached, and the texture is coarse and dry. Some therapies cause alopecia (hair loss), and some disease conditions and medications affect the coarseness of hair Hirsutism Excessive hairiness in women, or hirsutism, can develop on the body and face, affecting the patient’s self-image. Localized hirsutism may occur on pigmented nevi. 47  Generalized hirsutism can result from certain drug therapy or from such endocrine problems as Cushing’s syndrome, polycystic ovary syndrome, and acromegaly. Alopecia Alopecia occurs more commonly and extensively in men than in women. Diffuse hair loss, though commonly a normal part of aging, may occur as a result of pyrogenic infections, chemical, trauma, ingestion of certain drugs, and endocrinopathy and other disorders. Tinea capitis, trauma, and full-thickness burns can cause patchy hair loss. Evenness of growth of hair over scalp Normally: Evenly distributed Deviations from Normal: Patches of hair loss, i.e. Alopecia Hair thickness or thin 48  Neurological assessment Introduction The nervous system directs the complex processes of the body's internal environment and also provides a link to the external world. This allows us to respond to changes both from internal sources as well as form external stimuli. It is broken down into two major parts: the central nervous system, which includes the brain and spinal cord, and the peripheral nervous system, which includes all nerves (12 pairs of cranial nerves, and spinal and peripheral nerves) which carry impulses to and from the brain and spinal cord. Four regions of the brain: 1. Diencephalon: regulates consciousness 2. Brainstem: connects the upper part of the brain with the spinal cord, consist of (pons, medulla, midbrain) 3. Cerebellum: gait and coordination 4. Cerebrum: thinking and higher functions 49 Central Nervous System Brain components 1- Brain stem  Medulla Oblongata: The medulla oblongata is located just above the spinal cord. This part of the brain is responsible for several vital autonomic centers including:  The respiratory center, which regulates breathing.  The cardiac center that regulates the rate and force of the heartbeat.  The vasomotor center, which regulates the contraction of smooth muscle in the blood vessel, thus controlling blood pressure.  The medulla also controls other reflex actions including vomiting, sneezing, coughing and swallowing.  Midbrain: The midbrain extends from the pons to the diencephalons. The midbrain acts as a relay center for certain head and eye reflexes in response to visual stimuli. The midbrain is also a major relay center for auditory information. 2- The Diencephalon The diencephalon is made up of four main components: the thalamus, the subthalamus, the hypothalamus, and the epithalamus.  Thalamus: the thalamus is responsible for "sorting out" sensory impulses and directing them to a particular area of the brain. Nearly all sensory impulses travel through the thalamus.  Hypothalamus: The hypothalamus is the great controller of body regulation and plays an important role in the connection between mind and body, where it serves as the primary link between the nervous and endocrine systems. The hypothalamus produces hormones that regulate the secretion of specific hormones from the pituitary. The hypothalamus also maintains water balance, appetite, sexual behavior, and some emotions, including fear, pleasure and pain. 51 3- Cerebellum: The functions of the cerebellum include the coordination of voluntary muscles, the maintenance of balance when standing, walking and sitting, and the maintenance of muscle tone ensuring that the body can adapt to changes in position quickly. 4- Cerebrum: The cerebrum is composed of two hemispheres (right and left hemispheres). The cerebral hemispheres are divided into pairs of frontal, parietal, temporal and occipital lobes.  Frontal –personality, behavior, emotions, intellectual function  Parietal -primary Centre for sensation  Occipital–Primary visual receptor Centre  Temporal–Primary auditory reception Centre. 5- Meninges: They are fibrous connective tissue that covers the brain and the spinal cord to provide protection, support, and nourishment. Because the brain and spinal cord are vital organs they are protected by three meningeal layers. 51 6- Spinal Cord The spinal cord and brain stem forms a continuous structure extending from the cerebral hemispheres and serving as a connecting link between the brain and the periphery.  Approximately 45 cm long and about the thickness of a finger  The vertebral column surrounds and protects the spinal cord and consists of 7 cervical, 12 thoracic, 5 lumbers as well as 5 sacral, and 1 coccygeal.  The spinal cord is an H shaped with nerve cell bodies (gray matter) surrounded by ascending and descending tracts (white matter). 7- Cerebrospinal Fluid The cerebrospinal fluid is a clear liquid that circulates in and around the brain and spinal cord. Its function is to cushion the brain and spinal cord, carry nutrients to the cells and remove waste products from these tissues. 52 The peripheral central nervous system The peripheral nervous system includes the cranial nerves, the spinal nerves, and autonomic nervous system 1. Cranial nerves There are 12 pairs of cranial nerves that emerge from the lower surface of the brain and pass through the foramina in the skull. Three are entirely sensory (I, II, VIII), five are motor (III, IV, VI, XI, and XII), and four are mixed (V, VII, IX, and X) as they have both sensory and motor functions. The cranial nerves are numbered in the order in which they are arising from the brain. 2. Spinal nerves  The spinal cord has 31 pairs of spinal nerves; each segment has 1 for each side of the body. 8 cervical, 12 thoracic, 5 lumbers, 5 sacral, and 1 coccygeal. Spinal nerves attach to the spinal cord; each nerve has an anterior (ventral) root containing motor fibers and a posterior (dorsal) root containing sensory fibers  Most peripheral nerves contain both sensory (afferent) and motor (efferent) fibers  Spinal cord contains both gray and white matter 53 Autonomic nervous system  The autonomic nervous system regulates the activities of the internal organs such as the heart, lung, blood vessels, digestive system, maintenance and restoration of internal homeostasis.  There are two major divisions; the sympathetic and parasympathetic systems, which generally act in opposition to each other.  The autonomic nervous system is regulated by centers in the spinal cord, brain stem, and hypothalamus. 54 The sympathetic nervous system  It prepares the body to handle stressful situations.  Under stress condition from either physical or emotional causes, sympathetic impulses increase greatly  The sympathetic neurons are located in the thoracic and the lumbar segments of spinal cord and emerge from eighth cervical or first thoracic segment to the second or third lumbar segment The parasympathetic nervous system:-  The parasympathetic nervous system functions as the dominant controller for most visceral effectors. During quiet, non-stressful conditions, impulses from parasympathetic fibers predominate. The fiber of the parasympathetic system are located in two section, one in the brain stem and the other from spinal segments below L2 because of the location of these fibers, the parasympathetic system is referred to as the cranio-sacral division. Protective structure 1- The skull:- The brain is contained in the rigid skull which protects it from injury. Its major bones are the frontal, temporal, parietal, and the occipital bones. 2- The meninges 3- Cerebrospinal fluid Functions of nervous system:  It receives stimuli from internal and external environmental through afferent sensory pathways.  The peripheral nervous system communicates information between distant parts of the body and the central nervous system.  It computes and processes the information received to determine appropriate responses to the situation.  It transmits the information over efferent or motor pathways for body action. The neurologic assessment: Components of neurological Assessment  General Signs & Symptoms 55   Health History  Physical Examination which includes mental status which includes level of consciousness, cranial nerves II, III, IV,V& VI were tested with ophthalmic examination, VIII was tested with hearing and ears  Reflexes  Motor function  Sensory function  Diagnostic measures and laboratory investigation General Signs / Symptoms Subjective data collection: Headache, Head injury, Dizziness/vertigo, Seizures, Tremors, Weakness, Incoordination, Numbness or tingling, Difficulty swallowing, Difficulty speaking, Significant past history, Environmental/occupational hazard. Past Medical & Surgical History Medications / allergies Habits / Lifestyle Changes (alcohol/ drug abuse) Familial History of neurologic disorders Physical Examination Considerations Assessing mental status and speech: A quick check of mental status To quickly screen a patient for disordered thought processes, ask the questions below. An incorrect answer to any question may indicate the need for a complete mental status examination. Mental status assessment reflects client`s general cerebral function it includes: Intellectual function ― cognitive‖ Emotional function ―affective‖ Major areas of mental status assessment are: Language Orientation Memory Attention span 56  calculation Level of Consciousness: Assessment Tools Glasgow Coma Scale (GCS) with  Three Categories: Eye opening Best motor response Best verbal response  Scoring Highest or best possible score 15 A score of < 8 indicates coma Cranial Nerves: The nurse must be aware of each cranial nerve functions to detect the abnormalities 57  Reflexes:  A reflex is an automatic response of the body stimuli  It involuntary  It is assessed using a percussion hammer  It can be measured by scale starts from 0 - 14 Assess Motor Movements & Strength Evaluate each extremity and compare with opposite side; record each extremity separately. Deep Tendon Reflexes (DTR) Tap appropriate tendon with percussion or reflex hammer Achilles, quadriceps, brachioradialis, biceps and triceps Reflexes are graded 0 to 4+ 4+: Very brisk, hyperactive, with clonus 3+: Brisker than average; possible by not necessarily indicative of disease 58  2+: Average; normal 1+: Somewhat diminished; low normal 0: No response Notes: Hyperactive reflex indicate CNS disease Absent or diminished of reflex indicate loss of sensation, relevant spinal segment damage, or PN damage Sensory Function: It includes: Touch, Pain, Temperature, Position, Tactile judgment In case of any complain of: Numbness, Peculiar sensation Abnormal sensation Anesthesia… loss of sensation Hyperesthesia…increase sensation than normal Hypoesthesia… decrease sensation than normal Paresthesia… abnormal sensation as in burn, pain or electric shock Tactile Discrimination One & two point discrimination. Sterognosis is the ability to recognize object by touching them Extinction is the failure to perceive touch on one side of the body when other two areas are touched symmetrically Diagnostic and laboratory investigation 1- Plain X-ray Skull plain x-ray: reveals:  Fracture of the skull or bony defects.  Size & shape of the skull bone.  Presence of foreign bodies e.g. tumors. Preparation Hair pins, dentures, must be removed from the patient. 59  Spinal X-ray:- Spinal X- ray reveals:  Spinal fracture lesion.  Comparison.  Dislocation. Nursing role Patient with neurologic disorder should be assessed for level of conscious & treatment with the patient according to his condition. If the patient has a suspected spinal fracture; the neck is immobilized prior to moving the patient to make the X- ray. Metal items should be removed from the body parts. 2- Computed Tomography scanning (CT): Useful to diagnosing disorder of multiply body system as regard the brain, head injury, Cerebrovascular disorder, hydrocephalus, Identification spacing occupying lesions, metastasis tumors and brain abscess. 3- Magnetic Resonance Imaging (MRI) 4- Electroencephalogram (EEG) Records the electrical activity of the brain through a series of electrodes on the scalp. Used to diagnose and evaluate seizures disorders, identify tumors, brain abscesses or infections and to confirm of brain death. 5- Lumbar puncture Lumbar puncture is insertion of a needle into lumbar subarachnoid space to withdrawal cerebrospinal fluid (CSF) for diagnostic & therapeutic purposes. Nervous System Changes in Old Age Person born with all the brain neurons- about 100 billion nerve cells that will ever have. This network performs communication within the brain and to the rest of the body. After age 25, everyone loses nerve cells both in the brain and spinal cord. Gradually over time, this results in a reduced the ability of nerve transmission, changing response time, coordination, diminished all senses of smell, taste, sight, touch and hearing over time. 61  The brain also shrinks in size, which does not significantly affect functioning except in the most extreme cases. These changes may also affect sleeping patterns somewhat by decreasing the length of total sleep time, and causing depression in more than 25.0% of elderly people. Some neurological problems:  Agnosia: Inability to recognize object by sight (visual agnosia), touch (tactile agnosia), or hearing (auditory agnosia).  Akinesia: Complete or partial loss of voluntary muscle movement.  Aphasia: Absence or impairment of ability to communicate through speech, writing, or signs.  Expressive (motor) aphasia: Inability to express language even though person knows what he or she wants to say (also called Broca’s or motor aphasia). Frontal lobe affected.  Fluent aphasia: Words can be spoken but are used incorrectly.  Non-fluent aphasia: Slow, deliberate speech, few words.  Receptive (sensory) aphasia: Inability to comprehend spoken or written words (also called Wernicke’s or sensory aphasia). Temporal lobe affected in auditory-receptive; parieto-occipital nerve affected in visual-receptive.  Apraxia: Inability to carry out learned sequential movements or commands.  Circumlocution: Inability to name objects verbally, so patient talks around object or uses gesture to define it.  Dysarthria: Defective speech; inability to articulate words; impairment of tongue and other muscles needed for speech.  Dysphasia: Impaired or difficult speech.  Dysphonia: Difficulty with quality of voice; hoarseness.  Neologisms: Made-up, nonsense, meaningless words.  Paraphrasia: Loss of ability to use words correctly and coherently; words are jumbled or misused. 61   Tremors: Involuntary movement of part of body.  Intension tremor: Involuntary movement when attempting coordinated movements.  Fasciculation: Involuntary contraction or twitching of muscle fibers. 62  Assessment of cardiovascular system The cardiovascular system is the lifeline of the body. Its primary function is to act as a transport system, delivering oxygen by way of the red blood cells and delivering nutrients, metabolites, and hormones to every cell in the body. At the same time, it transports metabolic wastes for detoxification and excretion. The cardiovascular system also contains white blood cells, whose main function is to fight infection. Structures and Functions of the Cardiovascular System The cardiovascular system is a closed system consisting of the heart and blood vessels. The peripheral vascular system includes those arteries and veins distal to the central vessels, extending all the way to the brain and to the extremities. Cardiovascular assessment includes:- History Physical examination Diagnostic & lab investigations 1. Review of History During the health history, collect biographical data and ask patient about his or her current health, past health, review of systems, and family and psychosocial history as it relates to the cardiovascular system. If time is an issue and you are unable to perform a complete health history, perform a focused cardiovascular history 1. Personal habits (Smoking, Alcohol intake, Exercise), diet, personal and family history of diabetes, hypertension, hyperlipidemia. 63  2. Common signs and symptoms of cardiac disease 3. Chest Pain, Fatigue, Fainting; transient loss of consciousness, profuse sweating, palpitations, dyspnea interference with daily living activities , use of pillows, orthopnea, cough, edema, numbness or pain in the extremities. 2. Physical examination a. General Assessment: including color, ease of respirations, signs of distress, and both upper extremities in at least two positions b. Inspection of the extremities: including color, hair distribution, capillary refill, skin integrity, venous pattern, and nails. c. Assessment of the lower limb edema (extremities) d. Assessment of the heart: including: Landmarks for inspection, palpation, auscultation Heart sounds Palpation for thrills and heaves Abnormal auscultation findings Thrill Bruits Notes: For most of the cardiac examination heart examinations are usually performed while the client is in a semi reclined position (supine with the head elevated 30°). Two other positions are also needed 64  a. Turning to the left side b. Leaning forward Heart is located behind and left to the sternum The upper part of the heart is called Atria ―right & left atrium‖ base of the heart while the lower part of the heart is called "ventricles" apex of the heart Landmarks for inspection, palpation, auscultation: The apex of the left ventricle usually touches the chest wall near to the fifth left intercostal space ‖ LICS‖ which is slightly below left nipple 65 Cardiovascular landmarks lines key Axillary line (anterior) Axillary line (posterior) Mid-axillary line Mid-clavicular line Mid-sternal line Lateral thorax. Anterior thorax Assessing the heart “Inspection” 1. Inspect and palpate the pericardium for presence of abnormal pulsation, lifts or heaves. 2. Inspect and palpate the aortic, pulmonic, tricuspid, apical area for pulsations or heaves. 3. Inspect and palpate the epigastric area at base of sternum for abdominal aortic pulsations. 4. Auscultate the heart in 4 anatomic areas (the aortic, pulmonic, tricuspid, apical area). 66 Palpation Maintain a gentle touch when palpate. Follow a systematic palpation sequence covering the sterno-clavicular, aortic, pulmonic, tricuspid, and epigastric areas. Palpating the apical pulse To find the apical pulse, use the ball of hand, then fingertips, to palpate over the precordium. Note heaves or thrills, fine vibrations that feel like the purring of a cat. Auscultating Heart sounds Heart sounds can be heard by Auscultations The first heart sound S1 occurs with atrio-ventricular valves closed when ventricles sufficiently filled Characteristics: dull, low pitched sound described as Lub In one second or less depending on heart rate 67  The second heart sound S2 occurs after the ventricles empty and semi lunar valves close Characteristics: short in duration , high pitched sound described as The two heart sounds are audible in the pericardial area, but they are best heard over the: aortic, pulmonic, tricuspid and apical areas. Normally: S1 usually heard in all sites usually louder at apical area, S2 usually heard in all sites usually louder at base of heart. S3 in children and young adults S4 in many older adults. S3 is best heard at the apex when the patient is lying on his left side. e. Vascular system assessment: including 1. Assessing general appearance First, take a moment to assess the patient’s general appearance. Is he overly thin? Obese? Alert? Anxious? 68  Note skin color, temperature, turgor, and texture. Are his fingers clubbed? (Clubbing is a sign of chronic hypoxia caused by a lengthy cardiovascular or respiratory disorder). If the patient is dark-skinned, inspect his mucous membranes for pallor. 2. Assessing the neck vessels a. Inspecting the neck vessels can provide information about blood volume and pressure in the right side of the heart. Carotid arteries: Palpate the carotid artery with cautions. Palpate only one carotid artery and avoid exerting too much pressure and massaging area Ask the client to turn the head slightly toward the side being examined. b. Auscultate the carotid artery for presence of bruit. Bruit: Bruit is blowing or swishing sound It is commonly developed with older adults It is due to: narrowing of the arterial lumen Condition of anemia Hyperthyrodism which elevates cardiac output Ask the client to turn the head slightly away from the side being examined listen to presence of bruit if present gently palpate the artery to determine the presence of thrill. 69 Thrill It is a vibrating sensation like the water running from the hose It is frequently accompanies by bruit It indicates turbulence in blood flow due to a valvular dysfunction. Jugular veins: Inspect the jugular veins for distention while the client is placed in semi-fowler's position with head support on small pillow. Normally, veins not visible (right side of heart is functioning normally). If jugular distention is present, assess the jugular venous pressure. Locate the highest visible point of distention of internal jugular veins. Measure the vertical height of this point in cm from the sternal angle, the point at which the clavicle meet. Repeat the preceding steps on the other sides. Bilateral measurements above 3 to 4 cm are considered elevated indicated right side heart failure. Documentation How the nurse can assess adequacy of Right side heart & venous pressure? Normally external neck veins are distended and visible when a person lying down vice versa Why? Because of gravity encourages venous drainage By inspection the jugular veins for pulsations and distention Bilateral jugular vein distention (JVD) may indicate right sided Assessment of peripheral vascular system 71 Assessing the peripheral vascular system based on: Blood pressure measuring Palpating peripheral pulses Inspecting , palpating and auscultating, the carotid pulse Inspecting the jugular and peripheral veins Inspecting the skin and tissues to determine perfusion to the extremities. Start by making general observations. Are the arms equal in size? Are the legs symmetrical? Then note skin color, body hair distribution, and lesions, scars, clubbing, and edema of the extremities. If the patient is confined to bed, check the sacrum for swelling. Examine the fingernails and toenails for abnormalities. Palpation First, assess skin temperature, texture, and turgor. Assess capillary refill in the nail beds on the fingers and toes. Refill time should be no more than 3 seconds, or long enough to say, ―Capillary refill.‖ Palpate the patient’s arms and legs for temperature and edema. Palpate arterial pulses. Peripheral pulses: 1. Palpate the peripheral pulses (Peripheral veins) 2. Inspect the peripheral veins in the arms and legs for presence of superficial veins when limbs are dependent, and limbs are elevated. Normally: in dependent position, presence of distention and nodular bulges. When limbs elevated, veins are collapse. 3. Assess the peripheral leg veins for signs of phlebitis. Normally: limbs not tender, symmetric in size. 71 Auscultation: Using the bell of the stethoscope, follow the palpation sequence and auscultate over each artery. Assess the upper abdomen for abnormal pulsations, which could indicate the presence of an abdominal aortic aneurysm. Finally, auscultate for the femoral and popliteal pulses, checking for a bruit or other abnormal sounds. Peripheral perfusion: Inspect the skin of the hand and feet for color, temperature, edema and skin changes. Normally, skin pink in color, skin temp normal, no edema, skin texture resilient and moist. 72  Assessment of respiratory system Anatomic and physiologic overview The respiratory system is composed of the upper and lower respiratory tracts. Together, the two tracts are responsible for ventilation (movement of air in and out of the airway). The upper tract, known as the upper airway, warms and filters inspired air so that the lower respiratory tract (the lungs) can accomplish gas exchange. Gas exchange involves delivering oxygen to the tissues through the bloodstream and expelling waste gases, such as carbon dioxide, during expiration. Oxygen transport: Oxygen is supplied to and Carbon Dioxide is removed from cells by way of the circulating blood. Cells are in close contact with capillaries, whose thin walls permit easy passage or exchange of Oxygen and Carbon Dioxide. Oxygen diffuses from the capillary, through the capillary wall to the interstitial fluid, and then through the membrane of tissue cells, where it can be used by the mitochondria for cellular respiration. The movement of Carbon Dioxide also occurs by diffusion and proceeds in the opposite direction, from cell to blood. 73 Gas exchange: After these tissue capillary exchange, blood enters the systemic veins (where it called venous blood) and travels to the pulmonary circulation. The Oxygen concentration in the blood within the capillaries of the lungs is lower than it is in the lung’s air sacs, which are called alveoli. As a result of this concentration gradient, oxygen diffuses from the alveoli to the blood. Carbon Dioxide, which has a concentration in the blood higher than that in the alveoli, diffuses from the blood into the alveoli. Movement of air in and out of the airways (called Ventilation) continually replenishes the Oxygen and removes the Carbon Dioxide from the airways in the lung. This whole process of gas exchange between the atmospheric air and the blood and between the blood and the cells of the body is called Respiration. Characteristics of Normal Breathing Normal rate and depth Regular inhalation and exhalation pattern Audible on each side of chest Equal rise and fall of each side Sign of abnormal breathing Rate slower than 8 per minute or faster than 24 per minute Pale or cyanotic skin Shallow or irregular Pursed lips 74 Assessment of the respiratory system: 1-Chief reason for seeking health care: Dyspnea Pain (quality, intensity, onset) Wheezing ((is a high-pitched musical sound heard mainly on expiration) Hemoptysis (is the expectoration of blood from the respiratory tract) The questions that should be asked  When the symptoms are started?  How long it is lasted? 2- History: Allergies Smoking history Nature of any cough (dry, productive) Sputum production Dyspnea Respiratory treatments or medications Last pulmonary tests e.g. chest radiograph. Occupation Exercise tolerance. 3- Examination of the Chest and Lungs Inspection Observe the rate, rhythm, depth, and effort of breathing, rate in adult is 14–24 c\m may arrive to 40 c/m in the infant Note whether the expiratory phase is prolonged. Observe the chest for asymmetry, deformity. Note masses or scars that indicate trauma or surgery. 75  Inspect related structure as skin, tongue, mouth, fingers, and nail beds. Patients with a bluish tint to their skin and mucous membranes are considered cyanotic. Clubbing of the fingers may signal long-term hypoxia Palpation Identify any areas of pain, tenderness or deformity by palpating the ribs and sternum. Assess expansion and symmetry of the chest by placing hands on the patient's back, thumbs together at the midline, and ask them to breathe deeply. Percussion Posterior Chest Percuss from side to side and top to bottom. Omit the areas covered by the scapulae. Compare one side to the other looking for asymmetry. Note the location and quality of the percussion sounds you hear. Find the level of the diaphragmatic dullness on both sides. Anterior Chest Percuss from side to side and top to bottom using the pattern shown in the illustration. Compare one side to the other looking for asymmetry. 76  Note the location and quality of the percussion sounds you hear. The examiner uses percussion to: Determine whether or not the underlying tissues are filled with air, fluid, or solid material. Estimate the size and location of certain structures within the thorax (e.g. heart, liver, diaphragm) Auscultation: Auscultation is useful in assessing: The flow of air through the bronchial tree The presence of fluid or solid obstruction in the lung structure 77 Auscultation Using the diaphragm of the stethoscope, listen to the movement of air through the airways during inspiration and expiration. Instruct the patient to take deep breaths through their mouth. Listen through the entire respiratory cycle because different sounds may be heard on inspiration