Nursing Assessment 104 - Midterm Study Guide PDF

Nursing Assessment 104 - Midterm Study Guide​ 1 Week 1 Index: Chapter 4, Chapter 5 & Chapter 29 ​ Vital signs: Pulse, Respiration, Blood Pressure, [Jarvis] O2 saturation Chapter 4: The Interview...

Nursing Assessment 104 - Midterm Study Guide​ 1 Week 1 Index: Chapter 4, Chapter 5 & Chapter 29 ​ Vital signs: Pulse, Respiration, Blood Pressure, [Jarvis] O2 saturation Chapter 4: The Interview ​ Developmental Considerations ​ Objective vs Subjective Data Week 3 Index: Chapter 19 ​ Process of Communication Chapter 19: Respiratory [ Lungs and Thorax] ​ Ethical + Inclusive Care ​ Complete Respiratory Examination ​ Physical Setting ​ Landmarks [Surface + Anterior + Posterior + ​ Communication Techniques: Open vs Reference lines] Close-ended questions, Verbal vs Non-verbal ​ Mechanics of Respiration ​ Developmental Considerations ​ Subjective Data + Questions + Health History ​ Challenging Situations Questions Chapter 5 Complete Health History ​ Examination of the Thorax [IPPA] ​ Health History ​ Thorax Shapes and Patterns ​ Symptom Analysis: OPQURSTUV ​ Objective Data: Measurement ​ Past Health + Family History ​ Abnormal Findings [Adventitions] breath sounds ​ Considerations ​ Developmental Considerations ​ System Review [comprehensive assessment] ​ Cultural and Social Consideration ​ Functional Assessment incl. Activities of daily Week 4 Index: Chapters 20, 21 living Chapter 20 Heart and Neck Vessels ​ Developmental Considerations ​ Structure and Function Chapter 29: Bedside Assessment and Reporting ​ Systolic vs Diastole ​ Hospital Setting ​ Heart Sounds ​ Subjective vs Objective Data ​ Neck Vessels ​ Electronic Charting ​ Developmental Considerations ​ SBAR FRAMEWORK ​ Cultural and Social Considerations Week 2 Index: Chapters 9, 10, 11 ​ Subjective Data Chapter 9: Assessment Techniques in a Clinical ​ Objective Data (IPPA) [Physical Exam] Setting ​ AUSCULATORY AREAS [A, PET, Monkey] ​ Cultivating your senses ​ Promoting Health ​ Inspection ​ Heart Rate ​ Palpation ​ Cardiac & PV Assessment ​ Percussion ​ Abnormal Findings ​ Auscultation Chapter 21: Peripheral Vascular System & ​ Types of Equipment Lymphatic System ​ Clean + Safe environment ​ Structure and Function ​ Developmental Consideration: Children vs ​ Complete Peripheral Assessment Adults ​ PALPABLE PULSES Chapter 10: General Survey, Measurement and Vital ​ Objective Data: Arms Signs ​ Subjective Data: Health History ​ General Survey ​ Objective Data: Legs ​ Measurement ​ Peripheral Vascular Disease: Legs ​ Temperature ​ Promoting Health: Foot Care ​ Abnormal Findings Pain + Disease  Nursing Assessment 104 - Midterm Study Guide​ 2 ​ Abnormal Findings: Arms ​ Promoting Health: Use of digital music Week 5 Index: Chapters 14, 15, 16, 17 players Chapter 14: Head and Neck, Including Regional ​ Subjective data: Health History Lymphatic System ​ Objective Data: Physical Exam ​ Head structure and Function ​ Otoscopic Exam ​ Subjective + Additional Health History ​ Inspect with the Otoscope Questions ​ Tympanic Membrane ​ Developmental Considerations ​ Testing Hearing Acuity ​ Objective Data: Physical Exam: Neck ​ Tuning Fork tests ​ Neck Structure and Function ​ Weber Test ​ Lymphatics Structure and Function ​ Rinne Test ​ Lymph nodes ​ Abnormal Findings ​ Thyroid Glands Chapter 17: Nose, Mouth, Throat ​ Promoting Health: Brain Injury ​ Developmental Consideration Prevention ​ Cultural and Social Consideration ​ Abnormal Facial Appearances with ​ Subjective Data: Health History - Nose Chronic Illnesses ​ Subjective Data: Health History - Mouth ​ Pediatric Facial Abnormalities and Throat ​ Abnormal Findings ​ Promoting Health: Smokeless Tabacco Chapter 15: Eyes ​ Physical Exam - Nose, Sinus Areas, ​ Structure and Function Mouth ​ Subjective Data: Health History ​ Throat ​ Use of Ophthalmoscope Week 6: Chapter 24 ​ Objective data: Physical Exam (Optic Chapter 24: Musculoskeletal System Disc) ​ Function of MSK system ​ Snellen Eye Chart ​ MSK movements ​ Test Visual Fields ​ Cultural and Social Consideration ​ Confrontation test ​ Promoting Health: Preventing ​ Inspect Extraocular Muscle Function Osteoporosis ​ Inspect External Ocular Structures ​ Subjective Data: Health History ​ Inspect Anterior Eyeball Structures ​ Additional Health History Q ​ Record Findings: PERRLA ​ Objective Data: Physical Examination ​ Abnormal Findings ​ Assessment Approach: IPROMS ​ Developmental Consideration ​ Techniques: Inspection, ROM ​ Promoting Health: Screening for ​ Outline of Examination Glaucoma ​ TMJ: ROM Chapter 16: Ears ​ Objective Data: ​ Structure and Function ​ ​ Pathways of Hearing ​ Developmental Consideration ​ Cultural and Social Consideration Nursing Assessment 104 - Midterm Study Guide​ 3 Week 1: Health assessment Two parts in Health Assessment Health History Physical Exam ​ Includes subjective data ​ Objective data ​ Patients Perceptions and reactions to ​ Inspecting, Percussing, Palpating and their health state i.e. physical, mental, Ausuctating during the examination spiritual and emotional health + life ​ Includes pt. Record, lab results and circumstances other diagnostic elements ​ Helps Identify pt. Health strengths, ​ Includes complained or observed pain goals, problems and functions as a bridge to the next step in data collection Interview process: (5 milestones) -​ Gather complete accurate data about the pt. -​ Must establish rapport and trust, must ensure pt feels accepted (continued rapport helps build a therapeutic relationship) -​ Awareness of complicit bias or unconscious judgment which influences the actions of others -​ Share info with pt. About their health state -​ Always look for opportunities to engage in health promotion and illness prevention cont’d -​ Social determinants of health are a key element regarding environmental and social influences on pt health + access to resources. Process of Communication Verbal Communications Non-verbal communication -The words you speak, tone of voice -Body language: posture, gestures, facial - A pt, receiving words and gestures must be expression, eye contact, foot tapping, touch, interpreted in a specific context to have what you do with your hands, where you meaning, therefore clarification is essential place your chair -Message can be misinterpreted by the -more reflective of what you are feeling, listener due to attached meaning from past thinking or reacting during an interaction experiences from the receiver -​ Mutual Understanding is necessary for communication to be effective Communication Skills -Unconditional Positive regard: an assumption of their strengths and acceptance of their limitations -> Pt. must feel unconditionally accepted even if you might think Pt. Is engaging or making unhealthy choices -Empathy: recognizing and accepting a person's feelings/actions/perspective while remaining yourself -Active Listening: active and demanding that requires complete attention -> can engage in positive encouraging verbal cues or convey interest through nonverbal cues Nursing Assessment 104 - Midterm Study Guide​ 4 Attending to Physical Setting -Ensure Privacy -> “psychological privacy” as long as pt. Feels sure that no one can overhear the conversation or interrupt. Minimizing Interruptions -> Discourage other health care providers from interrupting you with their need for access to pt. -Distance between pt. About 1.5metres -Average space so pt. Back does not face the door and feels “blocked in” -Equal status seating- pt should be comfortably seated @ eye level with each other. Avoid facing across a desk or table as it may feel like a barrier -Avoid standing over the pt. It may be interpreted as being rushed and assuming your superiority -Taking notes - always ask/tell pt. To provide comfort and explain why notes might be taken EHR: Electronic health records -> can minimize redundancy, help stay focus on pt. And convey active listening. Open Ended Questions Close Ended Questions -Used for narrative Information -Used for specific information -longer hours -Calls for short (one-two word answers) -Elicits feeling, experiences, understandings, -Limits rapport and leaves interaction neutral opinions, ideas -Builds and enhances rapport Techniques of Communication (Positive Techniques) Traps (Negative) Techniques -Facilitation -False Assurance -> Unfounded reassurance -Silence (for open-ended questions) -Unwated Advice -Relfection -Using authority -Empathy -Avoidance Language -Interpertation -> Inference -Distancing -Explainations -> Sharing info w. Pt. -Professional jargon -Summary -Interrupting -Leading/Bold Question -Talking too much -”Why question” LGBTQ+: Should be aware of how heterosexist biases and communication of these biases can influence the way you interview Invervewing and Developmental Considerations Parents: When pt. Is a child, you must build a rapport with 2 people Infants: most look calm and relaced when needs are met, cry when frightened, hungry, tired -Responds best to firm, gentle handling and a quiet, calm voice -Older infants anxiety towards strangers, more comfortable when caregiver kept in view Nursing Assessment 104 - Midterm Study Guide​ 5 Preschoolers (2-4): Only the child’s own experience is relevant: May imagine inanimate objects can come alive and have human characteristics i.e. bp cuff can bite or pinch School Aged Youth 5-12): More objective and realistic, wahts to know functional aspects: How things work and why things are done -Has the verbal ability to add important data to history Youth (13-19): Capable of mature actions, may revert to childhood response and patterns especially in times of stress -Cannot treat youth as children, but cannot assume that their communication style, learning ability and montication are consistently at an adult level Adults and Older Adults: Introduce yourself and ask pt what name they would like to be addressed. (older pts. May be offended if called by first name) -Interview with Older adults may take longer due to longer story to tell -Important to adjust pace of interview to Older pt.s -May need a greater amount of response time to interpret questions and proces their answers, avoid hurrying them. Interviewing in Challenging Situations Pt.s with communications disabilities: Ask about their preferred way to communicate, allow extra time to respond, reduce background noise, speak clearly Actuely Ill pts.: Prompt action needed in emergencies. Combine interviewing w/ physical examination skills to determing life-saving actions Pt. experiences effects of substances: Asl simple, direction questions and convey nonjudgemental stance. Personal Questions: Some pt. Will cry during interview; do not presume that you have hurt the pt. Have addressed an important topic, do not go on a new topic. Let pt. Cry and express their feelings fully. Cont’d: If you sense threatening behaviour, act immediately to defuse situation, do NOT raise your voice or argue with agitated pt, act relaxed, open and nonthreatening while maintaining appropriate eye contact. Talk to pt in a clear calm voice and convey respect and empathy for pt. And validate concerns. People Experiences Poverty or Homelessness: Experience high level of stigma, victims of judgemental and discriminatory treatment wehn accesses health care. Use Trauma and Violence Informed care (TVIC) approach when interviewing ======================================================================== Health History: Includes: ​ Biological Data: ask the pt. To self-identify ​ Reason for seeking care: brief statement in pts. Word that describe reason for visit Nursing Assessment 104 - Midterm Study Guide​ 6 ​ Current Healht or history of Current illness: well pts can provide brief statement about general state of health. Ill pts. Choronological record of the reason seeking care from the time the symptom first started till now ​ Past Health ​ Family History ​ Review of Systems evaluate: past and current health state of each body system -> double check in case any significant data were oimmited in the current illness section -> evaluate health promoition practices. In documentation include who provided information (pt, pt family/significant other, police/paramedics/other healthcare providers). As well as any special circumstances i.e. Use of interpreter, Pt. orientation, Ability to communicate in Eng or choice of language Pain Analysis OPQRSTUV Onset: When did the pain start: Provocative/Palliative: Does y our pain increase w/ movement or activity? Are the symptoms relieved with rest? Were any previous treatments effective? Quality of Pain: What does your pain feel like? What words describe your pain? Region of the body/radiation: Where is your pain? Does your pain radiate, or move to other areas? Severity of pain: How would you rate your pain on an intensity scale? Treatment/Timing: What treatments have worked for you in a past? Is it constant, dull or intermittent pain? Understanding of pain: What do you believe is causing the pain? Values: What is your acceptable level for this pain? Is there anything else that you would like to say about your pain? Are there any other symptoms related to the pain? Pain assessment for Children: Wong-Baker assessment (Face pain scale) Past Health: Childhood illnesses, Accidents or Injuries, Serios or chronic illnesses, Hospitalizatiojns, Operations, Obstetrical History, Immunizations, Most recent examination date, Allergies, Current Medications Family History: Age and health or cause of death of blood relatives, health of close family members (spouse/children), history of various conditions i.e. heart disease, high BP, stroke, diabetes, blood disorders, cancer, obesity, mental health issues and others -Family Tree Cultural and Social Considderations: Immigrants -> when arrived in Canada and from wehre, Refugee or immigrant status, effect of historical events in country of origin from older pts., spiritual resources and religion, past health i.e. immunizations in country of origin, Health perception, Nutrition Review of Systems: Review past and current health states of each body systems; Double check for omission of significant data; evaluate health promotion practices -Subjective data NOT objective or physical examination data Nursing Assessment 104 - Midterm Study Guide​ 7 Evaluation of health promotion practices in relation to each body system Body system includes: General overall health state, Skin/Hair/Nails, head, eyes, ears, Nose/Sinuses, Mouth & Throat, Neck, Breasts, Axilla, Respiratory System Functional Assessment (Including ADL’s): List 1 ​ Self-concept, self-esteem ​ Activity and mobility ​ Sleep and rest ​ Nutrition and elimination ​ Interpersonal relationships and resources ​ Spiritual resources ​ Coping and Stress Management List 2 ​ Smoking History ​ Alcohol ​ Substance Use ​ Enviornment Hazards ​ Intimate Partner violence ​ Occupational Health Developmental Considerations Children: Past history ​ Prenatal status, labour and delivery, postnatal status ​ Childhood illnesses, serious accidents or injuries ​ Serious chornic illnesses, operations or hospitalizations, immunizations, allergies, medications Must consider: ​ Developmental history ​ Nutritional history ​ Family history ​ Review of systems ​ Functional assessments including ADL Adolescents: HEEADSSS method of interviewing ​ Home environment ​ Education and employment ​ Eating ​ Activities, peer-related ​ Drug (Substance) use ​ Sexuality ​ Suicide or depression ​ Safety from injury and violence Attention to ways of ADL are affected by normal aging process, chronic illness, or disability, and can recognize positive health measures ======================================================================== Bedside Assessment and Reporting ​ In Hospital setting pts. Not required to complete head-to-toe physical examination during 24-hour stay. Nursing Assessment 104 - Midterm Study Guide​ 8 ​ Documentaiton and communication of clinical findings are important aspects of assessment of hospitalized adult ​ Subjective, objective, assessment, plan (SOAP) (facilitates reasoning) charting to organize findings related to CLINICAL PROBLEM ​ The situation, background, assessment, recommendation (SBAR) (Facilitates communication) ​ SBAR communication between healthcare providers ​ Initial Assessment vs. Ongoing frequent Assessment ​ Assessments must be preformed frequently throughout shift ​ Pt. status may fluctuate, must continue monitoring and document any changes Report Critical Findings Necessitating immediate Attention: ​ Altered level of consciousness, confusion ​ Systolic BP less than or equal to 90 or more than equal to 160mmHg ​ Temperature more than or equal to 38 degrees ​ Heartrate lessthan or equal to 60 or more than 100bpm ​ Respiratory rate less than 10/min or more than 28/min ​ Oxygen Saturation less than 92% ​ Urine output less than 30ml/hour for 2 hours ​ Urine colour: Dark amber or bloody urine ​ Postoperatiuve Nausea or Vommiting not relieved with medication ​ Bleeding ​ Anxiety ======================================================================== Assessment Techniquies and Clinical Setting Cultivating Your Senses ​ Skills using sense of sight, smell, touch, and hearing to gather data Inspection [YOU ARE NOT TOUCHING THE PT!] ​ Concentrating on watching ​ Comparing Pt Symmetry ​ Inspecting Wholly + Verbalize what is being inspected ​ Instruments Used: Otoscope (ear), Opthalmoscope (eyes), Penlight (sinus) Palpation: Using sense of touch can confirm points noted during inspection ​ Light palpation - Using fingertips to detect surface characteristics i.e. tenderness, skin, abdomen, 2cm deep, circular motion ​ Deep palpation - Using FIngertips to detect surface characteristics of liver/speen, 4-5cm deep ​ Bimanual Palpation - Use of both hands to surround or catch a structure (Kidney) ​ Techniques used: Fingertips. Grasping Action of fingers and Thumb, back of hands , base of fingers ​ What can be assessed? ○​ Texture, Temperature,Moisture, Organ Location and Size, Swelling, Vibration or Pulsation Nursing Assessment 104 - Midterm Study Guide​ 9 ○​ Rigidity or Spasticity ○​ Pressence of lumps or masses ○​ Presence of Tenderness or pain ○​ Equal Feeling Percussion: Tapping skin with short, sharp strokes to assess underlying structures ​ Yields palpable Vibration and Characteristic sounds: Location, size, density of underlying organ ​ Direct Percussion: Striking hand contacts body wall directly ​ Indirect Percussion: Stationary hand, Striking hands ​ Importance: Provides more information immediately and is easily available and give instant feedback ​ Variation of percussion noted in: Amplitude (loud or soft), Pitch (frequency of vibration/second), Quality (subjective sound differences), Duration length of time ​ Information Obtained from Percussion: ○​ Resonant: clear. Hollow, over normal lung tissue, amp medium to loud pitch low, quality clear duration moderate ○​ Hyper-resonant: booming, normal over child’s lings, abnormal over adult lung- increase amount of air as in emphysema ○​ Tympany: Musical and drum like, over air filled viscus such as stomach or intestine ○​ Dull: Muffled thud, dense organs liver or spleen ○​ Flat: Abrupt stop of sound. When no air is present over muscle bone or TUMOUR Auscultation: Use sense of hearing detecting sounds via a stethoscope ​ Used to hear for: Heart, blood vessels, lungs and abdomen ​ Fit and quality of stethoscope: Diaphragm and bell endpieces ​ Eliminate confusing artifacts i.e. hair, clothes ​ Must know the difference between normal sounds vs abnormal sounds ​ Stethoscope is a common vehicle for transmission of infection, must alcohol swab between pt.s The Clinical Setting ​ Pt’s abd examiners emotional state ​ Hands on practice with a pt: ○​ Height, Weight and Vital signs ○​ Assessments of hands ○​ Concentrate on one step at a time ○​ Examination sequence ○​ Brief Health teaching ○​ When findings are complicated ○​ Summerize findings for person **** Add later, Developmental Considerations Children vs Adults ======================================================================== General Survey Nursing Assessment 104 - Midterm Study Guide​ 10 ​ Covering the general health state and any obcious physical characteristics of a whole person ​ What leaves an immediate impression? ​ Observe client interacting w/ environment and note abnormalities Consider Four Areas: Physical Apperance, Body Structure, Mobility an Behaviour Physical Appearance: ​ Age - Appears stated age ​ Sex - Development appropriate for age ​ Level of consciousness - Alert and orientated ​ Skin - colour pallor, cyanosis ​ Facial Features - Symmetrical with movement ​ No signs of Distress Body Structure ​ Stature excessively short or tall ​ Nutrition - weight withing range for height and body build; even distribution of body fat ​ Symmetry body parts equal bilaterally and relative proportion ​ Posture standing comfortably erect as appropriate for age, Position-sitting comfortably in a chair, bed or examination table ​ Body build, cointour Normal proportions: a) arm span (finger tip to finger tip) equal height. Mobility ​ Gait: Normally base width equal to shoulder width; even, well balanced walk; symmetrical arm swing ​ Range of Motion (ROM): Full mobility in each joint and deliberate accurate smooth and coordinated movement Behaviour: ​ Facial expression: Maintaining eye contact w/ examiner (unless cultural differences occur) expressions appropriate to situation ​ Mood and Cooperative with the examiner and response appropriately to questions asked ​ Speech: Clear and understandable articulation ​ Dress: Clothing appropriate for the climate, looks clean and fits the body, and is appropriate for the pts. Culture and age group (Can be mental health related) ​ Personal Hygiene: appearance is clean and groomed appropriately for pt.’s age, occupation, socioeconomic group CONT’D: Weight: Balance scale, recommended range for height Height: Evidence suppor tusing BMI in obesity risk assessment as it provides more accurate measure of total body fat Body Mass Index (BMI): Kg/m2 -> Normal weight BMI 18.5-24.9 Waist to hip ratio: dimensionless ration of the circumference of the waist to that of the hips. Calculated as wasit measurement divided by hip measurement (W/H) VITAL SIGNS Nursing Assessment 104 - Midterm Study Guide​ 11 Temperature: Influences Include: Diurnal cycle, Menstrual Routes of temperature: Oral, electronica cycle, excercise, age thermometer, axillary, rectal, tympanic -Oral: 35.8 to 37.3 C, accurate & convenient, membrane thermometer Under tongue, close mouth tight -Rectal most accurate: Rectal measures 0.4 to 0.5C Higher. Unable to close mouth, comatose -> lubricate rectal probe, only 2-3 cm in rectum -Axillary -> Least invasive, 0.5C lower than oral temp, used for infants/ pt. With mental illnesses -Tympanic: 0.8C higher than oral temp. -> accurate quick, in ear canal Pulse: must report Rate, Rhythm, Force and ​ 50-95 bpm tradional resitng heart rate Elasticity limits -Report as beats per minute ​ Children have higher and louder -Normal rate for age group pulses -Bradycardia -> slow 50 below ​ Senior: Increase in pulse due to less -Tachycardia -> fast 95 Above compliant arteries Rythym ​ Pregnant individuals: Increase of 10 to Sinyus Arrythmia 15 bpm Regular or Irregular Arterial Pulse points (Top to bottom) Force: 3+ bounding, 2+ normal, 1+ weak or ​ Temporal thread 0 absent ​ Carotid Elasticity- Artery feels springy, straight, ​ Brachial Radial resilient ​ Femoral ​ Popliteal ​ Posterial tibial ​ Dorsalis Pedis Blood Pressure: force of the blood pushing Influences: against the side of the vessel wall. Strength ​ Age, Gender, Ethnocultural of the push changes with the even in the background, Diurnal rhythm, Weight, cardiac cycle. Exercise, Emotion, Stress Systolic: MAXimum pressure felt on the Psycological Factors artery during left ventricular contraction or ​ Cardiac Output systole ​ Peripheral Vascular resistance Diastolic: elastic recoil or resting, pressure ​ Volume of circulating blood that the blood exerts constantly between ​ Viscosity each contraction ​ Elasticity of vessel Walls Pulse pressure: the difference between the systolic and diastolic pressures *** Korotkoff’s Sounds Equipment: Sphygmomanometer, cuff width and size Respirations: Neonate: 30-40 breaths/min Adults: 10-20 breaths/min 1 year: 20-40 breaths/min Ration of pulse rate to respiratory rate should 2 years: 25-32 breaths/min Nursing Assessment 104 - Midterm Study Guide​ 12 be approx. 4:1 4 years: 23-30 breaths/min 8-10 years: 20-26 breaths/min 12-14 years:18-22 breaths/min 16 years: 12-20 breaths/min Adult: 10-20 breaths/min Oxygen Saturation Measurement: Pulse Oximetry Sensor compares ration of light emitted to light absorbed by hemoglobin and converts into percentage of SpO2 Value of >95% is acceptable Developmental Considerations Infants and Children: ​ Height (length) and weight measurement ​ Child growth patterns according to WHO ​ Normal limits from 5th to 65th percentile ​ Head and chest Circumference ​ Reverse order of Vitals: Temperature, Pulse, Respiration (TPR) ​ Rectal Temperature ​ Consideration in taking pulse, respiration, and blood pressure measurements Older Adults ​ Changes in body contour, posture and gait related to age ​ Decrease in body weight and height ​ Vital signs: greater risk for hypothermia, pulse rate may be irregular, shallower respiratory rate, increase in blood pressure ======================================================================== Thorax and Lungs Complete Respiratory Examination Subjective: Health history questions or data Objective (Anterior and Posterior) based related to the respiratory system Inspection: Chest rise/fall/depth, Skin Symptoms: shortness of beath, habits (colour), Effort (wheezing) (smoking), family history, enviornment, Palpation: Vibration, tenderness, symmetry allergies, self-care (inflation) Percussion: Resonance (Hyper/dull) Auscultation: Abnormal Sounds (crackling, whooshing) For Infants and Children: CONT’D ​ Illness-frequent colds Inspection: Shape and configuration of chest ​ Allergy wall, skin, positionof client (best position: ​ Chronic respiratory illness sitting up straight), Anteroposterior transverse ​ Safety-childproofing;inhalation of toxic diameter substances Palpate: ​ Environmental smoke ​ Symmetrical Expansion Nursing Assessment 104 - Midterm Study Guide​ 13 For Older Adults ​ Tactile (or Vocal Fremitus) ​ Activity intolerance ​ Technique “99” ​ Level of activity ​ Factors that affect normal intensity or ​ Lung disease tactile fremitus i.e. vibrations, fluid ​ Pain resonance, can check for pneumonia + inflammation ​ Palmate the entire chest wall Percuss: ​ Predominant note over lung fields ​ Resonance Auscultate ​ Breath sounds ​ Technique (Intensity from soft to Very loud) ​ Vesivular breath: soft, relatively low, can be heard from both lungs ​ Brachovesicular breath: Intermediate, often in the 1st & 2nd Interspaces anteriorly between scapulae ​ Bronchial breath sounds: Loud, Over manubrium ​ Tracheal: Very Loud, Over the trachea in the neck ​ Adventitious sounds: Crackles, Wheeze Atelectatic crackles Objective Measurement ​ Pulse oximeter -> values evaluated in contect of pt. Hemoglobin level, acid-base balance and ventilatory status ​ 6-minute distance walk ​ Landmarks- Anterior Thoracic Cage + Posterior + Reference Lines Nursing Assessment 104 - Midterm Study Guide​ 14 Surface Landmarks: Anterior Thoracic Landmarks Posterior Thoracic Landmarks ​ Suprasternal notch ​ Vertebra Prominens ​ Sternum ​ Spinous processes ​ Costal angle ​ Inferior border of scapula ​ Intercostal spaces (2nd) ​ Twelfth rib ​ Angle of Louis ​ Xiphoid Process​ Thorax Shapes and Patterns Barrel Chest (COPD) Rounded, bulging chest that resembles a barrel, may indicate underlying condition Pectus Carinatum (pigeon chest) Deformity of chest wall - breastbone is pushed outward Pectus Excavatum (Funnel chest) Breastbone is sucken into their chest Kyphosis (Humpback) Forward rounding of the back -common in older adults Scoliosis Abnormal lateral curvature of the spine Abnormal Findings Respiration Patterns ​ Sigh ​ Tachypnea ​ Bradypnea ​ Hyperventilation ​ Hypoventilation ​ Chyne-Stokes Nursing Assessment 104 - Midterm Study Guide​ 15 ​ Biot’s Respiration ​ Chronic Obstructive breathing Tactile Fremitus ​ Increased Tactile Fremitus ​ Decreased Tactile Fremitus ​ Rhonichial Fremitus ​ Pleural friction fremitus Adventitious Breath Sounds Crackle- Fine, Course (Rales & Rhonchi) ​ Air though moisture (fluid) ​ Pneumonia, CHF, COPD Wheeze Sibulant-Sonorous ​ Air through narrowed airways ​ Asthma Pleural Friction Rub-Crunch ​ Inflammed pleura ​ Pneumonia Stridor-Seal sounding ​ Air through narrowed upper airways ​ Croup Developmental Considerations Infants and Children ​ The respiratory system dopes not function until birth- first breath ​ Vulnurability related to small size and immaturity of pulmonary system ​ Crying enhances palpation of tactile fremitus ​ On auscultation, localization of breath sounds more difficult ​ Percussion limited use in newborns Pregnant Women ​ Enlarged uterus elevates diaphragm; decreases vertical diameter of thoracic cage, increase in horizontal diameter Older Adults ​ Lungs more rigid and harder to inflate ​ Decrease in vital capacity ​ Decrease in number of alveoli ​ Increased risk for postoperative complication ​ Mucous membrane becomes direr, bacterial growth may occur ​ Round barrel-shape cage and kpyhosis ​ Chest expansion somewhat  Nursing Assessment 104 - Midterm Study Guide​ 16 decreased Acutely Ill Patients ​ Second examiner needed to support pt in upright position for exam Cultural & Social Consideration ​ Due to homelessness + bad living environment, new and re-emerging cases of TB in Canada ​ Asthma rates down, but due to school + pollen, contributing factor in 10% of hospital admissions of children age less than 5 years ​ Preventable risk factors: tobacco smoke, poor air quality ​ Lung cancer is leading cause of cancer death in Canada ​ Women incur greater lung damange from exposure to environmental tobacco compared with men ======================================================================== Heart and Neck Vessels Position and surface Great Vessels Heart Wall Chambers Valves landmarks: ​ Precordium ​ Superior and ​ Pericardium ​ Atria- ​ Atrioventricular ​ Mediastinum Inferior ​ Myocardium Left and ​ Tricuspid ​ Apex and Venae cavae ​ Endocardiu Right ​ Mitral base of heart ​ Pulmonary m ​ Ventricl ​ Semilunar ​ Right and Artery es Right ​ Pulmonic Left cardiac ​ Pulmonary and Left ​ Aortic Borders Veins ​ Aorta Diastole: Ventricles relax, AV (Tri & Bi) open, Atrial pressure > Ventricular Pressure, Blood flow from atria to ventricles, Atrial Contraction pushes 25% of blood to Ventricles Systole: AV valves close = S1 sound “Lubb”, Opening of Aortic valve, Semi-lunar valve closes= S2 “Dubb”, Ventricular pressure > Atrial pressure Extra Heart sounds ​ Third sound vibration in lateral position (sloshing) -> Heart failure, Ventricular diseases, Increased cardiac output dieases (Hyperthyroid, anemia, pregnancy) ​ Fourth heart sound Vibration heart at the end of diastole (gallop) “Ta-lub-dub” -> Coronary artery disease, Hypertension, MI, Aortic pulmonic stenosis ​ Murmurs: abnormal sounds during heartbeat cycle (turbulent blood) -> Frequency (pitch), Intensity, Duration, Timing ○​ Common Causes of a heart murmur: Increased velocity of blood, Decreased VISCOSITY of blood, Valve defects, Abnormal chamber openings ○​ Measured in Grades 1-6 (6 being the largest) Neck Vessels ​ Carotid Artery + Jugular Artery (Internal, External, Venous pulse and pressure Developmental Considerations Nursing Assessment 104 - Midterm Study Guide​ 17 Infants and Children ​ Difference in apical and radial pulses ​ Murmurs are more common first few days ​ Foramen ovale: small hole located in the septum, wall between two upper chambers of the heart ​ Patent Ductus Arteriosus: occurs when blood vessel that is normal while a baby in womb fails to close after baby is born ​ Position of heart in chest Pregnant Women ​ Increase in blood volume ​ BP change w/ position ​ Increase in stroke volume (may change heart sounds) ​ Cardiac output Older Adults ​ Influence of lifestyle ​ Increase in systolic blood pressure ​ Orthostatic hypotension -> lying/sitting up then dizzy when getting up -> lower BP ​ Avoid pressure on Carotid Artery Health History Subjective Data: Objective Data Questions: Preparation: ​ Chest pain: Tightness, pallor, ​ Position and draping palpitations nausea, PQRSTU ​ Room Prep ​ Dyspnea: Any shortness of breath ​ Order of examination steps ​ Othropnew: How many pillows do you Equipment Needed use when sleeping or lying down ​ Stethoscope w/ diaphragm and bell ​ Cough: Do you have a cough? ​ Alcohol wips ​ Fatigue: Do you seem to tire Easily Carotid Arteries ​ Cyanosis or pallor: Facial skin turn ​ Palpate blue or ashen ​ Auscultate for bruit ​ Edema: Swelling in your feet or legs Jugular Veins ​ Noctoria: Do you wake up at night ​ Inspect the jugular venus pulse urgent to urinate? How long has this Physical Exam been occuring ​ Precordium ​ Cardiac History: History in ​ Inspect the anterior chest hypertension etc ​ Palpate the apical impulse (leftside, ​ Family Cardiac History: hypertension 4th-5th ICS, MCL) *** Palpate order, etc apex, 2nd left ICS MCL, DOWN ​ Palpate across precordium Auscultation ​ Indentify Auscultatory areas ○​ A PET M(onkey) -> Right -> Left -> Down -> Left ○​ Aortic [Right, 2nd ICS, sternal Nursing Assessment 104 - Midterm Study Guide​ 18 border] ○​ Pulmonic [Left 2nd ICS] ○​ Erbs point [3rd ICS] ○​ Tricuspid: [5th ICS] ○​ Mitral area [Left 5th ICS MCL] ​ Note rate and rhythm ○​ Sinus arrhythmia ○​ Pulse deficit - Find difference between apical and peripheral pulse (atrial fib, pace makers) ​ Identify S1 and S2 ​ S1 is louder than S2 @ apex ​ S1 coincides with carotid artery pulse ​ S1 coincides with R wave on ECG ○​ Listen to S1 and S2 separately ○​ Listen to extra heart sounds and mumurs Infants: Heart Rate: ​ Maternal Health Bradycardia ​ Feeding ​ HR < 50bpm (adult) ​ Growth ​ Can lead to hypoxemia (low O2) ​ Activity ​ Inferior wall ischemia (restricted blood Children flow -MI) ​ Growth ​ Can be used by drugs i.e. beta ​ Activity blockers, digoxin ​ Joint pain and fever Tachycardia ​ Headache and nosebleed ​ HR: 50-95 ​ Respiratory disease ​ Caused by a large # of events ​ Family History ○​ Increased Temperature Pregnant Individuals: ○​ Pain ​ Hypertension ○​ Anxiety ​ Hypotension ○​ L ventricular failure Older Adults: ○​ SOB ​ Disease ○​ Shock syndromes ​ Medication ​ Environment ======================================================================== Peripheral Vascular System + Lymphatic System Structures: Arteries Veins Nursing Assessment 104 - Midterm Study Guide​ 19 ​ Temporal ​ Jugular ​ Carotid ​ Veins in the arm ​ Arteries in the arm ​ Veins in the leg ○​ Brachial ○​ Deep veins: Femoral, Popliteal ○​ Ulnar ○​ Superficial Veins: Great ○​ Radial Saphenous, Small saphenous ​ Arteries in the leg ​ Perforators (connecting veins) ○​ Femoral ○​ Popliteal ○​ Dorsalis pedis ○​ Posterior Tibial Palpable Pulses ​ Upper extremity ○​ Carotid ○​ Brachial ○​ Radial ○​ Ulnar​ ​ Lover Extremity ○​ Femoral Popliteal ○​ Dorsalis Pedis ○​ Posterior Tibialis ○​ Health History Subjective Data Objective Data Questions: Inspect & Palpate: ​ Leg pain or cramps ​ Skin ​ Skin changes on arm or legs ​ Profile sign ​ Swelling in arm sor legs ​ Capillary refill ​ Lymph nodes enlargement ​ Symmetry ​ Medications ​ Radial Pulses ​ Ulnar Pulses Good foot promotion ​ Brachial Pulses ​ Dry feet carefully ​ Epitrochlear lymph nodes ​ Are nails trip toenails straight across Cont’d Legs ​ Keep blood flowing to feet Inspect & Palpate ○​ Activity/stretching/elevation ​ Skin & Hair ○​ Do not cross legs ​ Symmetry ○​ Do not smoke ​ Temperature ​ Wear comfortable-fitting shoes ​ Femoral pulse ​ Fit shoes to larger foot ​ Popliteal pulse ​ Low-heled shoes for women ​ Posterior tibial pulse ​ Keep skin smooth and soft ​ Dorsalis pedis pulse ​ Pretibial edema ○​ Must elevate and dangle ○​ Ask about pain Nursing Assessment 104 - Midterm Study Guide​ 20 ○​ 1+ to 4+ grading scale for pitting edema ○​ Angle circumference ​ Colour: Elevate and dangle Abnormal Findings - Pain: ​ Arterial Disease: Causes signs and symptoms of oxygen (O2) deficit ​ Venous Disease: Causes signs and symptoms of metabolic waste build-up ​ Symptom analysis of pain for: Location, character, onset and duration, aggravating factors, relieving factors, associated symptoms, risk factors Peripheral Vascular Disease (PAD) in Arms ​ Raynaud’s phenomenon ​ Lymphedema Cont’d PAD: Occlusions ​ Caused by atherosclerosis ​ Chronic buildup of fatty streaks, fibroid plagues, calcification of vessel walls and thrombus formation ​ Reduce blood flow, thus reducing the availability of O2 and nutrients Aneurysms ​ Sac formed by dilation in artery wall; most common is the aorta ​ Vessel wall weakened by atherosclerosis ​ Balloonlike enlargement from the effect of blood pressure Head and Neck, Including Regiona Lymphatic System Subjective Data Objective Data ​ Headache Inspect and palpate: ​ Head Injury ​ Skull, size and shape, tenderness ​ Dizziness or Vertigo ​ Temporal area: Temporal artery and ​ Neck pain or limitation of motion temporomandibular joint ​ Lumps or Swelling: ​ Facial structures Lymphnode/Cancer ​ Symmetry ​ History of Head or Neck Injury ​ Range of Motion Infants and Children ​ Lymph Nodes ​ Prenatal drug exposure Lymph Nodes ​ Type of delivery ​ Use circular motion of fingertips and ​ Growth pattern palpate lymph nodes ​ Note that salivary glands are not palpable ​ Palpate 10 groups of lymphnoeds in routine order: Preauricular, Posterior auricular (mastoid), Occipital, Sybmental, Submandibular ​ Cervical nodes nodes are often palpable ​ Normal nodes fell: movable, discrete, soft and nontender Nursing Assessment 104 - Midterm Study Guide​ 21 Thyroid ​ Shine light across neck to highlight any possible swelling ​ Supply person w/ glass of water and inspect neck as pt. Sip ​ Thyroid tissue moves up with a swallow ​ Auscultate: bruit is not present normally Abnormal Findings: Facial appearances w/ Chronic Illnesses ​ Parkinson’s ​ Cushing’s syndrome ​ Hyperthyroidism ​ Myxedema ​ Bell’s palsy ​ Stroke or cerebrovascular accident ​ Scleroderma Abnormal Findings: Lymph Nodes ​ Parotid is swollen with mumps ​ Parotid enlargement had been found with acquired immune deficiency syndrome ​ Lymphadenopathy: enlargement of lymphnodes from infection, allergy or neoplasm ​ If nodes are enlarged or tender, check area where they drain for the source of the problem Developmental Considerations Infant and Children ​ Fontanelles ​ Head growth ​ Lymphatic System ​ Skull: Head circumference ​ Face: Symmetry, Appearance, Presence of Swelling ​ Neck: Muscle development and presence of swelling ​ Special Considerations Pregnant Women ​ Slight enlargement of thyroid gland Older Adults ​ Sagging facial skin ​ Presence ofsenile tremors, concave cervical curve, dizziness on range of motion (ROM) Week 7: Neurological System Neurological Exams Screening ExamL health pt.s who have no significant subjective in their histories. Complete exam: on pt.s who have neurological concerns or have shown signs of Neurological dysfunction. Nursing Assessment 104 - Midterm Study Guide​ 22 Neurological recheck: pt.s who have been demostrated neurological deficits and need periodic assessments. Subjective Data Objective Data ​ Headaches ​ Mental Status: focus on symptoms ​ Head injury concerning alertness, perception, ​ Dizziness/Vertigo language, concentration and memory ​ Seizure ​ Cranial Nerves ​ Tremors ​ Motor System: includes tests for ​ Weakness muscle tones, strength and reflex ​ Incoordination ​ Sensory: coordination and gait ​ Numbness or tingling “Sensation and Coordination ​ Diffulcty Speaking ​ Neurological Examination: Pt. with ​ Significant past history Aletered Level of Consciousness ​ Enviornment and occupational hazar Glascow Coma Scale Additional Health History Questions Infants and Children ​ Maternal health ​ Neonatal period ​ Reflex ​ Weakness and balance ​ Seizure ​ Physical development ​ Enviormental hazards ​ Cognitive development ​ Family history Older Adults ​ Risk for falls ​ Cognitive function ​ Tremor ​ Vision ​ 12 pairs of cranial nerves (in order): Olfactory, Optic, Occulomotor, Trochlear, Trigeminal, Abducens, Facial, Acoustic/Vestibulocochcear, Glossopharyngeal, Vagus, Accessory, Hypoglossal ​ Cranial Nerves 3,4,6 are assessed together along with PERRLA (Pupils, Equal, Rough, Reactive, Light, Accommodation) Reflexes: basic defences mechanism of the nervous system; Helps maintain balance and muscle tone; Four types of reflexes: Deep tendon, superficial, visceral and pathological Involuntary: Operating belowthe lvl conscious control and permitting a quick reaction to potentially painful or damaging situations. Developmental Considerations Nursing Assessment 104 - Midterm Study Guide​ 23 Infants and children up to 6 years of age ​ 8 major Area: Vision, Hearing, Communication, Gross Motor, Fine Motor Skills, Cognitive, Social/Emotional ​ Neurons are not myelinated and need a strong stimulus and then respond via crying with whole movements ​ Spontaneous waking activity, response to environment, social smile ​ Cranial Nerves cannot be tested directly ​ Motor system using: Nipissing District Development Screen (NDDS) ​ Head control ​ Reflexes Primitive found in newbords: Landau, Babinski, Infantile automatism, Tonic neck ​ Observation of dress/undress/ buttons ​ Importantce of familiarity w/ developmental milestones ​ Test balance, finemotor coordination ​ Lack of reliability in testing sensation in young children Older Adults ​ Velocity of nerve conduction decreases between %5 and 10% with aging ​ General atrophy and loss of neurons in brain and spinal cord ​ Decrease i weight and volume of brain ​ Decrease muscle strength and impaired fine coordination ​ Dizziness and loss of balance ​ Decrease in muscle bulk in hand ​ Senile tremors ​ Dyskinesias ​ Difference in gait ​ Loss of anke jerk ​ Deep tendon reflexes less brisk Cultural + Social Consideration ​ Indigenous, African, South Asian = Increased likelihood of highblood pressure and diabetes ​ Greater risk for heart disease and stroke ​ Influence of social circumstances and ability to manage post-stroke Stroke prevention ​ Diet, Limit sodium intake, Moderaete exercise, meintain healthy weight Nursing Assessment 104 - Midterm Study Guide​ 24