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136 Cards in this Set

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- Body fluids are regulated by fluid intake, hormonal controls, and fluid output.
- The balance of these three is referred to as homeostasis.
- Fluid intake is regulated by the thirst mechanism which is located in the hypothalamus.
- For example, when we eat a potato chip, the osmoreceptors sense an increase in osmolarity due to the salt on the potato chips. The hypo-t is stimulated and we want to drink.
- The hypothalamus is also signaled when there is excess fluid loss of hypovolemia, such as in the case of vomiting or hemorrhaging.
Antidiuretic hormone or ADH
- is released by the posterior pituitary gland in response to changes in blood osmolarity.
- When the hypo-t senses an increase in osmolarity, ADH is released.
- The ADH causes the renal tubules to allow water to pass (stops urine production), returning water to the systemic circulation which dilutes blood and lowers its osmolarity.
- When homeostasis is reached, normal urine output is resumed.
Aldosterone
- is released by the adrenal cortex in response to increased potassium levels or as a part of the renin-angiotensin cycle.
- Aldosterone stimulates the renal tubules to save salt and excrete potassium.
- The retained salt leads to water retention.
Renin
acts to produce angiotensin 1&2 which cause vasoconstriction and increased blood flow to the kidneys, improving renal perfusion
Fluid output occurs through four organs of water loss: the kidneys, the skin, the lungs, and the GI tract.
- The kidneys are the major regulatory organ of fluid balance.
- The GI tract also plays a vital role in fluid regulation (normal loss is 100-200ml a day, can rise dramatically with diarrhea etc).
- We should take in 2,500ml of fluid a day, normal output via urine should be at least 30ml/hour
Normal Adult Output:
urine 1400 - 1500 ml
insensible loss
lungs 350 - 400 ml
skin 350 - 400 ml
sweat 100 ml
feces 100 - 200 ml
total = 2300 - 2600 ml
- Osmotic pressure is the drawing power for water (water movement), and it depends on the number of molecules in solution.
- A solution with a high solute concentration has a high osmotic pressure and draws water into itself (needs more water to equal out).
For example, if the concentration of solute is higher on one side of a semipermeable membrane than the other, water will move across the membrane (to the higher solute concentration-form low to high) until an equilibrium in the osmolarity is reached.
- A hypertonic solution pulls fluid from the cells. A hypotonic solution moves fluid into the cells.
- Filtration is able to occur in the capillary bed due to the pressure differences between hydrostatic pressure on the arterial and venous side of the bed.
- The pressure on the arterial side of the capillary bed is 32mmHg
- The pressure on the venous side is 12mmHg.
- The pressure inside the capillary bed is 22mmHg
- (Arterial 32 – venous 12=20)
- Due to the pressure Arterial 32, Capillary bed 20, Venous 12; the blood moves to the venous capillaries where it is drawn up.
- Active transport is the movement of particles across membranes in a process that requires the expenditure of energy.
- This allows cells to admit larger molecules than they would otherwise be able to admit, or to move particles from areas of lesser concentration to greater concentration against the concentration gradient.
- Active transport is how cells absorb glucose and other substances to carry out metabolic activity. (an example of active transport is the sodium/potassium pump, sodium out, potassium in against the gradient)
- This process makes it possible to keep a higher concentration of potassium in ICF and sodium in ECF.
- The osmotic pressure of blood is affected by plasma proteins, especially albumin.
- Albumin exerts colloid osmotic or oncotic pressure, which tends to keep fluid in the intravascular compartment.
- At the venous end of the capillaries, this oncotic pressure and decreased venous hydrostatic pressure draw water and waste products back into the capillaries to be filtered through the kidneys.
- At the arterial end of the capillaries, the hydrostatic pressure is greater than the colloid pressure, causing fluids and diffusible solutes to move out of the capillary and into the interstitial space.
- The excess fluids and solutes in the interstitial space are drawn up by lymph vessels into the intravascular space.
FVD
- Excessive fluid losses from:
– vomiting & diarrhea & fever
– gastric suction
– drainage of secretions, eg. fistula
– extreme diaphoresis
– diuretics
– third spacing – edema in an interstisial space
– Loss of plasma/whole blood, such as with burns/hemorrhage
– Decreased oral intake of fluids (anorexia, inability to swallow, unavailability, confusion)
– Use of diuretics
FVD
Assessment Findings: Postural hypotension, Tachycardia, Dry mucous membranes, Poor skin turgor, Thirst, Confusion, Rapid weight loss, slow vein filling, lethargy, oliguria, weak pulse
Lab Findings:
- Spec. Grav. Less than 1.025
- Increased Hct (above 50%)
- increased BUN (greater than 25mg/100ml
FVD
Defining Characteristics
• Muscle weakness, esp. upper body
• decreased skin turgor , “tenting”)
• dry mucous membranes, furrowed tongue
• Soft/sunken eyeballs
• tachycardia, weak, thready pulse
• peripheral vein fill time > 5 sec.
• Orthostatic hypotension, hypotension
• narrow pulse pressure
• flattened neck veins in supine position
• constipation
• polyuria
• Specific Gravity is elevated (less water, more concentrated)
• Hematocrit is elevated (thicker blood due to less fluid)
- infants are not protected from FVD
- Children 2-12 operate in a narrow range with less tolerance for large changes
- Adolescents & MA have increased metabolic processes & increased water production
- OA experience changes in the renal filtration rate, changes in lung function & take multiple medications which can affect fluid volume.
head/chest trauma, burns and shock place clients at risk for FVD.
(The greater the burns, surgery, or trauma; the greater the deficit)
FVE
- Etiology of FVE
• Excessive intake of Na-containing fluids from IV therapy
• Excessive ingestion of sodium in diet or drugs
• Increased serum aldosterone & steroids
• Disturbed regulation of fluid balance (CHF, Renal failure, Cirrhosis of the liver)
• Low intake of dietary protein
• Corticosteroid therapy
Defining Characteristics of FVE
• Weakness and fatigue
• dependent edema, pitting and non-pitting
• ascites- fluid in abdomen
• sudden weight gain
• peripheral vein emptying takes > 5 sec.
• Jugular venous distention
• Progressively worsening dyspnea
• tachypnea
• irregular crackles/ rails
• possible pulmonary edema & pleural/pericardial effusion
• tachycardia
Defining Characteristics of FVE
• bounding pulse
• hypertension
• 3rd heart sound, S3 gallop
• High or low urine output depending upon renal function
• Specifig Gravity decreased due to watery urine
• anorexia, nausea, vomiting
• Decreased hematocrit level due to watery blood
Assessment findings of FVE: rapid weight gain, edema, hypertension, polyuria, neck vein distention, increased venous pressure, crackles in lungs
Lab findings:
- Decreased Hct levels (below 38%)
- decreased BUN levels (below 10mg/100ml)
Third-Space Syndrome
when fluid gathers where it normally never does such as in the case of a distended abdomen
Osmolar Imbalances
- involve loss or gain of only water so that the concentration or osmolality of the serum is altered.
Hyperosmolar Imbalance (dehydration) : Osmolar loss of only H2O
- Causes:
1) Diabetes
2) Interruption of the thirst drive (neuro impairment)
3) Osmotic diuresis (lose water)
4) Administration of hypertonic parental (IV) fluids or tube feeding formulas (these pull water from cells)
Assessment findings of Hyperosmolar imbalance: dry and sticky mucous membranes, flushed and dry skin, thirst, elevated body temp, irritability, convulsions, coma
Lab findings:
- Increased serum sodium (above 145mEq/L)
- increased serum osmolality (above 295mOsm/kg)
Hypoosmolar Imbalance (water excess): Osmolar gain of only H2O ex Diabetes insipidis
Causes:
1)Syndrome of inappropriate antidiuretic hormone (SIADH) (head injury causes a continuous release of ADH, thus water is saved by the body)
2) Excess water intake
* Assessment findings of hypoosmolar imbalance: Decreased LOC, convulsions, coma
Lab findings:
- Decreased serum sodium levels (below 135mEq/L)
- Decreased serum osmolality (below 280mOsm/kg)
LAB VALUES:
a) Plasma osmolality (280-295mOsm/kg)
b) Urine osmolality (50-1400mOsm/kg)
c) Hematocrit (Men 42%-52%, Women 37%-47%)
d) Urine Specific Gravity (1.010 – 1.025)
e) BUN (10-20mg/100ml)
f) Serum creatinine (0.5-1.2mg/100ml)
- Sodium (Na+)
- Serum norm - 135 - 145 mEq/L
- Regulator - Aldosterone
Functions:
• Regulates fluid volume within ECF
• Controls distribution between ECF & ICF
• Maintains blood volume & controls size of vascular space
• Helps maintain neuromuscular irritability
Hyponatremia:
• occurs with overhydration
• Na loss > corresponding H2O loss
• Intake of H2O > intake of Na
• Loss through GI tract
• Clinical Signs of Hyponatremia
• feeling of apprehension/anxiety
• cold, clammy skin
• fatigue, lethargy, weakness
• abdominal cramps, diarrhea
• postural hypotension, shocky
• Serum Na < 135mEq/L
Excess - hypernatremia
• intake of Na > intake of H2O
• H2O loss > Na loss
• use of antibiotics- nephrotoxicity ex: aslocillin, carbenicillin, piperacillin, ticarcillin, & Unasyn
Clinical Signs of Hypernatremia
• Extreme thirst
• dry, sticky mucous membrane
• tongue red & dry
• flushed skin
• febrile, restless, agitated
• Serum Na > 145 mEq/L
- Potassium (K+)
• Major intracellular cation
• Normal Range: 3.5-5.0mEq/L
• Regulators: kidneys, aldosterone, Na/K pump
- Food sources: Avocado, bananas, oranges, grapefruit, Dates, figs, Nuts, Broccoli, Molasses
• Functions: maintains cellular transmembrane, electrical balance, neuromuscular transmission, normal osmotic pressure
• Use of supplements may lead to GI disturbances, including gastric & intestinal ulcers, and diarrhea
Hypokalemia
• Results from: decreased dietary intake, anorexia, fasting, loss of GI secretions, increased urine output from diuretics
• Clinical S&S: EKG changes, ventricular arrhythmias, weakness/fatigue, nausea, vomiting
• use of Milk of mag (magnesium hydroxide)
Hyperkalemia
• Results from: Rapid IV administration; cellular breakdown (burns), stored blood bank transfusion
• Clinical S&S: EKG changes, weakness, muscle cramps, diarrhea
• Use of antibiotics- nephrotoxicity ex: vanco, methicillin, & aminoglycosides
- Calcium (Ca++)
- extracellular cation
- Serum norm - 4.3 - 5.3 mEq/L
- Regulator - parathyroid hormones,
- calcitonin from the thyroid, and Vitamin D hormone
- sources: Dairy, broccoli, kale, turnip, salmon, soy beans, tofu
Functions:
• bone and tooth formation
• transmission of nerve impulses
• blood clotting
• muscle contraction and relaxation
hypocalcemia
• removal of parathyroids
• excessive loss of intestinal secretions
• acute pancreatitis
• inadequate intake of Vitamin D
• alcohol abuse
• thyroid carcinoma
• use of diuretis
Clinical Signs of Hypocalcemia
• numbness, tingling sensation fingers or mouth
• abdominal and skeletal muscle cramps
• severe tetany (sharp flexion of wrists & ankles, cramps) which can lead to convulsions)
• + Trousseau’s sign
• +Chvostek’s sign
• serum calcium level < 4.3 mEq/L
hypercalcemia
• drinking too much milk
• taking too many calcium tablets
• cancer of the bone, prolonged immobility
• tumor of the parathyroids
• use of diuretics
Clinical Signs of Hypercalcemia
• lethargy, weakness
• relaxed muscles
• deep bone pain
• flank pain caused by renal calculi
• crisis - nausea, vomiting, dehydration, coma
- Magnesium (Mg++)
• Essential for enzyme activities, neurochemical activities, & cardiac and skeletal muscle excitability.
• Plasma concentrations range from 1.5 – 2.5 mEq/L
• Regulated by dietary intake, renal mechanisms, & actions of the parathyroid hormone (PTH)
• 50 - 60% is in the bone
• only 1% is in the ECF
• the rest is inside the cells
- Hypomagnesemia
• Phyisical examination: Muscle tremors, hyperactive deep tendon reflexes, confusion & disorientation, dysrhythmias, & positive Chovostek’s sign & Trousseu’s sign
• Signs & symptoms are directly related to the neuromuscular system
• Lab findings: serum magnesium level < 1.5 mEq/L
- Causes of Hypomagnesemia:
• Inadequate intake: malnutrition, & alcoholism
• Inadequate absorption: diarrhea, vomiting, NG drainage, fistulas, diseases of SI
• Excessive loss resulting from thiazide diuretics
• Aldosterone excess
• Polyuria
- Hypermagnesemia
• Depresses skeletal muscles & nerve function
• The depression of acetylcholine leads to a sedative effect, which can lead to bradycardia, ECG changes, cardiac arrythmias, & decreased respiratory rates and depth.
• Physical examination: physical findings that are more frequent in acute elevations in magnesium levels: hypoactive deep tendon reflexes, decreased depth & rate of respirations, hypotension, & flushing
• Lab findings: serum magnesium level > 2.5 mEq/L
- Causes of Hypermagnesemia:
• Renal failure
• Excess oral or parental intake of magnesium
- Chloride (Cl-)
• The major anion of the ECF
• The transport of chloride follows sodium
• Normal concentrations range from 90 – 110 mEq/L
• Regulated by dietary intake & the Kidneys
• A person with normal renal function who has a high chloride intake will excrete a higher amount of urine chloride
- Hypochloremia
• Causes include vomiting or prolonged & excessive NG or fistula drainage b/c of loss of hydrochloric acid.
• Use of loop & thiazide diuretics results in increased chloride loss as sodium is excreted
-Hyperchloremia
• Usually occurs with other imbalances
Hypotonic - Any solution less than 5% dextrose or 0.9% NaCl is Hypotonic because it has a lower osmilality than normal blood plasma
• 0.45% sodium chloride (half normal saline) – WHEN DEHYDRATED GIVE THIS!!!!
• 0.33% sodium chloride (one third normal saline)
Hypertonic - Any solution containing more than 5% Dextrose or 0.9% NaCl is Hypertonic because it has a higher osmilality than normal blood plasma
• 5% D/W in 0.9% NaCl
• 3% sodium chloride- extremely hypertonic, givn in small amount for small time (15ml/3h)
• Dextrose 10% in H2O
• 5% D/W in 0.45% NaCl
• D5LR
Isotonic – anything with an osmilality the same as the normal blood plasma osmolality which is between 280-295mOsm/kg. (The same number of Positive and Negative ions).
Examples of Isotonic:
- 5% Dextrose and water – Dextrose is quickly metabolized, leaving free water to be distributed evenly in all fluid compartments
- 0.9% NaCl(normal saline)- although it is isotonic b/c the total concentration of electrolytes equals plasma concentration, it contains 154 mEq of both sodium & chloride, which is a higher concentration of these electrolytes that is found in the plasma, which can cause FVE
- 2.5% Dextrose/0.45% normal saline
- Ringers Solution
- Lactated ringers- Contains sodium, potassium, calcium, chloride & lactate
Isotonic fluids are most commonly used for extracellular fluid replacement (such as in the case of a FVD after vomiting)
* The use of a hypo/hypertonic IV solution depends on the specific fluid or electrolyte imbalance. A person with a hypertonic fluid imbalance will be given a hypotonic IV to dilute the extracellular fluids and rehydrate cells. Hypertonic fluids pull fluid into the vascular space by osmosis and increase vascular volume.
Potassium Chloride – Potassium is extremely irritating to the gastric & intestinal mucosa, so it must be taken w/at least ½ a glass of fluid
(1) Kay Ciel
(2) Slow-K
(3) K-Lyte
(4) K-Dur
- Caution used with Cardiac disorders & burns
- To correct potassium deficit; strengthens cardia & muscular activities, prevents hypokalemia in at-risk clients.
- Transmits & conducts nerve impulses, contracts skeletal, smooth & cardiac muscles
- Side effects include NVD, abdominal cramps, irritability, rash, phlrbitis w/IV administration
B. Calcium Carbonate
(1) Os-cal
(2) Caltrate
- Caution used in renal or respiratory disorders, & GI hypomotility
- To correct calcium deficit or tetany symptoms, & prevention of osteoporosis
- Transmits nerve impulses, contracts skeletal & cardia muscles, maintains cellular permeability; promotes strong bone & teeth growth
- SE include NV, constipation, pain, drowsiness, headache, muscle weakness
C. Calcium Gluconate
(1) Kalcinate
- essential for nervous, muscular & skeletal systems
- Maintains cell membrane & capillary permeability
- acts as an activator in the transmission of nerve impulses & contraction of skeletal, cardiac & smooth muscles
- essential for bone formation & blood coagulation
- replacement of calcium in deficiency states
- monitor BP & HR
- can cause hypercalcemia, renal calculi & V-fib
Magnesium Oxide
(1) Mag-Ox
- essential for the activity of many enzymes
- plays an important role in neurotransmission & muscular excitability
- replacement in deficiency states
- give w/full glass of water
LAB VALUES:
a. Serum osmolality
b. Urine specific gravity (1.010-1.025)
c. Blood urea nitrogen (10-20mg/100ml)
d. Creatinine (0.5-1.2mg/100ml)
Hyponatremia- Syndrome of inappropriate ADH (SIADH)
Metabolic alkalosis- Excess aldosterone
Hypomagnesemia- Malnutrition & alcoholism
Hypocalcemia- Pancreatitis
Hyperkalemia- Renal failure
Hypokalemia- Diarrhea & vomiting
Hypermatremia- Diabetes insipidus
Hypercalcemia- Prolonged immobilization
Extracellular CATIONS (+)
sodium 142mEq/L
potassium 5mEq/L
calcium 5mEq/L
magnesium 2mEq/L
= 154mEq/L
Extracellular ANIONS (-)
chloride 105mEq/L
bicarbonate 24mEq/L
proteinate 16mEq/L
organic acids 6mEq/L
phosphate 2mEq/L
Sulfate 1mEq/L
= 154mEq/L
Intracellular CATIONS (+)
potassium 160mEq/L
magnesium 35mEq/L
sodium 10mEq/L
= 205mEq/L
Intracellular ANIONS (-)
phosphate 140mEq/L
proteinate 55mEq/L
bicarbonate 8mEq/L
chloride 2mEq/L
= 205mEq/L
Each exerts only 1mEq of chemical activity. Example: All have different weights BUT - All have the same buying power (2 nickels, 1 dime, 10 pennies); you are making up a guest list for your child’s birthday party. You will invite the same number of boys and girls, NOT 1000 lbs of boys and 1000 lbs of girls
1 mEq of any electrolyte is chemically equivalent to 1 mEq of any other electrolyte, even though the weights may differ
Regulation of Fluid Balance:
- Thirst
- GI System
- Renal System
- Lymphatic system – intersticial space; transports solutes to tissues; blockage/ removal = can not removal fluid = local edema
- Neuroendocrine system (hormones ADH & Aldosterone)
Orientation phase
- before beginning the interview, the nurse reviews the purpose for the interview, the types of data to be obtained, length of time, and the methods most appropriate for conducting the interview.
- The nurse opens the interview by explaining the purpose of the interview, by discussing the types of questions to be asked, and by telling the client what their role will be.
- This allows the nurse and client to have a few minutes to become acquainted with each other and to develop a rapport.
- Establishes the nurse-client relationship
Working phase
- as the interview progresses, the nurse begins asking questions to form a database, from which the nursing care plan will be developed.
- The nurse asks open/close-ended questions or employs other interview techniques.
Termination phase
- during the termination phase, the client is given a clue that the interview is coming to an end.
For example, the nurse may say, “I have two more questions, or just a few more minutes.”
- It is as organized as the opening.
- The interview is terminated in a friendly manner, with the nurse indicating when there will be additional contact.
State the objectives of a nursing health history
- To identify patterns of health and illness
- To identify risk factors for physical and behavioral health problems
- To identify deviations from the norm
- To identify available resources for adaptation
components of a health history:
1) Biographical information-
2) Reason for seeking health care
3) Client expectations
4) Present illness
5) Past health history
6) Family health history
7) Environmental history
8) Psychosocial history- client's support system
9) Spiritual health
10) Review of systems
11) Physical Examination
Demographic data
– Age
– Address
– Occupation and working status
– Marital status
– Types of insurance coverage
the importance of asking a patient their reason for seeking health care
• Determine the main reason patient is seeking health care, called chief complaints.
• When recorded, the statement is enclosed in quotation marks to indicate the clients words. Ex. “I’ve had chest pain since early morning.” “ My stomach hurts and I feel awful.”
• Identifies potential areas for education, counseling, or community resources required.
Common client expectations:
a) To get info needed to care for their problem independently
b) To receive caring and compassion from nurse and others
c) Relief of pain and symptoms
d) Timely response to their questions
e) To be involved in decision making
f) A clean environment
questions the nurse should ask to gather information regarding a present illness.
• Ask the patient to describe the chief complaints.
• Dig for details.
• Ask about onset, duration, and location.
• Use terms the patient is familiar with.
• Evaluate symptom severity
• Ask the patient to quantify the symptom; rate the intensity of pain on a scale of 1 to 10.
• Ask about aggravating and relieving factors.
• Explore associated symptoms – Nausea, SOB, palpitation, or sweating.
PQRST Method
- Provoking Factors – What, provokes the pain/discomfort? Anything that makes it worse or relieves it? What was the patient doing when it began?
- Quality Of Pain – Have patient describe. Avoid “feeding” descriptive terms.
- Region Of Radiation – Ask if it travels any place else. Ask if it has moved from the region of onset. Point to area(s).
- Severity – Quantify. Scale1-10.
- Time – Time of onset, constancy, & duration of symptoms
areas which are assessed when gathering data on a patient’s past health history.
- Food, drug, or other allergies
- Identify lifestyle habits such as use of alcohol, tobacco, caffeine, OTC drugs, or routinely taken meds
- Assess sleeping pattern
- Assess exercise and nutrition habits
- The plan in the health care facility should match the client’s lifestyle patterns as much as possible.
- Health care experiences– Medical-surgical history
- Allergies - reaction
- Current medications- prescription, OTC, herbal
- Lifestyle patterns – ETOH (CAGE questionnaire) – Tobacco– Recreational Drug Use– caffeine
CAGE Questionnaire
• C: Have you ever thought you should Cut down your drinking?
• A: Have you ever been Annoyed by criticism of your drinking?
• G: Have you ever felt Guilty about your drinking.
• E: Do you ever have an Eye-opener (a drink) in the morning?
Determining Pack-Years
• The number of cigarette packs the patient smokes per day multiplied by the number of years he has been smoking. ex. Patient John Doe has smoked 2 packs of cigarettes per day for 20 years. To determine his pack-years, multiply 2 packs by 20 years; the result is 40 pack-years.
objectives of a family history.
- To obtain data about immediate blood relatives to determine whether the client is at risk for illness of a genetic or familial tendency.
- To identify areas of health promotion and illness prevention
- To get information about family structure, interaction, and function (will they help or hinder)
- Example: DM, HTN, CVA, CAD, Pulmonary disease, arthritis, CA, renal disease, mental illness, and alcoholism.
- Genogram- a chart that shows a patient’s family relationships and health history patterns.
information gathered in an environmental history:
- Obtains data about the client’s home environment and support systems
- Identifies exposures to pollutants that can affect health
- Identifies whether they live in a high crime area and can’t get out to exercise
- Identifies available community resources
- Provides data about patient’s home environments and any support systems that may be needed.
- Functional utilities; Heat, running water, electricity, telephone service, smoke detectors, carbon monoxide detectors?
- Presence of any barriers or risks to patient’s safety; Layout of rooms
- More than one story; stairs, overcrowded living environment
- How many people the patient lives with
- Identifies exposure to pollutants
- Existence of high crime neighborhood
- Available community resources
information included in the psychosocial history.
- Reveals the clients support system such as spouse, children, friends
- Reveals how the client copes with stress
- Reveals if the client has experienced a recent loss
- Reveals the patient’s support system- Spouse, children, family members, friends
- Recent losses/death in the family.
- Stress- Coping mechanisms
importance of assessing spiritual health in a health history.
- Life experiences and events are shaped by ones spirituality
- Reveals their beliefs about life, their sources for guidance in acting on beliefs, and the relationship they have with family in exercising their faith.
- Rituals and religious practices are assessed
- Strong influence on patient’s health, illness and medical treatment ex: Jehovah’s Witnesses
- Source of emotional support during illness: Church, religious organization affiliation, or other spiritual groups (resource for him during or after illness or hospitalization)
Concluding the health history:
• Review findings
• Ask more questions (if necessary), to clarify conflicting or ambiguous information
– “What do you think the problem is?”
– “What concerns you most right now?”
• Thank patient for the time and cooperation
• Assessment data are recorded in clear, concise manner using appropriate terminology.
Position of internal organs: The heart is in the center of the chest and slightly to the left of the sternum.
Abdomen:
-Upper Right quadrant: Liver, kidney, and the transverse colon
-Upper Left quadrant: Stomach and kidney
-Lower Left quadrant: Small intestines, descending colon, sigmoid colon
-Lower Right quadrant: Ascending colon
purpose of physical assessment.
1) To gather baseline data about the client’s health
2) To supplement, confirm, or refute data obtained in the nursing history
3) To confirm and identify nursing diagnoses
4) To make clinical judgments about a client’s changing health status and management
5) To evaluate the physiological outcomes of care
A health screening involves measurement of specific physical functions or diagnostic tests to detect persons with high probabilities of having a disease or condition.
- For example, blood pressure screenings to detect the risk for high BP or a TB skin test.
- Information from health screenings determines the need for more comprehensive examinations.
A health assessment involves a more detailed review of the client’s condition.
- the nurse gathers a nursing history & performs a behavioral/physical examination.
- The health history involves an interview with the client to gather subjective data about the client’s level of wellness (present and past), family history, changes in life patterns, sociocultural history, spiritual health & mental/emotional reactions to illness.
- A physical examination is a head-to-toe review of each body system that offers objective information about the client and allows the nurse to make clinical judgments.
Inspection: the process of observation.
- The nurse inspects body parts to detect normal characteristics or significant physical signs.
- The nurse must know normal physical characteristics before trying to distinguish abnormal findings.
- Composed of general & systemic inspection.
- To inspect effectively, the nurse observes the following principles:
1) Make sure good lighting is available
2) Position and expose body parts so that all surfaces can be viewed
3) Inspect each area for size, shape, color, symmetry, position, and abnormalities
4) If possible, compare each area inspected with the same area on the opposite side of the body
5) Use additional light (penlight) to inspect body cavities
6) Don’t hurry the inspection, pay attention to detail
Palpation:
- Assessment made through the sense of touch.
- Through palpation, the hands can make delicate and sensitive measurements of specific physical signs, including resistance, resilience, roughness, texture, and mobility.
- When palpating, the client should be relaxed and positioned comfortably because muscular tension impairs the effectiveness of palpation.
- Asking the client to take deep breaths and placing their arms along their sides reduced tension and abdominal rigidity.
-TENDER areas should be palpated last.
- Light (1/2” deep) palpation always proceeds deep (1”-2” deep) palpation.
The most sensitive parts of the hand, the palmar surface of the fingers and finger pads are used to assess position, texture, size, consistency, form of a mass, and pulsation.
- Temperature is best measured using the back of the hand and fingers where the skin is thinnest.
- The palm is more sensitive to vibration.
- The fingertips are used to measure position, consistency and turgor.
• Using the hands through the sense of touch.
– Light palpation
– Deep palpation
– Bimanual palpation
– Palmar surface
– Ball of hand
– Forefinger and thumb
– Entire hand
• Usually the second step in PE , except when assessing the abdomen; palpation is performed after auscultation.
• Know the reason for palpation; consider the patient’s condition; (ex. fractured rib).
• Do not palpate carotid arteries at the same time.
Percussion:
- Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and to discover fluid in body cavities.
- It requires considerable skill and is the least used assessment skill.
- Through percussion, the location, size, and density of an underlying structure are determined.
- Percussion involves striking one object against another (the middle fingers), thus producing a vibration and subsequent sound waves.
- The character of the sound depends on the density of the underlying tissue.
- The direct technique involves the direct striking of the body surface with one or two fingers.
- The indirect technique involves placing the middle finger of the non-dominant hand (pleximeter) firmly against the body, palm down, with the remaining fingers off the body.
- The tip of the dominant hand middle finger (plexor) is then used to strike the other middle finger.
- A quick sharp stroke is used.
- Percussion produces five types of sound: tympany, resonance, hyperresonance, dullness, and flatness.
Percussion Sounds
• Tympany: a high-pitched, drum-like sound, is usually heard over the stomach.
• Resonance: a low-pitched, hollow sound, is usually heard over normal lung tissue.
• Hyperresonance: a loud, booming sound, is usually heard over a hyperinflated lung, as in patients with emphysema.
• Dullness: a soft high-pitched, thud-like sound, can generally be heard over dense organs, such as the liver.
• Flatness: a soft, high-pitched sound, is generally heard over bones, muscles, and tumors.
Percussion Techniques
• Direct
• Indirect
• Blunt percussion
Auscultation: listening to sounds produced by the body.
- carried out last, except during the abdominal examination.
- The stethoscope should always be placed on naked skin, because clothing obscures sound.
- The bell is used for low-pitched sounds, such as vascular and certain heart sounds.
- The diaphragm is best use for high-pitched sounds, such as bowel and lung sounds.
Through auscultation, the nurse notes the following characteristics of sound:
1) Frequency (the number of oscillations per second)
2) Loudness (amplitude of the sound wave)
3) Quality (blowing, gurgling)
4) Duration (the length of time the vibration lasts)
Auscultation requires concentration and practice.
• Listening to sounds
• Performed last (except during abdominal examination)
• Use of stethoscope
– to naked skin
– Bell: low-pitched sounds
– Diaphragm: high-pitched sounds
• Note character of sounds heard
Olfaction: When assessing with olfaction, the nurse should be familiar with the nature and source of body odors.
• Detects abnormalities difficult to recognize by other means
– Musty odor from casted body part- infection
– ETOH breath- alcohol/ drunk
– Halitosis- bad breath
– Sweet, heavy, thick odor from draining wound- psuedomonas
– Ammonia- decay
components of the general survey and expected findings of each component the nurse documents.
1. Observation of general appearance and behavior:
gender, race, age, signs of distress, body type, posture, gait, body movement, hygiene/grooming, body odor, affect and mood, speech, client abuse, substance abuse
* P&P pg 684 box 32-3 *
2. Vital signs
3. Hight & weight
* The survey provides information about a client’s hygiene and body image, emotional state, recent changes in weight, and developmental status. If abnormalities are found, the affected body system is closely assessed later
child abuse
1) Vaginal or penile discharge
2) Blood on underclothing
3) Pain or itching in genital area
4) Genital injury
5) Difficulty walking or sitting
6) Pain while urinating
7) Foreign bodies in rectum, urethra, or uterus
8) STD
Domestic abuse:
1)Injuries/trauma inconsistent with reported cause
2)Multiple injuries involving head, face, neck, breasts, abdomen, and genitals
3)X-rays showing old and new fractures in different stages of heeling
4)Cigarette burns
5)Human bites
Older Adult Abuse:
1)Injuries or trauma inconsistent with reported cause
2)Hematomas
3)Bruises at various stages of resolution
4)Signs indicating restraint (bruises, chaffing of wrists or legs)
5)Burns
6)Fractures inconsistent with cause described
7)Prolonged interval between injury and medical treatment
Substance abuse:
1)Missed appointments
2)Requesting excuses for missed work
3)Complaint of insomnia, bad nerves, or pain that fits no pattern
4)Frequently reports lost prescriptions or asks for frequent refills
5)Frequent doctor changed or meds issued by multiple doctors
6)History of GI bleeding, peptic ulcers, pancreatitis, cellulites, or frequent pulmonary infections
7)History of activities that place them at risk for HIV
8)Family history of addiction
the importance of understanding cultural diversity as it influences the approach to health assessment.
1)Influences their willingness to assume responsibility for their health and tendency to seek care
2)Must consider the clients health beliefs, nutritional habits, relationships with family, and use of alternative therapies
3)Must consider how comfortable the client feels with the nurses’ physical closeness during the exam and history taking
4)Do not stereotype on the basis of gender or race
5)The nurse should learn common disorders of the ethnic populations where the work
self-screening examinations commonly performed by clients
1)Breast self-exam (BSE)
2)Testicular self-exam (TSE)
3)Mouth care
4)Skin exam
- Breast Cancer: Ages 20-39- Monthly BSE and a doctor’s exam every 3 years
Over 40- Monthly BSE, annual exam, annual mammogram
- Colon/rectal cancer: 50 and over- Fecal occult blood test (FOBT) and sigmoidoscopy (if normal repeat FOBT annually and sig. every 5 years.
- Ear disorders: All ages- Periodic hearing checks as needed
Over 65- Regular hearing checks
- Uterine cancer: Sex active- Annual pelvic exam and PAP smear, Cervix, Endometrium
- Eye disorders: 40 and under- Complete eye exam every 3-5yrs (more of +Hx)
40-64- Complete eye exam every 2 years
65+- Complete eye exam every year
- Heart/Vasc. Dis.: Any age- Regular measurement of total blood cholesterol & triglyceride levels, BP screenings
- Oral cavity: All ages- Regular dental exam every 6 months
- Ovarian cancer: sex active- Annual pelvic exam
- Prostate cancer: Age 50+- Digital exam and PSA screening, earlier if at risk
- Skin cancer: All ages- Regular skin self-exam
- Testicular exam: Age 15+ Monthly TSE
Skin: – Inspection
• color: general color, skin pigmentation, cyanosis, pallor, vitiligo, jaundice, erythema, tan-brown
• freckles, birthmarks, moles
• chronically ill or hospitalized: signs of skin breakdown (pressure points); IV sites (infiltration, infection, phlebitis)
• Check for skin lesions, rashes, wounds, & bruising, petechiae, & edema
– Palpation
• Skin temperature
• Skin turgor, induration (hardening)
• Lesions: raised (papular) or flat (macular), senile keratosis (thickening of skin), cherry angiomas (ruby red papules), basal cell & squamous cell carcinomas, & melanoma
Skin: – Olfactation
• Note odors in the folds of the skin, such as the axillae or under the female’s breast.
– Normal Findings
• Warm, dry, intact.
• Skin color even over entire body (vary with race). Darkskinned have lighter skin on the palms, the soles of feet, and nail beds.
• Areas that get regular sun exposure, expect darker skin & greater pigmentation.
– Abnormal Findings of skin:
• Lesions
• Malignancies
• Skin breaks
• Wounds
Hair and Scalp- Inspection, palpation & olfactation.
– Assess at the same time assessing the skin.
– Wear gloves if suspecting hair & scalp are infested with lice.
– Ensure adequate lighting & warmth- to prevent piloerection (gooseflesh).
– Hair: color, distribution, quantity, texture, moisture,
– Scalp: lesions, wounds, moisture, infestation (requires immediate treatment if discovered).
• Normal Findings of hair
– Hair distributed evenly over the scalp and body, except in men with male-pattern thinning and baldness.
– Hair color usually ranging from light blond to black. Color consistent throughout the scalp.
– Hair fine or coarse, straight or curly.
– Scalp free of injuries, lesions, excessive dryness or oiliness, scaling, infection, or signs of infestation.
• Abnormal Findings of Hair & scalp:
– Alopecia
– Hirsutism
– Dry, brittle hair
– Increased silkiness & fineness
– Scaling eruptions of the scalp
– Excoriation of scalp, eyelids & pubic area with small, nitlike flakes along the hair shaft
Nails
• Extensions of epidermis.
• Inspection and palpation can be done simultaneously.
• Assess when examining lower and upper extremities.
• Reflects general state of health, nutrition, occupation, level of self-care, and psychological state (nail biting).
• Normal Findings of Nails:
– Slightly convex curvature (160° between the nail & skin at the nail base.
– Nail surface feel smooth, even, and hard, with smooth, rounded edges.
– Capillary refill < 3 seconds
– With aging, nails become harder and thicker
• Abnormal Findings of nails:
– Brittle, thinning, or peeling nail plates
– Thickened nails, pallor of nail bed
– Greenish-black nail plates, yellow nail plates
– Abnormal curvature or a nail base angle of 180° or > (clubbing)
– Cyanosis (bluish mottling)
– Capillary refill > than 5 seconds
Head and Neck: – Inspect:
•head position: size, shape, and contour of skull).
•face for symmetry of structures & movement.
•mucous membranes in the nose & mouth.
•position & movement of the tongue, uvula, and soft palate
– Palpation of head & Neck:
•skull for nodules or masses.
•frontal & maxillary facial areas.
•temporo-mandibular joint (TMJ) space bilaterally.
•lymph node swelling.
•thyroid gland.
• Check gag reflex
• Inspect & palpate the position & movement of the trachea
• Assess the symmetry & strength of the jaw, neck, and shoulder muscles.
• Normal Findings of head & neck:
– Head round & symmetrical
– Abnormal:
Normal Findings of head & neck:
– Scalp pink in color, without scales & covered w/hair. Hair distributes evenly, without excess oils.
– Facial features symmetrical. The eyes open evenly & are equally displaced from the midline of the face.
– Nasolabial folds symmetrical. Skin of the face & neck pink, smooth, & firm in tone.
– Nasal mucosa flat & somewhat redder than oral mucosa. Nasal septum lies at the midline of the nose.
Normal Findings of head & neck:
– Lips moist , w/out cracks or fissures.
– Gums w/a red stippled surface. Margins around the teeth are sharp, & the teeth are firm in the sockets.
– Tongue at the midline, with full rounded appearance & smooth movement.
– Frontal & maxillary sinuses free of pain.
Normal Findings of head & neck:
– Trachea straight & at the midline of neck.
– Thyroid gland moves freely when the patient swallows.
– Lymph nodes in the neck nonpalpable, nontender, & not swollen. If palpable, they’re soft, round, full, & smooth.
– Resonance on percussion of the sinuses.
– Shoulder & neck muscles equal in strength & contraction bilaterally.
EYES- Inspect:
– position, shape, movement of eyes and associated structures.
– eyelids for color, texture, integrity, closure, lesions, and drooping.
– eyelash distribution, orientation, and granulations.
– cornea for clarity, surface integrity, reflex (if needed), and light reflection.
– eyeball surface for lubrication, tearing, redness, and swelling.
– pupil size, shape, light response, accommodation, and red reflex.
– extraocular movements, including the six cardinal positions of gaze.
• Palpate:
– for firmness, mobility, texture, and smoothness of eyelids and orbital rim.
– punctum for tenderness and discharge.
• Test for visual acuity.
• Perform the confrontation test (visual fields and peripheral vision)
• Perform opthalmic examination: internal eye structures with the use of the opthalmoscope
EYES- Normal Findings:
– Orbits symmetrical in placement, shape, and position; eyeballs freely mobile.
– Eyelids smooth, nontender, and free of discharge; ( ectropion, lid margins that turn out or in, entropion, may be seen in elderly patients).
– Tear ducts nontender and free of discharge.
– Eyelashes free of granulation, scales.
– Adequate surface lubrication and moisture.
– Conjunctiva clear and moist.
– Sclera white and opaque.
– Cornea smooth and transparent; arcus senilis
– a grayish-white ring around the cornea, common with aging; corneal reflex brisk.
– Irises flat and circular, with even bilateral pigmentation.
EYES- Normal Findings:
– PERRLA (Pupils Equal, Round, Reactive to light, and Accommodation).
– Eyes congruent (parallel) in all positions while testing the six cardinal positions of gaze.
– Visual acuity 20/20
– Full visual fields
– On palpation, eyeball is firm, smooth, and yielding slightly to pressure.
– Eyelid and puncta nontender and free of discharge.
– Red reflex bright and regular.
– Clear yellow optic nerve disk
– Redish pink retina (whites), or darkened retina (African-Americans).
– Light red arteries and dark red veins.
– Macula free of blood vessels.
EYES- Abnormal Findings:
– Exopthalmos or proptosis
– Incomplete eyelid closure (lagophthalmos)
– Ectropion or entropion
– Ptosis (drooping eyelid)
– Eyelid swelling
– Red eyelid margins, with dried mucus clinging to the eyelashes (blepharitis), a chronic inflammation with itching, burning, and irritation
– Stye or hordeolum
– Chalazion (bead-like swelling on the eyelid)
– Xanthoma (or Xanthelasma) palpebrarum (a soft, yellowish, raised, waxy lesion on or beneath the eyelid.
– Conjunctivitis (inflammation of the conjunctiva)
– Subconjunctival hemorrhage
EYES- Abnormal findings:
– Inadequate tear production (dry eye syndrome)
– Corneal haziness or cloudiness
– Red eye with tearing, foreign body sensation, pain, decreased visual acuity and photophobia→corneal abrasion.
– Irregularly shaped pupils
– Anisocoria (unequal pupil diameter), pinpoint pupils, dilated pupils, nonreactive pupils.
– Lack of parallel eye movement or deviation of one eye.
– Nystagmus (involuntary oscillating eye movement)
– Vision changes; loss of central vision
– Blind spots
– Homonymous hemianopia (loss of vision on one side of both visual fields)
Exopthalmos- Ears
• Inspect:
– ear size, placement, skin color, texture, and integrity.
– auricles for mobility, color, discharge, cyst, nodules, lesions, and tenderness.
– auditory canal for nodules, cyst, abrasions, discharge, lesions, inflammation, obstruction, cerumen impaction, and tenderness.
– Inspect periauricular and postauricular lymph nodes for size, consistency, and tenderness.
– Check auditory canal for patency, integrity, bony overgrowths, and pain.
• Otoscopic Exam: Look at tympanic membrane for color, integrity, cone of light, bony landmarks, bulging, erythema, perforation, drainage, fluid, air, and lesions.
Ear Complaints
• Ear Pain
• Ear Discharge
• Hearing loss
– Whisper test or watch-ticking test
– Weber Test and Rinne Test
• Vertigo (abnormal sensation of movement or spinning)
• Normal Findings of EARS:
– Auricles equal in size and placement, symmetrically positioned, and freely mobile.
– Skin over ears clean, dry, and same color as other skin; free of scales, redness, and inflammation.
– Preauricular and postauricular lymph nodes nonpalpable or small, soft, and nontender.
– External auditory canal patent and free of nodules, cysts, drainage, inflammation or obstruction; cerumen (yellow waxy substance) present but not excessive or impacted.
– Tympanic membrane intact, shiny, translucent, and pearly gray; cone of light present; bony landmarks visible
Thorax (chest) and Lungs
• Inspection:
– Breathing pattern- Muscles used
– Chest wall movement
– Shape and symmetry- AP diameter
– Width of the costal angle
– AP thoracic skeleton
• Posterior chest wall: Note for deformities, position of spine slope of the ribs, and symmetry
• Normal Findings:
– Quiet and barely audible; accessory muscles (trapezius, sternocleidomastoid, & abdominal) move little.
– Expansion is symmetric
– AP ⅓ - ½ of the transverse diameter.
– Angle is usually larger than 90°.
– Sternum & xiphoid relatively inflexible.
– Posterior chest wall: look for deformities, position of the spine, slope of the ribs, & symmetry of scapulae
Thorax & Lungs- Palpation:
– Lumps, masses, pulsation, tenderness, bulges & unusual movement or position.
• Normal Findings:
– Spine vertically straight, no lateral deviation; scapulae symmetric
• Palpation:
– Chest wall not tender; rib cage somewhat elastic; thoracic spine is rigid
– Measure posterior chest excursion; palpate for symmetry of respiration
– Tactile (vocal) fremitus (ball of hand over ICS, beginning at the lung apex; ask patient to say “99”; palpate both sides simultaneously)
• Normal Findings:
– Chest excursion should be symmetric, separating the thumbs 1¼ to 2 in. (3-5 cm)
– Faint vibration symmetric & strongest at the apex, near tracheal bifurcation; decreased in the periphery of chest
• Percussion:
– Percuss ICS; (air filled, fluid filled, or solid); indirect percussion; follow systemic pattern; compare both sides
– Measure diaphragmatic excursion
Thorax & Lungs- Normal findings:
– Posterior thorax usually resonant; dull over ribs, scapula
– Normal excursion distance is 1 ¼ to 2 inches (3-5 cm). The diaphragm is normally higher on the right than the left.
• Auscultation:- Best position is SITTING
– follow systematic pattern
– Listen to entire inspiration and expiration at each position
– Normal breath sounds:
• Vesicular: best heard over lung’s periphery (except scapula)air moving through smaller airways, soft breezy & low pitched
• Bronchovesicular: posteriorly between scapulae and anteriorly over bronchioles lateral to sternum at 1st and 2nd ICS. Air moving through large airways. blowing medium pitched & intensity sounds
• Bronchial: best heard over trachea. caused by air moving through trachea close to the chest wall. Loud & high pitched w/hollow quality
• Lateral Thorax:
– Patient seated and arms raised above head
– Inspect, palpate, percuss and auscultate in the same manner as with posterior thorax
– Use systematic method
– Excursion cannot be assessed laterally
• Anterior Chest Wall:
– Measure chest excursion
– Palpate for tactile fremitus
– Percuss from above the clavicles, moving across and down; compare both sides, considering the locations of the underlying liver, heart, and stomach
– Auscultate using same pattern
Laterl Thorax- Normal Findings:
– Should separate the thumbs 1¼ - 2 inches (3-5 cm)
– Fremitus is normally decreased over the heart, lower thorax, and breast tissue
– Percussion over the heart & liver are dull; the gastric air bubble is percussed as a tympanic sound
– Breath sounds are clear
Abnormal Findings
• Localized pain
• Crepitus
• Suspicious mass or swollen area on chest wall
• Use of accessory muscles of respirations or pursed-lip breathing
• Decreased fremitus
• Increased fremitus
• Abnormal breath sounds (adventitious sounds)
• Bronchophony or egophony
Adventitous Sounds
• Crackles (aka rales) alveoli/breaking
– Fine crackles:
– Coarse crackles:
• Rhonchi- mucus, most can be cleared by coughing/suctioning
• Wheezes- constriction of bronchi (asthma) heard during expiration
• Pleural friction rub
• Stridor
• Sound over lung consolidation
Voice Sounds
• Normal voice “e” – if positive Egophony (sounds like a goat eee)
• Normal whisper sound- Positive Whispered pectoriloquy if can hear the whispered sounds
• Muffled speech- positive Bronchophony
Heart
– Inspection and Palpation:
• Pulsation may be seen at the PMI (Point of Maximum Impulse)
– Normal Auscultation:
• S1: AV valves closure; “lub”
• S2: Semilunar valves closure; “dub”
• HR: 60-100/min
• Rhythm: regular
•Auscultatory Sites:
– Aortic area (2nd ICS Right Sternal Border )
– Pulmonic area (2nd ICS Left Sternal Bordre)
– Tricuspid area (4th ICS Left Sternal Border)
– Mitral area (5th ICS Midclavicular Line)
– Epigastric area (at the tip of the sternum)
Vascular System
• Inspection:
– Examine the internal jugular vein: JVD (Jugular Vein Distention)
– Normal: Negative JVD - veins are flat; pulsations are not evident
– Abnormal: Positive JVD
• Palpation– Carotid arteries
• Examine each peripheral pulses: Radial, ulnar, brachial, femoral, poplitial, dorsalis pedis, posterior tibial; Assess for strength and quality
• Normal pulse is 2+ and equal bilaterally
• When difficult to palpate a pulse or the pulse is not palpable, use a doppler.
• Pulse creates a regular “swooshing” sound.
• If arterial insufficiency is suspected, perform Allen’s test
• Assess for phlebitis in leg veins; inspect calves for localized redness, tenderness, and swelling over vein sites
• Check for Homan’s sign (while supporting the leg and keeping the knee slightly flexed, quickly dorsiflex the foot) – Positive Homan’s sign is abnormal
Heart & Vascular System
• Palpate lower extremities around feet and ankles for dependent edema; press firmly to 1-2 seconds and then release over the medial malleolus or the shins
• Normal findings: edema is absent
• Auscultation– Abnormal: bruit
Abnormal Findings Heart & Vascular System
• Irregular heart rhythm: symptomatic
• Symptomatic sinus bradycardia
• Symptomatic sinus tachycardia
• S3 gallop
• S4 gallop
• Quadruple gallop (S1, S2, S3, S4 all heard separately)
• Murmur
• Arterial occlusion
• Venous occlusion
• Carotid bruit
Breast
• Female Breast:
– Inspect sides, size, symmetry, contour and shape, note masses, flattening, retraction, or dimpling, venous patterns and presence of edema, lesions, or inflammation
– Inspect nipple and areola: size, color, shape, discharge, and the direction nipples point
– Palpate axillary lymph nodes:
• Supraclavicular
• Infraclavicular
• Axillary nodes
American Cancer Society Early Detection of Breast Cancer
• Monthly BSE (Breast Self-Examination): women 20 years of age and older.
• Every 3 years exam. By physician: age 20 to 40, and yearly for women over 40.
• Yearly physician’s exam. With family Hx of breast cancer.
• Screening mammogram by age 40; 40 & over, annual mammogram.
• Age 35 with Hx of breast cancer, yearly examination.
Breast: Abnormal Findings
• Dimpling (Peau d’orange appearance)
• Nipple retraction, discharge or bleeding.
• A palpable, unilateral mass that is hard, nontender, irregular in shape, fixed, and poorly delineated suggest a malignancy; (fibrocystic disease → benign; lumpy, painful, mobile, round & well delineated)
• Unequal contour (may be caused by an underlying lesion)
• Enlarged or tender lymph nodes.
• Galactorrhea
• Gynecomastia (male breast enlargement)
Abdomen
• Inspection
– color, scars, venous patterns, stretch marks (striae), lesion, contour, symmetry, surface motion of the abdomen, distention, umbilicus,
– Respiratory movement
– Peristalsis (intestinal motility)
– Pulsation
Abdomen - Auscultation
– Bowel sounds (High-pitched, soft, gurgling sound that occur 5-35 times/min)
– Bruit (bell): epigastric region, aortic, renal, iliac and femoral arteries, and thoracic aorta (no vascular sound audible)
• Percussion:
– Four quadrants (tympany; dullness, to locate borders of underlying organs (liver, stomach, kidneys)
• Palpation
– Light palpation; deep palpation (if tenderness is found, test for rebound tenderness)
– Never use deep palpation over tender organs, areas of bruits, or surgical incisions.
Female genitalia and reproductive tract
• Inspection:
– Perineum; labia majora; labia minora; urethral orifice: color and position; Skene’s & Bartholin’s glands;
• Internal Genitalia: Speculum Examination
– Cervix; Papanicolaou (Pap smear)→ test for cervical & vaginal cancer
– vagina
Abnormal Findings
• Vesicular lesions, moist ulcerations, and crusting erosions (herpes simplex virus) – Chancres (small open ulcers that drain serous material).
• Candidiasis- a white, curdlike discharge with mild to severe itching and erythema of the labia.
• Copious frothy, gray/green discharge with foul odor, with severe itching with or without erythema of the vulva → Trichomonas Vaginalis
• Dry, scaly, nodular lesions may be malignant changes in older women.
• Discharge & tenderness on palpation of Skene’s gland
• Inflammation & edema near the posterior end of the introitus → infected Bartholin’s gland.
• Cystocele - prolapse of the vaginal wall & bladder
• Rectocele – prolapse of the rectum
• Hematuria
Male genitalia
• External Genitalia:
– Inspect skin covering the genitalia for lice, nits, rashes, excoriation, or lesion; structures of penis (glans, urethral meatus, shaft) lesions, edema, discharge
– Scrotum: size, color, shape, symmetry, lesions, edema
– Inguinal ring and canal: with patient standing, palpate inguinal ring & canal; ask patient to bear down.
Abnormal Findings
• Swollen, tender testicle & presence of small, painless, & hard lumps.
• Syphylitic chancres.
• Condyloma acuminatum.
• Pediculus pubis.
• Difficulty starting stream of urine, decreased force of stream, or interrupted stream of urine.
• Hematuria.
Male Genital Self-Examination
• Genital Examination
– Bumps, sores, blisters, warts, discharge
• Testicular Examination
– Feel for small pea-sized painless lumps on the front and side of the testicle → call your MD; it is abnormal
* A cordlike structure on the top and back of the testicle, the epididymis, is not a lump. *
Rectum and Anus
• Inspection
• Digital Palpation in Men:
- Palpate the anterior wall for prostate gland (Rounded heart-shaped structure about 2.5 cm to 4 cm in diameter) less than 1 cm protrusion into the rectum; firm, no bogginess, tenderness or nodules
Recommendations for Early Detection of Colon Cancer
• After 40 years of age:
– DRE (Digital Rectal Examination) annually
• After 50 years of age:
– Yearly fecal occult blood test (FOB) (guaic test)
– Flexible sigmoidoscopy or colonoscopy (if colonoscopy is normal & annual FOB if normal, repeat colonoscopy every 10 years.
– Double contrast barium enema (if normal, repeat every 5-10 years.
Recommendation for Early Detection of Prostate Cancer (ACS)
• Digital rectal examination performed annually after age 50.
• Prostate specific antigen (PSA) blood test performed annually after age 50. If either test result is suspicious, a prostate ultrasound examination should be performed.
Abnormal Findings
• Acute rectal pain
• Palpable rectal mass.
• Hardness or nodules on prostate.
• Blood in feces.
• Pencil-shaped stool.
• Fatty stool (float in the toilet bowl, maybe light brown or chalky colored)
• Mucus in fecal matter.
• Pipestem & ribbon stool
Musculoskeletal System
• Inspection
– observe for dragging, shuffling, or limping, balance, presence of obvious deformity
– note cervical, thoracic, and lumbar curves (lordosis, kyphosis, scoliosis)
– Observe extremities (gross deformity, alignment, symmetry, bony enlargement, and overall size
Musculoskeletal System • Palpation
– To bones, joints, and surrounding muscles
– For unusual movement, joint swelling, stiffness, tenderness, & heat
• Range of Motion (ROM)
– goniometer
• Muscle tone & strength
Muscle Strength Rating
• 0 = no voluntary contraction
• 1 = slight contractility; no movement
• 2 = full ROM, passive
• 3 = full ROM, active
• 4 = full ROM, against gravity, some resistance
• 5 = full ROM against gravity, full resistance
Abnormal Findings
• Marked swelling, hematoma, ecchymosis, bruising, pain, and loss of function of extremity
• Muscular atrophy
• Fracture of the bone
• Bluish or black discoloration of tissues
• Swelling, pain, on movement, and erythema of major joint.
• Swelling and enlargement of soft tissue involving diarthrodial joints (fingers)
• Decreased ROM
• Joint swelling
Neurologic System
• Mental and Emotional Status
• Observe appropriateness of emotion and thought process
• Older adults: Dementia, Alzheimer’s
– Level of consciousness
• GCS (Glasgow Coma Scale) is used to determine cognition, behavior, and neurologic function using an objective numerical scale. Total scores can range from 3-15:
– 8 & < : severe injury
– 9-12 : mild
– 13-15: no injury
• Levels of Consciousness
– Lerthargic: drowsiness, sleepiness, somnolence or mental sluggishness.
– Stuporous: arousable only with vigorous or unpleasant stimulation; briefly arouses to visual or painful stimuli.
– Obtunded: aroused only by painful stimuli; response is nonverbal, never fully awakens; often as a result of intoxication, metabolic illness, infection or neurologic catastrophe.
– Comatose: cannot be aroused; most severe alteration of consciousness
– Behavior & Appearance
– Language:
• Apahasia: Sensory (receptive); Motor (expressive)
• Intellectual Function
– Knowledge
– Abstract Thinking
– Association
– Judgment
Cranial Nerves
On Old Olympus’ Towering Tops, A Finn And German Viewed Some Hops
1. Olfactory ~ 2. Optic ~ 3. Oculomotor ~ 4. Trochlear ~ 5. Trigeminal ~ 6. Abducens ~ 7. Facial ~ 8. Auditory ~ 9. Glossopharyngeal ~ 10.Vagus ~ 11.Spinal Accessory ~ 12.Hypoglossal
Sensory Function
• Pain
• Temperature
• Light touch
• Vibration
• Position
• Two-point discrimination
• Stereognosis
Motor Function
• Coordination
– Finger to Nose Test
– Rapid Alternating movement
– Finger to Finger test
• Balance
– Romberg Test
Reflexes
Deep tendon Reflexes:
• Biceps
• Triceps
• Patellar
• Achilles
Cutaneous Reflexes:
• Plantar
• Gluteal
• Abdominal
integument changes in a patient with chronic impaired oxygenation:
- The conditions of the skin, mucosa, and nail bed offers useful data about the status of circulatory blood flow.
- Central cyanosis indicates poor arterial oxygenation and may be due to heart disease.
- Central cyanosis can be noted by a bluish discoloration of the lips, mouth, and conjunctiva.
- Peripheral cyanosis indicates peripheral vasoconstriction, and is noted by blue lips, earlobes, and nail beds.
- When cyanosis is present, the nurse refers to lab data on oxygen saturation to determine the severity of the problem.
- The nails should be examined for clubbing, a bulging of tissue at the nail base, due to insufficient oxygenation at the periphery- can be caused by conditions such as chronic emphysema or CHF.
integument changes in a patient with chronic impaired oxygenation:
- The lower extremities are checked for color, temperature, and condition of the skin indicating either arterial or venous alterations.
- If an arterial occlusion is present, the client has signs resulting from an absence of blood flow.
- Pain will be distal to the occlusion.
- The three P’s- pain, pallor, and pulselessness- characterize an occlusion.
- The absence of hair growth over the legs may indicate circulatory insufficiency.
- Chronic recurring ulcers of the feet or lower legs are a serious sign of circulatory insufficiency and require a physician’s intervention.
adventitious lung sounds and possible causes:
1) Crackles- crackles are most commonly heard in dependent lobes (the right and left lung bases). Crackles are caused by random, sudden reinflation of groups of alveoli or the sudden disruptive passage of air. Types:
a) Fine crackles- short, fine, high-pitched, interrupted crackling sounds heard during the end of inspiration, they are usually not cleared during coughing.
b) Medium crackles- lower more moist sounds heard during the middle of inspiration and they are not cleared during coughing.
c) Course crackles- loud, bubbly sounds heard during inspiration. They are not cleared during coughing.
2) Rhonchi- rhonchi are usually heard over the trachea and bronchi.
- If they are loud enough, they can be heard over most lung fields.
- caused by muscular spasms, fluid, or mucus in larger airways, which cause turbulence.
- loud, low pitched, rumbling, course sounds heard most often during inspiration or expiration.
- They may be cleared by coughing
3) Wheezes- wheezes can be heard over all lung fields.
- They are caused by high-velocity airflow through severely narrowed bronchus.
- High pitched, continuous musical sounds like a squeak heard continuously during inspiration and expiration.
- are usually louder on expiration
4) Pleural friction rub- pleural friction rub is heard over the anterior lateral lung field (if the client is sitting upright).
- Pleural friction rub is caused by inflamed pleura, and parietal pleura rubbing against visceral pleura.
- has a dry, grating quality best heard during inspiration.
- It does not clear with coughing.
- It is heard loudest over the lower lateral anterior surface.
levels of consciousness (LOC):
- Alert
- Lethargic
- Stuporous
- Obtunded
- Comatose