Hesi Stuff

HEALTH ASSESSMENT HESI VERSION 1. September 16th 7:00-9:00 Nursing Process ADPIE Assess Diagnose Outcome identification Planning Implementation Evaluation History Taking and Documentations Subjective – What patient says about their history Collect Medical History Collecting data, 4 types Complete Health data base Episodic or problem-centered database Follow up database Emergency Data base Assess Pulse in Geriatric Patients May be irregular 50-90 bpm is normal Male Bladder Evaluation Note frequency, urgency and noctuira (pee at night) Polyuria – excessive Oliguria – diminished quantity Dysuria – hurts when peeing Gout – Big Toe -accumulation of sodium crytals Uric acid crystals and joint destruction of the base of the joint of the big toe. Gout is most common in men; in women, it usually occurs after menopause. Obesity is among the risk factors for gout. Inflammation and redness resulting from acute gouty arthritis on the big toe. Uric acid crystals in the finger joints result in painful inflammation and stiffness. An example of gout affecting the elbow. Fluid is withdrawn from the inflamed joint and analyzed for uric acid crystals. Fluid obtained from crystal deposits in a patient with gout. Stay well-hydrated and reduce alcohol consumption to prevent gout attacks. Additional prevention methods include weight reduction and dietary changes. Medications can provide some relief from painful gout attacks. Gout is a kind of arthritis caused by a buildup of uric acid crystals in the joints. Uric acid is a breakdown product of purines that are part of many foods we eat. An abnormality in handling uric acid and crystallization of these compounds in joints can cause attacks of painful arthritis, kidney stones, and blockage of the kidney filtering tubules with uric acid crystals, leading to kidney failure. Gout has the unique distinction of being one of the most frequently recorded medical illnesses throughout history. Inspection of Limbic Symmetry ˜Inspect and palpate neck (cont.) ØSymmetry •Head position is centered in midline, and accessory neck muscles should be symmetrical •Head should be held erect and still ØThyroid gland •Difficult to palpate; check for enlargement, consistency, symmetry, and presence of nodules Mobility (tremor) ˜Aging adult ØTemporal arteries may look twisted and prominent ØIn some aging adults, a mild rhythmic tremor of head may be normal •Test cranial nerve XII, hypoglossal nerve, by asking person to stick out tongue; should protrude in midline; note any tremor, loss of movement, or deviation to side Ataxia (Unsteady gait) lack of voluntary coordination of muscle movements. Ataxia is a non-specific clinical manifestation implying dysfunction of the parts of the nervous system that coordinate movement, such as the cerebellum. Several possible causes exist for these patterns of neurological dysfunction. Dystaxia is a mild degree of ataxia. Could be because equilibrium is off == can cause unsteady gait •Smooth, even gait reflects equal leg lengths and functional hip motion Posture and bed rest Posture worsen with bed rest. CV assessment for older adult May feel dyspnea on exertion (difficulty breathing) Common – gradual rise in systolic blood pressure Diastolic pressure remains the same Some older adult experience orthostatic hypotension – sudden drop in blood pressure when rising to sit or stand ˜Aging adult (cont.) ØHemodynamic changes with aging •From age 20 to 60 years, systolic blood pressure increases by about 20 mm Hg, and by another 20 mm Hg between ages 60 and 80 years •This is due to stiffening of large arteries, which, in turn is due to calcification of vessel walls (arteriosclerosis) †Creates increase in pulse wave velocity because less compliant arteries cannot store volume ejected •Overall size of heart does not increase with age, but left ventricular wall thickness increases †An adaptive mechanism to accommodate vascular stiffening mentioned earlier •No change in resting heart rate occurs with aging •Cardiac output at rest is not changed with aging •Decreased ability of heart to augment cardiac output with exercise •Shown by decreased maximum heart rate with exercise and diminished sympathetic response •Noncardiac factors also cause a decrease in maximum work performance with aging: decrease in skeletal muscle performance, increase in muscle fatigue, increased sense of dyspnea •Chronic exercise conditioning will modify many of aging changes in cardiovascular function Sensory assessment for older adult Cataracts is common ˜Aging adult ØVisual acuity •Perform same examination as described in adult section •Central acuity may decrease, particularly after 70 years of age; peripheral vision may be diminished ØOcular structures •Eyebrows may show loss of outer one third to one half of hair because of decrease in hair follicles; remaining brow hair is coarse •As result of atrophy of elastic tissues, skin around eyes may show wrinkles or crow’s feet; upper lid may be so elongated as to rest on lashes, resulting in pseudoptosis •Eyes may appear sunken from atrophy of orbital fat; orbital fat may herniate, causing bulging at lower lids and inner third of upper lids •Lacrimal apparatus may decrease tear production, causing eyes to look dry and lusterless and person to report a burning sensation •Pingueculae commonly show on sclera †These yellowish elevated nodules are due to thickening of bulbar conjunctiva from prolonged exposure to sun, wind, and dust; they appear at 3 and 9 o’clock positions •Cornea may look cloudy with age •Arcus senilis commonly seen around cornea †Gray-white arc or circle around limbus due to deposition of lipid material †As more lipid accumulates, cornea may look thickened and raised, but arcus has no effect on vision •Xanthelasma: soft, raised yellow plaques occurring on lids at inner canthus †They commonly occur around fifth decade of life and more frequently in women, occur with both high and normal levels of cholesterol, and have no pathologic significance HEARING ˜Aging adults ØIn aging persons, cilia lining ear canal become coarse and stiff •May cause cerumen to accumulate and oxidize, which greatly reduces hearing •Cerumen is drier with aging because of atrophy of apocrine glands •Impacted cerumen is a common but reversible cause of hearing loss in older people ØPresbycusis: type of hearing loss that occurs with aging, even in people living in quiet environment •Gradual sensorineural loss caused by nerve degeneration in inner ear or auditory nerve •Onset usually occurs in 50s and slowly progresses •First notice a high-frequency tone loss •Ability to localize sound is impaired also •Accentuated when unfavorable background noise is present •Auditory reaction time increases after age 70; takes longer to process sensory input and to respond to it Hip Dysfunction Geriatrics ˜Aging adult ØPostural changes include decrease in height, more apparent in eighth and ninth decades ØKyphosis common, with backward head tilt to compensate ØContour changes include a decrease of fat in body periphery; fat deposition over abdomen and hips ØBony prominences become more marked ØROM testing proceeds as described earlier •ROM and muscle strength much as younger adult, provided no musculoskeletal illnesses or arthritic present ØFunctional Assessment •For those with advanced aging changes, arthritic changes, or musculoskeletal disability, perform functional assessment for ADLs •Applies ROM and muscle strength assessments to accomplishment of specific activities •Goal to determine adequate and safe performance of functions essential for independent home life History Taking Geriatrics Minimize distractions Speak clearly Find main complaint Get all medications, frequency and dose CV assessment (PMI – Point Maximum Impulse) PMI – point of maximum impulse – Apex of the heart ØDuring contraction, apex beats against chest wall, producing an apical impulse •Palpable in most people, normally at fifth intercostal space, 7 to 9 cm from midsternal line •Heart rotated so that its right side is anterior and its left side is mostly posterior Cardiac Sounds: s1 and s2 S1: Intercostal space @APEX = systolic pressure S2: base of heart = Diastolic Pressure ØNormal heart sounds: first heart sound (S1) •Occurs with closure of AV valves and thus signals beginning of systole •Mitral component of first sound (M1) slightly precedes tricuspid component (T1) †Usually hear these two components fused as one sound †Can hear S1 over all precordium, but loudest at apex ˜Infants ØRapid rates make it more challenging to evaluate heart sounds •Expect heart sounds to be louder in infants than in adults because of infant’s thinner chest wall. •Also, S2 has a higher pitch and is sharper than S1 •Splitting of S2 just after height of inspiration is common, not at birth, but beginning a few hours after birth •Murmurs in immediate newborn period do not necessarily indicate congenital heart disease •Murmurs are relatively common in first 2 to 3 days because of fetal shunt closure Percussing for cardiac ØPercussion •Used to outline heart’s borders, but its use has often been displaced by chest x-ray or echocardiogram •Much more accurate in detecting heart enlargement •When right ventricle enlarges, it does so in anteroposterior diameter, which is better seen on x-ray film •Also, percussion is of limited usefulness with female breast tissue or in an obese person or a person with a muscular chest wall •Normally, left border of cardiac dullness at midclavicular line in fifth interspace and slopes in toward sternum as you progress upward, so that by second interspace border of dullness coincides with the left sternal border •Right border of dullness normally matches sternal border Carotid Bruit ˜Neck vessels (cont.) ØAuscultate carotid artery •For persons middle-aged or older, or who show symptoms or signs of cardiovascular disease, auscultate each carotid artery for presence of a bruit †This is a blowing, swishing sound indicating blood flow turbulence; normally none is present Located next to adam’s apple. (left side) above clavicle. Can suggest changed/reduced blood flow due to plaque build up (2) Endocrine Hypothyroidism, Thinning Hair Underactive (aging women)doesn’t produce enough thyroid hormone, may need synthetic hormonr Can cause hair loss Most common cause: Hashimoto Disease – auto immune disease GI – 7 Topics Descriptive Terminology Melena – Dark Stool Melena is black, tarry feces caused by the digestion of blood in the gastrointestinal tract, and it is common in newborns. GI bleeding or Iron medications Abdominal Assessment, State the rationale for performing auscultation of the abdomen before palpation or percussion Palpation and percussion can increase peristalsis, which would give a false interpretation of bowel sounds assess umbilicus Midline and inverted No discoloration, inflammation or hernia Everted = mass/hernia Blue = cullens sign, abdnormal bleeding = can predict acute pancreatitis Borborygmi – Rumbling Gurgling Normal sound in the stomach loud, gurgling bowel sounds signaling increased motility or hyperperistalisis, occurs with early bowel obstruction, gasteroenteritis, diarrhea Palpating the gall bladder Shouldn’t be palpable Tender/enlarged = acute cholecytis Non tender/enlarged = gall stones Rectal Findings Abnormal = itching, pain, burning, hemmorhoids –fissure, fistula Normal = smooth when palpate, no nodules inside, tight even sphincter (5) Integumentary – Skin Mole Change ABCDE Asymmetry Border Color Diameter Elevation Hirsutism = abnormal condition Hirsutism (HUR-soot-iz-um) is a condition of unwanted, male-pattern hair growth in women. Hirsutism results in excessive amounts of stiff and pigmented hair on body areas where men typically grow hair — face, chest and back. Assessing skin for cyanosis blue in color = not enough oxygen to tissue = decreased perfusion Facial assessment No slouching of one side Bruising, lesion, abnormal moles Muscoskeletal Assessment Able to feel light touches Normal ROM Neurological (5) DTR assessment – Deep Tendon Reflex use to detect neurologic response Deep Tendon Reflex – elicit using percussion hammer Neurologic Assessment : ØTest cerebellar function of lower extremities by asking person to run each heel down opposite shin ØElicit deep tendon reflexes: biceps, triceps, brachioradialis, patellar, and Achilles ØNormally these are 1+ to 2+ and are equal bilaterally Mental Status A – Appearance (posture, movement, dress) B – Behavior (Conscious, Expression, Speech) C – Cognition (Orientation, Attention Span, Memory, learning) T – Thought Process (perception, anxiety, depression) Neurostatus Stupororous- Neuro stuporous: stuporous = sleep like state: not conscious - low state of conciousness , sleep like Rhomberg Signs To test equilibrium, ask the patient to stand with arms at the sides, feet and knees close together, and eyes open. Check for swaying, and then ask him or her to close his or her eyes and maintain position. The examiner should be close enough to prevent falling if the patient cannot stay erect. If he or she sways with the eyes closed but not when the eyes are open (the Romberg sign), the problem is probably proprioceptive (awareness of body position). If the patient sways with the eyes both open and closed, the neurologic disturbance is probably cerebellar in origin. PERRLA = Pupils Equal Round Reacting to Light and Accommodation Cyanosis of dark skin Cyanosis is a bluish mottled color that signifies decreased perfusion; the tissues do not have enough oxygenated blood. Be aware that cyanosis can be a nonspecific sign. Do not confuse cyanosis with the common and normal bluish tone on the lips of dark skinned persons of the Mediterranean origin. Cyanosis is difficult to observe in darkly pigmented persons. gray or whitish Given that most conditions causing cyanosis also cause decreased oxygenation of the brain, other clinical signs such as changes in the level of consciousness and signs of respiratory distress will be evident Bone Density ˜Two newer techniques to measure body composition ØBioelectrical impedance analysis (BIA) ØDual-energy x-ray absorptiometry (DEXA) •Both BIA and DEXA measure fat and lean body mass •In addition, DEXA measures bone mineral density ˜Aging adult ØBone remodeling is cyclic process of resorption and deposition; after age 40 resorption occurs more rapidly than deposition •Net effect is loss of bone density, or osteoporosis Bone density (or bone mineral density) is a medical term normally referring to the amount of mineral matter per square centimeter of bones. Bone density (or BMD) is used in clinical medicine as an indirect indicator of osteoporosis and fracture risk. This medical bone density is not the true physical "density" of the bone, which would be computed as mass per volume. It is measured by a procedure called densitometry, often performed in the radiology or nuclear medicine departments of hospitals or clinics. The measurement is painless and non-invasive and involves low radiation exposure. Measurements are most commonly made over the lumbar spine and over the upper part of the hip. The forearm may be scanned if the hip and lumbar spine are not accessible. There is a statistical association between poor bone density and higher probability of fracture. Fractures of the legs and pelvis due to falls are a significant public health problem, especially in elderly women, leading to much medical cost, inability to live independently, and even risk of death. Bone density measurements are used to screen people for osteoporosis risk and to identify those who might benefit from measures to improve bone strength. (4) neurological MRI head Magnetic resonance imaging (MRI) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. MRI uses a powerful magnetic field, radio frequency pulses and a computer to produce detailed pictures of organs, soft tissues, bone and virtually all other internal body structures. The images can then be examined on a computer monitor, transmitted electronically, printed or copied to a CD. MRI does not use ionizing radiation (x-rays). Detailed MR images allow physicians to evaluate various parts of the body and determine the presence of certain diseases. Currently, MRI is the most sensitive imaging test of the head (particularly in the brain) in routine clinical practice MR imaging of the head is performed for a number of abrupt onset or long-standing symptoms. It can help diagnose conditions such as: •brain tumors •stroke •infections •developmental anomalies •hydrocephalus — dilatation of fluid spaces within the brain (ventricles) •causes of epilepsy (seizure) •hemorrhage in selected trauma patients •certain chronic conditions, such as multiple sclerosis •disorders of the eye and inner ear •disorders of pituitary gland •vascular problems, such as an aneurysm (a bubble-like expansion of the vessel), arterial occlusion (blockage) or venous thrombosis (a blood clot within a vein) Physicians also use the MR examination to detect brain abnormalities in patients with dementia, a disorder that can cause confusion or memory loss. Paresthesia (numbness) Paresthesia is a sensation of tingling, tickling, prickling, pricking, or burning of a person's skin with no apparent long-term physical effect. The manifestation of a paresthesia may be transient or chronic. The most familiar kind of paresthesia is the sensation known as "pins and needles" or of a limb "falling asleep". A less well-known but still fairly common paresthesia is formication Assess Communication Communication is all behavior, conscious and unconscious, verbal and nonverbal Sleep Assessment Sleep patterns, daytime naps, and any sleep aids used are all used to help assess sleep. Sleep assessments are used to help diagnose sleep vitals, sleep disorders, and dreams A usual sleep pattern will have you feeling rested during the day. Some questions you might ask to assess sleep are: Do you feel rested during the day? Do you have enough energy to get through the day? Do you need to nap during the day? Do you wake up in the middle of the night with shortness of breath? Do you sleep light? Do you feel you have insomnia (difficulty falling asleep, awakening during the night, or early morning wakening)? If no routine do you tend to nap all afternoon? Does insomnia worsen with lack of daily schedule? Smoking and Effect on sleep Not only is smoking associated with getting less sleep, but it also is responsible for changing your sleep pattern so that even a full night in bed does not feel restful. Smoking tobacco prevents a full night's sleep in several ways. Over the long term, it can also lead to a serious sleep disorder known as sleep apnea The most dramatic effect of smoking on sleep is a reduction in the time spent in deep sleep, which is known for creating that "restorative" feeling people have when they wake up in the morning. In 2008, the journal "Chest" reported that chronic smokers spend more time in light sleep, especially in the early parts of the night. The culprit is nicotine, which has a stimulating effect on the nervous system. Ironically, as nicotine is reduced in the bloodstream throughout the night, withdrawal symptoms increase. Symptoms include restlessness and insomnia. Speech Patterns distinctive manner of oral expression; "he couldn't suppress his contemptuous accent"; "she had a very clear speech pattern" accent pronunciation - the manner in which someone utters a word; "they are always correcting my pronunciation" drawl - a slow speech pattern with prolonged vowels As you perform this portion of the neurological assessment, pay special attention to the patient’s speech and language abilities. His speech should be clear, coherent, and spoken at an appropriate rate. The language used should be appropriate for the education and socioeconomic levels of the person. Altered speech patterns can alert you to the possibility of neurologic problems. Auscultation equipment – stethoscope Auscultation (based on the Latin verb auscultare "to listen") is the term for listening to the internal sounds of the body, usually using a stethoscope. Auscultation is performed for the purposes of examining the circulatory system and respiratory system (heart sounds and breath sounds), as well as the gastrointestinal system (bowel sounds). Clubbing & Oxygen Saturation Clubbing is the proliferation of soft tissue around the ends of fingers or toes, without osseous change. Clubbing is the rounding of the ends and swelling of fingers found in people with lung disease. Clubbing is an abnormal enlargement of the distal phalanges with a flattening of the curvature of the nail margin at the cuticle, where the nail meets the cuticle. It usually is associated with cyanotic heart disease or advanced chronic pulmonary disease but sometimes occurs with biliary cirrhosis, colitis, chronic dysentery, thyrotoxicosis, and sickle cell anemia. Clubbing occurs in all the digits but is most easily seen in the fingers. Advanced clubbing is obvious, but early clubbing may be difficult to diagnose. Clubbing is present if the transverse diameter of the base of the fingernail is greater than the transverse diameter of the most distal joint of the digit. The nail base angle measures more than 160°. Oxygen is carried in the blood attached to hemoglobin molecules. Oxygen saturation is a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry. Oxygen saturation is also referred to as SpO2 Carpal Tunnel – pregnancy 3rd trimester ØPhalen’s test •Ask person to hold both hands back to back while flexing wrists 90 degrees •Acute flexion of wrist for 60 seconds produces no symptoms in the normal hand •Test reproduces numbness and burning in person with carpal tunnel syndrome ØTinel’s Sign •Direct percussion of location of median nerve at wrist produces no symptoms in normal hand •Percussion of median nerve produces burning and tingling along its distribution, which is a positive Tinel’s sign for carpal tunnel syndrome Carpal tunnel syndrome (CTS) is a median entrapment neuropathy that causes paresthesia, pain, numbness, and other symptoms in the distribution of the median nerve due to its compression at the wrist in the carpal tunnel. The mechanism is not completely understood but can be considered compression of the median nerve traveling through the carpal tunnel. It appears to be caused by a combination of genetic and environmental factors. Some of the predisposing factors include: diabetes, obesity, pregnancy, hypothyroidism, and heavy manual work or work with vibrating tools. There is, however, little clinical data to prove that lighter, repetitive tasks can cause carpal tunnel syndrome. Other disorders such as bursitis and tendinitis have been associated with repeated motions performed in the course of normal work or other activities. The main symptom of CTS is intermittent numbness of the thumb, index, long and radial half of the ring finger. The numbness often occurs at night, with the hypothesis that the wrists are held flexed during sleep. Recent literature suggests that sleep positioning, such as sleeping on one's side, might be an associated factor. It can be relieved by wearing a wrist splint that prevents flexion. Long-standing CTS leads to permanent nerve damage with constant numbness, atrophy of some of the muscles of the thenar eminence, and weakness of palmar abduction. Pain in carpal tunnel syndrome is primarily numbness that is so intense that it wakes one from sleep. Pain in electrophysiologically verified CTS is associated with misinterpretation of nociception and depression. Conservative treatments include use of night splints and corticosteroid injection. The only scientifically established disease modifying treatment is surgery to cut the transverse carpal ligament. Phalen test use to asses Tinel signs detects irritated nerves Crackles Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis. Crackles, crepitations, or rales are the clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation. They are often heard only with a stethoscope. Bilateral crackles refers to the presence of crackles in both lungs. Basal or basilar crackles (not to be confused with the basilar artery of the brain) are crackles apparently originating in or near the base of the lung. Bibasal or bibasilar crackles refer to crackles at the bases of both the left and right lungs. Bilateral basal crackles also refers to the presence of basal crackles in both lungs. Crackles are caused by the "popping open" of small airways and alveoli collapsed by fluid, exudate, or lack of aeration during expiration. The word "rales" derives from the French word râle meaning "rattle". Crackles can be heard in patients with pneumonia, atelectasis, pulmonary fibrosis, acute bronchitis, bronchiectasis, or post thoracotomy or metastasis ablation. Pulmonary edema secondary to left-sided congestive heart failure can also cause rales. Interviewing Allergic Reaction While interviewing about allergies, make sure you ask what allergies the patient may have, and what the reaction to these allergies is Sleep Deprivation Sleep deprivation is the condition of not having enough sleep; it can be either chronic or acute. A chronic sleep-restricted state can cause fatigue, daytime sleepiness, clumsiness and weight loss or weight gain. It adversely affects the brain and cognitive function. However, in a subset of cases sleep deprivation can, paradoxically, lead to increased energy and alertness and enhanced mood; it has even been used as a treatment of depression. Few studies have compared the effects of acute total sleep deprivation and chronic partial sleep restriction. Complete absence of sleep over long periods has not been seen in humans (unless they suffer from fatal familial insomnia); it appears that brief microsleeps cannot be avoided. Respiratory – Crepitus (air bubbles) 1. grating sound of broken bone: the grating sound heard when the broken ends of a bone rub together 2. crackling chest noise: a crackling sound heard in the chest of somebody who has a lung disease such as pneumonia Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery. Normal Lung sounds The normal breath sounds are both inspiratory and expiratory. They occur as the air moves in and out of the chest when a person breathes normally. Bronchial breath sounds are loud when the breath is exhaled. Vesicular sounds, in contrast, are relatively quiet during expiration. Fremitus – Physical assessment of respiratory status Fremitus is a vibration transmitted through the body. In common medical usage, it usually refers to assessment of the lungs by either the vibration intensity felt on the chest wall (tactile fremitus) and/or heard by a stethoscope on the chest wall with certain spoken words (vocal fremitus), although there are several other types. For normal assessment – muffled voice sounds and symmetrical tactile fremitus. Lungs sound assessment These same steps are very popular today in assessment of all systems of the body. These steps are designed to take the nurse through the assessment in a logical and organized sequence. You first start with a very general inspection and history of the patient; then your exam becomes more detailed as you begin to examine the interaction of all body systems. Visual Inspection - is the first step of the examination. This is a very important part of the exam, since many abnormalities can be detected by merely inspecting the thorax as the patient is breathing. Palpation - is the first step of the assessment, where we will touch the patient. Many breathing difficulties can be seen during this step. Some systemic problems can be detected during this part of the exam as well as just mechanical breathing problems. Percussing - is usually helpful only in a limited capacity to the examiner, as we will discuss later. Ausculation - is the process of listening to the breath sounds with the use of a stethoscope. In this text, we will describe the characteristics of normal and common abnormal breath sounds. Pneumonia Osculation Findings – sounds Your lungs will make bubbling and crackling sounds when you inhale. Rales sounds will be heard on one side of the chest when you are lying down. There are abnormal rumbling sounds coming from your lungs. This may indicate there is sputum present in the large airways. The doctor will do a percussion test wherein he will tap your chest lightly and listen to its sound. A hollow drum-like sound should be heard. If a dull thud is heard instead, this may suggest that the condition has developed into pneumonia Orthopnea (pillow use) – cant breath while laying down Orthopnea or orthopnea is shortness of breath (dyspnea) which occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair. It is the opposite of platypnea. It is commonly seen as a late manifestation of heart failure, resulting from fluid redistribution into the central circulation, causing an increase in pulmonary capillary pressure. It is also seen in cases of abdominal obesity or pulmonary disease. ˜Orthopnea – subjective data ØHow many pillows do you use when sleeping or lying down? Ears ringing Tinnitus - You may hear a sound, such as a ringing or roaring, that does not come from your surroundings (nobody else can hear it). The sound may keep time with your heartbeat, it may keep pace with your breathing, it may be constant, or it may come and go. Tinnitus is most common in people older than age 40. Men have problems with tinnitus more often than women. There are two types of tinnitus: •Pulsatile (like a heartbeat) tinnitus is often caused by sounds created by muscle movements near the ear, changes in the ear canal, or blood flow (vascular) problems in the face or neck. You may hear sounds such as your own pulse or the contractions of your muscles. •No pulsatile tinnitus is caused by problems in the nerves involved with hearing. You may hear sounds in one or both ears. Sometimes this type of tinnitus is described as coming from inside the head Tuning Fork A tuning fork is an acoustic resonator in the form of a two-pronged fork with the prongs (tines) formed from a U-shaped bar of elastic metal (usually steel). It resonates at a specific constant pitch when set vibrating by striking it against a surface or with an object, and emits a pure musical tone after waiting a moment to allow some high overtones to die out. The pitch that a particular tuning fork generates depends on the length and mass of the two prongs An alternative to the usual A440 diatonic scale is that of philosophical or scientific pitch with standard pitch of C512. According to Rayleigh, the scale was used by physicists and acoustic instrument makers. The tuning fork that John Shore gave to Handel gives a pitch of C512. Tuning forks, usually C512, are used by medical practitioners to assess a patient's hearing. This is most commonly done with two exams called the Weber test and Rinne test, respectively. Lower-pitched ones (usually C128) are also used to check vibration sense as part of the examination of the peripheral nervous system Cardio Vascular (split s2) A split S2 is a finding upon auscultation of the S2 heart sound. It is caused when the closure of the aortic valve (A2) and the closure of the pulmonary valve (P2) are not synchronized. •When aortic valve closes significantly earlier than pulmonic valve, you can hear two components separately; this is a split S2 Jules Abdominal Inspection & Palpitation Inspect Contour Symmetry Umbilicus – normal is midline & inverted Skin, makes sure smooth and even Pulsation or Movement Hair Distribution Demeanor Auscultate Begin RLQ to RUQ to LUQ to LLQ Bowel Sounds – two distinct patterns, hyperactive sounds – loud, high-pitched, Hypoactive or absent sound – ab surgery, inflammation of the pertitoneum Liver Span – enlarged liver span indicated liver enlargement or hepatomegaly Spelinic Dullness – indicates enlargement of spleen, trauma and infection. The skills requisite for the abdominal physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, where auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information. Allan Test (ulnar artery) ABG test flow Before drawing sample for ABG(Arterial Blood Gas) from radial artery, perform the allen test to assess the collateral circulation. For the Allen test, the health professional drawing your blood will apply pressure to the arteries in your wrist for several seconds. This will stop the blood flow to your hand, and your hand will become cool and pale. Blood is then allowed to flow through the artery that will not be used to collect the blood sample. This is usually the ulnar artery, which is found on the outer (little finger side) of your wrist. Arterial blood gases are usually taken from the radial artery, which is found on the inner (thumb side) of the wrist. Allen test Normal (positive) Your hand quickly becomes warm and returns to its normal color. This means that one artery alone will be enough to supply blood to your hand and fingers. Abnormal (negative) Your hand remains pale and cold. This means that one artery is not enough to supply blood to your hand and fingers. Blood will not be collected from an artery in this hand.   If your hand remains pale and cold, the Allen test will then be performed on your other hand. If your other hand also remains pale, the blood often will be collected from another artery, usually in the groin or elbow crease. Babinski in adult When the Babinski reflex is present in a child older than 2 years or in an adult, it is often a sign of a brain or nervous system disorder. Disorders may include: Amyotrophic lateral sclerosis (Lou Gehrig disease)  Brain tumor or injury   Meningitis Multiple sclerosis   Spinal cord injury, defect, or tumor Stroke Back inspection in child Back inspection of a child child is standing, note posture, plumb line, shoulder level within 1 cm, scapula symmetric Child fever assess eardrum in infants or child with fevers asses is exposed to contagious skin conditions, scabies, impetigo, measles, chickenpox, scarlet fever, toxic plants, poison ivy incidence of meningitis, measles, mumps, otitis media or illness with persistent fever should be assess immediately sometime seizures may occur with high fever in infants and toddlers, or may be a sign of neurological disease Amenorrhea ideology Amenorrhea refers to the absence of menstrual periods; it may be either primary (meaning a woman never developed menstrual periods) or secondary (absence of menstrual periods in a woman who was previously menstruating). Genetic or inborn conditions are the most common causes of primary amenorrhea. Amenorrhea may result from disorders of the ovaries, pituitary gland, or hypothalamus. Intensive exercising, extreme weight loss, physical illness, and stress can all result in amenorrhea. Amenorrhea is a symptom and not a disease in itself, so amenorrhea can be prevented only to the extent that the underlying cause can be prevented. Infertility and bone loss (osteoporosis) are complications of amenorrhea. Treatments may include surgical correction of anatomical abnormalities, medications or hormone therapies, and treatment of any underlying conditions responsible for amenorrhea. Mental orientation (4) Mental Status assessment documents: Emotional and cognitive functioning Assess appearance, behavior, cognition and thought processes. Older adults have slower response time Abnormal Thought Process = BLOCKING Mental Status Examination: Assesses mental health strengths and coping skills and screens for any dysfunction. • Mental Health & Psychiatry o Most suicides occur after beginning of improvement with increase in energy levels o MAOIs … Hypertensive Crisis with Tyramine foods • Nardil, Marplan, Parnate • Need 2 wk gap from SSRIs and TCAs to admin MAOIs o Lithium Therapeutic Range = 0.5-1.5 o Phenothiazines (typical antipsychotics) – EPS, Photosensitivity o Atypical Antipsychotics – work on positive and negative symptoms, less EPS o Benzos (Ativan, Lorazepam, etc) good for Alcohol withdrawal and Status Epilepticus o Antabuse for Alcohol deterrence – Makes you sick with OH intake o Alcohol Withdrawal = Delerium Tremens – Tachycardia, tachypnea, anxiety, nausea, shakes, hallucinations, paranoia … (DTs start 12-36 hrs after last drink) o Opiate (Heroin, Morphine, etc.) Withdrawal = Watery eyes, runny nose, dilated pupils, NVD, cramps o Stimulants Withdrawal = Depression, fatigue, anxiety, disturbed sleep History taking in child ˜Health history adapted to include information specific for age and developmental stage of child ØBiographic data ØSource of history •Person providing information and relation to child •Your impression of reliability of information •Any special circumstances, e.g., use of an interpreter ØReason for seeking care ˜Children: history of present Illness ØSeverity of pain: note effect on usual behavior, e.g., does it stop child from playing? ØAssociated factors, such as relation to activity, eating, and body position ØParent’s intuitive sense of problem often accurate; even if proven otherwise, this gives an idea of parent’s area of concern ØParent’s coping ability and reaction of other family members to child’s symptoms or illness Health adolescent interview Use the the Adolescent: heeadsss psychosocial interview ˜Home ˜Education and employment ˜Eating ˜Activities ˜Drugs ˜Sexuality ˜Suicide and depression ˜Safety Bronchi ØTrachea and bronchial tree •Trachea and bronchi transport gases between the environment and lung parenchyma •Constitute dead space, or space that is filled with air but is not available for gaseous exchange •This is about 150 ml in adult •Bronchial tree also protects alveoli from small particulate matter in inhaled air •Bronchi are lined with goblet cells, which secrete mucus that entraps particles; bronchi lined with cilia, which sweep particles upward where they can be swallowed or expelled Reproductive Topic – breast exam ØHelp each woman establish regular schedule of self-care •The best time to conduct BSE is right after menstrual period, when breasts are smallest and least congested •Advise pregnant or menopausal woman not having menstrual periods to select a familiar date to examine her breasts each month •Stress that self-examination will familiarize woman with her own breasts and their normal variation; emphasize absence of lumps (not the presence of them) •Encourage her to report any unusual finding promptly Sensory – eyes & symptoms ˜Pupillary light reflex: normal constriction of pupils when bright light shines on retina ØSubcortical reflex arc, person has no conscious control over it •Sensory afferent link is cranial nerve II, optic nerve •Motor efferent path is cranial III, oculomotor nerve •When one eye exposed to bright light, a direct light reflex occurs, constriction of that pupil; and a consensual light reflex, simultaneous constriction of other pupil †Because the optic nerve carries the sensory afferent message in and then synapses with both sides of brain Macula – central blind area, common in diabetes Pathophysiology – changes as a result of diseases Abdominal Bruit Abdominal Bruit – clinical manifestation of GI bleeding Renal Abdomen vascular bruit ˜Auscultate bowel sounds and vascular sounds (cont.) ØVascular sounds •As you listen to abdomen, note presence of any vascular sounds or bruits •Using firmer pressure, check over aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension •Usually, no such sound is present Arthritis symptoms RA – systemic inflammation disease of joints and surrounding connective tissue Inflammation of synovial membrane which leads to thickening, then to fibrosis, which limits motion and finally to bony ankylosis Disorder is symmetric and bilateral. Characterized by heat, redness, swelling, and painful motion of the affected joints. RA is associated with fatique, weakness, anorexia, weight loss, low grade fever, and lymphandenopathy. Symptoms includes; ganglion cyst, carpal tunnel with atrophy of the thenar eminenece, ankylosis, colles fracture, dupuytren contracture, swan-neck and boutonniere deformity, ulnar deviation or drift, osteoarthritis. Acute RA – painful swelling and stiffness of joints, with fusiform or spindle-shaped swelling of the soft tissue. Reproductive – decrease urine stream Oliguria – decreased diminishing quantity of urine. Respiratory oscillation High-frequency oscillation in acute respiratory distress syndrome (ARDS) Editorial II: High-frequency oscillation in acute respiratory distress syndrome (ARDS) Over the past 15 years, the mortality associated with acute respiratory distress syndrome (ARDS) has steadily declined. Lesion assessment Wear gloves ˜Inspect and palpate skin (cont.) ØLesions: if any are present note: •Color •Elevation •Pattern or shape •Size •Location and distribution on body •Any exudate: note color and odor •Use a Wood’s light (ultraviolet light filtered through special glass) to detect fluorescing lesions Teach skin self-examination using ABCDE rule to detect suspicious lesions •A - asymmetry •B - border •C - color •D - diameter •E - elevation and enlargement Nail bed assessment Inspect and palpate the arms Lift both person’s hands in your hands Inspect, then turn person’s hands over, noting color of skin and nailbeds; temperature, texture, and turgor of skin; and the presence of any lesions, edema, or clubbing Use profile sign (viewing finger from side) to detect early clubbing Normal nail bed angle is 160 degrees Ethical – Native American Remedies Seek healing from Shamans – medicine man/woman American Indian shamans uses traditional medicine bag which carry necessary medicines.