NUR 2092 – Health Assessment Essays, Exams and study guide.
NUR 2092 – Health Assessment
Written Assignment: HEENT/Skin/Nails
Purpose: To apply assessment and documentation skills utilized for physical health assessment.
Overview: After reading/viewing the module assignment and attending lab, conduct an assessment of the
- Head
- Eyes
- Ears
- Nose
- Mouth
- Face
- Neck
- Skin
- Hair
- Nails
Directions: Conduct a HEENT, skin and nails assessment on a fellow student, friend, or family member. Remember to secure their permission.
ORDER A PLAGIARISM-FREE PAPER HERE
Use the HEENT documentation assignment attached to this assignment module to document your findings. Formulate a SOAP note with both subjective and objective data as indicated on the HEENT attachment.
Submit your work to the Module 7 dropbox. Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates. NUR 2092 – Health Assessment Essays, Exams and study guide.
Save your assignment as a Microsoft Word document. (Mac users, please remember to append the “.docx” extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown: Jstudent_exampleproblem_101504
This assignment is worth 20 points and will be graded using the graded rubric below.
| Components | Meets Expectations | Needs Improvement | Does Not meet Expectations |
| Assessment Findings and documentation
10 points |
An optimal and thorough assessment and summary is present for each system. | Poorly organized/or limited summary of pertinent assessment
Information. |
Less than 50% of pertinent assessment information is addressed or is grossly incomplete and or inaccurate. |
|
Soap Note 8 points |
Complete and concise summary of pertinent SOAP information. | Poorly organized/or limited summary of pertinent SOAP information. NUR 2092 – Health Assessment Essays, Exams and study guide. | Less than 50% of pertinent information is addressed or is grossly incomplete and or inaccurate. |
| Spelling and Grammar
2 point. |
No grammar or spelling errors. | Errors in grammar or spelling. | |
| Total: /20 |
Final Exam Study Guide
Geriatrics: functional assessment-what is being tested, best approach to testing; caregiver concerns; IADLs, ADLs; disability concerns; tools to assess
What is being tested
-Identify strengths
-Identify limitations – so interventions can be recognized
-Independence and prevention of functional decline
NUR 2092 – Health Assessment Essays, Exams and study guide
Best approach to testing
Caregiver concerns
-Decrease in attention, memory, orientation, language, planning and making decisions
-Depression is not a normal change
-Persistent depression – is concerning if it interferes with ADL’s
-Eating
IADLs
Instrumental activities of daily living
-measures functional abilities necessary for independent community living
-includes shopping, meal preparation, house-keeping, laundry, managing finances, taking medications, and using transportation NUR 2092 – Health Assessment Essays, Exams and study guide.
ADLs
Activities of daily living
-tasks necessary for self-care
-measure domains of eating/feeding, bathing, grooming, dressing, toileting, walking, using stairs, and transferring
Disability concerns
Tools to assess
-Katz Activities of Daily Living
-The Lawton Instrumental Activities of Daily Living Scale
-Hospital Admission Risk Profile
-Geriatric Depression Scale (short form)
-Inspect for lesions and moles – irregular shapes, change in size or color
-Check for pressure ulcers especially sacrum, heels & trochanters
-Clubbing – cardiac or pulmonary disorder
-Pitting/transverse groves – peripheral vascular disease, arterial insufficiency, or diabetes
-Brittleness – decreased vascular supply
-Yellow or brown nails – fungal infection
-Look for limited range of motion – arthritis or muscle weakness causing pain and discomfort
-While assessing range of motion – watch for reports of pain, dizziness, jerky or abnormal movements: may indicate fractured vertebrae, Parkinson’s disease, transient ischemic attack, or stroke NUR 2092 – Health Assessment Essays, Exams and study guide.
-Look for facial symmetry (asymmetry may indicate a stroke)
-Bowel sounds; Look for hernias, pulsatile masses
-Evaluate muscles for atrophy, tremors, and involuntary movements
-Note warmth, swelling, tenderness, crepitus and deformities
Cultural assessment: culturally competent care; definition of ethnicity; spirituality; concepts such as assimilation, acculturation, etc.
Culturally competent care
-Know self, understand own heritage
-Identify meaning of health to someone else
-Understand health care delivery system
-Gain knowledge re social backgrounds of clients
-Be familiar with language, resources for interpreters, resources within community
Ethnicity
Associated with culture; NUR 2092 – Health Assessment Essays, Exams and study guide . awareness of belonging to a group in which certain characteristics differentiate from one group to another
-Includes nationality, regional culture, language, ancestry
-Ex: Egyptian, Swedish, Mexican, Jewish, etc.
Spirituality
-Borne out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life.
-Comes from person’s life experiences
-Attempt to find meaning and purpose of life
-More abstract
-Relationship of self and something larger
Ethnocentrism
To believe one’s own beliefs or way of life is ‘superior’; will interfere with collection and interpretation of data, your development of a plan of care may be skewed; must be aware of your own biases
Acculturation
Adapting to and acquiring another culture
Assimilation
Developing new cultural identity and becoming like the dominant culture
Biculturalism
Divided loyalty, identifies with two cultures
Final Exam Study Guide
- Geriatrics: functional assessment-what is it, what is being tested, best approach to testing; caregiver concerns/burnout; IADLs, ADLs; disability concerns; expected changes in the elderly;
- Cultural assessment: culturally competent care; religion vs spirituality;
- Therapeutic communication: examples of effective and ineffective (barriers) techniques e.g. clarification, reflection, blaming, etc.;
- General survey – what is included?
- Nutrition: Dietary assessment methods; abnormal eating patterns, for example, anorexia.
- Skin: staging of decubitus ulcers, primary skin lesions like nodules, pustules, etc.; common skin lesions, for ex. Psoriasis, contact dermatitis; signs of malignant skin lesions; color differences seen in dark skinned individuals; lesion configurations;
- Musculoskeletal – range of motion techniques; points for comparison; osteoporosis risk factors; spinal assessment findings; testing various joints including jaw; types of fractures; problems such as rheumatoid arthritis, gout, etc.
- Thorax/Respiratory assessment – auscultation, palpation; normal sounds and locations; abnormal sounds & when you might hear them; proper method of auscultation; methods- e.g. voice sounds such as egophony, thoracic expansion, etc.; chest shapes
- Heart: cardiac cycle; auscultation sites; what causes the heart sounds;
- HEENT: eye examination techniques; PERRLA; hearing tests; lymph nodes; problems seen in head, ears, eyes, nose, and throat;
- Breasts: Risk factors for cancer
- GU: testicular cancer; assessing
- Pulses- where are they, how do you document information about them, including rate, amplitude, rhythm; peripheral vascular assessment, edema – appearance, scale; arterial vs venous insufficiency NUR 2092 – Health Assessment Essays, Exams and study guide.
- Neuro – Glasgow coma scale; reflexes; cranial nerves – how do you test each one; testing for cerebellar function; tests such as graphesthesia, position sense, stereognosis, etc., part of the brain being tested?; headache types
- Vital signs: BP – proper method, findings if not done properly; normal ranges; terminology used, e.g. bradycardia, tachypnea, etc.
- Abdomen – methods and order of assessment, anatomy, expected findings; colon cancer risk factors
- Pain assessment techniques
- History taking/symptom analysis – components of a health history (what is in each component, for ex. Past medical history); subjective vs objective data; examples of open and closed ended questions; history first; signs vs symptoms; health promotion levels
- Pediatrics – best methods for assessing; pain assessment
Health Assessment – NUR 2092 Exam 1
What are the 6 steps of the nursing process?
- Assessment
- Diagnosis
- Outcome
- Planning
- Implementation
- Evaluation
Assessment Definition (nursing process)
- Collect data
- Use evidence-based assessment techniques
- Document relevant data
Diagnosis Definition (nursing process)
- Compare clinical findings with normal and abnormal variation and developmental events
- Interpret data– make & test hypotheses
- Validate diagnoses
- Document diagnoses
Outcome Identification Definition (nursing process)
- Identify expected outcomes
- Individualize to the person
- Culturally appropriate
- Realistic and measurable
- Include a timeline
Planning Definition (nursing process)
- ESTABLISH PRIORITIES
- Develop Outcomes
- Set timelines for outcomes
- IDENTIFY interventions
- Integrate evidence-based trends and research
- Document plan of care
Implementation Definition (nursing process)
- Implement in a safe and timely manner
- Use evidence-based interventions
- Collaborate with colleagues
- Use community resources
- Coordinate care delivery
- Provide health teaching and health promotion
- Document implementation and any modifications.
Evaluation Definition (nursing process)
- Progress toward outcomes
- Conduct systematic, ongoing, criterion-based evaluation.
- Include patient and significant others
- Use ongoing assessment to revise diagnoses, outcomes, and plan
- Distribute results to patient and family
Acute pain
- Is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals.
- Self-protective purpose; it warns the individual of actual or threatened tissue damage.
Chronic Pain
- Over 6 months in duration
- Adaptive responses
Phantom pain
- Pain where limb used to exist
Malignant pain Vs nonmalignant pain
- Malignant pain is cancer-related and is caused by tumor cells that cause necrosis or stretching.
- Nonmalignant pain is often associated with musculoskeletal conditions.
Visceral pain
Originates from internal organs.
Somatic pain and deep somatic pain
- Somatic pain originates from musculoskeletal tissues or the body surface
- Deep somatic pain comes from sources such as blood vessels, joints, tendons, muscles, and bone NUR 2092 – Health Assessment Essays, Exams and study guide.
Referred pain
Pain that is felt at a particular site but originates from another location.
Nociceptive pain
- Develops when functioning and intact nerve fibers in CNS are stimulated.
- They are triggered by events outside nervous system from actual or potential tissue damage.
- Nociception can be divided into four phases:
(1) Transduction:
(2) Transmission: the pain impulse moves from the level of the spinal cord to the brain.
(3) Perception: signifies the conscious awareness of a painful sensation
(4) Modulation: a built-in mechanism that will eventually slow down and stop the processing of a painful stimulus
Neuropathic pain
- Pain caused by a lesion or disease of the somatosensory nervous system.
- This implies an abnormal processing of pain message from an INJURY to the NERVE FIBERS.
- This pain is very difficult to treat and assess.
Subjective Data
Pain is always subjective. What the patient is complaining of; SYMPTOM
Objective data
What the nurse observes; SIGN
Nutritional Status
This balance is affected by many factors, including physiologic, psychosocial, developmental, cultural, and economic factors
Nutritional Assessment
Food intake
24 hour recall
Food diary
Food frequency
Direct observation
Anthropometric measurements
Swallowing assessment prn
Lab tests
Pain assessment tools
- Brief pain inventory: asks the patient to rate the pain within the past 24 hours using graduated scales (0 to 10) with respect to its impact on areas such as mood, walking ability, and sleep
- McGill Pain Questionnaire: The short-form McGill Pain, asks the patient to rank a list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain
- Initial Pain assessment: asks the patient to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors. NUR 2092 – Health Assessment Essays, Exams and study guide.
- Pain rating scales
- Wong-Baker Faces pain rating scale
Pain Assessment
Posture/behavior
Facial expression
Sounds
Skin inspection/palpation
BP/pulse/respirations
Pupil size
How to assess domestic violence
“Abuse assessment screen” is a tool used by many healthcare providers.
Pulse Oximetry
Noninvasive
Estimate arterial oxygen saturation in blood
Normal Resp. Rate for adult
10-20
Normal BP for Adult
120/80
BMI requirements for being underweight, normal weight, overweight, obese.
Underweight = 18.5 BMI
Normal weight = 18.5- 24.9 BMI
Overweight= 25-29.9 BMI
Obese= 30+ BMI
How to document pulse
0=absent
1+= weak
2+= normal
3+= bounding
Definition of Eupnea
Normal/good breathing
Definition of Apnea
Breathing has stopped
What does the acronym PQRSTU stand for?
P= Precipitating/palliative/provocative, what brings it on? What were you doing when you noticed it?
Q= Quality or Quantity, how does it feel, sound? How intense/severe is it?
R=Region or Radiation, Where is it? Does it spread anywhere?
S= Severity Scale, Scale of 1-10. Is it getting better/worse?
T= Timing/ onset. When did it first occur? Duration? How long did it last? Frequency?
U= Understand patient’s perception of the problem. What do you think it means? NUR 2092 – Health Assessment Essays, Exams and study guide.
Vital Signs Influences
Blood Pressure
Age
Gender
Race
Diurnal variations
Emotions
Pain
Personal habits
Weight
Respiratory Rate
Exercise and anxiety
Heart Rate (Pulse)
Exercise, age, gender, anxiety, pain
Temperature
Diurnal variations – Lowest early AM, highest late afternoon/early evening
Exercise – rises
Menstrual cycle – increase mid cycle ovulation to menses
Age – very young wider variation; older typically lower
Drinks hot or cold
Normal pulse rate for adult
50-90
What happens to BP if cuff is too small or big?
If too small it will increase BP
If too big it will lower BP
Normal Oral temp + range
98.6. Range of 96.4 to 99.1
Is it normal for new born infant’s rectal temps to be higher?
Yes, average is 100
How do you measure BP cuff size?
With of bladder should equal 40% of circumference of persons arm.
Length of bladder should equal 80% of circumference.
What is the working phase of the interview?
The working phase is the data-gathering phase.
What are the steps to the “Tools of a physical Assessment”, 4 Steps
- Inspection—Visual examination of body
- Palpation—texture, temp., rigidity, lumps, masses
- Percussion—to evaluate size, borders, consistency, tenderness, extent of fluid
- Auscultation—listening to sounds body produces; pitch, loud or soft, duration, and quality
Delirium Vs Dementia
- Delirium is an ACUTE confusion state
- Dementia is a CHRONIC progressive loss of cognitive & intellectual functions. Disorientation, judgment loss, memory loss, impaired. NUR 2092 – Health Assessment Essays, Exams and study guide.
Complete total health database
Includes complete health history and full physical examination
Describes current and past health state and forms baseline to measure all future changes
Yields first diagnoses
Episodic or problem-centered database
For limited or short-term problems
Concerns mainly one problem, one cue complex, or one body system
History and examination follow direction of presenting concern
Follow-up database
Status of all identified problems should be evaluated at regular and appropriate intervals
Note changes that have occurred
Evaluate whether problem is getting better or worse
Identify coping strategies being used
Emergency database
Rapid collection of data, often compiled concurrently with lifesaving measures
Diagnosis must be rapid and comprehensive in nature
Two primary components of health assessment
Health history
Physical examination
Health history = Subjective data
Physical Assessment – Objective Data
Therapeutic Communication
Open ended questions: narrative information; tell me about you, how are you doing today?
Closed ended questions: specific information; do you have pain
BARRIERS TO COMMUICATION
Lack of interest or attention/ lack of respect
Physical barriers – a curtain, a door, a computer, a monitor, pain, room temperature
The patient’s inability to hear you, hearing deficit, or language barrier
Language/ use of jargon, or speaking above someone’s educational level
Safety – fear
Psychological barriers – embarrassment, disbelief, shock, anger, fear, grief, fatigue, hostility
Culture
Nonphysical traits – values, attitudes, beliefs, customs
Race – Identification of individuals or groups by shared genetic heritage and biological or physical characteristics
Ethnicity – associated with culture; awareness of belonging to a group in which certain characteristics differentiate from one group to another
Material – dress, tools, art and ways they are used
NON material – verbal and nonverbal language, beliefs, customs, social structures.
Ethnocentrism – to believe one’s own beliefs or way of life as ‘superior’
Acculturation– Adapting to and acquiring another culture NUR 2092 – Health Assessment Essays, Exams and study guide
Assimilation– Developing new cultural identity and becoming like the dominant culture; more two way; new affecting old
Biculturalism– Divided loyalty, identifies with two cultures
Causes of illness
Biomedical
Disease caused by bacteria, viruses, etc.
Involves scientific theories for cause of illness
Naturalistic
Illness caused when there is loss of natural balance
May align with yin/yang, hot & cold theory
Magicoreligious
Illness caused by supernatural force
May use folk remedies
Culturally Competent
Know self, understand own heritage
Identify meaning of health to someone else
Understand health care delivery system
Gain knowledge re social backgrounds of clients
Be familiar with language, resources for interpreters, and resources within community
6 steps of nursing process
Assessment
Diagnosis
Outcome identification
Planning
Implementation
Evaluation
Assessment
Interview, health history, ROS, physical examination, functional assessment, spiritual and cultural assessment
Subjective data
What patient SAYS
Objective data
What you OBSERVE
SMART component in outcome identification
Specific
Measurable
Attainable
Relevant
Time bound
First level priority
Emergent situations, life threading and needs immediate attention
Second level priority
Requires attention to avoid further deterioration
Third level priorirty
Can be addressed after more important problems are addressed
Complete total health Database
Full health history, and physical exam
Yields first diagnosis
Current and past health state
Focused or problem centered database
Limited and short term problems
Concerned with mainly one problem, or one body system
Follow up database
Follow up care to evaluate if problem is getting better or worse
Emergency database
Rapid urgent collection of data
Radio diagnosis
Primary prevention
Preventing health problems
Ex: vaccines, safety glasses
Secondary prevention
Timely screenings to catch a problem early and reduce impact
Example: mammograms
Tertiary prevention
Decrease impact of ongoing problem
Example: cardiac rehab, support group.
2 primary components of health assessment
Health history= subjective
Physical examination = objective
PQRSTU method of pain assessment
Provocative/ palliative
Quality/ quantity
Region/ radiation
Severity scale
Timing (onset)
Understand patient perception of the problem
Organic disorder
Disorder of the brain
Psychiatric disorders
Not yet determined to be organic
More complete mental assessment maybe necessary if:
Patients has anxiety/depression
If family is concerned
Deterioration in status from last visit
Aphasia
Acute psychiatric illness
Objective cues of mental health
ABCT
Appearance
Behavior
Cognitive function
Thought process
Delirium
Sudden onset
Altered consciousness
Rapid mood swings
Rapid, inappropriate, rambling speech
Can be reversed
Can cause fever, pain, low blood glucose, infection
Dementia
Slow and gradual onset
Flat agitation
Consciousness not altered
Repetitious speech
Can’t be reverse
Can cause HIV, chronic alcoholism, Alzheimer’s
Ethnocentrism
belief in the superiority of one’s own ethnic group
Ethnicity
Associated with culture
Awareness of belonging to a group in which certain characteristics differentiate from one group to another NUR 2092 – Health Assessment Essays, Exams and study guide
Race
Identification of individual groups by shared genetic heritage and biological or physical characteristics
Acculturation
Adapting to and acquiring another culture
Assimilation
Developing a new culture identity and becoming like the dominant culture
Biculturalism
Identifies with two cultures
Biomedical cause of illness
Disease caused by bacteria, viruses
Involves scientific theories
Naturalistic cause of illness
Illness caused due to loss of natural balance
Yin/yang or hot and cold theory
Magioreligious
Illness caused by supernatural forces
Percussion
The sharp striking of one thing against another.
Used to evaluate the size, borders, consistency, tenderness, extent of fluid
Striking produces vibration
Direct percussion
Sinuses, CVA tenderness
Indirect percussion
Thorax, abdomen
Flatness
Bone or muscle
Dullness
Heart, liver, spleen
Resonance
Air filled lungs. Hollow
Hyper resonance
an abnormal booming sound produced during percussion of the lungs. Emphysematous lung
Tympany
Air filled stomach (drumlike)
Auscultation
Listening to sound produced by body
Pulse oximetry
Estimates oxygen saturation in blood
Normal value: 95-100%
COPD patients might have high 80s
Temperature
Normal range: 96.4 to 99.1 F
Most accurate temperature
Rectal
Pulse
Normal range 50-95 bpm
Ear canal in older
Pull and up
Ear canal in children
Pull and down
Pulse and respiration rate is _________ in infants
Faster
Nociceptive pain
Acute pain starts outside the nervous system
Responsive to anti-inflammatory and opiates
Neuropathic pain
Chronic pain
Abnormal processing
Numbness, tingling, shooting, burning, phantom pain
From injury to nerve fibers or CNS
Phantom pain
Pain felt in a body part that is no longer there
Referred pain
Felt at a site different from organ affected
Breakthrough pain
Pain restarts or escalates before next scheduled analgesic dose
What does OLDCARTS stand for?
Onset
Location
Duration
Characteristics
Aggravating/associated factor
Relieving factors
Treatments thus far
Significance of symptoms
When do you use “old carts”?
Whenever a patient reports a symptom, it needs to be explored
What does IPPA stand for?
Inspection
Palpation
Percussion
Auscultation
-perform in that order
What is an assessment?
Collection of data about the individual’s health state
Compare subjective and objective data.
Subjective data is what the person says about themselves during history taking; objective data is data you observe by inspecting, percussing, palpating, and auscultating during the physical exam
What elements form the database?
-patients record
-lab studies
-subjective data (in pt. history)
-objective data (in physical)
What is the purpose of assessment?
Make a judgement or diagnoses
What is diagnostic reasoning?
Process of analyzing health data and drawing conclusions to identify diagnoses
What are the six phases of the nursing process?
- Assessment
- Diagnosis
- Outcome identification
- Planning
- Implementation
- Evaluation
What are the six parts of a health assessment?
-review of the clinical record
-health history
-physical examination
-functional assessment
-risk assessment
-review of the literature
What is a nursing diagnosis?
A clinical judgement about a person’s response to an actual or potential health state NUR 2092 – Health Assessment Essays, Exams and study guide
What are the three types of nursing diagnoses?
- Actual diagnoses
- Risk diagnoses
- Wellness diagnoses
What is a medical diagnosis?
Diagnosis that evaluates the cause or etiology of the disease
What are the four different types of databases?
-complete
-focused or problem centered
-follow-up
-emergency
What is a complete database?
Complete health history and full physical exam
What is a focused or problem centered database?
For a limited or a short term problem
What is a follow up database?
When the status of identified problems are evaluated at regular and appropriate intervals
What is an emergency database?
A rapid collection of data, diagnosis must be swift and sure
After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be:
Objective
A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types of data would be:
Subjective
The patient’s record, laboratory studies, objective data, and subjective data combine to form the:
Data base
When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. The nurse’s next action should be to:
Validate the data by asking a coworker to listen to the breath sounds
The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using:
A set of rules
Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as:
Intuition NUR 2092 – Health Assessment Essays, Exams and study guide
The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP?
EBP emphasizes the use of best evidence with the clinician’s experience
The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem?
Individual with shortness of breath and respiratory distress
When considering priority setting problems, the nurse keeps in mind that second-level priority problems include which of these aspects?
Abnormal laboratory values
Which critical thinking skill helps the nurse see relationships among the data?
Clustering related cues
The nurse knows that developing appropriate nurse interventions for a patient relies on the appropriateness of the ________ diagnosis
Nursing
The nursing process is a sequential method of problem solving that nurses use and includes which steps?
Assessment, diagnosis, outcome identification, planning, implementation, and evaluation
A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
Breathing, pain, sleep
Which of these would be formulated by a nurse using diagnostic reasoning?
Diagnostic hypothesis
Barriers to incorporating EBP include:
Nurses’ lack of research skills in evaluating the quality of research studies NUR 2092 – Health Assessment Essays, Exams and study guide
What step of the nursing process includes data collection by health history, physical examination, and interview?
Assessment
During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems?
Teach the nurses how to conduct electronic searches for research studies
When reviewing the concepts of health, the nurse recalls that the components of holistic health include with of these?
Holistic health views the mind, body, and spirit as interdependent
The nurse recognizes that the concept of prevention in describing health is essential because:
Prevention places the emphasis on the link between health and personal behavior
The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the:
2×5 cm scar on the right lower forearm
A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is more appropriate to collect in this setting?
A complete health data base because of the nurse’s primary responsibility for monitoring the patient’s health
Which situation is more appropriate during which the nurse performs a focused or problem centered history?
Patient in an outpatient clinic has cold and influenza-like symptoms
A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should:
Collect a follow-up data base and then check her blood pressure
A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection?
Simultaneously ask history questions while performing the examination and initiating life-saving measures
A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to:
Provide culturally sensitive and appropriate care
In the health promotional model, the focus of the health professional includes:
Helping the consumer choose a healthier lifestyle
The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?
Evaluate the individual’s condition, and compare actual outcomes with expected outcomes
Which statement best describes a proficient nurse? A proficient nurse is one who:
Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient
The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply.
- Inspiratory wheezes noted in left lower lobes
- Nonproductive cough
- Patient reports dyspnea upon exertion
- Rate of respirations 16 breaths per minute
Put the following patient situations in order according to the level of priority.
1st: A teenager who was stung by a bee during a soccer match is having trouble breathing.
2nd: An older adult with a urinary tract infection is also showing signs of confusion and agitation.
3rd: A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer.
A teenager who was stung by a bee during a soccer match is having trouble breathing.
First level priority problems
An older adult with a urinary tract infection is also showing signs of confusion and agitation
Second level priority problems
A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer.
Third level priority problems
The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis?
Inspiratory wheezes notes in the left lower lobes, Nonproductive cough, Patient reports dyspnea upon exertion, Rate of respirations 16 breaths per minute
Exam 2 review
Function of the Skin
The skin is a waterproof, almost indestructible covering that has protective and adaptive properties:
- Protection. Skin minimizes injury from physical, chemical, thermal, and light-wave sources.
- Prevents penetration. Skin is a barrier that stops invasion of microorganisms and loss of water and electrolytes from within the body.
- Perception. Skin is a vast sensory surface holding the neurosensory end-organs for touch, pain, temperature, and pressure.
- Temperature regulation. Skin allows heat dissipation through sweat glands and heat storage through subcutaneous insulation.
201
- Identification. People identify one another by unique combinations of facial characteristics, hair, skin color, and even fingerprints. Self-image is often enhanced or deterred by the way society standards of beauty measure up to each person’s perceived characteristics.
- Communication. Emotions are expressed in the sign language of the face and body posture. Vascular mechanisms such as blushing or blanching also signal emotional states.
- Wound repair. Skin allows cell replacement of surface wounds. NUR 2092 – Health Assessment Essays, Exams and study guide.
- Absorption and excretion. Skin allows limited excretion of some metabolic wastes, by-products of cellular decomposition such as minerals, sugars, amino acids, cholesterol, uric acid, and urea.
- Production of vitamin D. The skin is the surface on which ultraviolet (UV) light converts cholesterol into vitamin D.
| Etiology | Light Skin | Dark Skin |
| Pallor | ||
| Anemia—Decreased hematocrit Shock—Decreased perfusion, vasoconstriction |
Generalized pallor | Brown skin appears yellow-brown, dull; black skin appears ashen gray, dull; skin loses its healthy glow—Check areas with least pigmentation such as conjunctivae, mucous membranes |
| Local arterial insufficiency | Marked localized pallor (e.g., lower extremities, especially when elevated) | Ashen gray, dull; cool to palpation |
| Albinism—Total absence of pigment melanin throughout the integument | Whitish pink | Tan, cream, white |
| Vitiligo—Patchy depigmentation from destruction of melanocytes | Patchy milky-white spots, often symmetric bilaterally | Same |
| Cyanosis | ||
| Increased amount of unoxygenated hemoglobin Central—Chronic heart and lungdisease cause arterial desaturation |
Dusky blue | Dark but dull, lifeless; only severe cyanosis is apparent in skin—Check conjunctivae, oral mucosa, nail beds
NUR 2092 – Health Assessment Essays, Exams and study guide |
| Peripheral—Exposure to cold, anxiety | Nail beds dusky | |
| Erythema | ||
| Hyperemia—Increased blood flow through engorged arterioles such as in inflammation, fever, alcohol intake, blushing | Red, bright pink | Purplish tinge but difficult to see; palpate for increased warmth with inflammation, taut skin, and hardening of deep tissues |
| Polycythemia—Increased red blood cells, capillary stasis | Ruddy blue in face, oral mucosa, conjunctiva, hands, and feet | Well concealed by pigment; check for redness in lips |
| Carbon monoxide poisoning | Bright cherry red in face and upper torso | Cherry-red color in nail beds, lips, and oral mucosa |
| Venous stasis—Decreased blood flow from area, engorged venules | Dusky rubor of dependent extremities; a prelude to necrosis with pressure sore | Easily masked; use palpation for warmth or edema |
| Jaundice | ||
| Increased serum bilirubin, more than 2 to 3 mg/100 mL from liver inflammation or hemolytic disease such as after severe burns, some infections | Yellow in sclera, hard palate, mucous membranes, then over skin | Check sclera for yellow near limbus; do not mistake normal yellowish fatty deposits in the periphery under the eyelids for jaundice; jaundice best noted in junction of hard and soft palate and also palms |
| Carotenemia—Increased serum carotene from ingestion of large amounts of carotene-rich foods | Yellow-orange in forehead, palms and soles, nasolabial folds, but no yellowing in sclera or mucous membranes | Yellow-orange tinge in palms and soles |
| Uremia—Renal failure causes retained urochrome pigments in the blood | Orange-green or gray overlying pallor of anemia; may also have ecchymoses and purpura | Easily masked; rely on laboratory and clinical findings. NUR 2092 – Health Assessment Essays, Exams and study guide. |
| Brown-Tan | ||
| Addison disease—Cortisol deficiency stimulates increased melanin production | Bronzed appearance; an “eternal tan,” most apparent around nipples, perineum, genitalia, and pressure points (inner thighs, buttocks, elbow, axillae) | Easily masked; rely on laboratory and clinical findings |
| Café au lait spots—Caused by increased melanin pigment in basal cell layer | Tan to light brown, irregularly shaped, oval patch with well-defined borders | |
PERRLA, which stands for Pupils are Equal, Round, and Reactive to Light and Accommodation. It’s a good thing. It means “normal.
Breath sounds
rhonchi, which are low-pitched sounds
crackles, which are high-pitched sounds – pneumonia
wheezing, which is a high-pitched whistling sound caused by narrowing of the bronchial tubes – asthma
stridor, which is a harsh, vibratory sound caused by narrowing of the trachea NUR 2092 – Health Assessment Essays, Exams and study guide.
Normal – The bronchial breath sounds over the trachea has a higher pitch, louder, inspiration and expiration are equal and there is a pause between inspiration and expiration
| PITCH | AMPLITUDE | DURATION | QUALITY | NORMAL LOCATION | |
| BRONCHIAL (TRACHEAL) | High | Loud | Inspiration < expiration | Harsh, hollow tubular | Trachea and larynx |
| BRONCHOVESICULAR | Moderate | Moderate | Inspiration = expiration | Mixed | Over major bronchi where fewer alveoli are located: posterior, between scapulae especially on right; anterior, around upper sternum in 1st and 2nd intercostal spaces |
| VESICULAR | Low | Soft | Inspiration > expiration | Rustling, like the sound of the wind in the trees | Over peripheral lungfields where air flows through smaller bronchioles and alveoli |
signs of long term hypoxia – clubbing, persistent inspiratory crackles, barrel chest
- Respiratory assessment of lungs:
- Repirations & rate
- Expansion
- Vibration on each side
- Breath through mouth!
- Listen to full cycle (Expiration and inspiration)
- Bronchophony – 99, 99 – if heard clear abnormal
- Ecocophony – e – e abnormal if AYE is heard
- Whispered – 1,2,3 abnormal if heard clearly
- Crackles – fluid in alveoli, pneumonia
- Rhonchi – rattling, hoarse, bronchitis
- Wheezing – constricted bronchioles, asthma
- Stridor – obstruction of airway
Risk factors: Diabetes=not modifiable
Jugular distension – Congenital heart failure
Colon cancer risk factors – Family history of polyps or cancer in colon or rectum, being 50 or older, crohn’s disease, African American race, low-fiber, high fat diet, inactive lifestyle, diabetes, obesity, smoking, alcohol
Hernias – weakness in abdominal wall, know types
Review vocabulary
Inspection – make sure ears are free of wax, check eyes for redness and for pupils to be the same, know testing for ocular movement
Lymph nodes – submental, submandibular, tonsillar, occipital, post auricular, pre-auricular, posterior cervical, anterior cervical, supraclavicular. NUR 2092 – Health Assessment Essays, Exams and study guide.
KNOW – skin and lesion vocabulary
Levels of Edema – 1+ bounces back, 2+ takes 1-2 second, 3+ takes 4-5 seconds, 4+ can take minutes
Bruit – murmurs (not in heart) caused by abnormal narrowing of an artery
Arterial insufficiency – blue/cold/lesion – normal border
Venous insufficiemcy – red/brown/warm – irregular with discharge
Start breast mammograms @45, abnormal signs: pain, lump, discharge, rash
Risk factors for breast cancer – age, early menstrual period, inactivity, starting menopause after age 55, obesity, dense breasts, birth control pills, personal or family history of breast cancer, alcohol.
Right lung has 3 lobes, left lung has 2 lobes
arterial insufficiency
- wounds occur secondary to ischemia from inadequate circulation of oxygenated blood
- ulcer on toes
- ulcer on lateral malleolus
- smooth edges, deep, well defined
- severe pain
- edema normal
- skin temp decreased
- tissue thin and shiny
- hair loss of skin
Venous insufficiency
- wounds are irregularly shaped
- wounds shallow
- pain is mild to moderate
- pedal pulses normal
- edema increased
- skin temp is normal
- skin is flakey and dry
- elevation lessens pain
- skin had a brownish discoloration
Screening mammography can discover small, potentially curable breast cancers, and the American Cancer Society recommends beginning annual screening at 40 years of age. The percentage of women 40 years of age and older who report having a mammogram in the last 2 years was 66.5% in 2010.2 This included higher rates of cancer screening for women of color in recent years: 67% of non-Hispanic Whites, 66% of African Americans, 64.4% of Hispanics/Latinas, and 62% of Asians reported mammography. NUR 2092 – Health Assessment Essays, Exams and study guide. However, women least likely to have had a recent mammogram include those with less than a high school education, with no health insurance, or who are recent immigrants.2 Low-income women have multiple barriers to screening mammography, including lack of insurance coverage, lack of access to care, not having a regular health care provider, and lack of comprehensive breast cancer knowledge, not merely screening awareness. NUR 2092 – Health Assessment Essays, Exams and study guide.
The valve areas are:
- Second right interspace—Aortic valve area
- Second left interspace—Pulmonic valve area
- Left lower sternal border—Tricuspid valve area
- Fifth interspace at around left midclavicular line—Mitral valve area
| Right Upper Quadrant (RUQ) | Left Upper Quadrant (LUQ) |
| Liver
Gallbladder Duodenum Head of pancreas Right kidney and adrenal Hepatic flexure of colon Part of ascending and transverse colon |
Stomach
Spleen Left lobe of liver Body of pancreas Left kidney and adrenal Splenic flexure of colon Part of transverse and descending colon |
| Right Lower Quadrant (RLQ) | Left Lower Quadrant (LLQ) |
| Cecum
Appendix Right ovary and tube Right ureter Right spermatic cord |
Part of descending colon
Sigmoid colon Left ovary and tube Left ureter Left spermatic cord |
The first heart sound (S1) occurs with closure of the AV valves and thus signals the beginning of systole. The mitral component of the first sound (M1) slightly precedes the tricuspid component (T1), but you usually hear these two components fused as one sound. You can hear S1 over all the precordium, but usually it is loudest at the apex.
The second heart sound (S2) occurs with closure of the semilunar valves and signals the end of systole. The aortic component of the second sound (A2) slightly precedes the pulmonic component (P2). Although it is heard over all the precordium, S2 is loudest at the base.
Effect of Respiration.
The volume of right and left ventricular systole is just about equal, but this can be affected by respiration. To learn this, consider the phrase:
MoRe to the Right heart, Less to the Left
That means that during inspiration, intrathoracic pressure is decreased. This pushes more blood into the vena cava, increasing venous return to the right side of the heart, which increases right ventricular stroke volume. The increased volume prolongs right ventricular systole and delays pulmonic valve closure.
Meanwhile on the left side, a greater amount of blood is sequestered in the lungs during inspiration. This momentarily decreases the amount returned to the left side of the heart, decreasing left ventricular stroke volume. The decreased volume shortens left ventricular systole and allows the aortic valve to close a bit earlier. NUR 2092 – Health Assessment Essays, Exams and study guide. When the aortic valve closes significantly earlier than the pulmonic valve, you can hear the two components separately. This is a split S2.
Extra Heart Sounds
Third Heart Sound (S3).
Normally diastole is a silent event. However, in some conditions ventricular filling creates vibrations that can be heard over the chest. These vibrations are S3. S3 occurs when the ventricles are resistant to filling during the early rapid filling phase (protodiastole). This occurs immediately after S2, when the AV valves open and atrial blood first pours into the ventricles. (See a complete discussion of S3 in Table 19-8, p. 499.)
Fourth Heart Sound (S4).
S4 occurs at the end of diastole, at presystole, when the ventricle is resistant to filling. The atria contract and push blood into a noncompliant ventricle. This creates vibrations that are heard as S4. S4 occurs just before S1.
Murmurs
Blood circulating through normal cardiac chambers and valves usually makes no noise. However, some conditions create turbulent blood flow and collision currents. These result in a murmur, much like a pile of stones or a sharp turn in a stream creates a noisy water flow. A murmur is a gentle, blowing, swooshing sound that can be heard on the chest wall. Conditions resulting in a murmur are as follows:
- Velocity of blood increases (flow murmur) (e.g., in exercise, thyrotoxicosis)
- Viscosity of blood decreases (e.g., in anemia)
- Structural defects in the valves (a stenotic or narrowed valve, an incompetent or regurgitant valve) or unusual openings occur in the chambers (dilated chamber, septal defect)
Characteristics of Sound
All heart sounds are described by:
- Frequency (pitch)—Heart sounds are described as high pitched or low pitched, although these terms are relative because all are low-frequency sounds, and you need a good stethoscope to hear them. NUR 2092 – Health Assessment Essays, Exams and study guide.
- Intensity (loudness)—Loud or soft
- Duration—Very short for heart sounds; silent periods are longer
- Timing—Systole or diastole
Conduction
Of all organs, the heart has a unique ability—automaticity. The heart can contract by itself, independent of any signals or stimulation from the body. It contracts in response to an electrical current conveyed by a conduction system (Fig. 19-8). Specialized cells in the sinoatrial (SA) node near the superior vena cava initiate an electrical impulse. (Because the SA node has an intrinsic rhythm, it is the “pacemaker.”) The current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum. NUR 2092 – Health Assessment Essays, Exams and study guide. There it is delayed slightly so the atria have time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles.
High Blood Pressure.
Although all adults have some potential CVD risk, some groups (defined by race, ethnicity, gender, socioeconomic status, educational level) carry an excess burden of CVD. Stage 1 hypertension is a systolic BP (SBP) of ≥140 mm Hg or diastolic BP (DBP) of ≥90 mm Hg or currently taking antihypertensive medicine. A higher percentage of men than women have hypertension until age 45 years. From age 45 to 64 years, the percentages are similar; after age 64 years women have a much higher percentage of hypertension than men have.1 Hypertension also is 2 to 3 times more common among women taking oral contraceptives (especially among obese and older women) than in women who do not take them. NUR 2092 – Health Assessment Essays, Exams and study guide.
Among racial groups the prevalence of hypertension in Blacks is among the highest in the world, and it is rising. The prevalence of hypertension is 41.4% for African Americans, 25.8% for American Indians or Alaska natives, 28.1% for Whites, 22.2% for Hispanics, and 18.7% for Asians.1 Compared with Whites, African Americans develop high BP earlier in life, and their average BPs are much higher. This results in African Americans having a greater rate of stroke, death from heart disease, and end-stage kidney disease.
Risk factors related to who you are
Common hereditary and physical risk factors for high blood pressure include:
- Family history
If your parents or other close blood relatives have high blood pressure, there’s an increased chance that you’ll get it, too. - Age
The older you are, the more likely you are to get high blood pressure. As we age, our blood vessels gradually lose some of their elastic quality, which can contribute to increased blood pressure. However, children can also develop high blood pressure. Learn more about children and high blood pressure. - Gender
Until age 45, men are more likely to get high blood pressure than women are. From age 45 to 64, men and women get high blood pressure at similar rates. And at 65 and older, women are more likely to get high blood pressure. Learn more about women and high blood pressure. - Race
African-Americans tend to develop high blood pressure more often than people of any other racial background in the United States. For African-Americans, high blood pressure also tends to occur at younger ages and to be more severe. Learn more about African-Americans and high blood pressure.
Risk factors related to how you live
Unlike the traits you are born with, the risk factors related to how you live are things you can change to help prevent and manage high blood pressure, including:
- Lack of physical activity
Not getting enough physical activity as part of your lifestyle increases your risk of getting high blood pressure. Physical activity is great for your heart and circulatory system in general, and blood pressure is no exception. Learn more about getting regular physical activity. - An unhealthy diet, especially one high in sodium
Good nutrition from a variety of sources is critical for your health. A diet that is too high in salt consumption, as well as calories, saturated fat and sugar, carries an additional risk of high blood pressure. On the other hand, making healthy food choices can actually help lower blood pressure. Learn more about improving your diet. - Being overweight or obese
Carrying too much weight puts an extra strain on your heart and circulatory system that can cause serious health problems. It also increases your risk of cardiovascular disease, diabetes and high blood pressure. Learn more about managing your weight. - Drinking too much alcohol
Regular, heavy use of alcohol can cause many health problems, including heart failure, stroke and an irregular heartbeat (arrhythmia). It can cause your blood pressure to increase dramatically and can also increase your risk of cancer, obesity, alcoholism, suicide and accidents. Learn more about alcohol, high blood pressure and the importance of moderation.
Potential contributing risk factors
In addition to the known risk factors, there are others that may contribute to high blood pressure, although how is still uncertain. These potential contributing risk factors include:
- Smoking and tobacco use
Using tobacco can cause your blood pressure to temporarily increase and can contribute to damaged arteries. Secondhand smoke, exposure to other people’s smoke, also increases the risk of heart disease for nonsmokers. Learn more about quitting smoking. - Stress
Stress is not necessarily a bad thing in and of itself. But too much stress may contribute to increased blood pressure. Also, too much stress can encourage behaviors that increase blood pressure, such as poor diet, physical inactivity, and using tobacco or drinking alcohol more than usual. Learn more about managing your stress.
The rhythmic movement of blood through the heart is the cardiac cycle. It has two phases, diastole and systole. In diastole the ventricles relax and fill with blood. This takes up two thirds of the cardiac cycle. Heart contraction is systole. During systole blood is pumped from the ventricles and fills the pulmonary and systemic arteries. This is one third of the cardiac cycle.
Diastole.
In diastole the ventricles are relaxed, and the AV valves (i.e., the tricuspid and mitral) are open (Fig. 19-6). (Opening of the normal valve is acoustically silent.) The pressure in the atria is higher than that in the ventricles; therefore blood pours rapidly into the ventricles. This first passive filling phase is called early or protodiastolic filling.
image
19-6
Toward the end of diastole the atria contract and push the last amount of blood (about 25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial systole, or sometimes the atrial kick. It causes a small rise in left ventricular pressure. (Note that atrial systole occurs during ventricular diastole, a confusing but important point.)
Systole.
Now so much blood has been pumped into the ventricles that ventricular pressure is finally higher than that in the atria; thus the mitral and tricuspid valves swing shut. The closure of the AV valves contributes to the first heart sound (S1) and signals the beginning of systole. The AV valves close to prevent any regurgitation of blood back up into the atria during contraction.
For a very brief moment all four valves are closed. The ventricular walls contract. This contraction against a closed system works to build pressure inside the ventricles to a high level (isometric contraction). Consider first the left side of the heart. When the pressure in the ventricle finally exceeds pressure in the aorta, the aortic valve opens, and blood is ejected rapidly.
After the ventricle’s contents are ejected, its pressure falls. When pressure falls below pressure in the aorta, some blood flows backward toward the ventricle, causing the aortic valve to swing shut. This closure of the semilunar valves causes the second heart sound (S2) and signals the end of systole.
Diastole Again.
Now all four valves are closed, and the ventricles relax (called isometric or isovolumic relaxation). Meanwhile the atria have been filling with blood delivered from the lungs. Atrial pressure is now higher than the relaxed ventricular pressure. The mitral valve drifts open, and diastolic filling begins again.
Events in the Right and Left Sides.
The same events are happening at the same time in the right side of the heart, but pressures in the right side of the heart are much lower than those of the left side because less energy is needed to pump blood to its destination, the pulmonary circulation. Also, events occur just slightly later in the right side of the heart because of the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes you can hear them separately. In the first heart sound the mitral component (M1) closes just before the tricuspid component (T1). And with S2, aortic closure (A2) occurs slightly before pulmonic closure (P2).
Jugular Venous Pulse and Pressure
The jugular veins empty unoxygenated blood directly into the superior vena cava. Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about activity on the right side of the heart. Specifically they reflect filling pressure and 467volume changes. Because volume and pressure increase when the right side of the heart fails to pump efficiently, the jugular veins expose this.
Two jugular veins are present in each side of the neck (see Fig. 19-10). The larger internal jugular lies deep and medial to the sternomastoid muscle. It is usually not visible, although its diffuse pulsations may be seen in the sternal notch when the person is supine. The external jugular vein is more superficial; it lies lateral to the sternomastoid muscle, above the clavicle.
Although an arterial pulse is caused by a forward propulsion of blood, the jugular venous pulse is different. The jugular pulse results from a backwash, a waveform moving backward caused by events upstream. The jugular pulse has five components, as shown in Fig 19-12.
image
19-12 Note: Match color on waveform with its description.
The five components of the jugular venous pulse occur because of events in the right side of the heart. The A wave reflects atrial contraction because some blood flows backward to the vena cava during right atrial contraction. The C wave, or ventricular contraction, is backflow from the bulging upward of the tricuspid valve when it closes at the beginning of ventricular systole (not from the neighboring carotid artery pulsation). Next the X descent shows atrial relaxation when the right ventricle contracts during systole and pulls the bottom of the atria downward. The V wave occurs with passive atrial filling because of the increasing volume in the right atria and increased pressure. Finally the Y descent reflects passive ventricular filling when the tricuspid valve opens and blood flows from the RA to the RV.
Normal bowel sounds – 5-30 per minute
Listen for 5 minutes
- Rectal bleeding, blood in the stool. Ever had black or bloody stools? When did you first notice blood in the stools? What is the color—bright red or dark red–black? How much blood: spotting on the toilet paper or outright passing of blood with the stool? Do the bloody stools have a particular smell?
Melena.
Black stools may be tarry due to occult blood (melena) from GI bleeding or nontarry from ingestion of iron medications.
Red blood in stools occurs with GI bleeding or local bleeding around the anus and with colon and rectal cancer
Lymph nodes: infection if swollen, hard: possible cancer
Diseases of GI system?
Cancers
Abdominal aortic aneurysm
Peptic ulcer disease
Inflammatory bowel disease (Crohn’s or ulcerative colitis)
Gallbladder disease
Colon cancer:
- 2nd leading cause of cancer related deaths in US
- Non-modifiable risk factors: Age over 50, Family history, African American ethnicity, pre-existing condition, diabetes
- Modifiable risk factors: smoking, alcohol, obesity, excessive processed and red meat, low fruit and vegetable intake, lack of dietary fiber
ABDOMEN: Inspection first
Auscultate AFTER inspection and BEFORE percussion
Palpate last
Look at abdomen for:
Color
Shape
Lacerations
Scars
Tattoos
Ecchymoses
Obesity
Guarding
Bulges
Peristalsis, or pulsations
Ascites
Divide into 4 quadrants
Listen in each area: RLQ, RUQ, LUQ, LLQ ( 5 – 15 secs)
Listening for bowel sounds – bubbles, hissing,
Record as present/normoactive, hyperactive, hypoactive, or absent.
What conditions would cause each of the above?
Using bell – auscultate for vascular sounds
Cystitis is the medical term for inflammation of the bladder. Most of the time, the inflammation is caused by a bacterial infection, and it’s called a urinary tract infection (UTI). A bladder infection can be painful and annoying, and it can become a serious health problem if the infection spreads to your kidneys.
Less commonly, cystitis may occur as a reaction to certain drugs, radiation therapy or potential irritants, such as feminine hygiene spray, spermicidal jellies or long-term use of a catheter. Cystitis may also occur as a complication of another illness.
The usual treatment for bacterial cystitis is antibiotics. Treatment for other types of cystitis depends on the underlying cause.
Nephrolithiasis specifically refers to calculi in the kidneys, but renal calculi and ureteral calculi (ureterolithiasis) are often discussed in conjunction. The majority of renal calculi contain calcium. The pain generated by renal colic is primarily caused by dilation, stretching, and spasm because of the acute ureteral obstruction.
Signs and symptoms
The classic presentation for a patient with acute renal colic is the sudden onset of severe pain originating in the flank and radiating inferiorly and anteriorly; at least 50% of patients will also have nausea and vomiting. Patients with urinary calculi may report pain, infection, or hematuria. Patients with small, nonobstructing stones or those with staghorn calculi may be asymptomatic or experience moderate and easily controlled symptoms.
The location and characteristics of pain in nephrolithiasis include the following:
Stones obstructing ureteropelvic junction: Mild to severe deep flank pain without radiation to the groin; irritative voiding symptoms (eg, frequency, dysuria); suprapubic pain, urinary frequency/urgency, dysuria, stranguria, bowel symptoms
Stones within ureter: Abrupt, severe, colicky pain in the flank and ipsilateral lower abdomen; radiation to testicles or vulvar area; intense nausea with or without vomiting
Upper ureteral stones: Radiate to flank or lumbar areas
Midureteral calculi: Radiate anteriorly and caudally
Distal ureteral stones: Radiate into groin or testicle (men) or labia majora (women)
Stones passed into bladder: Mostly asymptomatic; rarely, positional urinary retention
Abdominal assessment – method of assessment, anatomy, possible findings, e.g. aneurysm, hernias; disease risk factors POWERPOINT
HEENT – possible abnormal findings, developmental concerns with assessment, assessment methods for each area, possible tonsillar findings BOOK
Assessment of the heart – placement of stethoscope; heart sounds CHAPTER 19
Skin – types and patterns of lesions PAGE 226
Skin – signs of cancer PAGE 236 and nails
KNOW ORGANS AND QUADRANTS
Assessments and Health and Illness Beliefs Essay
A consideration of the patient’s culture is paramount in the process of the interview, diagnosis, and treatment of culturally diverse individuals. Healthcare can be a complex issue. Cultural and language barriers can complicate the situation even more. NUR 2092 – Health Assessment Essays, Exams and study guide. Assessment of these patients can raise many issues that the nurse needs to be aware of and address in order to come up with a specific diagnosis and an acceptable plan of treatment that respects the patient’s cultural beliefs.
I have been an eye witness to how a person’s cultural beliefs can have an effect on a person’s decisions as far as their medical care goes. Last year my mother in law, who is Hispanic, and is in her early seventy’s broke her hip. She went to the hospital with at least half a dozen relatives most of whom spoke little to no English so a translator was requested in order to be sure she understood everything being said. NUR 2092 – Health Assessment Essays, Exams and study guide. Her condition was explained to her in detail. The doctor explained to her that she needed surgery, he explained and stressed the importance of the having the procedure. After speaking to my husband and the other handful of relatives that were present she still decided that it was best for her to go home. Despite the argument made by myself, my husband, and another one of the relatives she wanted to speak with someone in her church and someone she viewed as a natural healer for guidance before making a decision on the matter. We again put forth our best arguments but she was adamant that she would return if she felt it was the best course of action after speaking to someone of her faith that she knew and trusted.
She has a deep belief in her religion and sees a lot of illness issues as an imbalance between internal and external forces. Prior to this incident she relied heavily on medical treatment from home remedies, folk healers, and prayer giving God the chance to heal her first. NUR 2092 – Health Assessment Essays, Exams and study guide.
Cultural beliefs may also mandate how medical information is dispersed or received. In the Latino culture, the mother usually determines when a family member requires medical attention; but it is the male head of the household that gives permission to seek that medical care. In my mother in laws case more than one reliable source must provide the information, such as a spiritual/religious leader, doctor, or folk healer or family elder. People from many immigrant cultures bring their beliefs, and the practices that accompany them, into the health care system here. This often proves to be a challenge for nurses and to other health care professionals who have been trained in the philosophy, concepts, and practices of traditional medicine. If a person believes the health care provider may disapprove or refuse to respect their beliefs and traditions, they may not be forthcoming with information about the use of non-traditional remedies that they are using or advice they are seeking out NUR 2092 – Health Assessment Essays, Exams and study guide. This may result in dangerous interactions of medications or treatments. Which will lead to a disastrous end for the patient.
So as nurses it is our job to establish a positive, supportive, trusting relationship with the patient. Seek an understanding of the causes of illness from the person’s cultural point of view. In providing information consider: whether primary importance is placed on the individual, family or on the community. What are the generally accepted roles of women, men, and children? And do our best to utilize all available avenues to acquire the skills and competencies necessary for quality cultural care.
References
Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Retrieved January 7, 2017. NUR 2092 – Health Assessment Essays, Exams and study guide.