Florida University :NUR 3125 Health Assessment Exam 2/ General Survey and Measurement,100% CORRECT

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Florida University :NUR 3125 Health Assessment Exam 2/ General Survey and Measurement Chapter 9: General Survey and Measurement General Survey: the study of the whole person, covering the gene... ral health state and any physical characteristics; begins when you meet a person ● Components ○ Physical Appearance ■ Age: the person appears his or her age ● Some people may appear older because of chronic illness or chronic alcoholism ■ Sex: sexual development is appropriate for their age ● If the individual is transgender, note the stage of transformation ● Some individuals experience delayed or precocious puberty ■ Level of Consciousness: alert and oriented to person, place, time, and situation, responds appropriately to questions ● Some may be confused, drowsy, lethargic due to illness ■ Skin Color: tone should be even, appropriate to genetic background; skin is intact, no obvious lesions ● Note any tattoos or piercings, stage of healing ● Note deviations such as pallor, cyanosis, jaundice, erythema ■ Facial features: symmetric with movement ● Abnormal findings include immobile, asymmetric, masklike, drooping ■ Overall appearance: no signs of acute distress ● Cardiac or respiratory signs (diaphoresis, SOB, wheezing, pain signs like clutching chest, grimacing) ○ Body Structure ■ Stature: normal range for age and genetic heritage ● Abnormally short or tall, abnormal proportions ● Table 9.2 abnormalities in body height and proportion ○ Hypopituitary dwarfism: deficiency in growth hormone results: in growth below 3rd percentile; delayed puberty onset; hypothyroidism; adrenal insufficiency ○ Achondroplastic dwarfism: genetic disorder resulting in cartilage becoming bone, results in: normal trunk size, short arms and legs, large head with frontal bossing, midface hypoplasia; sometimes thoracic kyphosis, lumbar lordosis, and abdominal protrusion; men around 4’4” and women around 4’1” ○ Acromegaly: excessive growth hormone secretion in adults after normal body growth, causes overgrowth of bone in face, head, hands, and feet with no change in height; internal organs can enlarge (cardiomegaly example), metabolic disorders can be present ○ Anorexia nervosa ○ Endogenous Obesity: excessive ACTH stimulates secretion of cortisol or administration of adrenocorticotropin; cervical obesity, moon face (round, fat); weight gain in central trunk, cervical obesity, muscle wasting, weakness, think extremities, reduced height, thin fragile skin with purple abdominal striae, bruising, and acne ○ Gigantism: excessive secretion of growth hormone during childhood, results of overgrowth of entire body; when it occurs before cone epiphyses close it causes increased height, weight, and delayed sexual development ○ Marfan syndrome: inherited connective tissue disorder characterized by tall, thin stature (>95%), arachnodactyly, hyperextending joints, arm span greater than height, flat feet (pes planus), sternal deformity such as pectus excavatum, narrow face, high-arched and narrow palate, and more; cardiovascular complications can cause early morbidity and mortality ■ Symmetry: body parts look equal bilaterally and are in relative proportion to each other ● Asymmetry or unilateral hypertrophy/atrophy ■ Nutrition: normal weight and height, body fat evenly distributed ● Cushing's obesity is different than normal obesity ■ Posture: person sits comfortably with arms relaxed at sides and head turned to the examiner ● Tripod: leaning forward with arms braced on chair arms, occurs with chronic pulmonary disease, asthma ● Sitting up straight and resisting lying down- heart failure ● Fetal position- pain, usually abdominal ■ Body build and contour ● Proportions: arm span = height; crown to pubis = pubis to sole (roughly) ● Elongated arms could be from marfans, hypogonadism ■ Obvious physical deformities: not any congenital or acquired defects such as missing extremities, webbed digits, shortened limb ○ Mobility ■ Gait: smooth walk, no assistance, symmetry, feet about shoulder width apart ● Propulsion- difficulty stopping ■ Range of motion: rom for each joint and movements are deliberate, accurate, smooth, and coordinated ■ Involuntary movements: tics, tremors, seizures, abnormal muscle movements ○ Behavior ■ Facial expression: culturally appropriate eye contact, expressions appropriate to situation, note face at rest and while talking ● Anxiety is common in ill people, some people smile when they are anxious ● Abnormalities can include flat, depressed, angry, sad, anxious, etc ■ Mood and affect: comfortable and cooperative ■ Speech: articulation is clear and understandable ■ Speech pattern: fluent, even pace, word choice is appropriate, conveys ideas clearly, communicates easily on their own or with interpreter ■ Dress: appropriate, clean, fits properly ■ Personal hygiene: clean, well groomed, “normal” ○ Measurements ■ Weight: remove heavy outer clothing and shoes, aim for weighing at same day with same type of clothing, record in kg and lbs; before breakfast, after void ● Look for weight loss and gain ● Example: patient with initial weight in undergarments and gown should be repeated in gown ● Unexplained loss: from short term or chronic illness (malignancy, endocrine disease, depression, anorexia, bulimia) ○ Person treated for pneumonia for several weeks may have some weight loss ● Unexplained gain: fluid retention ■ Height: measured with a wall-mounted device or pole on balance scale; align extended headpiece with top of head, person should be shoeless, standing straight and looking straight ahead, slight traction under jaw; feet, shoulders, butt should be in contact with the wall or measuring pole ■ BMI: there are two tables, one for inches, and one for meters. Look at it ● BMI is a practical marker for optimal healthy weight for height, indication of obesity or malnutrition. Should be used with other measures such as weight circumference ● Review the classifications. You should already know them ● Formula: Weight (kg) divided by height^2 (m^2) OR [(lbs)/(in^2)]*703 ■ Waist circumference: should be <40in men, <35in women, measured at iliac crest; larger increases risk for T2D, heart disease, dyslipidemia, CVD, hypertension, etc ○ Developmental competence ■ Infants and children ● Length/height: should be measured on horizontal board until 2 years of age, not by tape measure, may need to momentarily extend legs, stretch spine and hold head against plate; repeat to ensure accuracy ● Chest circumference: tape is encircled around chest at nipple height or an infant ● Head circumference ○ Newborns: 32-38cm, 34 avg; measure at eyebrows ■ Will be about 2cm larger than chest; will reach same size some time between 6 months and 2 years because chest grows faster, after 2 years chest will be bigger than the head ● Weight: to the nearest 10g (½ oz) for infants and 100g (¼ lb) for toddlers ○ Platform-type scales for infants ● Physical growth is the best indicator of a child’s general health. Recording height and weight will help determine growth patterns. Consider genetic background in the small-for-age child, but the most important factors are economic, nutrition, and environmental ■ The aging adult ● Postural changes: general flexion occurs by 8th or 9th decade ○ Kyphosis (humpback) common in very old and those with osteoporosis, slight flexion in knees and hips ● Decreased body weight: muscle shrinkage (more evident weight loss because of greater muscle shrinkage in men), decrease in subcutaneous fat from face and periphery, and additional fat deposited in abdomen and hips ○ More prominent body landmarks ● Changes in overall proportions: shorter trunk, longer extremities (long bones don't shorten with age) ● Measuring vitals and observing specific body systems while performing a physical assessment are not part of a general survey but are part of a physical examination Documentation (pg 135) ● Subjective: appears healthy and of stated age. Alert, oriented, and cooperative during health history ● Objective: Skin tone is even with senile lentigines on dorsa of hands and forearms bilaterally. Gait smooth; feet slightly wider than shoulders. No obvious physical deformities. Intention tremor noted when completing history form. Speech appropriate, clear, and understandable. Kempt appearance. Height 152 in (5 ft 10 in), weight 75 kg (165 lb). BMI 23 (healthy). Waist circumference 30 in. ● Another example: Mrs Jones, a 28 year old obese African American single woman, who presents for complete physical examination and evaluation for right for injury, is alert and oriented, seated upright on exam table. She is in no apparent distress. She is well nourished, well developed, and dressed appropriately with good hygiene. Be sure to practice documented general surveys in clinicals! Chapter 10: Vital Signs Vital signs are performed often and can be delegated to the nursing assistant personnel depending on the patient’s situation. Even if taking vitals is delegated when the patient is stable, interpretation is the responsibility of the nurse. You must interpret the findings based on the patient’s condition. Always follow provider’s orders for vital signs range and understand each patient is different. Vital signs are composed of ● Temperature: balance between heat production and heat loss; the body maintains a steady temp through a feedback mechanism regulated by the hypothalamus which regulates heat production from metabolism, exercise, food digestion, and other external factors ○ Oral (sublingual): most convenient and accurate ■ Need to wait 15 minutes before taking temperature if patient has ingested hot or cold liquids, 2 minutes if patient smoked ■ Normal Oral temps ● Avg 98.6 F ● Range of 35.8 C to 37.3 C (96.4 F to 99.1 F) ■ Methods: ● Glass thermometer: infrequently used but still available ○ Should be left in place for 3-4 minutes is the patient is afebrile ○ Should be left up to 8 minutes if the patient is febrile ○ Before use, shake down to 35.5 C, place at base of tongue ■ Should not be used in persons who cannot follow commands or are unable to close their mouths ● Electronic: swift and accurate ■ Blue probe = oral ○ Rectal: taken when other routes are impractical ■ Ex: patients are comatose or confused because they are unable to follow directions for oral temp; patients who are in shock or those who cannot close mouth because of oxygen tubes, wired mandible, or other facial dysfunctions ■ Normal temps ● About .4-.5 C (.7-1 F) higher than oral ■ How to: ● Blunt tip should be lubricated and inserted only 2-3 cm (about an inch); left in place for 2.5 minutes if using glass thermometers; hold and support it; ½ inch for infants less than 6 months ■ Red probe = rectal ■ Cigarette smoking does not affect ○ Tympanic membrane temperature: useful for young children who do not cooperate with oral temp and fear rectal temp, toddlers who squirm with rectal route ■ Use in newborn infants and young children is conflicting because it is not as accurate as other devices ■ Shares vascular supply that perfuses thalamus so it is an accurate measurement of core body temp ○ Temporal artery thermometer: uses infrared, newest measurement, takes multiple readings and provides avg; more accurate that TMT but still some concerns on accuracy ○ Axillary: questionable accuracy and reliability ○ Factors that influence ■ Diurnal cycle: 1-1.5 F with trough occuring in the early morning hours and peak in the late afternoon or early evening ■ Exercise: moderate to hard exercise increases temp ■ Hormones ● Menstrual cycle: progesterone w/ ovulation at mid-cycle causes a .5-1 F rise until menses ○ Reason why they use basal body temperature as a method of contraception (change in temp) ■ Age ● Older adults: lower temperatures with a mean of 36.2 C (97.2 F) by oral route ● Children: wider normal variations in infants and young children because of less effective heat control mechanisms ■ Mechanisms of heat loss ● Radiation ● Evaporation of sweat ● Convection ● Conduction ● Pulse ○ Rate: ■ Measuring 30 sec x2 is more efficient when HR is normal or rapid and when rhythm is regular compared to 15s by 4 because any one beat in the later measurement would result in an error of 4 beats per minute ■ If rhythm is irregular count for one full minute ■ Bradycardia: HR under 50 mins ● HR in 50s or lower normally occurs in well-trained athletes since heart muscles develop with skeletal muscles ■ Tachycardia: over 100 ● Can increase with anxiety and exercise to match body’s demand for increased metabolism ■ Normal: 50-95 BPM; traditional limits 60-100BPM; both used in adults ■ Table 10.1 Normal Rates in Infants and Children ● Newborn ○ Awake: 100-180 ○ Asleep: 80-160 ○ Exercise/fever: Up to 220 ● 1wk-3mo ○ Awake: 100-220 ○ Asleep: 80-200 ○ Exercise/fever: Up to 220 ● 3mo-2yr ○ Awake: 80-150 ○ Asleep: 70-120 ○ Exercise/fever: Up to 220 ● 2-10yr ○ Awake: 70-100 ○ Asleep: 60-90 ○ Exercise/fever: 195-215 ● 10-20yr ○ Awake: 55-95 ○ Asleep: 50-90 ○ Exercise/fever: 195-215 ■ Apical rate ● Auscultate for 1 min in infants and toddlers, then assess for irregularities such as sinus dysrhythmia ■ Stroke volume: about 70ml in adults into aorta; flares arterial walls and generates a pressure rate which is felt in the peripheral pulse ● Peripheral pulse examples ○ Radial ○ Brachial ○ Dorsalis Pedis ○ Posterior tibial ○ Rhythm ■ Respiratory sinus arrhythmia: heart rate varies with respiratory cycle, speeding up at peak of inspiration and slowing to normal with expiration; common in children and young adults. ● Inspiration momentarily causes a decreased stroke volume from left side and to compensate HR decreases ■ Is not assessed by dynamo ○ Force: ■ Scale: usually 0-3 but some agencies use a four point scale ● 3: full, bounding ● 2: normal ● 1: weak, thready ● 0: absent ■ Is not assessed by dynamo ■ Judging between 2-3 is somewhat subjective, experience helps ■ In older people there is an increase in the rigidity of the arterial walls which makes palpation easier ● Respiratory rate ○ Rate: how many times a full cycle occurs (one inhalation and one expiration) ■ Infants assess through abdomen because their respirations are more diaphragmatic ■ Elderly: decreased vital capacity, decreased inspiratory reserve volume ● Observer may notice a shallower inspiratory phase and an increased rate attributed the aging process ■ There’s a table for rates she didn’t mention. It’s on page 245 of the PDF. May be worth looking at or you can just ignore until Peds next semester ○ Depth: ■ Shallow ■ Normal ■ Deep ○ Rhythm: ■ Regular: count for 30 seconds ■ Irregular: if suspected, count for one full minute, maintain position as if taking pulse and count to make sure patient is not aware ■ Place hand on upper chest of abdomen if you are having trouble to help you feel them ● Blood pressure: force of blood pushing on the vessel walls ○ Five determining factors: from table on pg 145 physical book, 246 PDF ■ Cardiac output ● Increase: exercise to meet body demand for increased metabolism ● Decrease: with pump failure (weak pumping action after MI or in shock) ■ Peripheral vascular resistance ● Increase: with vasoconstriction ● Decreases with vasodilation ■ Volume of circulating blood ● Decrease: hemorrhage, dehydration ● Increase: increased Na and H2O retention, IV fluid overload ■ Viscosity ● Increases: increased hematocrit and polycythemia ■ Elasticity of vessel walls ● Increase: rigidity and hardening such as in arteriosclerosis as heart is pumping against greater resistance ○ Influencing factors ■ Age: normal rise through childhood into adult years ■ Hormones/Sex: after menopause, in women, BP is higher than in men; after puberty females are lower ■ Obesity: BP is higher in obese people than in people of normal weight of the same age, including adolescents ■ Ethnicity/Race: in the US african american adults BP is higher than non-hispanic white adults of the same age, incidence of hypertension is twice as high as well. Full reasoning unknown, but genetic profile and environmental factors involved. ■ Emotions: temp rise with fear, anger, pain thanks to SNS ■ Stress: elevated ■ Diurnal rhythm: high in late afternoon and early evening, low in early morning ■ Exercise: elevated ○ Assessing BP ■ Systolic: numerator, maximum pressure felt on artery during left ventricular contractions or systole; Phase 1 Korotkoff Sound that is best indicator of systolic BP ■ Diastolic: denominator, elastic recoil or resting pressure that the blood constantly exerts between contractions; pressure in vessels when the heart is at rest; in adults the last audible sound best indicates diastolic pressure ● When variance is greater than 10-12mm between Phases 4 and 5 both phases should be recorded with diastolic reading ○ Ex: First Korotkoff sound at 142, at 98 you are hearing sounds, at level 80mm you hear the last sounds. Record 142 over 98/80 ○ Disappearance of Phase 5 can be used as diastolic reading in both children and adults ■ MAP: the pressure forcing blood into the tissues averaged over the cardiac cycle, perfusing organs ● [Systolic +( Diastolic*2)] / 3 ● Diastolic + ⅓ Pulse pressure ● ⅓ systolic + ⅔ diastolic ● Given my dinamap and some of the wifi-based vital monitors ● At least 60mm to perfuse vital organs ■ Children BP guidelines based on age, sex, height of child ● Children younger than 3 make hearing korotkoff sounds with stethoscope difficult because of small vessel; nurse can use electronic BP device with oscillometry or doppler ultrasound to amplify the sound ■ Pulse pressure: difference between diastolic and systolic pressures, reflects stroke volume as well ● Systolic minus diastolic = Pulse Pressure ● In older adults the pulse pressure is widened ■ Palpated BP: done before auscultating to detect presence of auscultatory gap ● Palpate radial artery or brachial and inflate; note number that you notice the pulse disappears, inflate 20-30mm more; “to detect presence of auscultatory gap inflate 20-30mm more than when the pulse disappears” ○ Ex: Palpated pulse and inflated cuff, pulsation of radial artery stops at 100, add 20-30; so 120-130 ● Auscultatory gap: period in when the korotkoff sounds disappears during auscultation ○ occurs in 5% of population, most often in those with hypertension because of non-compliant arterial period ○ If it is not detected the systolic may be falsely low or the diastolic may be falsely high ○ Ideally done every time. In the clinical area you look at the trend in patients BP, however palpated BP is done before auscultated ■ Auscultated BP ■ Technique ● Position: comfortable, relaxed position yields accurate BP; nurse should allow at least 5 minutes rest before measuring BP because patients may be anxious or a person may have walked from the end of the parking lot, person may have been running from being afraid of being late ● Cuff sizing ○ A narrow cuff yields a falsely high pressure because it takes extra pressure to compress the artery ○ The width of the rubber bladder should equal 40% of the circumference of the arm ○ The length should be equal to 80% of the width of the bladder ● Table 10.4 Common Errors in BP measurement, pg 249 pdf, 149 book ○ Falsely high ■ Narrow/tight cuff, loose cuff ■ Crossed legs ■ Person supports arm - high diastolic ■ Arm is below level of heart ■ Emotional responses, exercise ■ Too quick - high diastolic ■ Too slow - high diastolic ■ Failure to wait before repeat - high diastolic ■ Halting descent and reinflating - high diastolic ○ False lows ■ Arm above heart ■ Cuff narrow, loose, or uneven; balloon out of wrap ■ Inflation not high enough - low systolic ■ Stethoscope too much pressure - low diastolic ■ Too quick - low systolic ● Orthostatic hypotension ● Coarctation of the aorta: obstructs blood flow to lower portion of body ○ When measurement is excessively high in adolescents or young adults, compare with thigh pressure to check for coarctation of the aorta (congenital form of narrowing); normally thigh pressure is 10-40mm higher systolic and diastolic is the same as the arm but if the arm is higher there is a problem ● Oxygen Saturation Sequence ● Adults: Temp, pulse, RR, BP ● Infants: RR, pulse, temp ○ Rectal temp may cause infants to cry which will raise the other rates Temp-> pulse -> resp -> BP Children Resp->Pulse->Temp-> BP Chapter 11: Pain Assessment Nociceptive Pain: develops when functioning and intact nerve fibers in the periphery and CNS are stimulated ● Triggered by events outside the nervous system from actual or potential tissue damage ● Four phases ○ Transduction: neurotransmitters released and transmit pain message along afferent sensory fibers to spinal cord ○ Transmission: pain message moves from spinal cord to brain ○ Perception: indicates conscious awareness of painful sensation; sensation recognized by higher cortical structures and identified as pain ○ Modulation: pain message is inhibited by neurotransmitters neurons release ● Descriptors: ○ Somatic: Dull, aching, well localized, nocturnal ○ Visceral: deep, squeezing pressure, local tenderness and referred, poorly localized ● Associated disorders ○ Somatic: Post-op pain, bone metastasis, arthritis, sports injury, mechanical back pain ○ Visceral: liver metastases, pancreatic cancer ● Treatment: underlying cause; NSAIDs, Opioids, muscle relaxant, corticosteroids, biphosphate Neuropathic Pain: implies an abnormal processing of a papin message; due to lesion or disease in somatosensory nervous system; does not adhere to typical and predictable phases of nociception; somatosensory nervous system ● Examples of conditions that can cause ○ Diabetes mellitus ○ Herpes zoster virus (shingles) ○ HIV/Aids ○ Sciatica ○ Trigeminal Neuralgia ○ Chemo ○ Phantom Limb pain ○ CNS alterations: stroke, MS, tumors ● Minor stimuli can cause significant pain ● Descriptors: constant dull ache, burning, stabbing, viselike, electric shock, numbness, tingling, allodynia, hyperalgesia, hyperpathia ● Associated disorders: distal polyneuropathy (diabetes, HIV), central poststroke pain, herpes zoster, trigeminal neuralgia, neuropathic back pain, complex regional pain syndrome ● Treatment: TCAs, anticonvulsants, antidepressants, anti neuroleptics, local anesthetics, bisphosphonate, corticosteroids, opioids, interventional techniques ● Peripheral neuropathy: symmetric damage to peripheral nerves resulting in pain without stimulation of nerves; numbness, tingling, interspersed shooting or lancinating pain ○ Etiologies: diabetic neuropathy that may relate to demyelination of larger nerves and increase in smaller nerves, ischemic damage, hyperglycemia; burning pain bilaterally that is worse at night ● Chemotherapy induced peripheral neuropathy: after chemo, increases with number of agents used, dose, pre-existing neuropathy, older age ○ Symptoms: numbness, burning, shooting pain in a glove and stocking distribution ○ Address new onsets of pain to rule out recurrence of cancer Sources of pain ● Visceral: originates from larger internal organs; described as dull, deep, squeezing, cramping ○ Ex: pain from cholecystitis, ureteral colic, appendicitis, ulcer pain ● Somatic: pain from musculoskeletal tissues or body surface ○ Deep somatic: tendons, joints muscles, bone, blood vessels ■ Described as aching or throbbing ○ Cutaneous: pain derived from skin surface and subcutaneous tissues ■ Superficial, sharp, burning ○ Usually well localized and easy to pinpoint ● Referred: pain that is felt at a particular site but originated in another location ○ Shared nerve Types of pain ● Duration ○ Acute: short term and self limiting, follows a predictable trajectory, dissipates after injury healths ■ Ex: surgery, trauma, kidney stones ■ Self-protective purpose ■ In cases where cause of acute pain is uncertain establishing the diagnosis is a priority but symptomatic treatment of pain should be given while investigation is proceeding ■ Rarely justified not to give analgesia until diagnosis is made; exception in initial exam of patient with an acute abdomen ○ Chronic: pain for 6 months or longer; malignant vs nonmalignant pain ○ Breakthrough pain Patients with poorly controlled pain respond with tachycardia, elevated BP, and hypoventilation A comfortable patient is able to cooperate with diagnostic procedures. Developmental Competence ● Infants and pain: infants feel pain just like adults; evidence suggests that repetitive and poorly controlled pain in infants can lead to changes in CNS that cause hypersensitivity ● Older adults and pain: no evidence suggests that pain perception is reduced with aging ○ Pain indicated a pathological incident or injury, should never be considered something an older adult should expect or tolerate ● Patients with dementia: become less able to identify and describe pain over time even though pain is still present ○ Patients may say no when asked about the existence of pain when there actually is a problem. Words seem to have lost their meaning ○ Communicate through behavior: agitation, pacing, repetitive yelling ■ May indicate pain and not worsening dementia Gender: women have greater pain sensitivity than men Culture- review Pain: a subjective experience, self report is the most reliable indicator of pain; physical exam can lend support but the nurse cannot exclusively diagnose pain on physical assessment findings, vital signs, or diagnostic results such as cat scans Pain Assessment tools: let patient describe pain in his or her own words ● OPQRST ○ Onset ■ What were you doing when it started? ○ Provocative/palliation: alleviating or aggravating factors ■ What makes the pain better or worse ○ Quality: nurse should refrain from providing descriptions, can help determining nociceptive vs neuropathic pain ■ What does the pain feel like ○ Region/Radiation: localized or multiple sites ■ Where is your pain? ○ Severity: assess intensity, multiple scales available ■ How much pain do you have? ○ Timing ■ When did it start? How long did it last? How often is it happening? ○ U: Quality impairment ■ How does the pain limit your function? What does it mean to you? ● Initial Pain Assessment: location, intensity, quality, onset, duration, variation, rhythms, manner of expressing pain, relief and causes; effects on: sleep, appetite, physical activity, relationship/emotional impact, concentration, symptoms; other comments; plan ● Brief Pain inventory: asks the patient to rate the pain within the last 24 hours using 0-10 scales with respect to its impact on mood, walking ability, and sleep ● Short form McGill Pain Questionnaire:: ask patient to rank list of descriptors in terms of their intensity and to give and overall intensity rating to the pain ● PAINAD for dementia patients: breathing, negative vocalization, facial expression, body language, consolability ● Pain Rating Scales: can be introduced at the age of 4-5 years ○ Numeric rating: 0-10, easy and consistent ○ Verbal descriptor: words to describe patient’s feelings and meaning of the pain for the person ○ Visual analogue scale: lets patient make a mark along 10cm horizontal line from no pain to worse pain imaginable ● Tools for infants and children: children do not have the ability to rate pain accurately on a numerical scale because a numerical scale is abstract ○ Faces pain scale - revised (FPS-R): six drawing of faces that show pain intensity, avoids smiles or tears so that children will not confuse pain intensity with happiness or sadness; asks child to choose face that shows how much hurt or pain they have now ○ CRIES neonatal post-op pain measurement ■ Crying ■ O2 requirement ■ Increased vitals ■ Expression ■ Sleepless ○ FLACC: nonverbal tool for infants and children under 3 ■ Facial expression ■ Leg movement ■ Activity level ■ Cry ■ consolability Table 11.5 pg 284 - Reflexive Sympathetic Dystrophy ● A key feature of this condition is that a typically innocuous stimulus creates a severe, intensely painful response. Affected extremity becomes less functional over time Chapter 12: Nutritional Assessment Nutritional status: the balance between nutrient intake and nutrient requirements ● Affected by physiologic, psychosocial, developmental, cultural, and economic factors Optimal nutritional status: achieved when sufficient nutrients are consumed to support day-to day body needs and any increased metabolic demands caused by growth, pregnancy, or illness ● People who achieve this are more active, have fewer physical illnesses, and live longer than people who are malnourished Undernutrition: occurs when nutritional reserves are depleted and/or when nutrient intake in inadequate to meet day-today needs or added metabolic demands ● Vulnerable groups: infants, children, pregnant women, recent immigrants, people with low incomes, hospitalized people, aging adults ○ At risk for impaired growth and development, lowered resistance to infection and disease, delayed wound healing, longer hospital stays, higher healthcare costs Overnutrition: caused by the consumption of nutrients, especially calories, sodium, and fat, in excess of body needs ● Can lead to obesity ○ BMI: calculated by using height/weight; practical marker of optimal weight for height and an indicator for obesity ○ Risk factor for many diseases Developmental competence ● Infants and children: a great deal of growth in the first four years of life in regards to weight, height, length, and brain development; need to maintain adequate fat and caloric intake ○ Fats which are calories and fatty acids are required for proper growth and development ○ Breastfeeding: recommended for full-term infants for the first year of life because breast milk is ideally formulated to promote normal infant growth and development and natural immunity through IgA antibodies ■ Other advantages ● Fewer food allergies and intolerances ● Reduced likelihood of overfeeding ● Less cost ● Increased mother-infant time ○ Cow’s milk not recommended until 1 year of age; children under 2 should not drink skim milk or low fat milk or be placed on low fat diets ○ Small portions, finger foods, simple meals, and nutritious snacks help improve dietary intake of young children ○ Avoid foods that can be easily aspirated or cause choking such as hot dogs, nuts, grapes, round candies, or popcorn ● Adolescence: after a period of slow growth in late childhood, adolescence is characterized by rapid growth and endocrine and hormonal changes; caloric and protein requirements increase to meet demand ○ Because of bone growth and increasing muscle mass, and in girls the onset of menarche, calcium and iron requirements also increase ○ Increased body awareness and self consciousness which can cause eating disorders such as anorexia nervosa and bulimia; perceived body image does not favorably compare with an ideal body image ● Pregnancy and lactation: in particular, iron, folate, and zinc are essential for fetal growth and vitamin and mineral supplements are often required ○ The National Academy of Sciences recommends a weight gain of 25-35lbs during pregnancy for women of normal weight ■ Women who are underweight should gain between 28 and 40 lbs ■ Overweight women should gain 15-25 lbs ■ Obese women should gain 11-20 lbs ● Adulthood: important time for education to preserve health and/or delay onset of chronic illness ○ Metabolic syndromes carry increased cardiac risks; diagnosed when a person has ⅗ biomarkers: elevated BP, increased fasting plasma glucose, elevated triglycerides, increased waist circumference, low high-density lipoproteins ■ Table 12.5 ● BP: >130 sys, or >85 dia, or drugs for hypertension ● TG >150 or drug treatment ● HDL <40 in men <50 in women, or drug treatment ● Glucose >99 or drug treatment ● Waist measurements >39 men >34 women ■ People with elevated cholesterol should be taught about planning a healthy diet that limits the intake of foods high in saturated fats. Reducing dietary fats is part of the treatment for this condition ● The aging adult: socioeconomic conditions frequently affect the nutritional status of the aging adult ○ Physical limitations, income, and social isolation are frequent problems that interfere with the acquisition of a balanced diet ○ Physiologic changes that occur in aging such as decrease in taste and smell, slowed or decreased GI motility and absorption, decreased saliva production, decreased visual acuity, and poor dentition can directly impact nutrition status ○ If a person reports changes in appetite, taste, smell, chewing, and swallowing should ask about the type of change and when the change happened or occurred. These problems interfere with adequate nutrient intake ○ Dysphagia or impaired swallowing: interferes with adequate nutrient or food intake ○ Asking about medications: assesses the potential interactions with foods or nutrients ■ Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and oral contraceptives are drugs that can interact with nutrients affecting their digestion, absorption, metabolism, or use. ○ Important nutritional features ■ Decreased energy requirements from loss of lean body mass which is the most metabolic active tissue ● Sarcopenia is the age related loss of muscle mass; sarcopenic obesity is characterized by low muscle mass with excess fat and can be attributed to low levels of physical activity and poor diet ■ Increased fat mass means less energy calorie foods Culture and genetics ● Immigrants from underdeveloped countries in general have poor nutrition ○ Hypertension, diarrhea, lactose intolerance, osteomalacia, scurvy, dental caries are among the more common nutrition related problems of new immigrants from developing countries ● Dietary practices/restrictions of selected cultural groups - Table 12.1 ○ Buddhism: Will vary depending on the Buddhist sect; All meat (some sects); Alcohol; Pungent spices (garlic, onion, scallions, chives, leeks) ○ Catholicism: Meat by some denominations on Ash Wednesday, Good Friday, and other holy days; Alcoholic beverages by some denominations ○ Hinduism: Lacto-vegetarianism often favored; Alcohol and intoxicating substances; Garlic, onion, and spicy foods by some; Fasting on some holy days ○ Islam: All pork and pork products; Meat not slaughtered according to ritual; Alcoholic beverages and alcohol products (e.g., vanilla extract), coffee, and tea; Food and beverages before sunset during Ramadan ○ The Church of Jesus Christ of Latter-Day Saints: Alcoholic beverages; Hot beverages, specifically coffee and tea; Food and beverages for 2 consecutive meals on fast Sunday ○ Orthodox Judaism: All pork and pork products; Meat not slaughtered according to ritual; All shellfish (e.g., crab, lobster, shrimp, oysters); Dairy products and meat at the same meal; Leavened bread and cake during Passover; Food and beverages on Yom Kippur ○ Seventh-Day Adventist: All pork and pork products; Shellfish; Meat, dairy products, and eggs by some; Alcoholic beverages, coffee, and tea Types of Nutrition Assessment ● Nutrition screening: first step in assessing nutritional status, based on easily obtained data; a quick and easy way to identify individuals at nutritional risk ○ Parameters used ■ Weight and height history ■ Conditions associated with increased risk ■ Dietary info ■ Routine laboratory data ● Example: albumin level, a person who is on a low protein diet for a period of time may have a serum albumin of less than 3.5 g/dL ● Methods of collecting current dietary intake information ○ Food frequency questionnaire: information is collected on how many times per day, week, or month the individual eats a particular food which provides and estimate of usual intake ■ This is used to assess how many times a person eats a specific food ○ Food diary: asks individuals to write down everything consumed for a certain period of time ■ Can be sued for a person with irritated food patterns ○ Calorie count: calculates calories of all foods consumed for a period of time; often performed for hospitalized clients ○ 24 hour recall: interview or questionnaire that asks person to recall everything they ate within the last 24 hours ○ Direct observation of feeding and eating process can detect problems that are not easily identified through standard nutrition interviews ● Individuals identified at risk should undergo a comprehensive nutritional assessment which includes dietary history and clinical info, physical examination for clinical signs, anthropometric measures, and laboratory tests ● Objective data ○ Anthropometric measures ■ Height ■ Weight ● Unintentional loss of >5% over one month, 7.5% over 3 months, or 10% over 6 months is clinically significant ● Current weight at 85-95% of usual indicates mild malnutrition; 75-84% indicates moderate malnutrition, and <75% indicates severe malnutrition ■ BMI ■ Waist to hip ■ Arm span or total arm length ● Subjective data ○ Eating patterns ○ Usual weight ○ Changes in appetite, tast, smell, chewing, swallowing ○ Recent surgery, illness, trauma, burns ○ Chronic illness ○ GI patterns ○ Allergies or intolerances ○ Meds and supplements ○ Alcohol or drug use ○ Exercise and activity patterns ○ Family history ● Abnormal findings: ○ Marasmus (PCM): protein calorie malnutrition, starved appearance ○ Kwashiorkor: high in calories but no protein, appear well nourished or even obese ○ Scorbutic (scurvy gums) gums: swollen, ulverated, bleeding gums because of vitamin C induced defects ○ Bitot spots: foamy plaques on cornea and accumulation of keratin are a sign or vitamin A deficiency; can result in conjunctival xerosis, corneal ulceration, keratomalacia (destruction of eye) ○ Magenta tongue: riboflavin deficiency ○ Pellagra: niacin deficiency ○ Follicular hyperkeratosis: deficiency in linoleic acid ○ Ricketts, osteomalacia: vitamin d deficiencies, bent bones ○ Table 12.2 Clinical signs of malnutrition Chapter 13: Hair, Skin, and Nails Skin: the largest organ system of the body; first line of defense against environmental stresses; adapts to environmental stressors ● Holds information about the body’s circulation, nutritional status, and signs of systemic disease as well as palpable data ● Two layers ○ Epidermis: highly differentiated, thin but tough ■ Inner basal layer forms new skin cells ■ Keratin: a fibrous protein and the major ingredient of skin ■ Melanocytes: same number in all people but the amount they produce varies with genetic, hormonal, and environmental influences ○ Dermis: supportive layer mostly made of connective tissue or collagen, which is a tough fibrous protein that enables the skin to prevent tearing ■ Nerve sensory receptors, blood vessels, and lymphatic vessels lie in the dermis ■ Hair follicles, sebaceous glands, and sweat glands are all embedded in the dermis ○ Subcutaneous: composed of adipose tissues which is made up of lobules of fat cells ■ Stores fat for energy, provides insulation, and aids in protection ● Two types of sweat glands ○ Eccrine glands (sweat glands): coiled tubules that open directly onto skin surface and produce saling solution called sweat ■ Widely distributed throughout the body and are mature in a two month old infant ○ Apocrine glands: produce thick, milky secretion that open into hair follicles ■ Located in axilla, niples, navel, ano-genital areas ■ Vestigial in humans ■ Active in puberty and secretion occurs with emotional and sexual stimulation ■ Bacteria + apocrine sweat produces musky body odor ■ Function decreases with age ● Sebaceous glands: produce lipid sebum that protects skin from water loss Hair: threads of keratin; cyclical growth with active and resting phases ● Two types ○ Vellus hair: fine and faint hair that covers most of the body ○ Terminal hair: thicker hair that grows on other parts of the body Nails: hard plates of keratin on dorsal edges of fingers and toes Developmental competence ● Infants and children ○ Skin: newborn skin is similar to adults but many of the functions are not fully developed; newborn skin is smooth, elastic, and more permeable than adults placing them at greater risk for fluid loss and dehydration ○ Lanugo hair in newborns, disappears and is replaced by vellus hair ○ Vernix caseosa on newborns skin ● Aging adult ○ Skin: increased loss of elastin and decrease of subcutaneous fat that leads to wrinkled, thin and dry skin ■ Factors for skin disease and breakdown ● Thinning of skin ● Decrease in vascularity and nutrients ● Loss of protective cushioning of the subcutaneous layer ● Lifetime of environmental trauma to skin ● Social changes of aging ○ Increased sedentary lifestyle ○ Chance of immobility ■ Xerosis: excessive dryness of skin ○ Hair: hair becomes grey or white and begins to feel thin and fine due to decreased function of melanocytes ■ Male patterned alding ○ Nail growth slows ● Pregnant women ○ Skin changes ■ Linea nigra ■ Striae ■ Chloasma: brown patches of hyperpigmentation ■ Vascular spiders ● Culture and genetics: ○ Conditions more common in african americans ■ Keloids: benign and excess scars that grow beyond normal boundaries of the wound with very compact collagen below; more common in African Americans, hispanics, asians ● Caused by: surgery, ance, ear piercings, tattoos, infections, burns ● Looks smooth, rubbery, shiny, claw like, is smooth and firm ● Found in earlobes, back of neck, scalp, chest, and back ● May occur months to years after initial trauma ■ Hyper and hypopigmentation ■ pseudofolliculitis : razor bumps and ingrown hairs ■ Melasma: mask of pregnancy ○ Melanoma: higher in white people ■ Common locations: trunk and back, legs in women, palms and soles of feet and nails in african americans ■ Incidence ● Melanoma is most common cancer in women ages 25-29 years old, second most common after breast cancer in women 30-34, more common in women vs men under 50 but men double women after age 65 ■ Risk factors: UV radiation from sun exposure, indoor tanning, family history Subjective data ● Past history of skin disease: allergies, hives, psoriasis, eczema; how it was treated ● Change in pigmentation ● ABCDEs of moles ● Excessive dryness or moisture ● Pruritus: itching skin ● Excessive bruising ● Rash or lesions ● Medications ○ Increase sunlight sensitivity and give burn response ■ Sulfonamides ■ Oral hypoglycemics ■ Tetracyclines ■ Thiazide diuretics (diuril brand) ○ Cause hyperpigmentation ■ Antimalarials ■ Anticancer ■ Hormones ■ Metals ■ tetracyclines ● Hair loss ● Changes in nails ● Environmental and occupational hazards Objective data for skin, abnormal conditions ● Color ○ Jaundice: exhibited by a yellow color of the skin and mucous membranes, which indicates rising levels of bilirubin in the blood. It is first noticed in the junction of the hand and soft palette of the mouth, and sclera. ■ True jaundice – yellow sclera of jaundice extends up to the edge of the iris. ○ Pallor: attributable to shock, with decreased perfusion and vasoconstriction ■ In black-skinned people will cause the skin to appear ashen, gray, or dull ■ It occurs when the red-pink tones from oxygenated hemoglobin are lost and the skin takes on the color of the connective tissue (or collagen) which is mostly white. ○ Cyanosis: is a bluish-gray color of the skin ○ Erythema: is an intense redness of the skin caused by excess blood (or hyperemia) in the dilated superficial capillaries. ○ ● Pigmentation ○ Freckles ○ Moles ■ Asymmetry ■ Border irregularity ■ Color variation ■ Diameter ■ Evolution ■ And any other symptoms such as change in size, itching, bleeding, or new pigmented lesions raise the suggestion of melanoma and warrant immediate referral. ○ Cutis marmorata: transient mottling in the trunk and extremities in response to cooler room temperatures; forms reticulated red or blue patterns over skin ■ ○ Vitiligo: complete absence of melanin pigment in patchy areas of white, or light skin on face, neck, hands, feet, body folds, and around orfices ○ Senile lentigines: “liver spots” - clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure ● Temperature ● Moisture ● Thickness ● Edema ● Mobility and turgor ○ Test over abdomen in infant ○ Adults: under clavicle, forearm, anterior chest ○ Mobility: ease of skin to rise ○ Turgor: returns to place promptly ■ Poor turgor indicates dehydration or malnutrition ○ Represents elasticity ● Vascularity or bruising ○ Cherry angiomas ○ Bruises change color as time progressive ■ Reddish initially ■ Purple or blew ■ Greenish ■ Yellow ● Lesions ○ Acne: 90% of males 80% of females will develop acne. Caused by increased sebum production and epithelial cells that do not desquamate normally ○ Primary lesions ■ Nodule: solid, elevated, hard or soft growth that is larger than 1 cm ■ Papule: something one can geel, soliv, elevated, circumscribed, less that 1 cm in diameter and is due to superficial thickening of the epidermis ■ Vesicle: friction blister <.5cm ■ Bulla: larger than 1 cm, thin walled, superficial, blister >.5 cm ○ Vascular lesions ■ Erythema Migrans of Lyme Disease: bull’s eye rash in 50% of cases, fades in 4 weeks; caused by spirochete bacterium carried by black or dark brown deer tick which is common in northeast and upper midwest with cases in people who spend time outdoors in may through september ■ Petechiae: tiny, round purple spots due to bleeding under the skin. This may be in a small area due to minor trauma or widespread due to blood clotting disorder. ■ Purpura: rash of purple spots due to small blood vessels leaking blood into the skin, joints, intestines, or organs. ● Causes can be due to underlying disease or other factors ○ Bruising from trauma ○ Aging ○ Medication ○ Drawing blood ■ Impetigo: moist, thin-roofed vesicle with a thin erythematous base and is a contagious bacterial infection of the skin. Most common found in infants and children. (Measles – highly contagious) ● ■ Measles – or rubeola, the examiner assesses a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears, spreads over the face, and then over the neck, trunk, arms, and legs. The rash appears coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik spot ● ■ Psoriasis – hereditary, chronic inflammatory disease with inflammatory triggers. ● Plaque psoriasis: raised, scaly, erythematous patch with silvery scALES, often pruritic and painful, can occur on scalp, extensor surfaces of knees and elbows, lower back; accompanied by nail pitting or onycholysis ○ ■ Basal Cell Carcinoma - usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly. ● ■ Squamous Cell Carcinoma ● Arise from actinic keratosis or de novo. ● Erythematous scaly patch with sharp margins, 1 cm or more ● Develops central ulcer and surrounding erythema. ● Usually on hands or head, areas exposed to UV radiation ● Less common than basal cell carcinoma but grows rapidly ● ■ Pressure Injuries: ● Stage I: closed injury ● Stage 2: partial thickness skin erosion with a loss of epidermis or also the dermis; open blisters have a red-pink wound bed ● Stage 3: extends into subcutaneous tissue ● Stage 4: extends into muscle or bone ■ Keratosis ● Seborrheic keratosis - appear like dark, greasy, stuck-on lesions that primarily develop on the trunk. These lesions do not become cancerous ○ ● Actinic (senile or solar) keratosis: lesions that are red-tan scaly plaques that increase over the years to become raised and roughened ○ May have a silvery-white scale adherent to the plaque. ○ Occur on sun-exposed surfaces and are directly related to sun exposure ○ Premalignant and may develop into squamous cell carcinoma ○ ■ Acrochordons: skin tags ■ Sebaceous hyperplasia: raised yellow papules with central depression, common in older men and occur over forehead, nose, and cheeks, have a plebby look ● Abnormal conditions of the Hair ○ Kaposi Sarcoma: vascular tumor that, in the early stages, appears as multiple, patch-like, faint pink lesions over the patient’s temple and beard areas. ■ ○ Tinea Capitis: rounded patchy hair loss on the scalp, that leaves broken-off hairs, pustules, and scales on the skin are present, and is caused by a fungal infection. Lesions are fluorescent under a wood light and are usually observed in children and farmers. Tinea capitis is highly contagious. ■ ● Abnormal conditions of the nails ○ Clubbing of the nails: occurs with congenital cyanotic heart conditions/diseases and with other pulmonary diseases. Often seen in patients with cystic fibrosis. Health Promotion and Patient teaching: focus on teaching patients how to asses skin, which also includes hair and scalp Chapter 14: Head, Face, Neck, and Regional Lymphatics Head ● Infants ○ During the fetal period head growth predominates ○ Head size is greater than the chest circumference at birth ○ Reaches 90% of its final size when a child is 6 ○ At 2 years old the head circumference and chest circumference are the same ○ Chest circumference grows to excess head circumference by 5-7 cm ○ Fontanelles: membrane covered soft spots that allow for growth of the brain during the first year ■ Should be firm and concave in an infant ■ Will gradually ossify ■ Types ● Anterior: diamond shape; closes between 9 years - 2 months ● Posterior: triangular, closes by 1-2 months ■ Depressed fontanelle occur with dehydration or malnutrition ● No tears, dry membranes, no urine ■ Increased ICP will cause tense/pulsating fontanelles, appear convex or bulge ○ Head control is achieved by 4 months old ■ Defined by holding head erect and steady when pulled in a vertical position ● Cervical 7, C7 vertebra has a long spinous process called the vertebral prominence which is palpable when the head is flexed ● Cranial nerve 7 mediates facial muscles ○ Damage to this nerve will result in asymmetry of the palpebral fissures as in the case of bell’s palsy ● Cranial nerve 5 is the trigeminal nerve, mediates facial sensation of pain and touch, face symmetry such as eyebrows, palpebral fissures, nasolabial folds, and corners of the mouth ● In aging adults: ○ Facial bones and orbits appear more prominent and facial skin sags ■ Attributed to decreased elasticity, decreased subcutaneous fat, decreased moisture in skin ● Salivary glands ○ Parotid glands: in cheeks over mandible, anterior to and below the ear ■ Largest but normally non-palpable; become swollen with onset of mumps; swelling is most evident below the angle of the jaw and is most visible when the head is extended ■ Enlargement has been found in people with HIV ■ Stensen duct ○ Submandibular glands: beneath the mandible at the angle of the jaw ■ Warden’s fuct ○ Sublingual: below tongue in floor of mouth ● Temporo-mandibular joint: located just below the temporal artery and anterior to the tragus ● Temporal bruits: common in skull of children under 4 or 5 years of age and in children with anemia ○ Systolic or continuous and hurt over the temporal area ● Temporal arteritis: artery appears more torturous and feels sharpened and tender ○ s/s: sharp localized pain over a tender, nodular, temporal artery; fever, malaise, anorexia, weight loss, polymyalgia, ischemic jaw, face pain ○ Headaches and blindness are the major dangers ■ Left untreated blindness may may occur in both eyes, not reversible ○ An emergency, refer to ER ● Cranial nerve 12: innervates muscles of the tongue; involved in speech and swallowing The Neck and Lymphatics ● Cranial nerve 11 (spinal accessory nerve): innervates sternomastoid and trapezius muscle ○ Assists with head rotation, flexion, extension, and turning; movement of shoulders ○ Assess function: ask patient to shrug against resistance, place hand on face and ask patient to push to side ● Thyroid gland: highly vascular endocrine gland that secretes T3 and T4, two lobes ○ Hormones stimulate the rate of cellular metabolism ○ Elevated levels (hyperthyroidism): tachycardia with an enlarged thyroid gland (goiter), or nodular lump ■ If enlarged assess for bruit ● Bruit: soft, pushing, flowing sound heard best with the bell side of the stethoscope- occurs with accelerated or turbulent blood flow ● If heart blood vessels are compressed ○ Pregnancy enlarges it slightly because of hyperplasia of the tissues and increased vascularity ○ Examination ■ Posterior approach ■ Anterior approach: tip head forward and to right, then left ■ Choose approach based on culture ● Trachea ○ Displaced to unaffected side with tumor, pneumothorax, unilateral thyroid lobe enlargement ○ Displaced to affected side: pleural adhesions, fibrosis, large atelectasis ○ Tracheal tug: downward pull that is synchronous with systole and occurs with aortic aneurysm ● Lymphatics ○ Lymph nodes: located all throughout the body but only accessible in four areas, assess with 1-3 fingers ■ Head and neck ■ Arms ■ Axilla ■ Inguinal area ■ Specific nodes: ● Preauricular, in front of the ear ● Posterior auricular (mastoid), superficial to the mastoid process ● Occipital, at the base of the skull ● Submental, midline, behind the tip of the mandible ● Submandibular, halfway between the angle and the tip of the mandible ● Jugulodigastric (tonsillar), under the angle of the mandible ● Superficial cervical, overlying the sternomastoid muscle ● Deep cervical, deep under the sternomastoid muscle ● Posterior cervical, in the posterior triangle along the edge of the trapezius muscle ● Supraclavicular, just above and behind the clavicle, at the sternomastoid muscle ■ ○ Normal nodes feel moveable, discrete, soft, and nontender; may be up to 1cm in size in cervical and inguinal areas ○ Palpable lymph nodes ■ Normal in children until puberty (10-11 years) when lymph node tissue begins to atrophy after growing past adult size from ages 6-10 ■ Palpability decreases with age, most are non-palpable in adults ■ When enlarged, check area which they drain for source of problem ● Problem is proximal or upstream to location of abnormal nodes ● Acutely infected lymph nodes bilaterally: enlarges, warm, tender, firm, freely moveable ■ Unilaterally enlarged nodes that are firm, non-tender, and may indicate cancer ■ Use gentle pressure because using strong pressure can push nodes into neck muscle ● Palpate with both hands in a gentle, circular motion ● Palpate in a systematic and thorough manner Headaches: Table 14.1 ● Migraines: supraorbital, retro-orbital, or frontotemporal with throbbing qualities ○ Can be relieved by lying down, dark spaces, eyeshades, sleep, take NSAIDs early, avoid opioids if possible ○ Associated with family history, hormones, foods, hunger, letdown after stress, sleep deprivation, changes in weather, sensory stimuli, and physical activity ○ Aura, photosensitivity, n/v, phonophobia, abd pain, prodrome ○ Chronic migraine: more prevalent among whites and hispanics; >14 days/month ○ Maybe caused by stimulation of cranial nerve 5 (trigeminal) with neurotransmitter changes in CNS and changes in vessel tone ○ Rapid onset, peaks 1-2hr, lasts 4-72 hours ○ Throbbing and pulsating ● Cluster headaches: produced pain around eyes, temples, forehead and cheek ○ Unilateral, usually on the same side of the head, excruciating with ANS signs (nasal congestion, runny nose, watery or reddened eyes, eyelid drooping, miosis, agitation) ○ Treatment/relief: need to move, pacing floor ○ Continuous, burning, piercing, excruciating, severe, stabbing pain ○ Abrupt onset, peaks in minutes, last 45-90 minutes; exacerbated by alcohol, stress, daytime napping, wind or heat exposure ○ Can occur multiple times in day, in clusters, lasting weeks ○ Excruciating, can occur once or twice per day and can last .5-2 hours ● Tension headaches: both sides, across frontal, temporal, and occipital region of head (forehead, sides, back of head); musculoskeletal in origin ○ Bandlike, ciselike, non throbbing, non pulsatile; diffuse and dull aching pain ○ Lasts 30 minutes to days ○ Rest, NSAIDS, massage muscles Developmental competence ● Infants and children ○ Skull ■ Caput succedaneum: edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma ● Usually causes skull to look markedly asymmetric ● Gradually resolves within first few days of life and needs no treatment ■ Cephalhematoma: subperiosteal hemorrhage from birth trauma ● Soft, fluctuant, and well defined over one cranial bone because the periosteum holds the bleeding in place ● Appears several hours after birth, gradually increasing in size ● Will be reabsorbed during first few weeks of life without treatment ● No discoloration, but looks bizarre; reassure parents ■ Hydrocephalus: obstruction of drainage of CSF which results in excessive accumulation, increasing ICP, and enlargement of head ● Face looks small compared with enlarged cranium ● ICP produces dilated scalp veins, frontal bossing, setting sun eyes ● Cranial bones thin, sutures separate and percussion yields cracked pot sound (macewen sign) ■ Down syndrome: most common chromosomal abnormality ● Head and face: upslanting eyes with inner epicanthal folds, flat nasal bridge, small, broad, flat nose; protruding thick tongue; ear dysplasia; short broad neck with webbing ■ Craniosynostosis: severe deformity of the head with marked asymmetry caused by premature closure of the sutures ● Hypoplasia of the face can result ■ Microcephaly: abnormally small head ■ Plagiocephaly: positional deformity; asymmetry of cranium when seen from top; can be mitigated by tummy time ● Physical therapy and corrective headbands ■ Atopic facies (allergic facies): in children with chronic allergies you may see exhausted face, blue shadows below eyes (allergic shiners) from sluggish venous return, a double or single crease on lower eyelids, central facial pallor, and opened mouth breathing (leads to malocclusion of teeth and malformed jaw) ■ Meningeal irritation: characterized by acute onset of neck stiffening (nuchal rigidity) and pain along with headache, fever; can lead to a severe headache in adults or children who have never had it before (red flag) ● Projectile vomiting ■ Fetal alcohol spectrum disorders: severe cognitive and psychosocial impairment, changes in face and brain structure ● Facial characteristics: short palpebral fissures, flat midface, short nose, indistinct philtrum, thin upper lip, epicanthal folds, low nasal bridge, minor ear abnormalities, micrognathia ● Smaller head circumference, decreased birth weight, feeding problems, irritability, neurologic and behavior defects including intrusive talking, inattention, poor abstract reasoning, problems with IADLs ● Leading preventable cause of intellectual disability, learning disability, and birth defects ■ Sutures no longer palpable at 5-6 months ■ Positional molding: from sleeping, flattened cranial bone and occiput ■ Note head posture and head control ○ Face: symmetry, wrinkling, swelling ○ Neck: looks short until 3-4 years, check ROM ● Pregnant women: chloasma on face, increased thyroid ● Aging adult ○ Temporal arteries may look twisted and prominent ○ Mild tremor may be normal ○ Isolated tremors and benign and include head nodding, tongue protrusion ○ Kyphosis w/ increased anterior curve on head extension ○ Slower ROMs ○ Prolapse of submandibular glands can be mistaken for tumors, should be soft and present bilaterally ○ Low lying thyroids that are non-palpable Head and neck ● Multinodular Goiter: multiple nodules usually indicate inflammation ○ Any painless, rapidly growing nodules, especially a single nodule in a young person should be suspected for cancer; usually hard and fixed to surrounding structure ■ Increased cancer risk for females, past history of goiter or nodules, size >4cm ● Grave’s disease: hyperthyroidism, autoimmune; increased metabolic rate manifested by goiter, eyelid retraction, exophthalmos (bulging eyes) ○ Symptoms: nervousness, fatigue, weight loss, muscle cramps, heat intolerance ○ Signs: forceful tachycardia, SOB, excessive sweating, thin silky hair, warm and moist skin, fine muscle tremor, infrequent blinking, staring appearance, brisk ankle jerks ● Hypothyroidism: reduces metabolic rate and when severe causes non pitting edema (myxedema) ○ Usual cause is Hashimoto Thyroiditis ○ Symptoms include fatigue and cold intolerance ○ Signs include puffy, edematous face, especially around eyes (periorbital edema); puffy hands and feet; coarse facial features; cool, dry skin; dry, coarse hair and eyebrows; slow reflexes; and sometimes thick speech. ● Congenital torticollis ● Simple diffuse goiter: lack of iodine ● Pilar cyst: contains sebum and keratin, overlying skin is shiny and hairless, benign ● Acromegaly: abnormal excessive secretion of growth hormone from pituitary gland after puberty, creates and enlarged skill and thickened cranial bones, massive face, overgrowth of nose and lower jaw, heavy eyebrow ridge, coarse facial features ● Cushin’s syndrome: excess ACTH and chronic steroid use; rounded moonlike face, prominent jowls, red cheeks, hirsutism on upper lick, lower cheeks, and chin, acneiform rash on chest ● Bell’s palsy: lower motor neuron lesion producing rapid onset of cranial nerve 7 paralysis of facial muscles, almost always unilateral ○ Reactivation of HSV1 latent since childhood ○ Paralysis of one side of face: smooth forehead, wide palpebral fissure, flat nasolabial fold, drooling, pain behind ear ○ Greatly improved if corticosteroids and antivirals given within 72 hours of onset ● Stroke: upper motor neuron lesion; BEFAST ● Parkinsons: deficiency in dopamine and degeneration of substantia nigra in basal ganglia; face looks flat, expressionless, masklike, elevated eyebrows, staring gaze, oily skin, drooling ● Cachetic appearance: accompanies chronic wasting diseases; sunken eyes, hollow cheeks, exhausted and defeated expression Chapter 15: Eyes External anatomy: ● Palpebral fissure: elliptical space the opens between the eyelids ○ Closes when lids close, normal finding ● Other anatomy ○ Extraocular muscles ● 3 Cranial nerves involved in movement of eye ○ Cranial nerve 3 ■ Superior rectus ■ Inferior oblique ■ Medial rectus ■ Inferior rectus ○ Cranial nerve 6 ■ Lateral rectus ○ Cranial nerve 4 ■ Superior oblique ● Oculus dexter: left eye ● Oculus sinister: right eye Internal anatomy ● 3 concentric coats ○ Cornea and sclera ■ Sclera: coat of the eye ■ Cornea: sensitive to touch ○ Choroid ■ Center layer, dark pigmentation to prevent light from reflecting and is highly vascularized to deliver blood to retina ○ Retina: inner layer where light waves are converted to nerve impulses ● Cranial nerve 5: trigeminal nerve, stimulated when outer surface of eye is stimulated ● Cranial nerve 7: facial nerve, stimulated when outer surface of eye is stimulated ● SNS: dilation of pupils, elevation of eyelids ● PSNS: constriction of pupils Visual pathways and fields ● Image formed in retina is upside down and reversed form it’s actual appearance in the outside world ○ Brain corrects it, left brain right eye, vice versa ● An object in the upper temporal visual field of the right eye reflects its image on the lower nasal area of the retina ● Visual reflexes ○ Pupillary light reflex: PERRLA ■ Assessment: note direct and consensual pupillary constriction of both eyes ● Room should be dark ● Ask patient to gaze into distance ● Advance light from side ○ Ensure light from pen will not be transmitted to other pupil ■ Pupils are small in older adults and reflex may be slowed but constriction should be symmetric ■ Brisk vs sluggish ■ Normal resting size is 3-5 mm ■ Anisocoria: unequal pupil size, 5% of population but also indicative of CNS injury or disease like increased ICP ● Ask patient if it is normal for them, when it occurred ○ Fixation: direction of eye toward object attracting attention ■ Image is fixed in center visual field (fovea centralis) ■ Movement impaired by drugs, alcohol, fatigue, inattention ○ Accomodation: assessed by pupillary constriction when looking at near objects; muscle fibers of iris contract the pupils to accommodate to near vision ■ Pupil constriction ■ Convergence of the axes of the eyes (motion toward) Developmental competence ● Infants and children ○ Birth: eye function is slimited, peripheral vision is intact ■ Macula absent but developing by 4 months and mature by 8 months ■ Eye movements may be poorly coordinated at birth; by 3-4 months infant establishes binocularity and can fixate simultaneously on a single image with both eyes simultaneously ■ Eye has little pigment, pupils are small ■ Lens is spherical but flattened throughout life, changes in consistency from soft plastic to rigid glass ■ By 2-4 weeks infant can fixate on an object ■ By 1 month infant should fixate and follow a bright light or small toy ○ Color vision: boys should be tested only once between ages of 4-8 years old ■ Not tested in girls bc rare ■ Testing performed with ischihara test ○ Eyeball reaches adult size by 8 years: serious of polychromatic cards ● Aging adult ○ External eye structures can droop due to atrophy, wrinkling, fat tissues ○ Lacrimal glands involute, decreased tear production and increased dryness or burning ○ Pupil size decreases, lens lose elasticity and ability to change shape and accommodate to vision (presbyopia, 50% of people by 40); cataract around 70 (normal transparent fibers begin to thicken and yellow) ○ Floaters common with myopia after middle age, contributable to condensed vitreous humor debris because vitreous humor not newed continuously ■ If present not significant but acute onset may occur with retinal detachment ○ Acuity diminishes gradually after 50 and more after 70 ○ Changes affect safety ○ Common diseases ■ Cataract: clouding of lens partially due to UV radiation, curable with lense replacement surgery ● Leading cause of blindness worldwide ● 80% preventable or curable ● More common in AA men and women in every age category ● Surgery is cost effective and may help reduce poverty by returning people to work and increasing social mobility ○ Barriers: lack of insurance, transportation issues, low socioeconomic status, poor surveillance methods ■ Glaucoma: optic nerve neuropathy characterized by loss of peripheral vision, caused by increased IOP; 61% of women due to longer life expectancy ● 3-6x more likely in AA than whites, prevalence increases with age ● Open angle glaucoma: leading cause of blindness in AA and hispanics, virtually no symptoms exhibited ● Family history in first degree increases risk ● Measuring IOP not enough, visual field testing using special equipment in ophthalmology office needed ● Peripheral vision loss goes undetected because of intuitive compensation, head turning ■ Age-related macular degeneration: loss of central vision caused by yellow deposits (drusen) and neovascularity in macula ● 1/10 late stage by age 80, more common in women, caucasians; 19.7% over 75 have it ● Person is unable to read books, papers, sew, or do fine work and has difficulty distinguishing faces ● Loss of central vision causes great distress ● Risk factors: family hx, cigarette smoking, hyperopia, light iris color, hypertension, hypercholesterolemia, being female ■ Diabetic retinopathy: leading cause of blindness in adults 25-74 years old ● Difficulty driving, reading, managing diabetes, self care ● Intensified prevention has decreased prevalence slightly Culture and genetics ● Color of the iris: ethnical variations ● Retinal pigmentation: darker irises have darker retinas, ethnic variations ○ Individuals with light retinas have better night vision but can have pain in environments with too much light ● Normally in dark skin people small, brown macules may be present in sclera ● AA may have yellowish, fatty deposits under eyelid, away from cornea and extending up to iris ● See cataracts and glaucoma for familial and race risks Visual impairment: not being able to see letters on eye chart at line 20/50 or below ● Large impact on physical and mental health, increased risk for lost productivity, chronic health conditions, accidents and injuries, social isolation, depression, and mortality ● Commonly due to uncorrected refractive error that is easily improved through glasses, contacts, and refractive surgery ● Snellen eye chart: most commonly used and most accurate measurement of visual acuity ○ Positioned 20 feet away from patient, read smallest line possible ○ Normal acuity is 20/20 ■ Numerator: distance standing away from chart ■ Denominator: distance at which a normal eye can see; larger means poorer vision ■ Ex: 20/30 patient means patient can read at 20 feet what a normal person can read at 30 ○ Shorten distance to chart until letters seen ■ Ex: 10/100 means person is standing 10 feet away and can read what a normal person can see at 100 feet ● If lower, assess if they can count fingers in front of eyes and ability to distinguish light perception with penlight ● If vision is poorer than 20/30 a referral to optometrist or ophthalmologist is necessary ● Vision screening: crucial in preschool to detect strabismus (crossed eyes) and amblyopia (lazy eye) ○ Same rates in balck and white children but only 69.8 in hispanic children ○ Should occur at least once in all children ages 3-5 ● Near vision: JEEGER card, held 14 inches away from eye with good lighting ○ 14 inches mimics print size on snellen chart ○ Test each eye with person wearing glasses ○ Normal 14/14 ○ No JEEGER card, try newspaper or magazine reading ● Testing visual fields ○ Confrontation tests: loss of peripheral vision ■ Compares peripheral vision of person to examiner’s ○ Position of nurse and patient should be at eye level, two feet away ■ Looking straight at nuse, patient covers one eye and nurse covers the opposite ■ Nurse moves finger from outer periphery in several directions (kinesthetic) ● Say now when you see fingers ● Should be able to see at 50 degrees superiorly ● Seen at 90 degrees laterally, temporal ● Seen at 70 degrees inferiorly ● Seen at 60 degrees laterally, nasal ■ Nurse holds fingers and asks patient to determine number they are holding up (stationary) ● Inspect extraocular muscle function ○ Diagnostic position test: assess for muscle weakness during movement of eyes by leading eyes through six cardinal positions of gaze ■ Normal response is parallel tracking with both eyes ● Not parallel: weakness of muscle or dysfunction of cranial nerve that innervates it ■ Nystagmus: mild is normal at extreme gaze angle, any other positions it is not ■ Note upper eyelid continues to overlap the top of iris, even during downward movement ● If sclera is seen is is termed lid lag ○ Corneal light reflex (hirschberg test): person looks straight as you hold light about 12 inches awar ■ Reflection should be in the same spot on both corneas ■ Tests for strabismus or “lazy eye” ■ Cover test: cover one eye with card, normal response steady fixed gaze. Observe for movement when other is uncovered ● Inspect external ocular structure ○ Inspect eyebrow symmetry, they should move symmetrically ○ Eyelashes and lids ■ Ptosis: drooping of eyelid, observe distance between upper and lower lids ■ Periorbital edema: local infections, crying, systemic conditions (HR, RF, allergies, hyperthyroidism) ■ Yellow deposits mentioned earlier ○ Palpebral fissure are horizontal in non-asians, upward slant in asians ○ Conjunctiva and sclera ■ Sclera is china white but may have gray blue or muddy color in AA, small brown macules seen in sclera of AA ■ Scleral jaundice: even, extends up to the cornea ○ Lacrimal apparatus ■ Normal: no swelling, redness, drainage from punta ● Observed when duct is pressed against the inner orbital rim ● Anterior eyeball structures ○ Corneal and lens ■ Corneal abrasion: shine light to assess for smoothness and clarity ● Causes irregular ridges in reflected light which produces shattered appearance to iris ■ Normal iris flat with no shadows ● If shadows in anterior chamber when light comes from temporal side may be a sign of acute closure glaucoma ■ Red glow, feeling pupils: red reflex, normal finding, reflection from retina ■ Optic disc: nasal side of retina, color is creamy yellow orange to pink, edges are distinct, and sharply demarcated although nasal edge may be slightly dizzy, round or oval ■ No opacities (cloudiness) should be present ● Do not confuse arcus senilis with opacity, it is common in the elderly ■ Abnormalities ● Retinal detachment: shadows or diminished vision in one quadrant or half of visual field ● Macular degeneration: loss of central vision, most common cause of blindness ● Papilledema: “choke disc” serious sign of increased ICP, caused by space occupying mass such as brain tumor or hematoma; venous stasis in globe, redness, congestion, elevation of optic discs, large margins, hemorrhage, and absent venous pulsations ■ Hyphema: blood in anterior chamber as result of blunt trauma or spontaneous hemorrhage ● May indicate scleral sculpture or intraocular trauma ○ Eyelid abnormalities ■ Ectropion: condition where the lower lid does not approximate to the eyeball, punta cannot siphon tears so excessive tearing results; occur in older adults ■ Entropion: lower lid rolls in because of spasm or scar tissue contraction ■ Hordeolum (stye): acute, localized staph infection of hair follicle at lid margin ● Painful, red, swollen ■ Chalazion: nodule protruding on lid ● Caused by obstruction of meibomian gland ■ Blepharitis ■ Dacryocystitis (inflammation of lacrimal gland) ● Chapter 16: The Ears Ears: sensory organ for hearing and maintaining equilibrium ● External ear: the auricle or pinna consists of movable cartilage and skin ○ External auditory canal: 2.5-3cm long in the adult, terminated at the eardrum/tympanic membrane ■ Lined with glands that secrete cerumen, a yellow, waxy material that protects, lubricates, and waterproofs the auditory canal; is also antibacterial and traps foreign bodies; migrates out by chewing and talking ● Genetically determined types ○ Wet honey brown common in whites and blacks ○ Dry flaky white found in east asians and american indians ● Tympanic membrane: separates external and middle ear, faces downward and somewhat forward ○ Translucent, oval in shape, normally pearly grey in color ○ Slightly concave, pulled in at center by the malleus; can see the umbo, manubrium, and short process of the malleus through the drum ○ Has a prominent cone of light in the anteroinferior quadrant which is the reflection of the otoscope light ○ Small, slack, superior section is the pars flaccida, and the remainder which is thinner and taut is the pars tenna ○ The annulus is the outer fibrous rim of the drum ● Middle ear: tiny cavity inside temporal bone; contains the 3 ossicles or bones malleus (umbo, manubrium, and short process), incus, and stapes in oval window ○ 3 functions ■ Conducts sound vibrations from outer ear to the central heating apparatus in the inner ear ■ Protects inner ear by reducing the amplitude of loud sounds ■ Eustachian tube allows for equalization of air pressure on each side of the membrane so the membrane does not rupture; connects nasopharynx and middle ear and allows passage of air ○ Opening to the outer ear covered by tympanic membrane ○ Oval window at the end of stapes and the round window that opens to the inner ear ● Inner ear: embedded in bone, contains the bony labyrinth ○ Bony labyrinth: holds sensory organs for equilibrium and hearing ■ Vestibular apparatus ● Vestibule ● Semicircular canals ■ Cochlea: central hearing apparatus, looks like shell of a snail ○ Not accessible to direct examination but you can assess its functions Hearing ● Pathways of hearing ○ Air conduction pathway: most efficient way of conducting sound, starts when sound waves produce vibration on tympanic membrane ■ Vibrations carried by inner ear ossicles to stapes on oval window and are dissipated, then to cochlear basilar membrane which contains organ of corti hair cells and transmit to nerve ● Basilar membrane vibrates at frequency of sound ○ Numerous fibers that receive hair cells or organ of corti; as the hairs bend it mediates the vibrations to electrical impulse which is then conducted by the auditory portion of cranial nerve 8 ○ Bone conduction: bones of skull vibrate, vibrations transmitted directly to inner ear and cranial nerve 8 ● Hearing loss ○ Conductive hearing loss: mechanical dysfunction of external or missile ear ■ Only partial loss because the person is able to hear if sound amplitude is increased enough to reach normal nerve elements in inner ear ■ Causes: impacted cerumen, foreign bodies, perforated tympanic membrane, pus of cerumen in middle ear, otosclerosis (decrease in mobility of ossicles) most common cause in young adults between 20 and 40 years old ■ There is progressive hearing loss but speaking up lourdes or turning up TV volume may help ■ Blocks sound transmission somewhere in external canal, tympanic membrane, or middle ear ○ Perceptive (sensorineural): signifies pathology of inner ear, cranial nerve 8, or the auditory areas of the cerebral cortex ■ Increase in amplitude may not enable person to understand words ■ Presbycusis: age related sensory neuron loss; gradual nerve degeneration that occurs with aging and by ototoxic drugs that affect the hair cells in the cochlea ● Effects ½ of those over 60 and 80% of those over 85 years old ● Incidence increases as current baby boomers age ■ Other causes: trauma, meniere's disease, infection (meningitis, labyrinthitis), tumor, noise trauma, medications ■ Slowly progresses after 50 years, person first notices high frequency tone loss; harder to hear consonants a higher speech component than vowels, words sound garbled, ability to localize sound is also impaired ● Accentuated when background noise is present ■ Important to assess meds for cause of hearing loss ● Ototoxic drugs: aminoglycosides (antibiotic), cisplatin (anticancer), furosemide, vancomycin, chronic aspirin use ○ Recruitment: a hearing loss with low intensity speech but sound becomes painful when speaker repeats it in loud voice ○ Despite prevalence loss is underscreened and undertreated ■ People may experience social isolation, diminished quality of life, and depression ■ Hearing aids can help ■ Other causes ○ Any sound or hearing loss in one or both ears that is not associated with upper respiratory infections needs to be reported to healthcare provider ○ Mixed loss: combination of conductive and sensorineural types in same ear ● Table 16.1 Abnormal Findings of Hearing loss; pg 335 physical, or 458 pdf ○ ● Equilibrium Problems ○ Labyrinth: inflammation feeds wrong information to the brain ■ Vertigo: staggering gait and strong, spinning, whirling sensation ● Subjective: verbalizes that they feel they are spinning ● Objective: sensation of spinning objects around person; room is spinning Developmental competence ● Infants and children ○ Maternal rubella: during first trimester it can damage organ of corti and will result in impairment of hearing of the child ○ Infant can also be exposed to ototoxic drugs such as aspirin, which will place child at risk for hearing impairment ○ Nurse should ask if baby startles with loud noise ○ Eustachian tube: shorter and wider than the adult’s, position is more horizontal ■ Pathogens from nasopharynx can migrate more easily and move into middle ear, placing infants at greater risk for middle ear infections compared to adults ● Aging adult ○ High tone frequency loss is normal; finding is apparent in those affected with presbycusis ○ Pinna: loses elasticity causing earlobes to be pendulous ○ Eardrum: may be whiter in color, more opaque, duller in older adults than younger ○ Cilia lining ear canal becomes coarse and stiff, may cause the cerumen to accumulate and oxidize which reduces hearing ■ Cerumen is drier because of atrophy of apocrine glands ■ Cerumen should be removed when it leads to conductive loss or impacts with full assessment ■ Impaction can also block conduction in those with hearing aids Culture and genetics ● Presbycusis ○ Affects men more than women, lower prevalence among african americans than whites or hispanics ■ May relate to melanin protection of cochlea or other environmental factors ○ Socioeconomic gradient ● Otitis media: occurs because of obstruction of eustachian tube or passage of nasopharyngeal secretions into middle ear ○ Creates environment for bacteria to grow ○ 60% of children experience it within 1st year of life; by age 3 83% have an episode ○ Risk factors: infant eustachian tube anatomy, absence of breastfeeding in first 3 months, preterm birth, secondhand tobacco smoke, daycare attendance, being male, pacifier use, seasons (fall and winter), bottle feeding, presence of cerumen ● Cerumen: genetically determined, see notes above Objective data: follows subjective data ● Otoscopic exam ○ Infants and children ■ During the first days after birth the tympanic membrane of a newborn appears thickened and opaque; may look infected and have a mild redness from increase in vascularity ■ Eardrum of neonate is more horizontal making it difficult to see completely ● By one month it is in an oblique, vertical position like adults, making it easier to see ■ The nurse should choose the largest speculum that first comfortably in the ear ■ Infants and children under 3 years: the pinna (oracle or helix) should be pulled down ● Done before inserting otoscope ■ Eardrum assessment is mandatory for any child requiring care for illness or fever ■ Timing of otoscope exam is best done towards the end of the complete exam because young children protest vigorously and it is difficult to reestablish cooperation after ○ Adults ■ Pinna should be pulled up and back ■ Largest speculum that fits comfortably in ear ● Before inserting otoscope ○ Maintain hold on otoscope until exam is concluded ○ Tilt patients head slightly away and toward opposite shoulder ● Testing hearing acuity ○ Whispered voice test: pg 327 physical, 450 pdf ■ Head of examiner should be 1-2 feet away from ear, patient asked to place one finger on the tragus and phishing it in and out of the auditory meatus ■ The examiner will exhale and slowly whisper a random number and letters such as “5, V, 6”. Normal finding is that patient can repeat each number and letter correctly; passing score is correct repetition of 4/6 numbers or letters ● Different set of numbers on other ear “ 4, K, 2” ○ Infants: clapping or loud noise should make infant turn their head to localize sound or responding to their name; look for reaction to noise ■ 3-4 months: infant stops movement and appears to listen ○ Tuning Fork Tests Table 16.7, pg 342 physical book or 465 pdf ■ Weber test: normal finding is that person should hear equally loud in both ears ● Flick fork and place it on the midline of the skull, ask them if they can hear the sound equally loud on both ears ● Conductive hearing loss is present if the sound lateralizes to poorer ear from background room noise ○ Poorer ear: the one with conductive hearing loss, not distracted by background noise, better chance to hear bone conducted sound ● Sensory hearing loss: sound lateralizes to better ear or ear that is not affected ○ Ear that is affected where nerve fibers are lost is unable to perceive sound ■ Rinne test: normal sound heard 2x as long in air conduction than in bone conduction ● More accurate for conductive loss ● Positive test: 2x longer by air than bone ● Conductive loss: equal ratio or bone conduction lasts longer than air ● Sensorineural loss: normal ratio of air to bone but is reduced overall, person hears poorly both ways ● Two steps ○ Bone: stem of fork placed on mastoid process; time it ○ Air: fork placed near ear; time it ● External canal ○ Discharge ■ Frank blood ■ CSF: common in basal skull fractures ■ Other discharges ■ Observe for discharge in a person who sustained a significant blow to the head, especially the ears, or a person who is expected to have a basal skull fracture ● Observe for discharge leaking from ear, could be presence of CSF ○ Other abnormalities: start on pg 458 pdf, table 16.2 ■ Frostbite: won't be seen in SFL but in states with winter you might see it ● Reddish-blue discoloration of the auricle after exposure of severe cold ● Vesicles and bullae may develop, person may feel pain and tenderness, necrosis may ensure ■ Otitis externa: swimmer’s ear, infection of outer ear with severe painful movement of tragus, redness, swelling of pinna and canal, scanty purulent discharge, scaling, itching, fever, and enlarged tender regional lymph nodes ● More common in hot, humid weather ● Hearing normal or slightly diminished ● Swimming causes canal to become waterlogged and swell, skinfolds set up for infection ● Canal lumen can narrow to ¼ normal size, experience severe swelling, inflammation, and tenderness ● Early sign: hypomobility of the tympanic membrane on the otoscopic exam; as pressure increases tympanic membrane begins to bulge ● Prevention: rubbing alcohol or 2% acetic acid ear drops after every swim ■ Acute otitis media (pg 340 book, 464 pdf for photos): absence or distorted light reflection from increasing middle ear pressure, eardrum is bright red ● Results from middle ear fluid infection ● Absent light reflex from bulging is early sign ● Redness and bulging first noted in superior part of drum along with earache and fever, then fury red bulging and deep throbbing pain accompanied by possible fever loss ● Pneumatic otoscopy reveals drum hypomobility ○ Pneumatic otoscopy: attached bulb pushes air into membrane ■ Otitis media with effusion: amber yellow color to membrane suggests serum in middle ear that transduces the relieve negative pressure from blocked eustachian tube ● Symptoms: feeling of fullness, transient hearing loss, popping sound with ● swallowing. ● Also called serous otitis media, glue ear ■ Perforation: if acute otitis media is not treated the drum may perforate form increased pressure ● Can also occur from trauma ● To determine presence ask: “Is there any relationship between ear pain and discharge you mentioned?” because with perforation ear pain occurs first and resolves after popping ■ Dense white patches on tympanic membrane are sequalla of repeated ear infections; they do not affect hearing ■ Lumps and lesions ● Malignancy or carcinoma: an ulcerated, crusted nodule with and indurated base that fails to heal is characteristic of carcinoma; intermittently bleeds ○ Must refer for bipy ■ Otomycosis (pg 341 physical, 464 pdf): fungal infection; colony of white or black dots on drum canal suggests yeast or fungal infection Subjective data: questions on pg 446 pdf, pg 321 in physical copy; she only listed categories and I added the bullet questions ● Earaches ○ Location, pain when you push on ear, character, palliation, provocation ○ Accompanying cold symptoms, sore throat, problems with sinuses or teeth ● Infections ○ As adult or child ○ How frequent and treatment ● Discharge ○ Pus, bloody? ○ Odor? ○ Discharge and pain? ● Hearing loss ○ Trouble hearing? ○ Onset? Timing? ○ Speech understanding ○ Character: all of it or certain sounds? ○ When do you notice it? ○ Are people shouting at you? ○ Hollowness: barrel or underwater? ○ Airplane travel? ○ Treatments ○ Coping? ● Environmental noise ○ Regular noise level at work and during leisure ○ Exposure to noises that are so loud you need to shout to be heard by someone 1 yard away ○ Regularly exposed to gunfire noise? ○ Noise protection use ● Tinnitus: ringing, roaring, buzzing ○ When and for how long? ○ Seem louder at night? ○ Medications? ○ Everyday life: difficulty concentrating, sleeping, at work, leisure time, or with others? ● Vertigo ○ Ever felt ○ Palliation and provocation ○ Loss of balance ○ Giddy or lightheaded? ● Patient centered care ○ How do you clean your ears? ○ When did you have your hearing checking? ○ If loss: hearing aid? How long have you had it? Do you wear the hearing aid? Is upkeep, cleaning, or changing the batteries troublesome? ● Children: ○ Infections? How many? Treatment? Surgery of ears or removal of tonsils? Frequency and intensity of ear infections changing? ○ Does anyone smoke? ○ Care outside home: Daycare and how many kids? ○ Does the child seem to be hearing well? Do they startle with loud noise? Did they babble around 6 months? Do they talk? At what age did talking start? Was speech intelligible? ○ Testing hearing? ○ Loss: follow diseases in child or pregnancy of mother? ○ Do they put objects in the ears? Are they in contact sports? Health promotion and patient teaching: pg 332 physical, 454 pdf ● 1-3-6 program ○ 1: all newborns are screened for hearing loss before they leave hospital or within one month of life ○ 3: All infants who do not pass the hearing screening should be scheduled immediately for a follow-up appointment with a pediatric audiologist. This examination must happen by age 3 months. ○ 6: if the follow up confirms the baby has hearing loss they must receive appropriate interventions by 6 months of age, including hearing devices and early communication intervention (e.g., lipreading, signed English, American Sign Language, or others). ● Two tests for newborn screening ○ Otoacoustic emissions (OAE) test: soft probe is placed in canal to measure response (echo) when clicks or tones are played into baby’s ear ○ Auditory brainstem response (ABR): clicks or tones played through soft earphones placed over baby’s ears while electrodes are on head measuring how auditory nerve and brainstem carry sound from ear canal to brain ■ Electrodes come off like stickers and are painless ○ Baby can rest or sleep during both tests, each test takes 5-10 minutes ● Teach about tests patients can take ● Educate patient on properly cleaning ears ● Caution them not to use cotton tip applicators when cleaning ears because it can cause impacted cerumen which leads to hearing loss Documentation: see page 332-334 on pg 455; sample charting, subjective, objective, etc ● Document findings and don't jump to conclusion ○ Ex: Nurse finds white patches on tympanic membrane: “tympanic membrane visualized with areas of tympanic membrane noted”; white patches indicates frequent infection Chapter 17: The Nose, Mouth, and Throat Structure and function of the nose ● ● Nasal hairs “vibrissae: filter coarsest matter from inhaled air ● Ciliated mucous membrane/blanket: filters out dust and bacteria ○ Appears redder than oral mucosa because of rich blood supply present to warm inhaled air ● Turbinates: three parallel bony projections that increase surface area so more blood vessels and mucous membranes are available to warm, humidify, and filter inhales air ○ Superior, medial, and inferior turbinates ● Meatus: passageways or canals underlying each turbinate that collect drainage from sinuses and nasolacrimal duct ● Septum: divides the nasal cavity into two slitlike passages ○ Cranial nerve 1: connected to olfactory hairs at roof of nasal cavity and upper ⅓ of septum ○ Kiesselbach plexus: a rich vascular network in the anterior part of the septum ● Paranasal sinuses: air filled pockets within the cranium that lighten the weight of skull bones; serve as resonators for sound production, and provide mucus that drains into the nasal cavity ○ Openings are narrow and easily occluded which may cause inflammation or sinusitis ○ Accessible to exam ■ Frontal sinuses: in frontal bone above and medial to the orbits ● Fairly well developed by 7 or 8 years of age, reach full size after puberty ■ Maxillary sinuses: in maxill along side walls of nasal cavity ● Do not reach full size until all permanent teeth have erupted ○ Ethmoid and sphenoid sinuses are smaller and deeper, not accessible to exam ○ In newborns only the maxillary and ethmoid sinuses are present at birth ■ Ethmoid sinuses grow rapidly between 6 and 8 and after puberty ■ Sphenoid sinuses minute at birth and develop after puberty ○ Structure and function of the mouth ● Mouth: the first segment of the digestive system and an airway for the respiratory system. ● Oral cavity: a short passage bordered by the lips, palate, cheeks, and tongue ○ Contains the teeth and gums, tongue, and salivary glands ○ Lips: anterior border of oral cavity (transition zone from outer skin to inner mucous membrane lining the oral cavity) ○ Palate: arching roof of the mouth ■ Hard palate: made up of bone and is a whitish color, does not move ■ Soft palate: arch of muscle that is pinker in color and is mobile ○ Uvula: free projection hanging down from middle of the soft palate ■ To assess Cranial nerve 10 ask the patient to say “ahhhh” and watch the movement of the uvula and soft palate to see if they are midline ○ Floor of the mouth: consists of horseshoe shaped mandible bone, the tongue, and underlying muscles ○ Tongue: mass of striated muscle arranged in crosswise pattern so it can change shape and position ■ Frenulum: midline fold of tissue that connects the tongue to the floor of the mouth ● Anchors tongue to floor of mouth and stabilizes movement of the tongue ■ Papillae: rough, bumpy elevations on dorsal surface of tongue ● Should not be confused with abnormal growths ■ Ventral surface: smooth and shiny, shows veins ○ Salivary glands: secrete saliva, a clear fluid that moistens and lubricates the food bolus, starts digestion, and cleans and protects mucosa ■ 3 types ● Parotid ● Submandibular ● Sublingua ○ Teeth ■ Adults: 32 permanent teeth, 16 in each arch Structure and Function of the Throat ● Thoat, or pharynx, is the area behind the mouth and nose ● Oropharynx: separated from mouth by anterior tonsillar pillars (folds of tissue on each side) ● Tonsils: mass of lymphoid tissue behind the folds of skin ○ Same color as surrounding mucous membrane but look more granular and their surface shows deep crypts ○ Tonsillar tissue enlarges during childhood until puberty and then involutes (shrinks) ● Nasopharynx: continuous with the oropharynx, but above the oropharynx and behind the nasal cavity ○ Contains the pharyngeal tonsils (adenoids) and eustachian tube openings Developmental competence ● Infants and children ○ Salivation of infants starts at 3 months; baby drools for a few months before leaning to swallow saliva ■ Drooling does not herald the eruption of the first tooth, although parents may think it does ○ Teeth: all children have 20 deciduous (temporary) teeth ■ Erupt between 6 and 24 months ■ Should all appear by 2.5 years of age ■ Will eventually fall out and be replaced by permanent teeth form 6-12 years of age ● Appear earlier in girls tha\ n boys, erupt earlier in black children ● Pregnant women ○ Epistaxis (nosebleeds): nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract ○ Gums: may bleed from hormonal changes; may be hyperemic, red, swollen, softened; may bleed with normal toothbrushing ■ Can also happen during puberty ● Aging adult ○ Nose and sense of smell: may be reduced because of decrease in the number of olfactory fibers ■ Other factors in addition to aging that lead to diminished sense of smell: chronic allergies and cigarette smoking ■ Nasal hair grows coarser and stiffer ○ Gums recede ○ Saliva production decreases: can be caused by medications, more than 250 meds with dry mouth as side effect ○ Teeth are slightly yellower and appear longer because of recession of gingival margins ○ Tongue: looks smoother because of papillary atrophy Culture and genetics ● African Americans ○ Leukoedema: a milky, bluish-white opaque appearance of the buccal mucosa that occurs commonly in african americans ○ Lips and gums: some black people may have bluish lips and a dark line on the gingival margins ● Bifid uvula: a condition where the uvula is split, either partially or completely ○ 2% general pop, up to 10% in some American Indian groups ● Cleft lip and palate: rates are higher in asians and American indians and lower in African Heritage births; more common in males than females ● Torus palatinus: a bony ridge running in the midline or the hard palate occurs in 20-35% if the US population, more commonly in females Subjective data ● Epistaxis: caused by trauma, vigorous nose blowing, and foreign bodies ○ Interventions: sit up with head tilted forward and pinch the nose for 14-15 minutes ● Altered smell: diminishes with cigarette smoking, chronic allergies, aging ● Sore throat: viral and resolves within 3-5 days without intervention ○ Group A strep: more lively to occur with fever over 100.4, absence of cough, ctonsual exudate, and cervical nodes may display adenopathy (tenderness of anterior cervical nodes) ● Mouth ■ Untreated can cause peritonsillar abscess, rheumatic fever, and glomerulonephritis (rare in the US) ○ A patient with a history of hypertension and chronic lung disease, the patient is likely on medications ■ A side effect of antihypertensive, antidepressants, anticholinergics, antispasmodics, antipsychotics is xerostomia ■ Xerostomia: dry mouth ○ Dysphagia: difficulty swallowing ■ Occurs with stroke, other neurological diseases, esophageal cancer, pharyngitis, GERD Objective data ● Inspection and palpation of the nose ○ Assess nasal patency ■ Adults: gently push one nasal wing shut and ask the patient to sniff inward through the open nare; absent sniff indicates obstruction such as common cold, nasal polyps, and rhinitis ■ Newborns: must be checked because most newborns are obligate nose breathers; immediately after birth the nares are blocked by amniotic fluid which is gently suctioned with a bulb syringe; if obstruction is suspected a small 5-10 fr lumen is passed down each nare to confirm patency, if it cannot pass it could mean there is presence of choanal atresia which requires immediate treatment ○ Nasal cavity: inspected with otoscope and short, wide, tip speculum ■ Lift the tip of the nose and insert into the nasal vestibule, avoiding pressure on the septum ■ Rhinitis: nasal mucosa is swollen, bright red, with upper respiratory tract infections; discharge is common and varies from watery and coious to thick, purulent, and green- yellow ■ Chronic allergy: nasal mucosa looks swollen, boggy, pale, and grey ○ Palpation of the sinus area ■ Frontal sinus: use our thumbs to press the frontal sinuses by pressing firmly up and under the eyebrows ■ Maxillary sinuses: below, not over the cheekbones ■ Normal finding: pressure but no pain ■ For people with sinusitis and chronic allergies the areas are tender to palpation ● Inspection of the mouth ○ Lips: assess color, moisture, cracking and lesions, inner surface; should be deeper and pinker than facial skin ■ AA: may have bluish lips and dark lines on gingival margins ■ Pallor: shock and anemia in light skinned people ■ Cyanosis: hypoxemia and chilling (cold) ■ Cherry red: carbon monoxide poisoning, aspirin poisoning, ketoacidosis ○ Signs of suspected abuse: bruising, lacerations on buccal mucosa of infants or young adults ■ Trauma may be indicative of child abuse from forced feeding of a bottle too soon ○ Fordyce granules: small, isolated, white or yellow papules on the mucosa, cheek, tongue, or lips; are sebaceous cysts and are painless and insignificant ● Mouth and tongue ○ Dehydration: can cause dry mouth and deep vertical fissures in the tongue; due to reduced tongue volume ○ Sucking tubercle: small pad in the middle of the upper lip that occurs from friction of breast and bottle feeding, a normal finding in infants ○ Determining the number of teeth ■ Under 2 years old: child age in months minus 6 = expected number ■ All 20 deciduous teeth should appear by 2.5 years ○ Tooth decay ■ Infants: prolonged bottle use during the day or when going to sleep places infants at risk for tooth decay and middle ear infections ● Thoat ○ Tonsils: inspect and take note of tonsils ■ Grading ● 1: visible ● 2: halfway between tonsillar pillars and uvula ● 3: touching uvula ● 4: touching each other ■ Enlargement 2-4 can indicate acute infection ■ Tonsils graded at a 4 can indicate impaired airway Health promotion and patient teaching pg 491 pdf ● Smoking cessation: ““The most helpful thing we can do today is to talk about your smoking and tobacco dependence. Probably you know that smoking leads to many heart and lung diseases and to many cancers. But the good news is that tobacco dependence is very treatable. Also, you will see benefits within 24 hours as your lungs clear themselves of mucus and other smoking leftovers. Have you ever tried to quit? What worked? What didn't work? As we start, it is important to know that smoking is a form of addiction and that most people cannot quit without help from a counselor, a nurse, or a doctor.” ● As a nurse, our time and resources in your clinical setting will determine how many smoking-cessation efforts you can take on yourself. ● Smoking is the world's leading cause of early death and disability; smoking cigarettes leads to at least 21 diseases, including 12 types of cancer, 6 types of heart and blood vessel disease, and to diabetes, chronic obstructive lung disease, pneumonia, and influenza. ● It is imperative that you make an effort to teach at every patient encounter. At the very least, consider the Very Brief Advice on Smoking, which you can adapt to your work situation. ○ [Ask] “Do you smoke or use tobacco products? At what age did you start smoking? How many packs of cigarettes per day do you smoke? How many years have you smoked this amount?” ○ [Advise] “Smoking cigarettes leads to many heart and lung diseases and to many types of cancer. Stopping smoking is the very best thing you can do to improve your health. The best way to quit is a combination of behavioral support and medication. We have a local, friendly stop-smoking service. The people there are experts, and I can send you to them if you'd like?” ○ [Act] Refer the person to the stop-smoking service if he consents, another action aside from referral is document/make a note in the person's record that you have advised and the person is not ready to quit. ○ NOTE: When people smoke over 10 cigarettes per day or smoke within 30 to 60 minutes of waking up, it is likely that they will experience withdrawal symptoms when quitting. ● Sample charting ○ Subjective ■ Nose: No history of discharge, sinus problems, obstruction, epistaxis, or allergy. Colds 1- 2/yr, mild. Fractured nose during high school sports, treated by MD. ■ Mouth and throat: No pain, lesions, bleeding gums, toothache, dysphagia, or hoarseness. Occasional sore throat with colds. Tonsillectomy, age 8. Smokes cigarettes 1 PPD × 9 years. Alcohol, 1-2 drinks socially about 2×/month. Visits dentist annually, dental hygienist 2×/year, flosses daily. No dental appliance. ○ Objective ■ Nose: Symmetric, no deformity or skin lesions. Nares patent. Mucosa pink; no discharge, lesions, or polyps; no septal deviation or perforation. Sinuses—no tenderness to palpation. ■ Mouth: Can clench teeth. Mucosa and gingiva pink, no masses or lesions. Teeth all present, straight, and in good repair. Tongue smooth, pink, no lesions, protrudes in midline, no tremor. ■ Throat: Mucosa pink, no lesions or exudate. Uvula rises in midline on phonation. Tonsils out. Gag reflex present. ○ Assessment ■ Nose and oral structures intact and appear healthy ■ Needs teaching about risks of cigarette smoking Abnormalities ● Nose ○ Seasonal allergic rhinitis: an abnormal immune response from repeated exposure to antigens; rhinorrhea, itching of nose and eyes, lacrimation, nasal congestion, and sneezing are common ■ Physical exam: note any serous edema and swelling of turbinates; turbinates are usually pale but may appear violet in some patients; their surface should look smooth and glistening ■ ○ Allergic rhinitis: initial response is a clear, watery discharge, rhinorrhea; later the discharge becomes purulent and sneezing, itching, cough reflex, inflamed mucosa (and nasal obstruction) occur; turbinates appear dark red and swollen ■ ○ Foreign bodies: children in particular often put objects up their noses; this produces unilateral mucopurulent drainage and foul odor ■ Removal of object should be prompt because of risk for aspiration ■ ○ Sinusitis: acute inflamed sinus areas following upper respiratory infections are over 90% viral in origin and do not need antibiotics ■ Consider bacterial infections when signs last over 10 days without improvement ■ Signs: mucopurulent drainage, nasal obstruction, facial pain, pressure, fever, chills, malaise ● Lips ■ ■ Maxillary sinusitis: dull, throbbing pain in cheeks and teeth and pain with palpation, pain when bending over ■ Frontal sinusitis: pain above supraorbital ridge ○ Cold sores (HSV1): groups of clear vesicles with a surrounding, indurated, erythematous base ■ Evolve into pustules which rupture, weep, crust, ad heal in 4-10 days ■ Commonly appears on lip-skin junction and reoccurs at the same site ■ Recurrence can be precipitated by sunlight, fever, colds, and allergies ■ ○ Carcinoma: initially round and indurated; becomes crusted and ulcerated with an elevated border ■ Most occur between the outer and middle thirds of the lip ■ Lesions that do not heal after 2 weeks should be suspected and referred ■ ○ Angular cheilitis: Erythema, scaling, and shallow and painful fissures at the corners of the mouth occur with excess salivation and Candida infection. It is often seen in edentulous persons and those with poorly fitting dentures, causing folding in the corners of the mouth, which creates a warm, moist environment favoring growth of yeast. ● Buccal mucosa ○ Candidiasis or monilial infection: white, cheesy, curd-like patch on the buccal mucosa and tongue ■ Scrapes off leaving a raw, red surface that bleeds easily ■ “Thrush” in newborns ■ An opportunistic infection that occurs after use of antibiotics and corticosteroids in immunosuppressed persons ■ ■ A normal oral flora that is present in 60% of healthy adults ■ Adults: overgrowth can occur with steroid inhaler use, HIV infection, broad-spectrum antibiotic or corticosteroid use, leukemia, malnutrition, or reduced immunity ■ ● Tongue ○ Atrophic glossitis: smooth, glossy areas on the tongue that are slick and shiny; mucosa thinks and looks red from decreased papillae ■ Can be accompanied by dryness of tongue and burning ■ Occurs with vitamin B12 deficiency (pernicious anemia), folic acid deficiency, and iron deficiency anemia ■ Normally the tongue has rough papillae on the dorsal surface and can have a thin white coating, the ventral surface may show veins and be smoother ■ ○ Black hairy tongue: not actually hair but is elongation of the filiform papillae and painless overgrowth of mycelial threads of fungus; infection of the tongue ■ Color varies from brown to yellow ■ Occurs after prolonged use of antibiotics, which inhibit normal bacteria and allows proliferation of the fungus, and with heavy smoking ■ ○ Carcinoma: ulcerations on the side or at the base of the tongue, sometimes under the tongue ■ Investigate ulceration early ■ Grows insidiously and may go unnoticed for months ■ May have associated risks with leukoplakia ■ Risk for early metastasis because of rich lymphatic drainage ■ Smoking and alcohol use most common cause, but HPV related oral-pharyngeal cancers have also increased ■ ● Oropharynx ○ Bifid uvula: uvula looks partly severed ■ May indicate a submucous cleft palate which feels like a notch at the junction of the hard and soft palates ● May affect speech development because it prevents necessary air trapping ■ More common in american indians ■ ○ Oral Kaposi Sarcoma: bruise-like, dark red or violet, confluent macula, usually on the hard palate but may be on the soft palate or gingival margin ■ Oral lesions may be among the earliest lesions to develop with aids ■ [Show More]

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