Comprehensive Nursing Physical Assessment and Documentation Training

Edema Assessment and Pitting Scales

• Pitting Edema Measurement Standards and Subjectivity:     - The measurement of edema depth in millimeters corresponds to specific inch increments, though these are often very small and subjective to the examiner's perception.     - $2\,mm$ is approximately $\frac{1}{16}\,\text{inch}$.     - $4\,mm$ is approximately $\frac{1}{8}\,\text{inch}$.     - $6\,mm$ is just short of $\frac{1}{4}\,\text{inch}$.     - $8\,mm$ is approximately $\frac{1}{4}\,\text{inch}$.     - The difference between $\text{four millimeters}$ and $\text{eight millimeters}$ can be subjective (e.g., one nurse may document four while the next documents eight due to the minute difference between them).     - Edema measurement is similar to the pain scale in that it is subjective; however, it has specific numbers attached to it for grading.

• Grading by Recovery Time:     - Documentation at hospitals should consider the number of seconds it takes for the skin to return to its original state.     - A recovery time of $10$ to $12\,\text{seconds}$ represents a minimal grade.     - A recovery time greater than $20\,\text{seconds}$ corresponds to a more severe grade.

Pulse Volume and Objective Scales

• Pulse Volume Scale Comparisons:     - The pulse volume scale typically ranges from $0$ to $3+$.     - The edema scale typically ranges from $1+$ to $4+$.
• Grades of Pulse Volume:     - $0$: Absent pulse.     - $1+$: Weak and thready; requires significant effort to locate.     - $2+$: Normal pulse; easily felt.     - $3+$: Bounding; very easy to locate and sometimes visible to the naked eye.
• Objective vs. Subjective Assessment:     - Finding a pulse is more objective than measuring edema because everyone can generally agree on whether a pulse is weak, normal, or bounding. Edema measurement is less precise without a measuring device.

Core Nursing Assessment Skills and Anatomical Reference

• Primary Assessment Skills:     - Inspection: Seeing the edema (not the most complete way to assess it).     - Palpation: Using touch to determine depth and consistency (the best way to gather complete data about edema).     - Percussion: Not used for edema assessment.     - Auscultation: Not used for edema assessment.

• Directional and Regional Terms:     - Prone: Lying on the stomach.     - Midline: The center of the body.     - Lines of the body: Mid-axillary line and other major landmarks.     - Medial vs. Lateral.     - Anterior vs. Posterior.     - Distal: Father from the body/attachment.     - Proximal: Closer to the body part.     - Regions: Occipital, temporal, frontal, cervical, thoracic, lumbar.     - Quadrants: Right Upper Quadrant ($RUQ$), Right Lower Quadrant ($RLQ$), Left Upper Quadrant ($LUQ$), Left Lower Quadrant ($LLQ$), and BUQ/BLQ (Bilateral Upper/Lower Quadrants).     - Body Areas: Axilla, chest wall, and trunk.

Characteristics and Documentation of Masses

• When a mass is found, the nurse must evaluate it using several criteria:     - Location: Using precise anatomical documentation terms.     - Size: Measured using a device in $millimeters$ or $centimeters$. Using descriptors like the size of a dime or nickel is discouraged in favor of exact measurements.     - Shape: Oval, rounded, or elongated.     - Consistency: Hard (indurated), firm, or soft.     - Surface: Smooth or nodular (felt above the skin).     - Mobility: Is it movable (like a fatty sebaceous cyst) or fixed?     - Pulsation: Does the mass have a pulse? An increased blood supply to the area (common in tumors) may cause a pulse, which is generally not a good sign.     - Tenderness: Is it tender to palpation?

Primary and Secondary Skin Lesions

• Primary Lesions: These are reactions to a physiological process or problem.     - Macule: A flat lesion (e.g., freckles).     - Papule: A solid, elevated lesion that can be palpated; size is less than $1\,cm$ in diameter.     - Nodule: Solid, raised lesion that is deeper than a papule.     - Vesicle: A small blister-like raised area containing serous fluid; size is up to $1\,cm$ in diameter.     - Bulla: Similar to a vesicle but much larger (greater than $1\,cm$).     - Pustule: Similar to a vesicle or bulla but filled with perulent material.     - Wheal: Raised area like hives or an insect bite (e.g., a mosquito bite or a reaction from a TB skin test).     - Plaque: A patch or raised lesion greater than $1\,cm$ in diameter (often associated with psoriasis description).     - Cyst: A closed pouch that usually extends below the surface of the dermis.

• Secondary Lesions: Result from changes to primary lesions.     - Crust: A scab; found in conditions like infected dermatitis or impetigo.     - Excoriation: Scratch marks that break the skin (e.g., from scratching chickenpox or poison ivy).     - Fissure: A deeper crack or split in the tissue (e.g., athlete’s foot).     - Ulcer: An open area, such as a pressure sore.     - Lichenification: Hardening and thickening of the skin, usually from intense scratching or rubbing.     - Scar: A mark left after a wound or surgical incision heals.

Common Skin and Infectious Conditions

• Hand, Foot, and Mouth Disease: Characterized by lesions on the hands, feet, and in the mouth; common in children during spring and fall.
• Fifth Disease: One of the childhood viral illnesses (alongside measles, mumps, rubella); presents with a ‘slapped cheek’ appearance before widespread lesions appear.
• Ringworm (Tinea): Described objectively as a ring-shaped lesion unless a diagnosis is already confirmed.
• Candidiasis: Thick white yeast fungus; can be documented if previously diagnosed.

Nail Assessment and Abnormalities

• Normal Nail Angle: Should be approximately $160^{\circ}$.
• Clubbing: Found when the nail angle is flattened or greater than normal; caused by long-term hypoxia (commonly seen in patients with COPD).
• Spoon-shaped Nails: Indicate malnutrition or iron deficiency.
• Brittle Nails: Associated with hyperthyroidism, malnutrition, calcium deficiency, or iron deficiency.
• Soft/Boggy Nail Bed: A sign of hypoxia, indicating insufficient oxygen at the nail base.
• Paronaccia (verbatim perinatia): Infection, redness, swelling, or inflammation around the nail bed.

Hair and Scalp Assessment

• Symmetry and Quality: Check for symmetry of the head and face. Hair should be assessed for brittleness or oiliness.     - Brittle hair may be caused by thyroid problems or repeated chemical perms.     - Oily hair is common in adolescents due to active sebaceous glands.     - Aging leads to decreased sebaceous gland activity, causing loss of skin elasticity and drier hair.
• Scalp Examination: Nurses should palpate the scalp thoroughly. A hidden lump from a fall may only be discovered through tactile assessment and could necessitate a neurological evaluation.
• Head Shape Terminology:     - Normocephalic: Normal shaped head.     - Hydrocephalus: Fluid on the brain, causing an enlarged head.     - Microcephaly: Abnormally small head.     - Macrocephaly: Abnormally large head.
• Other Findings:     - Sunken Fontanels: Seen in dehydrated children.     - Hirsutism (verbatim Hershey): Excessive hair on the face, trunk, or other areas.     - Alopecia: Hair loss.     - Pediculosis: Lice infestation.

Ear and Hearing Assessment

• Ear Alignment: The top of the ear should align with the corner of the eye. Deviated alignment is often a sign of developmental abnormalities.
• Piercing Documentation: Nurses must document all piercings (helix, antihelix, tragus, antitragus, lobule) and any unexpected holes in the ears or body (nipple rings, belly button rings).
• Hearing and Vibratory Tests:     - Weber Test: Tests bone conduction. A tuning fork is placed on the forehead midline. Vibration should be heard equally in both ears. If unequal, it suggests cerumen (ear wax) buildup, membrane problems, or injury.     - Rinne Test (verbatim Rhinds): Measures both bone and air conduction. The tuning fork is placed on the mastoid bone until the patient can no longer hear it, then moved to the ear opening.     - Air conduction (AC) should be twice as long as bone conduction (BC) ($AC = 2 \times BC$).

Nose and Oral Assessment

• Nose Inspection:     - Use a penlight and push the tip of the nose up (especially in children) to see the nares/meatus.     - Deviated Septum: When the septum is not in correct alignment/straight in the middle.     - Nasal Polyps: Should be documented as a \"nasal lesion\" if not diagnosed, noting if it occludes the area.     - NG Tube Considerations: Before insertion, check for patency by having the patient occlude one nostril at a time. Insert the tube into the larger/more patent nostril.     - Nasal cannulas and NG tubes can cause ulcers on the inside of the nares.
• Oral Cavity:     - Lips should be pink and moist; check for cyanosis.     - Frenulum: The tissue underneath the tongue.     - Uvula: May be surgically altered in sleep apnea patients to prevent airway obstruction.     - Tonsils: May have \"tonsil tags\" if they have grown back after a tonsillectomy.     - Thrush: A thick white coating on the tongue; must be documented as \"white thick coating\" until a culture confirms the diagnosis.     - Gingivitis: Inflammation of the gums.     - Dental Caries: Medical term for cavities.     - Brown Stains on Teeth: Can be caused by smoking or taking antibiotics like tetracycline during tooth development.     - Geographic Tongue: A variation of normal that looks like a road map on the surface of the tongue.

Pupil Assessment (PERRLA)

• Normal Pupil Size: $3$ to $7\,mm$.
• PERRLA Definition: Pupils Equal, Round, Reactive to Light and Accommodation.
• Testing Procedure:     - Direct Reaction: Shine light into one eye and observe that pupil constrict.     - Consensual (Indirect) Reaction: Shine light into one eye and observe the other pupil constrict at the same time.     - Accommodation: Move an object (like a pen) from far away toward the tip of the patient's nose. Pupils should constrict and eyes should cross (converge).     - Extraocular Movement (EOM): Patient follows a finger or pen with their eyes to test muscle movement.
• Assessment Challenges:     - Dark brown eyes make it difficult to see constriction; the nurse may need to dim room lights or move the penlight closer from the side.     - Documentation limitations: If a patient has an artificial eye or developmental delays (e.g., autism) preventing them from following directions, the nurse can only document what was actively observed.

Cranial Nerves for Nursing Exams

• Cranial Nerve II (Optic): Tested using the Snellen eye chart.
• Cranial Nerve III (Oculomotor): Involved in pupil reaction (PERRLA) and extraocular movement.
• Cranial Nerve IV (Trochlear): Specifically involved in extraocular movement.
• Cranial Nerve VI (Abducens): Specifically involved in extraocular movement.
• Cranial Nerve XI (Accessory/Spinal Accessory): Tested by having the patient shrug their shoulders or turn their face to the left and right against resistance.

Neck and Lymph Node Assessment

• Jugular Vein Distension (JVD):     - Must be assessed with the patient lying at a $30$ to $45\,degree$ angle. JVD should not be documented if the patient is sitting straight up ($90\,degrees$).     - Normal finding: Veins are flat and undistended.
• Thyroid Gland:     - Located near the Adam’s apple; assessed by having the patient swallow while the nurse feels from the front or stands behind them.     - Goiters or large masses require further questioning.
• Lymph Nodes:     - Palpate from the mandibular area down the side of the neck and across the top of the clavicle.     - Normal nodes: Soft, squishy, and pea-sized.     - Abnormal findings: Nodes may remain permanently elevated after severe infections like strep throat.
• Carotid Pulse: Checked for strength and the presence of a bruit.

Questions & Discussion

• Question on Eye Swelling: A student asked when to differentiate between \"swelling\" and \"edema.\" The instructor clarified that the clinical term for swelling around the eye socket is \"peri-orbital edema.\"
• Discussion on Esthetics Careers: Speaker 8 discusses working in a longevity and esthetic clinic. They perform injections (with a Nurse Practitioner's sign-off on treatment plans) and manage clinic locations. They mention the stress of insurance/prior authorizations, stating a single MRI authorization can take $2$ to $3\,hours$. They would charge $200$ to $300\,dollars$ out-of-pocket for such administrative work.
• Anecdote on Assessment: The instructor mentions having a scar on their head from where a brother threatened to throw a rock; underscores the importance of parting hair to see the scalp during a physical exam.