HA
Breast and Genitalia
Know the normal and abnormal findings for breast exams.
- Lymph nodes are not palpable
- Affects the urethra, rectum, or throat
- Thick, yellow-green discharge coming from genitals
Genital Herpes – caused by HSV
- Small, painful, red-based, ulcer- like
Syphilitic Chancre – red ulcers
- Silvery white pa
- Painless
- Develops at sight of contact
- Makes should not experience dicharge
Know the STIs and differentiate between them.
Genital Warts – caused by HPV
- On labia and vestibule
- Moist, fleshy, painless
- On lesion
Gonorrhea – caused by bacteria.
Thorax and Lungs
Inspect: skin condition. Chest symmetry, and respiratory patterns
Abnormalities – barrel chest, kyphosis (hunchback), lordosis (seen in pregnant women)
Palpate: tenderness , respiratory expansion (have the patient breath in), tactile fremitus (99)
Percussion: place middle finger of your non dominant hand on the patient’s skin, and use your dominant finger to tap on your finger that is placed on the patient
auscultation: use the diaphragm of the stethoscope on the posterior thorax using a “Z” pattern
normal breath sounds-
bronchial – high pitched – heard in the neck around the trachea
- Inspiration slightly shorter than expansion
bronchovesicular – medium pitched near major bronchi (between shoulder blades
- Equal inspiration and expiration
vesicular – low pitched rustling in peripheral lung fields (lower lungs)
- Inspiration 3 times longer than expiration
abnormal-
crackles – when fluids are in the airways or alveoli
- Early in inspiration
wheezes – high pitched
- caused by narrowed or constricted airways such as acute asthma/bronchospasms
- Heard in both inspiration and expiration but mainly in expiration
stridor – high pitched (crowing)
- Narrow airways (whooping cough)
- Heard louder at the neck
What are the different tests in lung assessment and what do they mean?
Cardiovascular
Apex
- 3-4 cm above inner third of clavicles, in the anterior chest
- S1 is loudest at the apex
Base
- rests on the diaphragm near the 6th rib in midclavicular line
- S2 is loudest at the base
Stethoscope-
n Diaphragm – mainly used for higher frequency sounds, bowel sounds, abdomen, lungs
n Bell – mainly used for lower pitched sounds, heart sounds/murmurs, bruits , vascular sounds , S3 and S4
What is a bruit? Blowing, swishing sound indicating blood flow turbulence
What is a thrill? A vibration that is palpable in a cardiac exam
Carotid pulse assessment
- Carotid pulse coincides with S1
- Pulsations should be heard bilaterally, palpate them one at a time
- Auscultate with the bell of the stethoscope on the side of the neck to detect bruits
Capillary refill
- Color should return less than 3 seconds
Apical pulse
- located in the 5th intercostal space or inside the left midclavicular line
- take pulse for full minute
- when apical pulse is greater than the radial pulse, it indicates a pulse deficit
Radial pulse
- use a doppler if you have trouble palpating
- 4+ is bounding, 3+ is increased, 2+ is normal, 1+ is weak, 0 is absent
Edema
- May indicate fluid retention from cardiac/renal problems
- Firmly press skin to check for edema of the body
0 = none, 1+ = mild pitting, 2+ = moderate pitting, 3+ = deep pitting, 4+ = very deep pitting
Peripheral pulses – 4+ is bounding, 3+ is increased, 2+ is normal, 1+ is weak, 0 is absent
- Radial
- Popliteal
- Dorsalis pedis (if not palpable, use a doppler)
- Posterior tibial
- Brachial
Peripheral lymph nodes -identify and palpate. What do findings mean?????
- Femoral
o assess for strength and symmetry bilaterally, grade strength
- Inguinal
o in the groin, should feel small, soft, discrete and moveable
o Normal to palpate isolated node on occasion
- Axillary
o Are palpable
o In the armpit
As a nurse, the peripheral lymph nodes are the other thing we assess for
when auscultating the cardiac sites, use bell AND diaphragm
S1, S2, S3, S4: when do you hear; how do you best hear? What are the steps in auscultation?
S1 – loudest at the apex (mitral and tricuspid) – best heard at lower left sternal border
S2 – loudest at the base (aortic and pulmonic) – best heard in the pulmonic valve area, and second intercostal space
S3 – heard in early diastole at the apex – using the bell of the stethoscope – heard best when patient is in left lateral position – gallop sound - lub dub dee (“Kentucky”)
S4 – occurs late diastole, just before S1 – best heard at the apex with the bell of the stethoscope, and when the patient is in left lateral position - dee lub tub (“Tennessee”)
Orthostatic hypotension is when the systolic blood pressure drops 10/20 mL per mercury, with a pulse increase when standing up
Nutritional assessment – malnutrition and dehydration findings
- When you are dehydrated you have a thready pulse
- When you are fluid volume excess you have bounding
Labs in a nutritional assessment.
- Albumin
Eyes:
Assess each pupil for direct and consensual reaction to light – shine penlight in both pupils and they both should constrict
Assess six cardinal fields of gaze – “cat whiskers” – Cranal nerve is 3,4,6
Assess accommodation – move penlight closer and closer to the patient’s nose, (cross-eyed)
Perform cover and uncover patch test – to determine eye alignment
what is confrontation testing for? To test their peripheral vision
Identify all the structures, whether we assess them as nurses or not-
Eyelids – assess their ability to blink, frequency of blinking, and if position is in relation to the iris
Eyelashes – distribution and curve
Cornea (white part of eye) – for clarity
Iris – assess the color of the eye; controls light that is admitted to the retina
Pupil – assess color, shape, and size
Using the ophthalmoscope and what we can see when using it
- Want to elicit a red reflex in both eyes
- R>R L>L
- You can inspect the media and ocular fundus
Ear: What do you inspect and palpate? What might you see? What do those findings mean?
- Tragus, lobules, helix, antihelix, and mastoid processes
o For texture, elasticity, and areas of tenderness
- Tophi: white nodules on the ear
- Inspecting the tympanic membrane as well
o Shiny, translucent, pearly gray
o Right ear is 5 o’clock
o Left ear is 7 o’clock
Using the otoscope and what we can see when using it
- up and back: older than 3
- down and back : kids under 3
o save this exam for last
- inspecting the external auditory canal and middle ear
Rinne test
- tuning fork is placed behind the ear of the mastoid bone
- compares how well sound is heard through air obstruction
Weber Test
- determines if sound is lateralized to one ear; identify potential hearing loss in one ear
- tuning fork is placed on the forehead or midline of the skills
Romberg Test
- test balance
- have patient close their eyes for 5 seconds
Sinuses and assessment of sinuses- how do you assess?
- Both hands press on the sinuses to test for tenderness or swelling
Nose, Mouth and Throat assessment -how do you do these? What do the words mean? What can you see and not see during our assessment with the penlight?
Nose : test for patency and sense of smell
- Occlude one nare and have patient breathe through the other side, repeat on other side
- Determine between 2 different scents
Anosmia – the inability or loss od sense of smell
The ability to smell, decreases as we age
Epistaxis – nosebleed
- Penlight is used to look into the nose (should be pink inside)
Throat
- Tonsils graded in size as follows:
o 1+ Visible
o 2+ Halfway between tonsillar pillars and uvula
o 3+ Touching uvula
o 4+ Touching each other
Use penlight to look at mouth, teeth and gums, buccal mucosa, palate and tonsils
Mouth – uvula should rise when the patient says “ah”
Cranial nerves that we have learned thus far.
“oh oh oh try try again failure victory gives value and happiness”
Cranial nerve 1 (olfactory)
- testing the sense of smells
- Use garlic, coffee, cinnamon, and vanilla
Cranial Nerve 2 (optic nerve)
- PERRLA (pupils are equal to and reactive to light, accommodation)
- Flashing a light in the patients eye to see if the pupils restrict
o When shining a light in one pupil, the other should constrict as well
- Peripheral visual fields
Cranial Nerve 3 (oculomotor)
- Cover and uncover patch test to determine eye alignment
- Muscular eye movement
Cranial Nerve 4 (trochlear)
Muscular eye movement
Cranial Nerve 5 (trigeminal)
- TMJ
- Evaluate the strength of your jaw
- Performing hard soft or dull
Cranial Nerve 6 (Abducens)
- Six fields of gaze
- Direct penlight using a “cat whisker: motion to see if the patient is reactive to light
Cranial Nerve 7 (Facial)
- Puff out cheeks, smile, frown, raise eyebrows
- Evaluate strength of eyes
Cranial Nerve 8 (Acoustic )
- Assess hearing with the whisper test
- Have them say or do a phrase and they repeat it back to you or do what you say
Cranial Nerve 9 (Glossopharyngeal)
- Elicting the gag reflex
- Pressing the tongue depressor on the tongue
Cranial Nerve 10 (Vagus)
- Have patient say “ahh” and look to see if the soft palate and uvular rise midline
Cranial Nerve 11 (spinal accessory)
- The patient shrug their shoulders against pressure and moves head side to side against pressure
Cranial nerve 12 (Hypoglossal)
- Assessing the strength of tongue by pressing it against the cheek
- Client sticks out tongue, move side to side, and up and down
Oh oh oh try try agin failure victory give us value and happiness
Musculoskeletal
- Palpate for warmth or swelling in the joints, muscles, and bones
- Assess muscle strength against resistance
o Arms and legs
- Never force a joint
o Stop when there is resistance
Crepitation : crackling or gating joints contractures: stiffness, tightening of the muscle Flexion: “flexing”
ROM of Fingers- ulnar and radial deviation, finger taps, make a fist
ROM of Wrists – extension, hyperextension, flexion, radial deviation, and ulnar deviation
ROM of Elbows- flexion, extension, supination and pronation
ROM of Shoulders- abduction, adduction, hyperextension, flexion, internal and external rotation
ROM of Hips- external and internal rotation, abduction, adduction, flexion and extension
ROM of Knees- flexion and extension
ROM of Ankles – plantar flexion, inversion (inward to the midline of the body), eversion (outward from the body midline)
Kyphosis – hunchback; is an effecting aging
Lordosis – usually seen in pregnant women
Scoliosis – lateral curvature of the spine
Neurological
- Assess the patient walking, balance, sensation, DTR, Babinski reflexes, stereognosis, and Graphesthesia
Central and Peripheral nervous system is made up of the– brain and spinal cord
Glascow Coma Scale – LOC
- Eye opening
- Verbal response
- Motor response
Delirium – acute confusion, they were completely normal before they first walked into the hospital; can be corrected
Dementia is chronic and progression. Example is Alzheimer’s
Blood pressure:
- cuff size (what can cause false readings), Korotkoff sounds
- Cuff sizes that are too small for the patient can cause a false reading for high blood pressure. A cuff size too big could potentially give a false reading of low blood pressure or the cuff won’t sit on the arm properly.
How would you explain to a patient what systole and diastole is?
- Systole- pressure against the arterial walls while the heart is beating.
- Diastole- pressure against the arterial walls while the heart is at rest.
How do you take a two-step blood pressure?
- You would blow up the blood pressure cuff twice. The first time would measure when you feel the pulse begins and diminish. The second would be blood pressure reading.
Orthostatic blood pressure
- Blood pressure drops when changing position from sitting to standing
- Standing up and there is a decrease in blood pressure (10-20) -hypotension-
Interviewing skills and communication
- -closing an interview
- Ask the client if they have any questions or other concerns and allow them time to respond.
Therapeutic vs non-therapeutic communication
- Therapeutic: techniques that are used to actively listen and support a pt’s well-being.
- Non-therapeutic: communication that involves behaviors that hinder the patient and block communication with the patient.
Verbal vs non-verbal communication
- Verbal is listening to the words coming out of the client’s mouth. Non-verbal is reading the patient’s body language. It is always important to observe body language as it may not match what they verbalize.
Subjective vs Objective data
- Objective data is what the HC professional can observe and measure.
- Subjective is what the client tells you.
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Steps of the assessment process:
How and why do we palpate, percuss abdomen?
- We palpate to assess tenderness. Palpate from light to deep in a circular motion in all quadrants. Remember start in RLQàRUQàLUQàLLQ
- We can percuss to assess for obstructions. Tap the back of two fingers in each quadrant to listen for tympany or a dull, flat sound.
What are we looking for with palpation?
- We are looking for any signs of enlargement or abnormalities. We also was to observe the client to see if they are experiencing pain or tenderness.
Functional assessment- what is it? What are we checking for?
- Functional assessments are used to assess the patients ability to perform basic ADL’s. we would also assess their cognitive function.
Pain assessment tools, PQRSTU, COLDSPA
- Provocation: What makes it worse/better?
- Quality: Describe the pain?
- Region: Where does it hurt?
- Severity: How bad is the pain on a scale of 1 – 10?
- Timing: When did the pain start, is it on and off?
- Understanding: Understand the pts perception of the pain.
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- Character: describe the pain
- Onset: when did it start
- Location: where does it gyrt
- Duration: is it on and off, how often does it hurt.
- Severity: how bad does it hurt on a scale of 1 to 10.
- Associated Factors:
Acute pain vs chronic pain
- Chronic- long term pain lasting longer than 6 months.
- Acute- less than 6 months.
Vital sign norms
- BP: 120/80 – 90/60 mm hg RR: 12-18 BPM: 60 – 100 Pulse Ox – 90 and up
- Use of interpreter services
- When the client cannot full understand English and there is a language barrier. DO NOT USE THEIR FAMILY TO INTERPRET FOR YOU!
Purpose of health history
- This is subjective data that can tell us what the patient is at risk for and it can help explain what thy currently have. This also helps HC professionals create a care plan.
What is a review of systems? What information goes in a review of systems?
- This is a part of the assessment in which the HC provider asks a series of questions about specific body systems to elicit more information.
What is a healthcare database? What makes up the database?
- A collection of organized health data about individual clients that is stored electronically within the facilities system.
How to calculate BMI (use the formulas to calculate?)
- Weight (kg)/height(m) ^2 = BMI
- Weight (lbs)/height(in)^2 x 703 = BMI
How and when to perform rectal temperature?
- When a child is younger than three months and is showing signs of illness.
- Most accurate
- Lubricated
- 2-3 cm in adults
Extras
- different types of lesions – Macules, Papules, Nodules, Plaques, vesicles, pustules, wheals, bullae, and tumors.
- ABCDE – Airway, Breathing, Circulation, Disability, Exposure
- edema rating – on a rating of 0 – 4. 0 being zero pitting and 4 (pitting lasting longer than 30 sec)
- capillary refill – should be under 3 seconds. If its not it mean circulation is not brought to the surface
- Skin turgor – should be immediate on recoil. Older patient have more of a delay in skin turgor
- fingernail clubbing; head and neck findings, you mainly see it in COPD patients
- lymph nodes – should not be palpable unless the patient is sick or experiencing allergies, in which the lymph nodes would be palpable or the client will feel pain.
Assess if you can feel lymph nodes
- Thyroid- should not be palpable or enlarged.
Abdomen- normal vs abnormal findings. How do you do the assessment? Know your landmarks.
- Abnormal findings would be uneven skin distribution, lumps, masses, pain, or tenderness when palpating, and hypo/hyper active bowel sounds.
- Normal is no pain, tenderness, or masses when palpating. Active bowel sounds in each quadrant, and uneven skin distribution.
Extras:
Appendix is found in the RL quadrant
Liver is found in the RU quadrant
Gall bladder is RU quadrant
Spleen is found LU quadrant