HA Exam #2

Hepatitis A Overview

  • Acute Viral Liver Infection

    • Caused by Hepatitis A virus (HAV)

  • Transmission

    • Oral-fecal route via contaminated food and water

  • Prevention

    • Preventable with a vaccine

  • Demographic Impact

    • Affects adults more severely than children

  • Resolution

    • Typically resolves within a year.

Hepatitis A (Causes/Risk Factors)

  • Primary Risk Factors

    • Poor sanitation

    • Consumption of contaminated food or water

    • Close contact with infected individuals

    • Travel to endemic areas

Hepatitis A (Subjective Data)

  • Symptoms Reported by Patients

    • Fatigue

    • Malaise

    • Loss of appetite

    • Nausea

    • Right upper quadrant pain

Hepatitis A (Objective Data)

  • Signs Observable Upon Examination

    • Jaundice (yellowing of the skin and eyes)

    • Dark urine

    • Pale stools

    • Hepatomegaly (enlarged liver)

    • Elevated liver enzymes (specifically ALT, AST)

Hepatitis A (Complications)

  • Complication Overview

    • Usually self-limiting

    • Rarely leads to chronic conditions

    • Fulminant hepatitis is very rare

Hepatitis B Overview

  • Virus Type

    • DNA virus transmitted primarily via blood and body fluid exposure

  • Transmission Methods

    • Sexual contact

    • Perinatal (from mother to baby)

    • Perinatal infections are common in infants

  • Chronic Disease Potential

    • Can develop into chronic disease

Hepatitis B (Causes/Risk Factors)

  • High-Risk Behaviors and Conditions

    • IV drug use

    • Unprotected sexual intercourse

    • Healthcare exposure

    • Hemodialysis

    • Perinatal exposure

    • Additional Risk Factors: Advanced age, alcohol use, cigarette smoking, coinfection with Hepatitis C

Hepatitis B (Subjective Data)

  • Patient Symptoms

    • Fatigue

    • Anorexia

    • Nausea

    • Abdominal discomfort

    • Myalgia (muscle pain)

    • Arthralgia (joint pain)

Hepatitis B (Objective Data)

  • Visible Signs and Lab Findings

    • Jaundice

    • Dark urine

    • Clay-colored stools

    • Hepatomegaly

    • Positive HBsAg (Hepatitis B surface antigen)

    • Elevated liver enzymes (specifically AST and ALT)

    • Elevated bilirubin levels

Hepatitis B (Complications)

  • Potential Long-term Complications

    • Chronic hepatitis

    • Cirrhosis

    • Hepatic carcinoma (liver cancer)

    • Liver failure

Hepatitis B (Prevention)

  • Preventative Measures

    • Administration of the Hepatitis B vaccine

    • Avoiding needle sharing and unprotected sexual intercourse

    • Identifying and vaccinating at-risk individuals and infants

Hepatitis C Overview

  • Virus Type

    • RNA virus transmitted via blood and body fluids

  • Vaccine Status

    • No vaccination available for Hepatitis C

  • Chronic Development

    • Chronic Hepatitis C develops in over half of patients infected with acute Hepatitis C

Hepatitis C (Causes/Risk Factors)

  • High-Risk Behaviors and Conditions

    • IV drug use

    • Transfusions prior to 1992

    • Unsterile tattoos or piercings

    • Needlestick injuries

    • Alcohol use

    • Smoking

    • Coinfection with Hepatitis B or HIV

Hepatitis C (Subjective Data)

  • Symptoms Reported by Patients

    • Often asymptomatic until liver damage occurs

    • Fatigue

    • Malaise

    • Nausea

Hepatitis C (Objective Data)

  • Visible Signs and Lab Findings

    • Jaundice (occur in late stages)

    • Elevated liver enzymes

    • Hepatomegaly

Hepatitis C (Complications)

  • Potential Long-term Complications

    • Chronic hepatitis

    • Liver fibrosis

    • Cirrhosis

    • Liver cancer

    • Hepatocellular carcinoma

Sickle Cell Disease in African Americans Overview

  • Genetic Disorder

    • Glucose-6-phosphate dehydrogenase (G6PD) deficiency and lactose intolerance are more frequently diagnosed in African Americans

    • Genetic disorder leads to abnormal hemoglobin S, resulting in sickle-shaped red blood cells (RBCs) that can obstruct blood flow

    • Common among African Americans and those of Mediterranean descent

  • Common Symptoms in SCD

    • Splenomegaly (enlarged spleen)

    • Jaundice

Sickle Cell Disease (Causes/Risk Factors)

  • Genetic Inheritance

    • Autosomal recessive inheritance

  • Common Triggers

    • Dehydration

    • Infection

    • Cold exposure

    • Hypoxia

Sickle Cell Disease (Subjective Data)

  • Symptoms Reported by Patients

    • Severe pain (in joints, chest, abdomen)

    • Fatigue

    • Shortness of breath (SOB)

    • Weakness

    • Vomiting

Sickle Cell Disease (Objective Data)

  • Visible Signs and Lab Findings

    • Pallor (paleness)

    • Jaundice

    • Delayed growth

    • Tachycardia (rapid heart rate)

    • Leg ulcers

    • Fever

    • Swelling during crisis

Sickle Cell Disease (Complications)

  • Severe Complications

    • Vaso-occlusive crisis

    • Stroke

    • Organ ischemia

    • Acute chest syndrome

    • Increased risk of infection

Sickle Cell Disease (Nursing Interventions)

  • Primary Focus Areas for Care

    • Monitor for signs of crisis

    • Maintain hydration

    • Administer oxygen

    • Provide pain control

    • Educate patients on avoiding triggers

Visceral, Parietal, and Referred Pain

  • Visceral Pain Characteristics

    • Occurs when hollow organs are distended, stretched, or contract forcefully

    • Difficult to localize

    • Patients may describe it as gnawing, burning, cramping, or aching

    • If severe, may be associated with sweating, pallor, nausea, vomiting, or restlessness

    • Originates from internal organs; dull, deep, poorly localized pain caused by stretching, inflammation, or ischemia (e.g., appendicitis before peritoneal irritation)

  • Parietal Pain Characteristics

    • Results from inflammation of the peritoneum

    • Usually severe and localized over the involved structure

    • Patients describe it as steady, aching, or sharp, especially with movement or coughing (e.g., peritonitis)

    • Originates from the parietal peritoneum or body wall

  • Referred Pain Characteristics

    • Occurs in distant sites innervated at approximately the same spinal level as the disordered structure

    • Felt in a different location from its source due to shared nerve pathways (e.g., gallbladder pain in the right shoulder, cardiac pain in the left arm or jaw)

Self-Breast Exam (Purpose)

  • Objective

    • Early detection of breast abnormalities such as lumps or discharge

Self-Breast Exam (Timing)

  • Recommended Timing

    • Monthly, 3-5 days after menstruation

    • Postmenopausal women should select a consistent day for the exam

Self-Breast Exam (Steps)

  • Procedure

    1. Inspect breasts in a mirror for symmetry, dimpling, or redness

    2. Palpate breasts with three fingers in a circular pattern while standing or lying down

    3. Check nipples for discharge or tenderness

Self-Breast Exam (Abnormal Findings)

  • Indicators of Concern

    • Presence of lumps

    • Thickening of breast tissue

    • Peau d'orange (orange peel appearance)

    • Asymmetry in breast

    • Spontaneous discharge from nipples

Self-Breast Exam (Nursing Education)

  • Patient Education Key Points

    • Teach patients proper technique for self-exams

    • Encourage regular monthly checks

Mammography (Purpose)

  • Objective

    • Radiographic screening for breast cancer; aims to detect lesions before they become palpable

    • Recommended for women between 30 – 40 years of age

Mammography (Recommendations)

  • Age-specific Guidelines

    • Ages 40-44: Optional annual mammograms

    • Ages 45-54: Yearly mammograms

    • Age 55 and above: Every 1-2 years

Mammography (Patient Education)

  • Preparation and Guidelines

    • Avoid using deodorants or lotions before the test

    • Schedule the test for one week post-menses

    • Brief discomfort during the test is expected

Mammography (Abnormal Findings)

  • Indicators of Concern

    • Microcalcifications

    • Presence of masses

    • Distortion of breast tissue which requires further testing

DVT Overview

  • Definition

    • Formation of a clot in a deep vein, most commonly in the leg

    • Part of the Venous Thromboembolism (VTE) spectrum

  • Risk Factors

    • Increased immobility, surgery, pregnancy, oral contraceptive pills (OCPs), smoking, obesity, cancer

DVT (Subjective Data)

  • Symptoms Reported by Patients

    • Pain

    • Tenderness

    • Warmth

    • Heaviness in the affected leg

DVT (Objective Data)

  • Visible Signs and Lab Findings

    • Swelling

    • Redness

    • Warmth

    • Positive Homan’s sign (note: not diagnostic)

DVT (Complications)

  • Severe Risks

    • Pulmonary embolism

    • Post-thrombotic syndrome

DVT (Nursing Focus)

  • Key Nursing Responsibilities

    • Assess swelling and pain

    • Encourage ambulation

    • Elevate legs when possible

    • Use compression stockings

    • Monitor for signs of pulmonary embolism (PE)

Homan’s Sign

  • Definition and Use

    • Used to test for DVT

    • The test involves dorsiflexing the foot; pain during this maneuver suggests a positive result indicating DVT

    • Note: This test lacks sensitivity and specificity; it is recommended that Homan’s sign be omitted from the assessment of patients with suspected DVT.

Venous Thromboembolism

  • Definition

    • Includes both Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE); caused by thrombus formation in the venous system

  • Risk Increase

    • Risk increases with advancing age

  • Exercise Recommendations

    • Regular walking programs are important for improving quality of life

  • Neglect Risks

    • Inactivity may be an overlooked symptom in patients with undiagnosed Peripheral Arterial Disease (PAD) and can exacerbate the disease's progression

Venous Thromboembolism (Pathophysiology)

  • Virchow's Triad

    • Risk factors for thrombus development include:
      1) Venous stasis (immobility)
      2) Endothelial injury (trauma/surgery)
      3) Hypercoagulability (e.g., cancer, hormonal factors)

Venous Thromboembolism (Subjective Data)

  • Symptoms Reported by Patients

    • DVT: leg pain, heaviness

    • PE: sudden chest pain, shortness of breath (SOB), anxiety

Venous Thromboembolism (Objective Data)

  • Visible Signs and Lab Findings

    • DVT: swelling, redness, warmth, asymmetry

    • PE: tachycardia, tachypnea, decreased O₂ saturation, hypotension (noted in late stages)

Venous Thromboembolism (Nursing Interventions)

  • Primary Nursing Focus Areas

    • Encourage ambulation and perform leg exercises

    • Ensure adequate hydration

    • Use compression devices as applicable

    • Administer anticoagulants as prescribed

    • Monitor patients for signs of respiratory distress

Peripheral Artery Disease (Overview)

  • Description

    • Chronic arterial disorder caused by atherosclerosis that reduces blood flow to the limbs

Peripheral Artery Disease (Risk Factors)

  • Nonmodifiable Risk Factors

    • Age

    • Male sex

    • Family history

  • Modifiable Risk Factors

    • Smoking

    • Diabetes

    • Hypertension

    • Hyperlipidemia

    • Obesity

    • Sedentary lifestyle

Peripheral Artery Disease (Subjective Data)

  • Symptoms Reported by Patients

    • Intermittent claudication (pain or cramping in the legs during walking, relieved by rest)

    • Numbness

    • Coldness in the legs

Peripheral Artery Disease (Objective Data)

  • Visible Signs and Lab Findings

    • Weak or absent pulses in the lower extremities

    • Shiny, hairless skin

    • Pallor on elevation

    • Dependent rubor (redness when hanging down)

    • Ulcers present on toes

    • Delayed capillary refill time

Peripheral Artery Disease (Complications)

  • Severe Complications

    • Non-healing wounds

    • Gangrene

    • Possible amputation

Peripheral Artery Disease (Nursing Focus)

  • Key Nursing Responsibilities

    • Promote smoking cessation

    • Encourage exercise

    • Provide foot care information

    • Manage risk factors with medication or lifestyle changes

    • Assess pulses and temperature regularly

    • Keep the legs in a dependent position to promote blood flow

Cardiovascular Disease (Modifiable Risk Factors)

  • Key Modifiable Factors

    • Hypertension

    • Hyperlipidemia

    • Smoking

    • Diabetes

    • Obesity

    • Alcohol consumption

    • Stress

    • Poor diet

    • High cholesterol levels, high-fat diets, and physical inactivity contribute to cardiovascular disease

  • Behavioral Improvements

    • Healthy behaviors such as quitting smoking, reducing high blood pressure, and lowering high cholesterol are essential

  • Overall Goals

    • Improve cardiovascular health with better hypertension and cholesterol control, and increased educational efforts about signs and symptoms of disease, early detection, and treatment options (Reference: Office of Disease Prevention and Health Promotion [ODPHP], 2020)

Cardiovascular Disease (Nonmodifiable Risk Factors)

  • Key Nonmodifiable Factors

    • Age

    • Family history

    • Male gender

    • Ethnicity (higher prevalence observed in African American, Hispanic, and Native American populations)

Cardiovascular Disease (Nursing Focus)

  • Important Nursing Responsibilities

    • Monitor blood pressure, lipid levels, and glucose levels

    • Educate patients on lifestyle modifications and adherence to prescribed medications

Differential Diagnosis of Chest Pain

  • Cardiac Causes

    • Angina/myocardial infarction (MI): typically described as pressure or heaviness radiating to the jaw or arm

  • Pericarditis

    • Usually sharp pain, worse with inspiration

  • Pulmonary Causes

    • Sharp pleuritic pain

  • Gastrointestinal Causes

    • Burning pain relieved by antacids

  • Musculoskeletal Causes

    • Localized tenderness in response to palpation

  • Anxiety

    • May present as tightness and tingling sensations

  • Importance

    • Differential diagnosis of chest pain is critical as ischemic cardiac pain can result in loss of muscle cell function, which can lead to severe damage if untreated. An accurate description of the pain, along with alleviating factors and aggravating factors, can be highly indicative of the source.

Chest Pain (Nursing Focus)

  • Assessment Protocol

    • Assess onset, quality, radiation, and duration of the pain

    • Document associated symptoms

    • Obtain vital signs and an electrocardiogram (ECG) if cardiac distress is suspected

Grading of Pulses Scale

  • Pulse Grading

    • 0: Nonpalpable or absent

    • 1+: Weak and thready

    • 2+: Normal and expected

    • 3+: Full and increased

    • 4+: Bounding

  • Nursing Note

    • Assess all major arteries; compare sides for symmetry and strength

Stridor (Definition)

  • Description

    • High-pitched inspiratory sound arising from upper airway obstruction (larynx or trachea) attributed to laryngeal spasm or constriction. In cases of severe laryngospasm, the larynx may be completely closed off.

Stridor (Causes)

  • Common Causes

    • Croup

    • Epiglottitis

    • Foreign body obstruction

    • Laryngeal edema

    • Anaphylaxis

Stridor (Assessment)

  • Observations

    • Audible without a stethoscope

    • Signs of respiratory distress

    • Possible cyanosis

Stridor (Nursing Priority)

  • Critical Nursing Responsibilities

    • Conduct airway assessments

    • Ensure oxygen is available

    • Prepare for advanced airway interventions as needed

    • Immediate medical intervention is crucial for this life-threatening emergency

Crackles, Wheezes, Rhonchi

  • Crackles

    • Discontinuous sounds resulting from fluid in airways or alveoli, or from reopened collapsed airways during deep breathing

    • Sound resembles hair rubbing together or Velcro being pulled apart

    • Most often heard during inspiration but can also be heard during expiration

  • Wheezes

    • Continuous, high-pitched musical sounds produced by air squeezing through narrowed airways

    • Typical in asthma cases, usually heard during expiration; can be noted during inspiration in severe cases

    • Important to document when wheezes occur (inspiration, expiration, or both)

  • Rhonchi

    • Continuous, low-pitched snoring sounds due to movement of secretions in airways

    • Louder during expiration but can be heard throughout the respiratory cycle; may clear with coughing

    • Commonly associated with chronic bronchitis

Lung Sounds (Nursing Focus)

  • Key Responsibilities

    • Document timing, location, and changes in lung sounds with coughing

    • Record presence, quality, and associated symptoms with lung sounds

CHF (Overview)

  • Definition

    • Heart fails to pump effectively, resulting in fluid accumulation in lungs and tissues

  • Congestion Types

    • Left-sided: pulmonary congestion

    • Right-sided: systemic congestion

CHF (Subjective Data)

  • Symptoms Reported by Patients

    • Fatigue

    • Dyspnea (shortness of breath) on exertion

    • Orthopnea (difficulty breathing while lying flat)

    • Paroxysmal nocturnal dyspnea (PND; sudden nighttime difficulty breathing)

    • Weight gain due to fluid retention

CHF (Objective Data)

  • Signs Observable Upon Examination

    • Left-sided CHF: Crackles and pink frothy sputum

    • Right-sided CHF: Jugular vein distention (JVD), edema, hepatomegaly, ascites

    • Additional signs: S3 gallop, tachycardia

CHF (Complications)

  • Severe Risks

    • Pulmonary edema

    • Renal impairment

    • Arrhythmias

CHF (Nursing Focus)

  • Key Nursing Responsibilities

    • Assess lung sounds diligently

    • Monitor daily weights

    • Measure intake and output (I&O)

    • Administer diuretics as prescribed

    • Position patients upright

    • Implement a low-sodium diet and fluid restriction

Tuberculosis (Overview)

  • Chronic Infection

    • Caused by Mycobacterium tuberculosis, primarily transmitted via airborne routes

Tuberculosis (Subjective Data)

  • Symptoms Reported by Patients

    • Fatigue

    • Weakness

    • Anorexia (loss of appetite)

    • Weight loss

    • Night sweats

    • Persistent cough

    • Hemoptysis (coughing up blood)

Tuberculosis (Objective Data)

  • Notable Exam Findings

    • Fever

    • Tachycardia

    • Decreased breath sounds

    • Dullness to percussion

    • Positive TB test results

    • Cavitary lesions visible on chest X-ray

Tuberculosis (Nursing Focus)

  • Key Nursing Responsibilities

    • Implement airborne isolation precautions (N95 mask, negative pressure rooms)

    • Ensure adherence to long-term antibiotic regimens

    • Monitor for hepatotoxicity associated with treatment

Asthma (Overview)

  • Chronic Condition

    • Inflammatory airway disease characterized by reversible bronchoconstriction and airway hyperresponsiveness

Asthma (Triggers)

  • Common Triggers

    • Allergens

    • Infections

    • Exercise

    • Cold air

    • Tobacco smoke

    • Stress

Asthma (Subjective Data)

  • Symptoms Reported by Patients

    • Dyspnea

    • Chest tightness

    • Anxiety

    • Wheezing

    • Coughing

Asthma (Objective Data)

  • Observable Signs

    • Wheezing

    • Prolonged expiration

    • Use of accessory muscles for breathing

    • Tachypnea (rapid breathing)

    • Tachycardia (increased heart rate)

    • Low oxygen saturation (O₂) levels

Asthma (Complications)

  • Severe Risks

    • Status asthmaticus (severe asthma attack)

    • Respiratory failure

Asthma (Nursing Focus)

  • Key Nursing Responsibilities

    • Assess airway and breathing status

    • Provide oxygen as necessary

    • Administer bronchodilators and steroids

    • Educate patients about trigger avoidance

    • Instruct on proper inhaler techniques and peak flow meter use

Risk Factors for Oral Diseases

  • Key Risk Factors

    • Tobacco use

    • Alcohol consumption

    • Poor oral hygiene practices

    • High-sugar diets

    • Diabetes

    • Dry mouth from medications

    • Ill-fitting dentures

    • Underlying systemic diseases

  • Potential Outcomes

    • Leading to caries (cavities), periodontitis, and oral cancer

    • Education on proper hygiene and regular dental care is crucial

Tinnitus (Definition)

  • Description

    • Perception of ringing, buzzing, or roaring sounds without an external source

Tinnitus (Causes)

  • Common Causative Factors

    • Noise-induced hearing loss

    • Ototoxic drugs

    • Ear infections

    • Earwax (cerumen) impaction

    • Ménière's disease

    • Hypertension

Tinnitus (Subjective Data)

  • Reported Experiences by Patients

    • Ringing or roaring sounds

    • May affect sleep or concentration

Tinnitus (Nursing Focus)

  • Assessment Areas

    • Evaluate medication use and noise exposure history

    • Educate on ear protection

    • Refer to audiology as necessary

PERRLA

  • Definition

    • Documented when pupils are equal, round, and reactive to light and accommodation

PERRLA (Assessment)

  • Assessing

    • Check size and shape of pupils

    • Observe constriction to light and accommodation when focusing on nearby objects

PERRLA (Abnormal Findings)

  • Indicators of Concern

    • Unequal pupils

    • Sluggish or fixed pupil response; may indicate neurological emergencies

Head and Neck (Subjective Data)

  • Common Patient Complaints

    • Headaches

    • Dizziness

    • Vertigo

    • Stiffness in the neck

    • Lumps in the neck

    • Difficulty swallowing

    • Hoarseness

Head and Neck (Objective Data)

  • Assessment Findings

    • Inspect for symmetry of the head

    • Palpate scalp, lymph nodes, and thyroid; assess for trachea midline positioning

    • Evaluate range of motion (ROM)

Head and Neck (Abnormal Findings)

  • Indicators of Concern

    • Fixed lymph nodes

    • Presence of a goiter

    • Torticollis (twisted neck)

    • Tenderness upon palpation

Head and Neck (Nursing Focus)

  • Key Responsibilities

    • Document lymph node characteristics and any unusual findings

    • Observe for facial symmetry

    • Report any discovered masses promptly

Skin, Hair, Nails (Subjective Data)

  • Patient Concerns

    • Changes in skin or moles

    • Lesions

    • Hair loss

    • Nail changes

    • Itching

    • Dryness

    • Exposures to irritants or allergens

Skin, Hair, Nails (Objective Data)

  • Assessment Findings

    • Inspect skin color and presence of lesions or bruises

    • Palpate skin for temperature, texture, and turgor

    • Hair should appear even, nails should be pink and smooth, capillary refill should be less than 2 seconds

Skin, Hair, Nails (Abnormal Findings)

  • Indicators of Concern

    • Pallor

    • Cyanosis

    • Jaundice

    • Clubbing of nails

    • Poor turgor

    • Alopecia

    • Hirsutism

Skin, Hair, Nails (Nursing Focus)

  • Key Responsibilities

    • Assess pressure areas for ulcers

    • Document findings related to skin lesions

    • Educate patients on sun safety and importance of the melanoma detection ABCDE criteria (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolving)

Eye Assessment (Subjective Data)

  • Common Patient Concerns

    • Vision changes

    • Eye pain

    • Redness

    • Discharge

    • Halos around lights

    • Use of corrective lenses

Eye Assessment (Objective Data)

  • Assessment Findings

    • Inspect eyelids, conjunctiva, and sclera

    • Measure pupils (PERRLA)

    • Use Snellen chart for visual acuity assessment

    • Check extraocular movements (EOMs)

Eye Assessment (Abnormal Findings)

  • Indicators of Concern

    • Ptosis (drooping eyelids)

    • Redness, discharge

    • Unequal pupils

    • Nystagmus (involuntary eye movement)

    • Signs of cataracts or glaucoma

Eye Assessment (Nursing Focus)

  • Patient Education Focus Areas

    • Inquire about floaters/changes in eyesight

    • Encourage regular eye exams and lens safety

Ear Assessment (Subjective Data)

  • Common Patient Complaints

    • Hearing loss

    • Tinnitus

    • Vertigo

    • Ear pain

    • Ear drainage

    • History of noise exposure

Ear Assessment (Objective Data)

  • Assessment Findings

    • Inspect and palpate ears for tenderness

    • Conduct otoscopic examination to view the tympanic membrane (TM), which should be pearly gray and intact

    • Assess hearing using whisper, Weber, and Rinne tests

Ear Assessment (Abnormal Findings)

  • Indicators of Concern

    • Otitis externa or media

    • Cerumen impaction

    • Hearing loss

Ear Assessment (Nursing Focus)

  • Key Nursing Responsibilities

    • Review hearing aid use with patients

    • Teach on ear protection and proper cleaning techniques

Nose, Sinuses, Mouth, Throat (Subjective Data)

  • Common Patient Complaints

    • Nasal congestion

    • Nasal discharge

    • Sinus pain

    • Sore throat

    • Hoarseness

    • Dental hygiene habits

Nose, Sinuses, Mouth, Throat (Objective Data)

  • Assessment Findings

    • Inspect for midline nasal position and check mucosa for pink color

    • Palpate sinuses for tenderness

    • Ensure oral mucosa is intact, teeth are in good condition, and tonsils grade 1-2+ in size

Nose, Sinuses, Mouth, Throat (Abnormal Findings)

  • Indicators of Concern

    • Sinus tenderness

    • Nasal polyps

    • Oral lesions

    • Signs of tonsillitis or gingivitis

Nose, Sinuses, Mouth, Throat (Nursing Focus)

  • Key Responsibilities

    • Assess mucosal health

    • Encourage proper hygiene and hydration

    • Document any lesions or abnormalities

Abdominal Assessment (Subjective Data)

  • Common Patient Complaints

    • Changes in appetite

    • Nausea

    • Vomiting

    • Bowel habits fluctuations

    • Abdominal pain

    • Prior GI history

Abdominal Assessment (Objective Data)

  • Assessment Findings

    • Inspect contour of the abdomen

    • Auscultate bowel sounds

    • Percuss for tympany or dullness

    • Palpate for tenderness or masses

Abdominal Assessment (Abnormal Findings)

  • Indicators of Concern

    • Absent bowel sounds

    • Guarding or rigidity of the abdominal wall

    • Hepatosplenomegaly

    • Ascites (fluid build-up in the abdomen)

Abdominal Assessment (Nursing Focus)

  • Key Responsibilities

    • Assess bowel patterns routinely

    • Avoid palpation in the presence of suspected aneurysms

    • Monitor patient's nutritional status

Breast and Axillae Assessment (Subjective Data)

  • Common Patient Complaints

    • Presence of lumps

    • Tenderness

    • Nipple discharge

    • Family history of breast disease

    • Hormone therapy usage

Breast and Axillae Assessment (Objective Data)

  • Assessment Findings

    • Inspect breasts for size and symmetry

    • Palpate each quadrant of the breast and axillae systematically

Breast and Axillae Assessment (Abnormal Findings)

  • Indicators of Concern

    • Presence of lumps

    • Breast asymmetry

    • Peau d'orange texture

    • Retraction of the nipple

    • Node enlargement in axillae

Breast and Axillae Assessment (Nursing Focus)

  • Key Responsibilities

    • Teach self-breast examination (SBE) techniques

    • Encourage routine mammogram screenings

    • Report any new findings to healthcare provider promptly

Peripheral Vascular and Lymphatic (Subjective Data)

  • Common Patient Complaints

    • Leg pain

    • Swelling

    • Heaviness in legs

    • Tingling sensations

    • Presence of ulcers or varicose veins

Peripheral Vascular and Lymphatic (Objective Data)

  • Assessment Findings

    • Inspect color and condition of the legs

    • Evaluate for edema and varicosities

    • Palpate temperature, pulses, and lymph nodes

Peripheral Vascular and Lymphatic (Abnormal Findings)

  • Indicators of Concern

    • Presence of edema

    • Coolness of skin

    • Varicosities evident

    • Enlargement of lymph nodes

Peripheral Vascular and Lymphatic (Nursing Focus)

  • Key Responsibilities

    • Elevate legs for patients with venous issues

    • Keep legs dependent in arterial issues

    • Promote ambulation

    • Use compression stockings as indicated

Thorax and Lung (Subjective Data)

  • Common Patient Complaints

    • Cough

    • Sputum production

    • Dyspnea

    • Chest pain

    • Wheezing

    • History of smoking or relevant exposures

Thorax and Lung (Objective Data)

  • Assessment Findings

    • Inspect shape and symmetry of the chest

    • Palpate for chest expansion

    • Percuss for resonance

    • Auscultate for breath sounds

Thorax and Lung (Abnormal Findings)

  • Indicators of Concern

    • Asymmetrical expansion of the chest

    • Barrel chest appearance

    • Dull percussion notes

    • Diminished breath sounds

    • Presence of crackles, wheezes, or rhonchi

Thorax and Lung (Nursing Focus)

  • Key Responsibilities

    • Monitor respiratory rate diligently

    • Encourage deep breathing exercises

    • Document lung assessments and oxygen saturation status