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Fundamentals of Nursing

EVOLUTION OF NURSING Period of Intuitive Nursing (Prehistoric to early Christian era) Nursing was untaught and instinctive Performed out of compassion for others and desire to help others

Beliefs and Practices of Prehistoric Man Nursing was a function that belonged to women taking care of the children, the sick and the aged. Believed that illness causes the invasion of evil spirit through the use of black magic or voodoo. Believed that medicine man was called shaman or witch doctor having the power to heal using white magic. They also practiced trephining or drilling a hole in the skull with a rock or stone without anesthesia as a last resort to drive evil spirits from the body.

Contributions to Medicine and Nursing Babylonia o Code of Hammurabi provided laws that covered every facet of Babylonian life including medical practice and recommended specific doctors for each disease and gave each patient the right to choose between the use of charms, medications or surgical procedures. Egypt o Introduced the art of embalming o Developed the ability to make keen observation and left a record of 250 recognized diseases o Slaves and patients families nursed the sick Israel o Moses was recognized as the Father of Sanitation and wrote in Old Testament which: Emphasized the practice of hospitality to strangers and acts of charity Promulgated laws of control on the spread of communicable disease and the ritual of circumcision of the male child Referred to nurses as midwives, wet nurses or childs nurses whose acts were compassionate and tender China o Believed that in using girls clothes for male babies keep evils away from them o Prohibited the dissection of dead human body as a worship to ancestors o They gave the world knowledge of material medica (pharmacology) India o Men of medicine built hospitals, practiced an intuitive form of asepsis and were proficient in the practice of medicine and surgery

o Sushurutu made a list of function and qualifications of nurses. This was the first reference to nurses taking care of the patients. Ancient Greece o Nursing was the task of untrained slave o Introduced caduceus, the insignia of medical profession today o Hippocrates was given the title of Father of Scientific Medicine. He made major advances in medicine by rejecting the belief that diseases had supernatural causes. He also developed assessment standards for clients, established overall medical standards, recognized a need for nurses. Rome o The Romans attempted to maintain vigorous health, because illness was a sign of weakness o Care of the ill was left to the slaves or Greek physicians. Both groups were looked upon as inferior by Roman society. o Fabiola made her home the first hospital in the Christian world through the help of Marcella and Paula

Period of Apprentice Nursing (Founding of religious nursing orders to 1836 when Kaiserwerth Institute for the training of Deaconesses in Germany was established) Also called the period of on the job training. Nursing care was performed without any formal education and by people who were directed by more experienced nurses Religious orders of the Christian church were responsible for the development of this kind of nursing. Crusades Military religious orders established hospitals staffed with men Knights of Lazarus was founded and primarily for the nursing care of lepers in Jerusalem after the Christians had conquered the city. Rise of Secular Orders Religious taboos and social restrictions influenced nursing at the time of the Religious Nursing orders Hospitals were poorly ventilated and the beds were filthy There was overcrowding of patients: 3 or 4 patients regardless of diagnosis or whether dead or alive, may have shared one bed. Practice of environmental sanitation and asepsis were non-existent Older nuns prayed with and took good care of the sick, while younger nuns washed soiled linens, usually in the rivers. St. Catherine of Siena. The first Lady with a Lamp. She was a hospital nurse, prophetess, researcher and a reformer of society and the church. In 16th century, hospitals were established for the care of the sick where hospitals were gloomy, cheerless, airless and unsanitary. People entered hospitals only under compulsion or as a last resort. Dark Period of Nursing (17th to 19th century)

There were no provisions for the sick, no one to care for the sick Nursing became the work of the least desirable of women---women who took bribes from patients, who stole the patients food and who used alcohol as a tranquilizer. They worked seven days a week slept in cubbyhole near the hospital ward or patient and ate scraps of food when they could find them. Period of Educated Nursing (From June 15, 1869 when Florence Nightingale School of Nursing was opened until World War II) The development of nursing during this period was strongly influenced by trends resulting from wars, from an arousal of social consciousness, from the emancipation of women and from the increased educational opportunities offered to women Popularization of the philosophy of the Nightingale System o Importance of nursing education o Hospital affiliation o Nurses teaching students o Health teaching as critical responsibility o Enforced written physician orders o Expansion in no. of schools to North America o Specialization developed Facts about Florence Nightingale o Recognized as the Mother of Modern Nursing o Known also as the Lady with a Lamp o Raised in England and learned languages, literature, mathematics and social graces o Developed he self-appointed goal: to change the profile of nursing o Compiled notes of her visits to hospitals, her observation of the sanitary facilities and social problems of the places she visited o Noted the need for preventive medicine and good nursing o Advocated the care of those afflicted with diseases caused by lack of hygienic practices o At age 31, she entered the Deaconess School of Kaiserworth o Worked as superintendent for Gentlewomen during illness o Disapproved of the restrictions on admission of patients and considered this unchristian and incompatible with health care o Upgraded the practice of nursing and made nursing an honorable profession for gentlewomen o Led the nurses that took care of the wounded during the Crimean war o Put down her ideas in two published books: Notes on Nursing and Notes on Hospitals Period of Contemporary Nursing (Period after World War II up to present) Scientific and technological developments as well as social changes mark this period Establishment of WHO Use of atomic/nuclear energy for medical diagnosis and treatment Utilization of computers Use of sophisticated equipment for diagnosis and therapy Health is perceived as a fundamental human right Nursing involvement in community health is greatly intensified

Development of the expanded role of nurses Professionalization of nursing Nursing in the Philippines Early Beliefs and Practices Beliefs about causation of disease (evil spirits, enemy or a with) People believed that evil spirits could be driven away by persons with powers to expel demons People believed in special gods of healing, with the priest-physician and Herbolarios Superstitious beliefs and practices in relation to health and sickness such as Herbmen or Herbicheros as one who practiced witchcraft Persons suffering from diseases without identified cause were believed to be bewitched by mangkukulam. Spanish Period The religious orders exerted their efforts to care for the sick by building hospitals in the different parts of the Philippines Earliest hospitals established: Hospital real de Manila (1577) built to care for the Spanish kings soldiers San Lazaro Hospital (1578) built exclusively for patients with leprosy Hospital de Indio (1586) established by Franciscan Order; service was in general supported by alms and contributions from charitable individuals. Hospital de Aguas Santas (1590) founded by Brother J. Bautisita of the Franciscan Order. San Juan de Dios Hospital (1596) Founded by the Brotherhood of Misericordia and administered by the Hospitalliers of San Juan de Dios; support was derived from alms and rents; rendered general health service to the public. Nursing during Philippine Revolution Prominent persons involved in nursing works Jpsephine Bracken installed a first hospital in an estate house in Tejeros; provided nursing care to the wounded night and day Rosa Sevilla de Alvero converted their house into quarters for the Filipino soldiers, during the Philippine-American War that broke out in 1899. Dona Hilaria de Aguinaldo wife of Emilio Aguinaldo; organized Filipino Red Cross under the inspiration of Apolinario Mabini Dona Maria Agoncillo de Aguinaldo econd wife of Emilio Aguinaldo; provided nursing care to Filipino soldiers during revolution. President of Filipino Red Cross branch in Batangas Melchora Aquino Nursed the wounded Filipino soldiers and gave them shelter and food Capitan Salome a revolutionary leader in Nueva Ecija; provided nursing care to the wounded when not in combat Agueda Kahabagan revolutionary leader in Laguna, also provided nursing services to her troops Trinidad Tecson Ina ng Biac na Bato, stayed in the hospital at Biac na Bato to care for the wounded soldiers. Filipino Red Cross Malolos, Bulacan was the location of the national headquarters Functions:

o Collection of war funds and materials through concerts, charity bazaars, and voluntary contributions o Provision of nursing care to wounded Filipino soldiers Requirements for Membership o At least 14 years old, age requirement for officer was 25 years old o Of sound reputation

Hospitals and Schools of Nursing Iloilo Mission Hospital School of Nursing (Iloilo City, 1906) It was run by the Baptist Foreign Mission Society of America. In March, 1944, 22 nurses graduated; in April 1944 graduate nurses took the first Nurses Board Examination at the Iloilo Mission Hospital. St Pauls Hospital School of Nursing (Manila, 1907) Established by the Archbishop of Manila, the Most Reverend Jeremiah Harty under the supervision of the Sisters of St. Paul de Chartes. It was located in Intramuros and it provided general hospital services with free dispensary and dental clinic Philippine General Hospital School of Nursing (1907) Anastacia Giron-Tupas, the first Filipino nurse to occupy the position of chief nurse and superintendent in the Philippines St. Lukes Hospital School of Nursing (Quezon City, 1907) Mary Johnston Hospital and School of Nursing (Manila, 1907) Philippine Christian Institute Schools of Nursing Sallie long Read memorial Hospital School of Nursing (Laoag, Ilocos Norte, 1903) Mary Chiles Hospital School of Nursing (Manila, 1911) Frank Dunn Memorial Hospital (Vigan, Ilocos Sur, 1912) San Juan de Dios School of Nursing (Manila, 1913) Emmanuel Hospital School of Nursing (Capiz, 1013) Southern Islands Hospital School of Nursing (Cebu, 1918) First Colleges of Nursing in the Philippines University of Santo Tomas College of Nursing (1946) Manila Central University College of Nursing (1947) University of the Philippines College of Nursing (1948) Nursing Leaders in the Philippines Anastacia Giron-Tupas First Filipino nurse to hold the position of Chief Nurse Superintendent; founder of Philippine Nurses Association Cesaria Tan First Filipino to receive a Masters degree in Nursing abroad Socorro Sirilan pioneered in hospital social service Rosa Militar a pioneer in school health education Sor Ricarda Mendoza pioneer in nursing education Conchita Ruiz first full-time editor of the newly named PNA magazine The Filipino Nurse Loreto Tupaz Dean of the Philippine Nursing; Florence Nightingale of Iloilo

Health

A.

B.

Definitions of health vary 1. Traditional definition: freedom from disease 2. 1958 World Health Organization defined health as "state of complete physical, mental and social well-being and not merely the absence of disease and infirmity" Health belief model 1. Psychological and behavioral theory 2. Attempts to explain individual health behaviors 3. Health behaviors are based on three factors a. the individuals perception of susceptibility of illness b. the individuals perception of seriousness of the illness c. the likelihood that the person will take preventive action 4. Modifying factors a. cultural beliefs b. economics c. political factors d. social factors e. personal beliefs

Health Promotion C. Definitions 1. Health promotion behavior is behavior in which the client views health as a goal and engages in behaviors designed to achieve or maintain that goal. 2. Health care includes prevention, early detection, treatment and rehabilitation for clients with potential for or existing illness or disability. 3. Healthy lifestyle can increase or maintain client's level of wellness and functional ability. 4. Health screening (for risk factors or illness) can prevent or minimize illness and disability. 5. Disease prevention behaviors are behaviors designed to decrease the likelihood/risk of illness. a. primary prevention

b.

health promotion and disease prevention applied to clients considered physically and emotionally healthy III. example: exercise programs, healthy diet secondary prevention I. early detection of illness II. focuses on individuals who are experiencing health problems and illnesses and who are at risk for complications III. activities are directed at diagnosis and prompt treatment IV. example: breast self examination, cholesterol screening

I. II.

D.

tertiary prevention I. prevention of further deterioration in disease or disability II. occurs when a defect or disability is permanent and irreversible III. activities are directed at rehabilitation IV. example: alcoholics anonymous Primary health care 1. Accessible, community-based or work-based health care services based on principle of universal access, which ensures health care for all individuals regardless of employment or insurance status 2. Health Security Act of 1993 offered universal access to basic hospital, preventive, physician and long-term services. It included these seven services: a. physical examinations b. screening tests c. diagnosis and treatment of common acute illnesses d. management of chronic illnesses e. liaison with community resources f. provision of prenatal care g. identification of need for specialty referrals Providers include physicians, and advanced practice nurses, such as: nurse midwives and nurse practitioners 4. Services provided through a managed care model 5. Specialty services provided and reimbursed only after referral from the primary care provider 6. Primary care settings include a. health maintenance organizations (HMOs) b. public health departments c. occupational health clinics d. schools e. nurse managed clinics f. collaborative practice settings Healthy People 2010 1. The US Department of Health and Human Services released Healthy People 2010: National Promotion and Disease Prevention Objectives 2. Statement of national health objectives designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats 3. The goals of the project are: a. increase quality and years of healthy life b. eliminate health disparities 3.

c.

E.

F.

G.

Health promotion model 1. Developed by Nola Pender 2. Health promotion depends on seven factors of cognitionperception a. importance of health to the person b. perceived control of health c. perceived self-efficacy d. definition of health e. perceived health status f. perceived health benefits from the health-promoting behavior g. perceived barriers to the health-promoting behavior Risk factors - probability of acquiring a particular health problem 1. Varies with age, race, ethnicity, gender 2. Risk increases with certain lifestyle choices, such as smoking, occupation, diet, environment 3. Modifiable risk factors include occupation and diet 4. Non-modifiable risk factors include race and age 5. Examples: risk factors are important in a. coronary artery disease b. cancer c. colon cancer I. over 50 years of age II. family history of colon polyps or cancer III. urban living IV. diet high in fats and low in fiber d. tuberculosis I. history of exposure to person with TB II. history of travel or living outside United States III. history of prison time IV. HIV infection V. cancer chemotherapy VI. malnutrition VII. homelessness VIII. history of IV drug use IX. medical workers

diabetes: candidates for screening I. strong family history of diabetes mellitus II. markedly obese III. obstetrical history of babies weighing over nine pounds at birth IV. obstetrical history of miscarriage or fetal death V. pregnant women between 24-28 weeks gestation VI. history of gestational diabetes Health Promotion Programs and recommendations for the average American H. Screening Health Screening
A. Blood pressure screening 1. Screening should be done annually beginning at age 21 for both males and females 2. Screening for children and adolescents is also recommended but optimal interval has yet to be determined 3. Auscultatory method with a properly calibrated and fitting cuff should be used 4. Person should be seated quietly in a chair for at least five minutes with feet on the floor and arms supported at heart level 5. At least two measurements should be done, two minutes apart 6. Pre-hyerptensive individuals (SBP 120-139 and DBP 80-89) should be counseled on lifestyle modifications such as weight reduction, exercise, diet, and smoking cessation 7. SBP > 140 and / or DBP > 90 should be referred to a health care provider for antihypertensive drug therapy Breast self-examinations 1. Should be started by age twenty 2. Done at the same time of the month - preferably seven days after onset of the menstrual cycle; if no menstrual cycles, do at the same time each month 3. Technique should be reviewed by a health care provider to ensure effectiveness 4. Limited effectiveness, but when done regularly helps a woman understand how her breasts

e.

B.

lump or thickening (breast or underarm) red or hot skin orange peel skin dimpling or puckering itch or rash, especially in nipple area retracted nipple g. change in direction of nipple h. bloody or spontaneous discharge i. unusual pain j. a sore on the breast that does not heal C. Risky behaviors - assist in assessment of behaviors that impact the health of individuals in the following developmental stages 1. Adolescents (age 13-19) a. eating disorders i. anorexia nervosa - restrictive eating ii. bulimia nervosa - binge eating followed by purging b. injury prevention i. wearing of seat belts ii. wearing of helmets iii. sports injuries iv. homicide and suicide c. substance abuse i. tobacco ii. underage drinking iii. illicit drug use d. sexual behavior i. number of sex partners ii. use of contraception iii. unintended pregnancy iv. exposure to sexually transmitted diseases 2. Young adult (age 20-35) a. eating disorders - onset of obesity b. injury prevention i. motor vehicle accidents ii. occupational hazards iii. homicide and suicide c. substance abuse i. tobacco ii. alcohol use iii. illicit drug use d. sexual behavior i. sexually transmitted disease - use of condoms ii. unintended pregnancy e. stress i. changing roles marriage beginning a new family starting a new job ii. depression 3. middle adult (age 35-65) a. obesity b. lack of exercise c. substance abuse i. tobacco ii. alcoholism iii. illicit drug use d. lack of preventative health care e. stress i. job ii. family / divorce iii. acceptance of aging 4. older adult (age 65 and older) a. obesity b. lack of exercise c. substance abuse i. tobacco ii. alcoholism iii. illicit drug use d. injury prevention i. falls ii. seatbelts iii. suicide iv. multiple medications

a. b. c. d. e. f.

D. Scoliosis screening 1. Recommendations vary but generally accepted to perform screening at onset of adolescence 2. Significantly more prevalent in girls than boys 3. Early intervention important because untreated scoliosis can lead to disfigurement, impaired mobility, and cardiopulmonary complications 4. Technique: clothing should be removed from upper body a. while standing, check adolescent for asymmetry of shoulders, scapula, hips, or waist b. assess for misalignment of spinous processes - lateral curvature and convexity of thoracic spine indicate scoliosis c. with feet together and legs straight, have adolescent bend forward until back is parallel to floor; check for prominence of ribs on one side only and hip and leg asymmetry - chest wall on side of convexity is prominent and scapula on side of convexity is elevated 5. Abnormalities are to be followed up by a health care provider and referral to orthopedist may be necessary for severe curvatures E. Testicular self-examinations 1. Monthly self-examination should begin in adolescence, since this is the highest risk group 2. Best time to perform exam is during or after a bath or shower when the scrotum is relaxed 3. Limited research to determine if regular examinations reduce death rate but they are strongly encouraged for men with risk factors such as a. family history of testicular cancer Timing of Mammogramscryptochidism b. c. previous germ cell tumor in one testicle 4. Findings that shouldthe Americanto a health care provider their recommendations for The National Cancer Institute (NCI) and be reported Cancer Society differ in include a. hard lumps or nodules scheduling of mammorgrams. b. change in size, shape, or consistency of the testes The NCI recommends (2002): Women in their 40s should be screened every one to two years with mammorgraphy. Women aged 50 and older should be screened every one to two years.

1.

Cholesterol - once every five years if normal age 45 and older

In than average risk of breast Women who are 2. higherwomen: mammography cancer should seek expert medical advice about at
whether they should begin screening before age 40 and the frequency of screening.

The ACS guidelines for the detection of breast cancer in asymptomatic women (2002): Women 40 years of age and older should have a mammogram every year. Women 40 and older should have a physical examination of the breast every year, performed by a health care professional, such as a physician, physician assistant, nurse or nurse practitioner. This examination should take place near and preferable before, the annual mammogram. Women 20-39 should have a physical examination of the breast every three years, performed by health care professional such as a physician, physician assistant, nurse or nurse practitioner.

BSE is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away.

I.

J.

In women: the first papanicolau smear at the onset of sexual activity and/or over age 18, annually 4. In men: prostate-specific antigen - annually 50 years of age or at age 40 for those at risk 5. For colon cancer a. digital rectal exam every year after the age of 40 b. guaiac test for occult blood every year after the age of 50 c. proctoscopy every three to five years after the age of 50 after two negative annual exams d. colonoscopy 6. Tuberculosis skin tests: intradermal injection of antigen 7. Diabetes: fasting plasma glucose, ideally eight to 12 hours fast 8. Vision: after age 39, medical eye exam every three to five years 9. Hearing: candidates for screening include: a. family history of childhood hearing impairment b. perinatal infection (rubella, herpes, cytomegalovirus) c. low birth weight infants d. chronic ear infection e. down syndrome Compliance 1. Definition: adherence to primary or secondary prevention recommendations 2. Factors influencing compliance a. personal meaning and perceptions: knowledge, values, beliefs, outcome expectations b. social factors: environmental context, social relationships, social support, societal norms, economic resources c. deficiencies in the health care system: access, costs, wait time, monolingual services Noncompliance 1. An individual's informed decision not to adhere to a therapeutic recommendation 2. Individual unable or unwilling to alter habitual behaviors or adopt new behaviors necessary to a prescribed therapeutic regimen

3.

Health Assessment K. Health assessment in general 1. Purposes of health assessment a. data collection b. supplement, confirm or refute historical data c. identify changes in client's status d. evaluate the outcomes of care 2. Components of health assessment: history and physical

a.

history I. chief complaint II. III. IV. V. VI. VII. VIII. IX. X. XI. location quality quantity precipitating or aggravating factors duration associated findings

general health status medical history family history social history occupation activity level sleep nutrition medications; including substance use/abuse psychosocial factors

b. physical exam: skills i. inspection process of observing the differences between normal physical signs and deviations requires knowledge of normal physical signs throughout the lifespan principles of Inspection o in good lighting and with whole body part visible o observe each area for size, shape, color, and position o compare body parts bilaterally for symmetry ii. palpation
.

use touch to assess resistance, resilience, roughness, texture and mobility . palpation may be either light or deep in pressure use light palpation to determine tenderness ii. deep palpation usually depresses the area by 1 to 2 inches; use it to examine specific organs . use palmar surface of fingers to determine position, texture, size, consistency, and pulsation; also presence and shape of mass . use back of hand to test temperature . use palm of hand to sense vibration percussion tap the body with fingertips: to detect fluid, or to assess location, size, density and borders of organs. tapping the body produces vibration and sound waves which you hear as percussion tones methods
i.

ii.

direct: striking the body surface with two fingers ii. indirect: striking the middle finger of the nondominant hand on the back surface with the fingers of the dominant hand rather than the body surface, while keeping the palm and remaining fingers off the body character of percussion sounds depends on the density of the tissue being percussed CHARACTER OF PERCUSSION SOUNDS Tympany: Drumlike, loud, high pitch, moderate duration; usually found over spaces containing air such as the stomach Resonance: Hollow sound of moderate to loud intensity; low pitch, long duration; Usually heard over lungs Hyperresonance: Booming sound of very loud intensity; very low pitch, long duration; Usually heard in the presence of trapped air (such as emphysematous lung) Flatness: Flat sound of soft intensity; high pitch; short duration; Usually heard over muscle Dullness: Thud-like sound of soft intensity; high pitch; moderate duration; Usually heard over solid organs (such as heart, liver) iii. auscultation listening (with unassisted ear or stethoscope) to sounds made by the body assess presence of sounds and their character o frequency (high or low pitch) o loudness (loud or soft) o quality (blowing, gurgling, booming, thudlike, hollow, flat) o duration (short, moderate, long) olfaction use of sense of smell to differentiate common body odors from abnormal ones common odors include o urine: ammonia o skin: body odor o body wastes: feces, vomitus o mouth: halitosis physical exam equipment client positions

i.

v.

vi.

EQUIPMENT NEEDED FOR PHYSICAL EXAM


Client Gown Drapes Stethoscope Gloves Percussion Hammer Sphygmomanometer (Blood Pressure gauge and cuff) Thermometer Tape measure Cotton swabs Flashlight Tongue depressor Scale Lubricant Eye chart Miscellaneous: safety pin, ruler, paper towels

reporting general appearance and behaviors o gender and race o age o obvious signs of distress o body type o posture o gait o body movements o hygiene o dress o affect and mood o speech vital signs height and weight body temperature o range: 36 to 38 degrees Celsius (98.6 to 100.4 degrees Fahrenheit) o measure core temperature: rectum, tympanic membrane, esophagus, or urinary bladder o measure surface temperature: skin, axilla, or mouth o body temperature normally varies with age exercise hormone level circadian rhythm (time of day) stress environment

Health Assessment by Body Part


B. Eye 1. History a. current findings b. past problems c. family history - glaucoma, cataracts d. harmful exposure - chemical sunlight 2. Physical exam a. vision test b. extraocular muscle functions (EOM's) c. external eye structures d. internal eye structures and red reflex e. optic disc f. retinal vessels 3. Geriatric alterations of eye a. arcus senilis - Opaque white ring about the periphery of the cornea, seen in aged persons; caused by the deposit of fat granules in the cornea or by hyaline degeneration. b. pupils often miotic (smaller) with slower dilation c. iris may appear paler d. retina may appear paler

e. disc may be slightly smaller and more opaque f. presbyopia g. color perception may be dimmed C. Ear 1. History a. presenting problem or injury b. presence of hearing loss c. use of hearing assist d. associated findings e. onset f. precipitating factors g. aggravating and alleviating factors h. lifestyle factors: swimming, musician i. medical history j. family history of allergy or hearing disease k. medications 2. Inspection - external ear a. observe size, shape and symmetry of both ears b. auricles are normally level with each other, and upper point of attachment is in a straight line with the lateral canthus of the eye c. inspect ear skin for color, lesions, rash and scaling d. inspect area behind auricle for tophus (A deposit of sodium biurate in tissues near a joint, in the ear, or in bone in gout) Palpation a. palpate auricle, tragus and mastoid area for tenderness and elevated local temperature b. normal findings: auricle is normally smooth without lesions c. estimate size of external auditory meatus Otoscopic examination a. adult: grasp auricle and pull up and back to straighten external ear canal before inserting otoscope b. child: grasp auricle and pull down and back c. inspect ear canal for redness, swelling, discharge, crusting and foreign bodies d. expect a small amount of moist, usually orange cerumen (ear wax). Cerumen is usually dry in Asians, Native Americans, and the elderly e. tympanic membrane i. normal finding: translucent, shiny, light gray, taut disk; free from tears or breaks ii. test its mobility: ask client to say "ah" or swallow. Intact membrane will vibrate slightly Hearing acuity: four tests a. gross hearing is tested by client's response to normal conversation b. whispered word or ticking watch test c. Weber test: tuning fork of 512 cps is set to vibrate and placed perpendicularly on the midline vertex of the skull. Client asked to report in which ear sound is heard. If heard in one ear, suspect sensorineural loss in the other d. Rinne test - compares sound conduction: air versus bone i. set tuning fork to vibrate ii. place on mastoid process iii. ask client whether the sound is heard and when it can no longer be heard. Note how long the sound can be heard.

3.

4.

5.

6.

when client states that sound is gone, immediately move the tuning fork to about 2 cm from auditory canal v. ask the client again whether there is sound and when it stops vi. normal finding: latter sound should be heard twice as long as that of mastoid sound Geriatric alterations a. ear lobes may appear pendulous b. presbycusis

iv.

D.

Mouth and pharynx 1. Inspection: normal findings a. temporomandibular joint: smooth jaw excursion; easy mobility b. lips and buccal mucosa: symmetrical, pink; smooth and moist c. teeth and gums: 32 adult teeth; pink gums d. tongue: symmetry; pink; moist; papilla present e. hard and soft palate: hard palate is pale, immovable with transverse rugae; soft palate is pink and movable f. Oropharynx: symmetrical; midline uvula, tonsils may be present on either side 2. Geriatric alterations a. mucosa may be drier b. sense of taste may be diminished c. decreased saliva d. lips thinner, shiny e. teeth may appear yellowish f. tongue may appear smoother Skin 1. General appearance - inspection a. color i. varies with body part, and from person to person ii. color ranges "white" skin: Ivory or light pink to ruddy pink dark skin: light to dark brown or olive a. alterations in skin color hyperpigmentation hypopigmentation iii. cyanosis iv. jaundice v. erythema moisture temperature texture: varies from part to part i. smooth or rough ii. supple or tight iii. indurated turgor i. normally decreases with age ii. decreased in dehydration vascularity i. in older people, capillaries are more fragile ii. petechiae edema lesions

E.

i. ii.

b. c. d.

e. f.

g.
h.

i.

ii.
iii.

iv.

v.

i.

hair

normal finding: free of lesions age-related changes include keratosis senilis, cherry angiomas, and atrophic warts. primary lesions macule - Discolored spot or patch on the skin, neither elevated nor depressed, of various colors, sizes, and shapes papule - A small, red, elevated area on the skin, solid and circumscribed; a pimple patch - A small circumscribed area distinct from the surrounding surface in character and appearance. plaque - A patch on the skin or on a mucous surface vesicle = A small sac or bladder containing fluid. *A blisterlike small elevation on the skin containing serous fluid. bulla = A large blister or skin vesicle filled with fluid; a bleb pustule - A small elevation of the skin filled with lymph or pus nodule - A small node. secondary lesions (arise from primary) scale crust lichenification scar excoriation ulcer fissure keloid erosion for every lesion, note eight aspects: color location texture size shape type grouping distribution hirsutism alopecia

i. ii.

j. nails k. factors affecting skin condition i. hygiene ii. nutritional status iii. underlying disorders l. geriatric changes in skin (besides wrinkling, and loss/graying of both head and body hair) i. thinner skin ii. more freckles iii. hypopigmented patches iv. skin is drier, especially on lower extremities v. less perspiration vi. all skin becomes less elastic; hanging parts sag vii. toenails may be thick, distorted, and yellowish viii. lesions: cherry angiomas, senile keratosis, atrophic warts F. Heart

1. 2.

Assess the heart through the anterior thorax (front chest) Inspection and palpation a. client in supine position or with head elevated at 45 degrees b. anatomical landmarks of the heart i. second right intercostal space - aortic area ii. second left intercostal space - pulmonic area iii. third left intercostal space - Erb's point iv. fourth left intercostal space - tricuspid area v. fifth left intercostal space - mitral (apical) area vi. epigastric area at tip of sternum apical impulse i. fourth or fifth left intercostal space, midclavicular line ii. may or may not be seen iii. normally a short, gentle tap Auscultation a. client takes three positions: sitting, supine, left lateral recumbent b. use stethoscope to auscultate heart sounds c. S1 i. closing of the mitral valve ii. after long diastolic pause and iii. before short systolic pause iv. heard best at apex d. S2 i. closing of aortic valve ii. after short systolic pause and iii. before long diastolic pause iv. heard best over aorta - second right interspace v. high pitched, dull in quality e. pulse deficit f. murmurs i. grading system c.

3.

CLASSIFYING HEART MURMURS BY INTENSITY Grade I: Difficult to hear, even with stethoscope Grade II: Quiet, heard with stethoscope Grade III: Moderately loud, no thrill Grade IV: Loud, may have a thrill Grade V: Very loud, heard with a stethoscope partially off chest; has thrill Grade VI: Can be heard with a stethoscope off chest; has a thrill

ii.

iii. iv. v.
G.

asymptomatic or symptomatic thrill systolic murmur occurs between S1 and S2 diastolic occurs between S2 and S1

Vasculature 1. Blood pressure a. reflects relationship between cardiac output, peripheral vascular resistance, blood volume and viscosity, and arterial elasticity

b.

c. d.

factors influencing blood pressure i. age ii. stress iii. race iv. drugs v. diurnal (day-night) variations vi. gender alterations in blood pressure i. hypertension ii. hypotension range of normal blood pressure i. child under age 2 weighing at least 2700g: use flush technique, 30-60mg Hg ii. child over age two: 85-95/50-65 mm Hg iii. school age: 100-110/50-65 mm Hg iv. adolescent: 110-120/65-85 mm Hg v. adult: <130 mm Hg Systolic / <85 mm Hg diastolic BLOOD PRESSURE (BP)

Common Mistakes during Upper Extremity BP Checks


Too wide a bladder or cuff produces false low reading Too narrow a bladder or cuff produces false high reading Cuff wrapped too loosely produces a false high reading Deflating cuff too slowly produces false high diastolic reading Deflating cuff too quickly produces a false low systolic and false high diastolic reading Inaccurate inflation level produces a false low systolic reading Taking the blood pressure in lower extremities

Peripheral BP Measurement in the legs


Use the popliteal artery behind knee as a stethoscope auscultatory site Position the client prone or sitting with knees slightly flexed Use wide, long cuff; wrap it so that the bladder is over the posterior aspect of midthigh Systolic blood pressures in legs are 20-40 mmHg higher than in the brachial artery Diastolic pressure in the legs is about the same as in the brachial artery

2.

3.

4.

Internal carotid arteries in neck a. palpate each separately along margin of sternocleidomastoid b. normal findings: strong thrusting pulse c. auscultate both sides d. normal findings: no sound heard e. constriction causes bruit Jugular veins a. client in supine position with head elevated at 45 degrees b. normal findings: pulsations not evident c. jugular venous pressure (JVP): not to exceed 3 cm above level of sternal angle Peripheral arteries and veins a. pulse

i.

LOCATIONS OF PULSES

locations

Head - Neck 1. Temporal: over temporal bone lateral to eye 2. Carotid: over the carotid artery in neck Chest 3. Apical: between 4th and 5th intercostal space usually mid-clavicular line Arm 4. Brachial: in the antecubital area of arm 5. Radial: on thumb side of wrist 6. Ulnar: medial wrist Leg 7. Femoral: below the inguinal ligament ii. normal range of peripheral pulses 8. Popliteal: behind the knee 9. Posterior tibial: on inner side of each ankle infants: 120 to 160 beats/minutes toddlers: 90 to 140 beats/minutes 10. Dorsalis pedis: along top of foot preschool/school-age: 75 to 110 beats/

iii.

minute adolescent/adult: 60 to 100 beats/minute factors affecting rate exercise temperature stress drugs hemorrhage postural changes pulmonary conditions causing poor oxygenation

b. c.

rhythm - regular (normal) or irregular strength i. reflects volume of blood ejected with each beat

ii. PULSE GRADING SCALE grading system =0 No pulse Weak pulse = 1+ Difficult to palpate = 2+ Normal = 3+ = 4+ Bounding

d. e. f.

g.

equality alterations dysrhythmias tissue perfusion i. temperature ii. color: cyanosis iii. clubbing iv. edema

v. vi. vii. H. Lungs

skin and nail texture hair distribution on lower extremities presence of ulcers

1. 2.

History: smoking, infections, pain, discomfort, dyspnea, activity intolerance, fever Inspection a. general appearance: respirations i. breathing should be quiet and easy ii. respiration involves ventilation, diffusion, and perfusion of gases iii. factors influencing respirations exercise pain anxiety stress anemia posture drugs: narcotics, amphetamines iv. normal rates of respiration newborn: 35 to 40 breaths/minute infant: 30 to 50 breaths/minute toddler: 25 to 35 breaths/minute school age: 20 to 30 breaths/minute adolescent/adult: 14 to 20 breaths/minute adult: 12 to 20 breaths/minute v. depth: deep, normal, shallow vi. rhythm: regular, irregular; Normal finding: regular vii. skin color viii. chest wall configuration

normal findings: symmetrical with bilateral muscle development a-p to transverse ratio range: 1 to 5: 2 to 7

3.

4. 5.

Palpation a. feel for abnormalities such as masses, lesions, scars, swelling, crepitus, asymmetry b. crepitus indicates air in subcutaneous space (in thoracic area, usually due to pneumothorax) c. vocal fremitus i. vibration felt when patient speaks ii. increased over areas of consolidation Percussion - normal findings: resonance heard throughout lung fields Auscultation a. normal findings: quiet breathing throughout all lung fields b. whispered pectoriloquy i. client whispers "one, two, three" ii. over normal areas of the lung, only faint sounds are heard iii. over consolidated areas, the words are more distinct c. egophony i. client says "E"

6.

7.

ii. over consolidated areas, the sound is a nasal "A" Alterations in lung function a. cough b. expectoration c. dyspnea d. bradypnea e. tachypnea f. hyperpnea g. apnea h. Cheyne-Stokes respiration i. Kussmaul's breathing j. Biot's breathing k. grunting l. retractions m. hemoptysis n. pain o. accessory muscle use p. cyanosis q. adventitious sounds r. pursed-lip breathing i. prolonged exhalation ii. breathing out through puckered lips s. pleural friction rub i. grating sound produced by inflamed pleura rubbing together ii. usually heard loudest over lower lateral anterior chest at end of inspiration Pediatric differences a. smaller, shorter, more pliable airways, b. underdeveloped supporting cartilage c. above two factors increase the risk of obstruction due to mucus, edema, or foreign body d. flexible larynx more susceptible to spasm e. immature immune system f. incomplete myelinization g. increased basal metabolic rate h. decreased ability to mobilize secretions i. less forceful cough

I. Breasts 1. Inspection (performed with client in lying, sitting, or standing position) j. k. l. m. size: vary from convex to pendulous symmetry (the left breast is commonly larger than the other) skin: color, venous pattern, possibly a few hairs around areola alterations I. retraction II. dimpling III. lesions IV. edema V. inflammation VI. alterations with pregnancy and lactation I. enlargement of breasts II. soreness of nipples during lactation III. possible striae nipple and areola I. size

n.

2.

color: ranges from pink to brown shape I. areola: round or oval II. nipples: everted IV. symmetry: normally symmetrical V. direction: normally nipples point in same direction VI. alterations I. discharge II. inverted nipples III. bleeding Palpation - breast a. lymph nodes - normal findings: not palpable b. breast tissue 1. client in supine position with hand placed behind neck 2. methods of examining breast tissue clockwise or counterclockwise circling breast from nipple outward back and forth with fingers moving up and down each breast 3. consistency: varies widely from person to person normal findings: dense, firm and elastic 4. alteration - fibrocystic disease of the breast 5. geriatric alterations relaxed breasts may appear elongated or pendulous decrease in glandular tissue

II. III.

J.

Abdomen 1. History a. pain, bowel habits, dietary problems, weight change, difficulty swallowing, flatulence, belching, heartburn, nausea, vomiting, cramping b. changes in micturition including: change in amount and color of urine, irritation of the lower urinary tract, obstruction of the urinary tract, urinary incontinence, urinary tract pain 2. Inspection a. landmarks i. xiphoid process: marks upper boundary of abdomen ii. symphysis pubis: marks lower boundary iii. abdomen divided into four quadrants: RUQ, RLQ, LUQ, LLQ

3.

4.

5.

6.

7.

normal findings i. skin texture and color should be consistent with rest of body ii. stria may be present iii. umbilicus is normally flat or concave midway between xiphoid and symphysis pubis iv. abdomen may be flat, concave or convex; all three are normal if there is symmetry v. you may note peristalsis movement or aortic pulse vi. voiding: steady, straight stream with no pain or post void dribble Percussion a. normal findings: tympany over stomach and intestines; dullness over liver, spleen, pancreas, kidneys and distended (>150cc) bladder b. liver border i. usually noted in the 5th, 6th or 7th intercostal space ii. distance between upper and lower borders should range between 6 to 12 cm at right midclavicular line c. spleen i. left posterior midaxillary line: dullness at 6th to 10th rib ii. left intercostal space in anterior axillary line: tympany Palpation a. normal findings: soft with no palpable masses, no tenderness or rigidity b. bladder noted as a bulge in abdomen when filled with more than 500cc of urine c. deep palpation may produce tenderness - liver, kidneys, spleen inguinal nodes generally not palpable Auscultation a. bowel motility - normal findings: audible in all quadrants b. vascular sounds - normal findings i. no vascular sounds over aorta or femoral arteries ii. renal artery bruits can be heard Alterations a. distention b. ascites c. paralytic ileus d. borborygmus e. guarding (muscles contract) f. tenderness g. pain Geriatric alterations a. increased fat deposits over abdominal area b. muscle tone more lax

b.

K.

Female reproductive system 1. History: sexually transmitted disease, menstrual history, obstetrical history, contraception

2.

3.

Inspection a. external genitalia - normal findings i. hair distribution: variable; usually inverted triangle starting at symphysis pubis ii. skin of perineum smooth, clean, slightly darker than other skin iii. labia majora: may be closed or gaping iv. clitoris: about 2 cm in length and 0.5 cm in width v. urethral orifice: intact, pink without irritation vi. vaginal orifice: ranges from thin, vertical slit to large orifice with moist tissue vii. anus: moist and hairless: skin more darkly pigmented b. internal genitalia i. cervix - normal findings: pink; midline; usually about two to three cm in diameter; smooth, firm, rounded or oval; odorless, creamy or clear secretions ii. Papanicolaou (pap) smear iii. vagina: pink throughout; clear or cloudy, odorless secretions; about 10 to 15 cm in length Palpation a. ovaries may or may not be palpable; firm, slightly tender, oval, mobile; about 4 cm in diameter b. uterus: mobile; rounded; palpable at level of pelvis c. Skene's glands and Bartholin's gland - normal findings: nontender, no discharge

4.

Geriatric alterations a. labial folds flatten b. skin paler, shiny c. meatus usually more posterior d. cervix decreases in size; may appear paler e. scanty cervical discharge f. vagina shortens with age g. decreased vaginal secretions h. uterus diminishes in size; may not be palpable i. ovaries atrophy with age

L.

Male reproductive system 1. History: sexual history, sexually transmitted disease, contraception, surgery, associated urinary problems

2.

3.

4.

Inspection a. external genitalia b. hair distribution: varies; hair extends from base of penis over symphysis pubis; coarse and curly c. penis shaft, corona, prepuce, glans d. urethral meatus is slit like opening positioned on ventral surface, millimeters from tip of glans; opening should be glistening and pink e. scrotum i. skin more darkly pigmented; more wrinkled; usually loose ii. symmetry: left testicle is lower than right iii. size: changes with temperature f. inguinal canal - normal finding: no bulging Palpation a. penis i. foreskin should retract easily ii. small amount of thick white secretion between glans and foreskin is normal iii. testicle: ovoid; ranges from 2 - 4 cm in diameter, smooth and rubbery; nontender b. inguinal canal i. normal finding: inguinal lymph nodes not palpable Geriatric alterations a. increased bogginess of prostate

5.

b. testes softer Rectum and anus a. inspection of perianal areas i. skin: smooth and uninterrupted ii. anal tissues: normally moist and hairless b. digital palpation i. anal sphincter: note tone ii. rectal walls: smooth and even iii. prostate gland I. palpate through anterior rectal wall II. small walnut-sized, heart shaped structure III. ranges from 2.5 to 4 cm in diameter IV. normal findings: firm, protrudes < 1 cm into rectum c. alterations i. hemorrhoids

ii. iii. iv.


v. M.

fissures fistulas polyps pain

Musculoskeletal 1. History: participation in sports, risk factors for osteoporosis, impact of current problem on activities of daily living 2. Inspection a. gait - normal findings: client walks with arms swinging freely at sides; coordinated and smooth; rhythmic with push off and swing through b. posture and balance - normal findings i. upright stance with parallel alignment of hips and shoulders ii. feet aligned; toes pointing straight ahead iii. convex curve to thoracic spine iv. concave curve to lumbar spine v. can stand still without swaying or tilting c. extremities i. normal findings: bilateral symmetry in length, circumference, alignment, position and number of skin folds 3. Palpation

a. all muscles, bones, joints b. normal findings: muscles firm, non-tender 4. Range of motion - normal findings: able to move joints through required range of motion a. abduction - Lateral movement of the limbs away from the median plane of the body, or lateral bending of the head or trunk b. adduction - Movement of a limb or eye toward the median plane of the body or, in the case of digits, toward the axial line of a limb. c. dorsiflexion - Movement of a part at a joint to bend the part toward the dorsum, or posterior aspect of the body. d. eversion - Turning outward e. extension - A movement that brings the members of a limb into or toward a straight position f. flexion - The act of bending or condition of being bent in contrast to extension. g. hyperextension - Extreme or abnormal extension. h. inversion - A turning inside out of an organ (e.g., the uterus). i. plantar flexion NERVE FUNCTION so that the forepart is CRANIAL - Extension of the foot depressed with respect to the position of the ankle j. pronation - The act of lying prone or face downward. 1. Olfactory (CN I) k. supination - The condition of being on the back or having Can identify variety of smells the palm of the hand facing upward or the foot turned inward Deviation: Inability to identify aroma and upward 5. Muscle strength and symmetry - normal findings: arm on dominant side generally stronger 2. Optic (CN II) 6. Alterations a. Has visual acuity and full visual kyphosis - An exaggeration or angulation of the normal fields posterior Fundoscopic exam reveals no pathology curve of the spine, giving rise to the condition commonly known as humpback, hunchback, or Pott's Deviation: Inability to identify full visual fields - total or partial blindness of one or both eyes curvature. b. (CN IV), and abducens (CN VI) 3, 4, 6. Oculomotor (CN III), trochlear lordosis - Abnormal anterior convexity of the lumbar spine. c. scoliosis - A lateral curvature of the spine d. pain Follows up to six cardinal positions of gaze 7. Geriatric alterations Pupils are unremarkable a. stance Exhibits no nystagmus and no ptosis less upright with head and neck forward b. will lumbar curvature less pronounced Deviation: one or both eyes deviate from its normal position c. height decreased d. gait slower to initiate and stop 5. Trigeminal (CN V) e. less knee and ankle lifts f. steps may be shorter and more rapid Clenches teeth with firm bilateral pressure g. may need to hold onto furniture as age increases Has no lateral jaw deviation with mouth open h. muscles atrophy with disuse Feels a cotton wisp touched to forehead, cheek and chin i. weaker grip Differentiates sharp and dull sensations on face j. active range of motion may be slower and limited in one or Corneal reflex; blinks when cotton is touched to each cornea more joints Deviation: Absent or one-sided blinking of eyelids k. joints appear larger than surrounding tissue; may be stiff 7. Facial (CN VII)

Neurological system 1. History Has facial symmetry with and without a smile 2. Mental status Can raise the eyebrows symmetrically and grimaceExam (MMSE) - A commonly used a. Mini-Mental Status Can shut eyes tightly assessment tool to quantify a person's cognitive ability. It Can identify sweet, sour, salt orassesses the anterior tongue bitter on orientation, registration, attention and Deviation: Irregular and unequal facial movements calculation, and language. Scoring is from 0 to 30, with 30 Deviation: Inability to taste or identify taste indicating intact cognition Deviation: Inability 3. taste or identify salt,- sweet, sour, or bitter substancesspeech anterior two-thirds of the to Emotional status normal findings: affect matches on the tongue Deviation: Inability to smile symmetrically 4. Cranial nerve function

N.

8. Acoustic (CN VIII) Can hear a whisper at 1-2 feet Can hear a watch tick at 1-2 feet Does not lateralize the Weber test Can hear AC (air conduction) better than BC (bone conduction) in the Rinne test Deviation: Inability to hear spoken word

9, 10. Glossopharyngeal (CN IX) and Vagus (CN X) Swallows and speaks without hoarseness Palate and uvula rise symmetrically when patient says "ah" Bilateral gag reflex Can identify taste on the posterior tongue Deviation: Unequal or absent rise of uvula and soft palate as the client says, "ah" Deviation: Absent gag reflex Deviation: inability to taste or identify taste on the posterior tongue

11. Spinal accessory (CN XI) Resists head turning Can shrug against resistance Deviation: Weak or absent shoulder and neck movement

12. Hypoglossal (CN XII) Can stick tongue out and move it from side to side Can push tongue strongly against resistance Deviation: Tongue deviates to side

ALTERATIONS IN LEVEL OF CONSCIOUSNESS Level of consciousness (LOC) - normal findings a. alert Alert b. responds appropriately to visual, auditory, tactile and 1. Awake and aware of person, place, time, and situation painful stimuli 2. Responds appropriately and to verbal stimuli commands c. able to carry out simple d. Glasgow Coma Scale Lethargic e. alterations in LOC 1. Sleeps but easily aroused 2. Speaks and responds slowly and appropriately Obtunded 1. Difficult to arouse 2. Returns to sleep quickly; may respond inappropriately Stuporous 1. Aroused only through pain 2. No verbal response Semicomatose 1. Responds only to pain 2. Gag and blink reflexes intact Comatose 1. No response to pain 2. No reflexes or muscle tone 5.

Note: dying clients will proceed through these levels in this above-listed sequence.

ASSESSMENT OF SENSORY NERVE FUNCTION (done with client's eyes closed)


Superficial pain Prick with sterile needle Have client identify whether sharp or dull Temperature Two test tubes: one filled with hot water, the other with cold water Client identifies hot versus cold sensation and where it is felt Light touch 6. Sensory function - normal findings Cotton ball; apply light wisp of cotton to different surface points; Client identifies when touched Vibration Low pitched tuning fork Apply to distal interphalangeal joint of finger then toe, Client identifies when vibration stops Position Grasp client's finger or great toe, holding by its sides Client identifies if moving up or down Two-point discrimination Two safety pins Apply lightly and simultaneously to two different places on skin's surface. Usually start with finger pads, Find minimal distance at which client can discriminate one from two points, normally <5mm on finger pads; Client identifies when can discriminate one from two points Stereognosis Use coin or paper clip or any familiar object with client's eyes closed Client identifies object to identify by touch and manipulation Graphesthesia (number identification) Number is traced on the client's palm by a blunt object Client identifies number Extinction Corresponding areas on both sides of body are simultaneously stimulated Client identifies where touched

7.

visual: recognizes objects auditory: identifies sounds tactile: identifies objects through blind touch; perceives pain, hot and cold and vibration; two-point discrimination d. olfactory: identifies familiar smells Cerebellar function - position and balance CEREBELLAR FUNCTION

a. b. c.

Romberg test: tests position sense, note client's ability to stand upright when standing with feet together and eyes closed for 20-30 seconds Hop in place: maintains balance while hopping on one foot Knee bends: maintains balance while bending at knees Tandem walking: walks heel to toe in straight line Rapid skills: TESTS FOR REFLEXES 1. Pronates and supinates hands rapidly with equal timing and purposeful movement 2. Touches alternate finger to nose rhythmically with eyes open and closed Deep tendon reflexes with selected site stimulus 3. Moves finger alternately from nose to examiner's finger in coordinated fashion 1. Biceps reflex (C5, C6): flexion of arm at elbow 4. Runs contralateral heel down shin with bilateral coordination 2. Triceps reflex (C6, C7): extension of arm at elbow and contraction of triceps muscles 3. Brachioradialis (supinator) reflex (C5, C6): flexion at elbow and pronation of forearm One-foot balance 4. Quadriceps (knee-jerk or patellar) reflex (L2, L3, L4): extension of leg at knee and 1. Maintains balance on and language -least five seconds 8. Speech one foot for at normal findings contraction of quadriceps 2. Bilateral response with eyes flowing speech a. smooth open and closed 5. Achilles (ankle-jerk) reflex (S1, S2) b. able to formulate words without difficulty c. varied inflection Superficial reflexes d. 1. Pharyngeal reflex (CN able to write letters and numbers to dictation IX, CN X) e. vocabulary appropriate to educational level 2. Upper Abdominal reflex (T8, T9, T10): upward movement of umbilicus toward stimulus 9. Intellectual - normal findings above umbilicus a. memory: immediate recall and remote recall 3. Lower Abdominal reflex (T10,T11,T12): downward movement of umbilicus toward b. oriented to person, place and time stimulus below umbilicus c. able to abstract 4. Cremasteric reflex (T12, L1) Elevation of ipsilateral testicle (the side stimulated) d. 5. Gluteal reflex (L4-S3): demonstrates consistent insight and perception insertion contraction of anal sphincter with gloved finger of self 10. Reflexes - assessment and grading Pathologic reflexes in adults - documented as "positive for ___" a. pediatric considerations 1. Babinski reflex (Plantar) (L4-S2): stroking lateral sole of foot causes dorsiflexion of great toe with fanning of other toes (normal expectation in children up to age 18 months on the average) 2. Chaddock reflex (L4-S2): stroking below lateral malleolus causes dorsiflexion of great toe with fanning of other toes 3. Ankle Clonus: Brisk dorsiflexion of foot with knee flexed causes up and down movement of foot; found in severe preeclampsia 4. Oppenheim: stroking tibial surface causes great toe fans out 5. Gordon: squeezing calf muscle; great toe fans out 6. Hoffmann: flicking middle finger down; flexion of the thumb Common expected reflexes - normal for all ages 1. Gag 2. Corneal

REFLEX GRADING

0 1+ 2+ 3+ 4+
11.

= no response = sluggish or diminished response = normal = brisker than normal = hyperactive and very brisk (may be associated with spinal cord disorder)
Geriatric alterations in neuro status a. longer response time to sensory stimulation b. may resist new ideas or change c. thought patterns may become more concrete d. kinesthesia diminishes - The ability to perceive extent, direction, or weight of movement e. superficial and deep reflexes may be diminished or absent

X.

Client/Family Education A. Adult learning theory 1. Self-directed 2. Reservoir of experience 3. Adults prefer mutual planning/goal setting 4. Internally motivated 5. Established orientation to learning 6. Educator is facilitator of learning 7. Experiential rather than didactic 8. Must be immediately applicable to life B. Teaching/learning process 1. Assessment

C. D.

E.

2. Identification of learning needs 3. Outcome (goal) setting 4. Educational offerings 5. Evaluation of outcomes Learning styles 1. Vary with individuals 2. Learners can be visual, auditory, or tactile (kinesthetic) Teaching strategies 1. Demonstration / return demonstration 2. Programmed instruction 3. Role playing 4. Simulation 5. Case study analysis 6. May be individualized or in groups 7. May be computerized 8. May be media-based or print Legal implications 1. American Hospital Association issued the Patient Bill of Rights in 1973 that guaranteed clients the right to information necessary to give informed consent before treatment begins. 2. Individualized teaching must be documented in client's chart 3. Alterations for geriatric clients a. make sure client has glasses or hearing aid b. face the client and use a lower pitched voice c. supplement oral presentation with print materials d. use large print e. provide good lighting f. some clients have a hard time seeing color; use black on white or yellow paper g. keep sessions short and work with survival-level information initially h. repeat often for clients prone to memory loss i. break down learning into small steps j. use specific, step-by-step directions and have the client redemonstrate them k. get frequent feedback regarding client's level of understanding 4. Health Insurance Portability and Accountability Act (HIPAA)signed into law in 1996. This law includes important new protections for millions of working Americans and their families who have preexisting medical conditions or might suffer discrimination in health coverage based on a factor that relates to an individual's health. HIPAA places requirements on employersponsored group health plans, insurance companies and health maintenance organizations (HMOs). HIPAA includes changes that: a. limit exclusions for preexisting conditions b. prohibit discrimination against employees and dependents based on their health status c. guarantee renewability of health coverage to certain employers and individuals d. protect many workers who lose health coverage by providing better access to individual health insurance coverage. 5. The first-ever federal privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers took effect on April 14, 2003. Developed by the Department of Health and Human Services (HHS), these new standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed.

6.

The new privacy regulations ensure protection for patients by limiting the ways that health plans, pharmacies, hospitals and other covered entities can use protected medical records and to other individually identifiable health information, whether it is on paper, in computers or communicated orally. Key provisions of these new standards include: a. access to medical records b. notice of privacy practices c. limits on use of personal medical information d. prohibition on marketing e. stronger state laws f. confidential communications g. complaints

Points to Remember Health Promotion: Health Assessment


Measure vital signs when the client is at rest Compare both sides of the body for symmetry Assess the systems related to the clients major complaint first Offer rest periods if client becomes tired Culture and religious beliefs may play a role in observed differences Warm hands and equipment such as stethoscope before touching client Tell client what you are going to do before touching client Normal variations exist among clients and there is a range of normalcy for all physical findings Maintain the clients privacy throughout the examination Control for environmental factors which may distort findings Check equipment prior to exam for functioning Consider growth and developmental needs when assessing specific age groups Integrate client teaching throughout the exam

Vasculature

Compare blood pressure in arms left versus right Compare blood pressure with client lying, sitting and standing

Lungs - Airway

Anemic patients may never become cyanotic Polycythemic patients may be cyanotic, even when oxygenation is normal Cough results from stimulation of irritant receptors, with implications of either acute or chronic etiology. Cyanosis indicates decreased available oxygen. Etiology can be either peripheral or central in origin. Wheezes indicates narrowing/inflammatory process of lower airways Stridor harsh sound produced near larynx by vibration of structures in upper airway. Classic "barky cough" Crackles or rales adventitious sounds, usually on inspiration and indicating inflammation

Breast

Breast tissue shrinks with menopause Teach client breast self examination

Abdomen - Reproductive System


Auscultation should be performed before palpation to prevent distortion of bowel sounds Tightening of abdominal muscles hinders accuracy of palpation and auscultation Warm hands before touching clients abdomen. Men breathe abdominally; women breathe costally. Auscultate all four quadrants for bowel sounds Auscultate abdomen between meals

Musculoskeletal

Older adults walk with smaller steps and need a wider base of support

Neurological

Glasgow Coma Score

not valid in patients who have used alcohol or other mind-altering drugs possibly not valid in patients who are hypoglycemic, in shock, or hypothermic (below 34C) o should be compared to total of 10 when client is intubated Reflexes are normally less brisk or even absent in older clients Reflex response diminishes in the lower extremities before the upper extremities are affected Absent reflexes may indicate neuropathy or lower motor neuron disorder Hyperactive reflexes suggest an upper motor neuron disorder
o o

Teaching client and family


Teaching-learning process mirrors the nursing process Select teaching strategies that are compatible with the clients learning style, age, culture, level of education Client teaching should be multi-sensory Always confirm the clients understanding of the information presented Teaching must be geared to the level of the learner Repeat key information and summarize main points at intervals Explain medical terminology in lay terms Determine the clients learning style and gear teaching methods to using that style Sequence information the way the client will use it Be concrete and use the simplest words and the shortest sentences when teaching low literacy clients, or any client under stress