Health Assessment and Promotion Midterm Study Guide_ Latest updated 2021/2022
Introduction
- Health is specific to the individual and based on experience, upbringing, race/ ethnicity, sexual identity, culture, values
...
Health Assessment and Promotion Midterm Study Guide_ Latest updated 2021/2022
Introduction
- Health is specific to the individual and based on experience, upbringing, race/ ethnicity, sexual identity, culture, values
o Health: a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity (WHO)
o Biomedical health: absence of disease
o Holistic health: the view that the mind, body, and spirit are interdependent and function as a whole within the environment
o Wellness: a dynamic process and view of health; a move toward optimal functioning; a “positive” state of health
- Role of the professional nurse:
o To promotes health
o To prevent illness
o To treat human responses to health or illness
o To advocate for individuals, families, communities, and populations
- Health assessment: a systemic method of collecting and analyzing data
o Utilizes the American Nurses Association’s (ANA) Standards of practice, which incorporates the
nursing process
- Nursing Process: the traditional critical thinking competency that allows nurses to make clinical judgments and take actions based on reason
o Supports nurses to continually examine what they are doing and to study how it can be done better
o Benefits of the nursing process
▪ Diagnose both actual and potential problems
▪ Provide a blueprint or plan for patient care
▪ Systemic
▪ Dynamic
▪ Humanistic
▪ Outcome-focused
o Assessment → Diagnosis → Planning → Implementation → Evaluation
o Assessment: health history (subjective data), physical assessment (objective data), psychological, sociocultural, spiritual, economic, lifestyle, documentation of date
▪ Subjective data: symptoms, history
● Information the patient or their family tells you
● “I have a headache”; “My husband says he has a headache”
▪ Objective data: signs, physical examination
● The findings resulting from direct observation using all of your senses (sight, sound, touch, smell)
● Uses techniques of inspection, palpation, percussion, and auscultation
o BP 120/80; patient is restless; WBC 12,000; lungs crackles bilaterally
▪ Documentation: legal document of patient’s health status
● Baseline for evaluation; changes and decisions related to care
● Confidentiality: keeping patient health information private
o (HIPAA): requires protection of specific health information
Accuracy and completeness: must precisely reflect assessment data without bias; legally accepted abbreviation use; correction
● Narrative: SOAP, PIE, DAR, CBE
o SOAP: subjective, objective, assessment, plan
o PIE: plan, implement, evaluate
o DAR: data, action, response
o CBE: charting by exception (abnormal signs lead to additional assessments)
● Verbal: SBAR
o SBAR: situation, background, assessment, recommendation
▪ Types of Assessments:
● First level priority problems, second level priority problems, third level priority problems, collaborative problems
- Critical Thinking: an active organized, cognitive process used to carefully examine one’s thinking and the thinking of others
o Basic critical thinking: concrete and based on a set of rules, early step in developing reasoning, not enough experience to individualize; weak competencies
o Complex critical thinking: analyze and examine choices independently; look beyond expert opinion; thinkers separate self from experts; each solution has benefits and risks
- Data analysis, interpretation, and clinical judgment include:
o Identifying abnormal findings
o Correctly interpreting findings to select appropriate plan of care
o Applying clinical judgment to interpret or make conclusions regarding patient needs, concerns, or health problems
o After understanding the situation, the nurse responds by determining appropriate interventions
- Diagnostic Reasoning:
o Attending to initially available cues
o Formulating diagnostic hypothesis
o Gathering date relative to the tentative hypothesis
o Evaluating each hypothesis with the new data collected, thus arriving to at a final diagnosis
- Diagnosis: formulating using PES statement
o Problem
o Etiology
o S: defining characteristics
o Diagnosis (P) is related to (r/t) etiology (E) as evidenced by (aeb) characteristics (S)
▪ Diagnosis and etiology is not a medical diagnosis; characteristics is the assessment data
o Types of Diagnoses
▪ Medical: disease condition based on specific evaluation of signs and symptoms
▪ Nursing: judgment about the patient in response to an actual or potential health problem
▪ Collaborative: an actual or potential physiological complication that nurses monitor to detect the onset of changes in patient’s status
Medical vs. Nursing Diagnoses
Pneumonia Impaired gas exchange;
ineffective breathing pattern
Acute Myocardial
Infarction Chest pain; decreased
cardiac output
o Types of Nursing Diagnoses
▪ Actual: describes human responses to health conditions or life processes that exist in an individual, family, or community
▪ Risk (potential): describes human responses to health conditions/ life processes that may develop in a vulnerable individual, family, or community
▪ Wellness: describes human responses to levels of wellness in an individual, family, or community
- Evidence Based Practice: systematic approach to practice that emphasizes the use of best evidence in combination with the clinician’s experience, as well as the patient preference and values, to make decisions about care and treatment
- Complete Health History:
o Biographic Data
o Source of History
o Reason for seeking care
o Present Health/History of present illness
o Past Health
o Family History
o Review of Systems
o Functional Assessment
o Perception of Health
- Health promotion: behavior motivated by desire to increase well-being and actualize health potential; the process of enabling people to increase control over, and to improve, their health
o Disease prevention
o Behavior motivated by desire to avoid illness, detect illnesses early, and maintain functioning when ill
o Central component of nursing
o Begins with health assessment—data to identify patient’s health status, practices, and risk factors
o Interpretation of data allows the nurse to target health promotion needs
- Three levels of health promotion/protection:
o Primary prevention: optimize health and disease prevention through promotion of healthy lifestyles
o Secondary prevention: identify at an early stage to initiate prompt treatment; screening efforts
o Tertiary prevention: minimizing the effects of the disease or illness and allowing for the most productive life within limitations
- Health People 2020: objectives address most significant preventable threats to health with goals to reduce threats
o Four overarching goals:
▪ Attain high quality, longer lives, free from preventable diseases
▪ Achieve health equity, eliminate disparities, and improve the health of all groups
▪ Create social and physical environments that promote health for all
▪ Promote quality of life, healthy development, and healthy behaviors across all life stages
Interviewing & Health History Cultural Considerations
- Health Assessment: health history and physical examination
- The Interview
o Subjective Data: patient knows everything and you know nothing
▪ Primary data: from the patient
▪ Secondary data: from family, caregivers, chart
o Identify: areas of concern that should be addressed during the physical examination; topics for teaching and health promotion
o Goals: Record a COMPLETE health history
▪ Create a database used to create a plan, prevent disease, resolve problems, and minimize limitations
o Keys: gather complete and accurate data, including chronology and symptoms of illness; establish rapport and trust; teach about health state
o “Contract” between nurse and patient
▪ Consists of spoken and unspoken rules for behavior (verbal and nonverbal)
▪ Sending and receiving communication
o Verbal Communication: talking/ interacting
o Nonverbal Communication: appearance, sitting/standing, posture, facial expression, gestures, eye contact, touch
o Pre-interaction
o Beginning the interview:
▪ “Mr. Craig, I want to ask you some questions about your health and your usual daily activities so that we can plan your care here in the hospital.”
o The working phase: process by helping them to describe and clarify their experiences, to plan courses of action and try out the plans, and to begin to evaluate the effectiveness of their new behavior
o Closing the interview:
▪ “Are there any questions you would like to ask?”
o Therapeutic Communication: single-most important factor for successful interviewing is the communication skill of the nurse; professional communication gains the patient’s trust
o The Interview is Affected by numerous factors:
▪ Physical setting
▪ Nurse behaviors
▪ Type of questions asked
▪ How questions are asked
▪ Personality and behavior of patients
▪ How patient is feeling at the time of interview
▪ Nature of information being discussed or problem being confronted
o Physical setting: private, quiet, comfortable room without distractions; privacy is essential for sensitive issues
o Patient-related Variables:
▪ Consider patient age and physical, mental, and emotional status
▪ Ideally, the patient will be alert and in no physical or emotional discomfort
▪ If in distress, limit the number and nature of necessary questions. Save additional questions for later
o Asking Questions:
▪ The art of obtaining information and listening carefully is an essential competency of nurses
▪ Some areas of questioning are sensitive, and sensitivity varies
▪ Seek clarification
Open-Ended Questions Closed (Direct) Questions
Narrative Information Specific Information
Calls for long answers Calls for short one- to –two word answers
Elicits feelings, opinions, ideas Elicits cold facts
Builds and enhances rapport Limits rapport
Tell me about your headaches Are your headaches on one side or both
- Responses
o Patient’s frame of reference: active listening, facilitation, clarification, restatement, reflection, empathy
o Your frame of reference: confrontation, interpretation, explanation, summary
- Nonverbal skills
o Physical appearance
o Nonverbal: posture, gestures, facial expression, eye contact
o Touch
- Patient’s frame of reference:
o Active listening and facilitation
o Facilitation
▪ “Go on…”
o Silence
▪ Don’t interrupt
o Reflection
▪ Repeat to gain further insights
o Empathy
▪ “It must be hard…”
o Clarification
▪ Short summary
- Your frame of reference:
o Confrontation
▪ “Earlier you said…”
o Interpretation
▪ Make associations
o Explanation
▪ Give facts or information
o Summary
▪ Final review
- Traps of Interviewing:
o Using medical terminology confusing to patient:
o Expressing value judgments
o Mistaking sympathy for empathy
o Interrupting while patient is talking
o Having an authoritarian or paternalistic demeanor
o Asking “Why” questions that may threaten patient and make him or her defensive
o Using false reassurance
o Giving unwanted advise
- Special Needs
o Others in the room
o Language barriers
o Patient in altered mental states- coma, advanced dementia
o Older adults
o Hearing-impaired
o Acutely ill
o Under the influence of alcohol or drugs
o Anxiety
- Cross-cultural communication:
o Space and distance
▪ Social distance (4-12 ft) for interview
▪ Personal distance (0-4 ft) for physical exam
o Gender
o Silence
o Eye contact
o Touch
o Interpreters
Health History
- Health History: derived from the interview
o Patient’s statement about current and past health
o Screening for abnormal symptoms, health problems, and concerns
o Ongoing record of actual, potential, or resolved health problems
- Types of Health History
o Comprehensive health history establishes complete database
o Problem-based or focused health assessment includes data limited to the scope of problem
o Episodic or follow-up assessment focuses on specific problems for which patient is already receiving treatment
- Biographic data
- Source of history
- Reason for seeking care (chief complaint)
- History of present illness (HPI)
o Location; character or quality; quantity or severity; timing; setting; aggravating or relieving factors; associated factors; patient’s perception
▪ Use of mnemonics- such as “OLDCARTS”
▪ (onset, location, duration, character, associated or aggravating and relieving factors, timing, severity)
- Present health status
- Past health
- Family history
- A genogram can be used to review family patterns
- Social history and functional assessment:
o Psychosocial/family
o Religion/spirituality
o Activity/exercise
o Sleep/rest
o Nutrition
o Cultural assessment
o Safety
o Sexual health
o Tobacco and substance use
o Other health promotion activities
- Review of Systems
o General symptoms
o Integumentary system
o Head and neck
o Breasts
o Respiratory system/chest
o Cardiovascular system
o Gastrointestinal system
o Urinary system
o Reproductive system
o Musculoskeletal system
o Neurologic system
o Health Maintenance
- Pediatric health history: variations
o Additions of pregnancy, prenatal care, growth and development, behavioral status, and immunizations status, safety
o Observe interactions between parent and child
o Most data are obtained from adult accompanying child, but should include child as much as appropriate for age
o Nurse determines if an adult or pediatric database format is appropriate for adolescent
o Nurse determines whether to interview adolescent alone or with parent present
- Older Adult Variations
o Many older adults have multiple symptoms, conditions, medications, and a long past health history
o As adults grow older, they experience gradual changes in every body system
o Functional ability focuses on ability to perform self-care activities or basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs)
o Environmental safety and comfort data should be gathered with specific focus on problems unique to older adults
- Cultural Competence
o Culturally competent care is delivered when nurses value health or illness experiences through patient’s eyes
o Nurses working together from diverse cultures may practice in different ways
o Diversity creates challenges when:
▪ Culture and languages differ
▪ Caring for individuals by not forcing compliance but by working with beliefs and value systems
o Culture: All the socially transmitted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, lifeways, and characteristics that influence a worldview
o Ethnicity: Social group within a cultural and social system that shares common cultural and social heritage that includes:
▪ Language, history, lifestyle, religion, or all of these
o Religion refers to an organized system of beliefs, rituals, and practices in which an individual participates
o Spirituality is a broader concept
o Spiritual and religious beliefs influence interpersonal behaviors and expectations
o Steps to Cultural Care
▪ Understand OWN heritage, cultural values, beliefs, attitudes, and practices
▪ Identify meaning of health to the patient.
▪ Understand the healthcare delivery system.
▪ Be knowledgeable about the social background of the patient.
▪ Be familiar with the language and/or interpretation resources.
Assessment Techniques: General Survey & Vital Signs & Pain Assessment
- Order of Assessment:
o Inspection
o Palpation
o Percussion
o Auscultation
o NOT for abdominal assessment!
- Inspection
o Begins with the General Inspection
o Done for every body system
o Always comes first!
o Requires
▪ Good lighting (may need penlight)
▪ Adequate exposure (only as much as necessary)
▪ Instruments (for more advanced practice)
- Palpation
o Uses sense of touch to assess:
▪ Texture
▪ Temperature
▪ Moisture
▪ Organ location and size
▪ Swelling
▪ Vibration or pulsation
▪ Crepitation
▪ Abnormal lumps/masses
o Fingertips
o Fingers and thumb (grasping)
o Back of hands (dorsa)
o Base of fingers (or ulnar surface of hands)
- Percussion
o Mapping out location and size of an organ
o Signaling density of a structure (air, fluid, solid)
o Detecting abnormal masses
o Detecting tenderness
o Eliciting deep tendon reflexes (percussion hammer)
o Direct Percussion: tapping with your hand
o Indirect Percussion: tapping using your other hand on your other hand’s fingers
▪ Stationary hand
▪ Striking hand
▪ Listening for:
● Amplitude
● Pitch
● Quality
● Duration
- Auscultation
o Listen to body sounds
o Diaphragm (high pitch)
o Bell (low pitch)
o Quiet room
o Warm room
o Clean stethoscope
o May need to wet hair
o NEVER LISTEN THROUGH A GOWN
o Careful of own artifact
- Standard Precautions
o Proper hand hygiene
o Personal Protective equipment as needed
o Gloves, gown, mask, eye protection or face shield
o Cleaning instruments
o Alcohol wipes
- The General Survey:
o Begins with the first moment of the encounter with the patient and continues throughout the exam
o Start of OBJECTIVE DATA collection
o Contributes to formation of global impression of the person
o Includes physical appearance, body structure, mobility, and behavior
o Will occur simultaneously with SUBJECTIVE DATA collection (complete health history)
o Physical appearance
▪ Overall Appearance
● Normal: appears stated age, facial features, movements and body are symmetrical
● Abnormal: appears older than stated age
▪ Hygiene, dress
● Normal: well-groomed; clean clothing
● Abnormal: appears disheveled, malodorous, ill-fitting clothes
▪ Sexual development
● Normal: appropriate for age and gender
● Abnormal: delayed or early puberty
▪ Level of consciousness; speech*
● Will discuss in mental status assessment
▪ Skin color
● Also part of INTEGUMENTARY SYSTEM
● Normal: even tone, normal for ethnicity, no lesions
● Abnormal: discoloration (pallor, cyanosis, jaundice, etc.) or lesions
▪ Facial features
● Also part of HEENOT
● Normal: symmetric, no distress
● Abnormal: drooping, grimacing, mask-like
▪ Body Structure
● Stature
o Normal: height in normal range for age, gender, genetic heritage
o Abnormal: gigantism, dwarfism
▪ Nutrition
● Normal: weight in normal range for height and build, even body fat distribution
● Abnormal: cachexia, anorexia nervosa, Cushing syndrome, obesity
▪ Body Structure
● Symmetry
o Normal: equal bilaterally, relative proportion
o Abnormal: atrophy, hypertrophy
● Posture*
o Also part of MUSCULOSKELETAL SYSTEM
o Normal: erect
o Abnormal: lordosis, kyphosis, scoliosis, slumped
● Position
o Normal: comfortable, relaxed
o Abnormal: tripod position, fetal position
● Body build
o Normal: arm span equal to height and crown to pubis equal to pubis to sole, no obvious deformities
o Abnormal: Marfan syndrome, missing extremities or digits, shortened limbs, webbed digits
▪ Mobility
● Assessed with NEUROLOGICAL and MUSCULOSKELETAL SYSTEMS
● Gait
o Normal: shoulder-width base, proper arm swing, smooth/even/balanced
o Abnormal: wide base, shuffling, dragging, limping
● Range of motion
o Normal: smooth and coordinated, no involuntary movements
o Abnormal: limited, stiff, uncoordinated, jerky, paraylsis, tics, tremors
▪ Emotional and mental status/behavior
● Agitation
● Confusion
● Lethargy
- For vital signs:
o Inspection
o Palpation
o Auscultation
- Measurements: height and weight, body mass index (BMI), waist circumference
o Measurement of height (recumbent length), weight, and head and chest circumferences are important indicators of growth.
- Vital Signs:
o Temperature
▪ “Normal” oral temperature is 35.8º C – 37.3º C (96.4º F – 99.1º F)
▪ Rectal temperature is 0.5º C (1.0º F) higher
▪ Axillary temperature is 0.5º C (1.0º F) lower
o Pulse
▪ Done using palpation
▪ A radial pulse is typically used
▪ Also can assess carotid, brachial, femoral, and dorsalis pedis among others
▪ Rate: normal is 60-100 beats per minute
▪ Rhythm: regular, irregular
● Count for 30 seconds (1 minute if irregular)
▪ Force: 0 to 3+
o Respirations
▪ Don’t mention that you are checking respirations!
▪ Normal adult is 12-20 respirations per minute
▪ Count for 30 seconds and multiply by 2
▪ If irregular, count for a full minute
▪ Also assess depth and effort of breathing
o Blood pressure
▪ Two measurements:
● (1) Systolic
o Maximum pressure during left ventricular contraction, or systole
● (2) Diastolic
o Resting pressure or pressure that blood exerts constantly between each contraction, at end of diastole
▪ Normal is < 120/80 mm Hg
▪ Blood pressure varies based on
● Age, diurnal rhythm, weight, exercise, emotions, stress
▪ Blood pressure determined by
● Cardiac output, peripheral vascular resistance, volume, viscosity, and elasticity of arterial walls
▪ Tools for measuring BP: stethoscope, sphygmomanometer
▪ Positioning: arm supported at heart level and legs uncrossed
▪ Korotkoff sounds: this is what you are listening for with the stethoscope while doing blood pressure measurement
● Initial inflation of cuff: NO SOUND!; complete compression of brachial artery
● Phase I
o First sound heard
o Soft, clear tapping that starts increasing in intensity
o Reading at FIRST TAPPING SOUND is the systolic blood pressure
● Phase II
o Soft swooshing sound that may follow tapping
o Turbulent blood flow through partially occluded artery
o Sound heard through majority of time between systolic and diastolic pressures
● Phase III
o Crisp, high-pitched knocking sound
o May occur as brachial artery opens more but still closes shortly before diastole
● Phase IV
o Abrupt muffling of sound
o Sound becomes a low-pitched murmur
o Typically occurs about 10 mm HG above the diastolic blood pressure
● Phase V
o Silence
o Last audible sound is the diastolic pressure (some will say 2 mm Hg below last audible sound)
Pain
▪ Steps
● Palpate brachial artery
● Center cuff 1 inch (2.5 cm) above the brachial artery and wrap evenly
● Inflate cuff while palpating brachial or radial artery until pulse is no longer felt
● Deflate cuff and allow patient to rest for 15 to 30 seconds
● Relocate the brachial artery by palpation
● Place bell (or diaphragm) over brachial artery
● Re-inflate cuff to level where pulse was obliterated + 30 mm Hg
● Deflate cuff slowly and evenly (2 mm Hg per heartbeat)
● Note first appearance of sound (systolic pressure), muffling of sound, and disappearance of sound (diastolic pressure)
▪ Falsely high
● Person is anxious, angry, just exercised
● Arm below heart level
● Supporting own arm
● Legs not positioned correctly
● Improper cuff size (too narrow)
● Deflate too slowly, re-inflate too soon
▪ Falsely low
● Arm above heart level
● Improper cuff size (too wide)
● Not finding occlusion pressure first
● Deflate cuff too quickly
▪ Other errors
● Pain due to inflating cuff too high
● Faulty technique
● Examiner rushing
● Examiner preference
● Defective equipment
o Oxygen saturation (typically done with vital sign measurements in the hospital)
▪ Measurement of oxygen saturation is included with vital signs in many settings
● Oxygen saturation levels lower than 90% are considered abnormal and require further evaluation
- Urgent Assessment
o Indicators of an urgent situation
▪ Extreme anxiety; acute distress
▪ Pallor; cyanosis; mental status change
o Interventions begin while continuing the assessment
o Urgent Assessment requires a team
o Rapid response team may be called for
▪ An acute change in mental status
▪ Stridor
▪ Respirations <10 or >32 breaths/min
▪ Increasing effort to breathe is necessary
▪ Oxygen saturation <92%
▪ Pulse <55 beats/min or >120 beats/min
▪ Systolic BP <100 mm Hg or >170 mm Hg
▪ Temperature <35°C or >39.5°C
▪ New onset chest pain
▪ Agitation
- THE FIFTH VITAL SIGN: pain
o Pain is always subjective
o Pain is whatever the experiencing person says it is, existing whenever he or she says it does
o Because pain occurs on a neurochemical level, clinician cannot base diagnosis of pain exclusively on physical examination findings, although these findings can lend support
o Subjective report is most reliable indicator of pain
- Subjective Pain Assessment
o Do you have pain?
o Where is your pain?
▪ Location
o When did your pain start?
▪ Onset and duration
o What does your pain feel like?
▪ Burning, stabbing, aching
▪ Throbbing, firelike, squeezing
▪ Cramping, sharp, itching, tingling
▪ Shooting, crushing, sharp, dull
o How much pain do you have now?
▪ Rating scales
o What makes pain better or worse?
o How does pain limit your function or activities?
o How do you usually behave when you are in pain?
o What does this pain mean to you?
- Objective Pain Assessment
o Physical assessment
▪ Musculoskeletal (muscles and joints)
▪ Integumentary (skin for bruising, lesions, etc.)
▪ Abdominal (inflammation, organ enlargement)
o Nonverbal Pain Behaviors – ACUTE
▪ Grimacing, moaning, guarding, restlessness or stillness
▪ Fear, anxiety, fatigue
▪ Can affect all physiological systems
● Cardiovascular
● Pulmonary
● Gastrointestinal
● Renal
● Urinary retention
● Musculoskeletal
● Immune system
o Nonverbal Pain Indicators – CHRONIC
▪ Bracing, rubbing, sighing
▪ Depression, isolation, confusion, anger
▪ Poor quality of life
▪ Limited mobility
▪ Change in appetite
▪ Sleeping
- Pain and Children
o Neonate responses to pain are global, evidenced by increased heart rate, hypertension, pallor, sweating, and decreased oxygenation saturation.
o Young children have difficulty understanding pain but have a basic ability to describe pain and location.
o School-age children better understand pain and are able to describe pain location.
- Pain and Older Adults
o May have multiple health problems associated with pain
o Changes in Functional status may be the presenting behavioral cue of pain
o Fear of dependency, further testing or invasive procedures, may impact reporting of pain
o During interview establish an empathic and caring rapport to gain trust.
The Integumentary System: Skin, Hair, and Nails
- Function of Skin:
o Protection
o Prevents Penetration
o Perception
o Temperature regulation
- Subjective Data
o Health history and review of systems
▪ Have you ever experienced…
▪ Do you have history of…
▪ Do you have family history of…
▪ Past history
▪ Medications
▪ Environmental or occupational hazards
▪ Self-care behaviors
▪ Review of systems
● Assessing for negative and positive findings
● Chart negative findings as well (“denies”)
● For positive findings:
o Onset
o Location
o Duration
o Characteristics
o Aggravating/alleviating factors
o Related symptoms
o Treatment (self)
o Severity
● Skin
o Pigment or color change
o Change in mole
o Excessive dryness or moisture
o Pruritis
o Excessive bruising
o Rash or lesion
▪ Characteristics – color, raised or flat, crust, odor
▪ Related symptoms – itching, pain, fever
▪ SETTING – others with similar complaints, new pets, camping, new foods or drugs
● Hair
o Recent loss
o Change in texture
● Nails
o Change in shape, color, or brittleness
▪ Older adults
● Any skin changes over the last several years?
● Any delay in wound healing?
● Any skin itching or other skin pain?
● Any changes in feet, toenails? Any bunions? Is it possible to wear shoes?
● Do you fall frequently? Easy bruising?
● Any history of diabetes or peripheral vascular disease?
- Objective Data
o Although we are discussing the entire integumentary system, skin is actually assessed throughout the entire physical exam as you get to each body part/system
o Always separate areas with skinfolds
o Equipment
▪ Strong direct lighting and penlight
▪ Small centimeter ruler
o Inspection and palpation
▪ Skin, hair, nails
o Skin Inspection:
▪ General pigmentation and skin tone (“normal for ethnicity”)
▪ Common pigmented areas include:
● Freckles
● Moles (nevi)
● Birthmarks
● Striae
▪ Tattoos
▪ Abnormal color changes
● Pallor: anemia, shock, arterial insufficiency; albinism, vitiligo
● Cyanosis: central, peripheral
● Erythema: hyperemia, polycythemia, carbon monoxide poisoning, venous stasis
● Jaundice: increased serum bilirubin, uremia
▪ Bruising
▪ Abnormal findings
● Bruising not consistent with expected trauma (physical abuse, falls)
● Varicosities
● Needle marks/track marks
▪ Cherry angiomas
● Small (1-5 mm) and increase with age
● Normal
o Skin- Palpation:
▪ Temperature
● Warmth equal bilaterally (hands and feet may be slightly cooler)
● Abnormal findings
o Hypothermia, hyperthermia
o Localized or general
▪ Moisture
● Skin dry (but not flaky) and mucous membranes smooth and moist
● Abnormal findings
o Diaphoresis, extreme dryness
o Dry, cracked mucous membranes
▪ Texture
● Smooth and firm
● Abnormal findings
o Typically related to thyroid (hormonal/metabolic) issues
o Hyperthyroidism – smooth, soft, velvety
o Hypothyroidism – rough, dry, flaky
▪ Thickness
● Uniformly thin
● Thickened over palms and soles
● Abnormal findings
o Calluses
o Extremely thin and shiny (arterial insufficiency)
▪ Mobility and Turgor
● Abnormal findings include
o Decreased mobility – edema, scleroderma
o Decreased turgor – dehydration, extreme weight loss
▪ Edema
● Abnormal findings
o 1+ : mild pitting, slight indentation
o 2+ : moderate pitting, indentation subsides rapidly
o 3+ : deep pitting, indentation remains for a short time, leg looks swollen
o 4+ : very deep pitting, indentation lasts a long time, leg is very swollen
- Danger signs:
o A – Asymmetry
o B – Boarder irregularity
o C – Color variation
o D – Diameter greater than 6 mm
o E – Elevation or Evolution
- Assessment of lesions:
▪ 1. Color
▪ 2. Elevation
▪ 3. Pattern or shape
▪ 4. Size (use cm ruler)
▪ 5. Location and distribution
▪ 6. Exudate
- Skin lesions
o Shapes and configurations of lesions:
Annular: Confluent: Discrete: Gyrate:
Grouped: Linear: Target:
Zosteriform: Polycyclic:
o Primary skin lesions:
Pustule Cyst
- Secondary skin lesions
o Crust, scale, fissure, erosion, ulcer, excoriation, scar, atrophic scar, lichenification, keloid
o Debris on skin surface
▪ Crust; scale
o Break in continuity of surface
▪ Fissure; erosion; ulcer; excoriation; scar; atrophy; scar; lichenification; keloid
- Non-Pressure Ulcers
o Neuropathic Ulcers
o Venous Ulcers
o Arterial Ulcers
▪ These ulcers are not graded using the pressure ulcer stages.
- Hair: inspection
o Color
▪ Graying begins as early as the third decade
o Distribution
▪ Male or female pattern baldness
▪ Some races/ethnicities have diminished hair
▪ Abnormal findings: absence or sparseness or excessive hair (Hirsutism) related to endocrine abnormalities
- Hair: Palpation
o Texture
▪ Fine or thick
▪ Straight, curly, or kinky
▪ Abnormal findings: brittle, with gray-scaly areas
o Lesions
▪ Separate hair into sections and lift
▪ Minor dandruff (seborrhea) is normal
▪ Abnormal findings: head or pubic lice
- Nails: Inspection
o Shape and contour
▪ Slightly curved
o Abnormal findings: jagged, bitten, clubbing
o Consistency
▪ Smooth and regular
▪ Abnormal findings: pits, thickened and ridged
o Color
▪ Translucent with pink bed underneath
▪ Abnormal findings: pallor or cyanosis
- Nails: Palpation
o Nails and nail beds should be firm
o Soft, flexible nails could indicate thyroid issues or arthritis
o Capillary refill (cardiovascular)
▪ Depress nail bed until it is blanched
▪ Release and note return of color
▪ Should return immediately or within 1-2 seconds
▪ Indicates status of peripheral circulation
- Pediatric Variations in the Integument System
o Toddlers and children
▪ Communicable diseases and bacterial infections
▪ Bruising and lesions related to abuse/violence
o Adolescent
▪ Skin texture takes on adult characteristics; in addition, skin has increased perspiration, oiliness, and acne secondary to increase in sebaceous gland activity
▪ Most common abnormal finding and concern for adolescent is acne
▪ Hair changes related to puberty
- Older Adult Variations
o Age-related changes
▪ Skin
▪ Hair, nails
o Abnormal changes
▪ Nutrition
▪ Hydration
▪ Circulation
- Possible Nursing Diagnosis in the Integument System
o Impaired skin integrity (and risk for)
o Impaired tissue integrity
o Other
▪ Latex allergy response (and risk for)
▪ Impaired oral mucous membrane
▪ Risk for trauma
- Health Promotion in the Integument System
o Skin self-examination
▪ Lesions - watch for DANGER signs:
● A – asymmetry
● B – border irregularity
● C – color variation
● D – diameter > 6 mm
● E – elevation or enlargement
o Sun Exposure
▪ Amount of sun exposure
▪ Use of sunscreen – at least SPF 15
▪ Tanning – indoor/outdoor
o Nail Care
▪ Encouragement of cessation of nail biting
▪ For diabetics, encourage use of podiatrist for care and clipping of toe nails
● Risk for complications r/t compromised skin integrity
▪ Fungal infections in older adults
Violence Assessment
- Family violence
o Child maltreatment
o Intimate Partner Violence
▪ Can involve threatening or coercive tactics
o Elder abuse
▪ Could be financial
o Victim is biologically related to offender or was related via marriage, adoption, or legal guardianship.
o Children often have trauma symptoms: anxiety; depression; anger; aggression
o In IPV, perpetrators most often male; Behavior involving threatened/actual violence and/or coercive tactics; psychological/emotional abuse.
o IPV among immigrants, refugees is culturally acceptable and victims may have limited options of escape, barriers.
o IPV in pregnancy.
o Risk factors for elder abuse: dependency; cognitive decline; caregiver mental/physical health strain; finances
- Violence against adults with disabilities
o Includes harmful acts of commission (abuse) or omission (neglect)
o Intentional/unintentional abuse/neglect: physical; sexual; psychological; financial
o More likely
▪ Severe and long-term abuse; victims of multiple violent episodes
▪ Abused by many perpetrators
o Sexual assault exceptionally high in women with developmental disabilities
- Youth and school violence
o Punking: verbal and physical violence; humiliation and shaming; in public or with an audience
o Bullying: verbal violence, especially in middle and high school girls
- Sexual violence
o Forced sex in dating, marital relationships
o Gang rape; sexual harassment; molestation
o Inappropriate touching; sex with a patient
o Forced prostitution; forced exposure to sexually explicit behavior
- Hate crimes
o Perpetrator chooses a victim because of a characteristic, provides evidence that hate motivated the crime.
o Race; ethnicity; gender; sexuality; religion
- Human trafficking
o Recruitment, transportation, transfer, harboring, or receipt of people through threats, force, coercion, or deception for indentured servitude.
o Commercial sex trade businesses
o Sexual exploitation; forced marriage
o Cheap domestic/commercial labor
o Domestic servitude; Sweatshop factories; migrant agricultural work
- Approximately 1/3 of women are victims worldwide. Often goes unreported.
- Violence include physical, mental, emotional, sexual.
- Can be abuse or neglect.
- Assessment:
o Screening tools
▪ Domestic partners, children, elders
o History
▪ Watch partner, parent, or caregiver behavior
● Answers all questions?
● Won’t allow patient to remain alone with health care provider?
● Becomes easily angered at certain questions?
- Subjective Data
o Statements to the nurse
o Family and friends’ report, validation of patient’s data
o Ask open-ended questions
▪ Assimilating verbal and nonverbal data
o Establish rapport first
o Common symptoms of victims
▪ Easily triggered: anxiety, panic episodes
▪ Isolation, social withdrawal; difficulty
focusing
▪ Numbing/shutting down feelings
▪ Spacing out; forgetfulness
o Hematomas from hitting with fists or objects.
o Petechiae from vigorous crying or coughing which raises venous pressure.
o Bruises in multiple stages of healing.
- Documentation
o Written
▪ Verbatim (as much as possible)
▪ Do not “sanitize”
o Photographic
▪ Needs prior written consent
▪ Can be invaluable
▪ What if patient is unconscious or cognitively impaired?
- Denial
o What if the patient denies any type of abuse?
▪ Indirect questioning
▪ Repeated screening
▪ Offering of services if the patient “ever feels they need it”
- Reporting Abuse
o Nurses are mandatory reporters for the following types of abuse:
▪ Child abuse/neglect
▪ Elder abuse/neglect
▪ Other “vulnerable” populations
o When child, elder, vulnerable-adult abuse or neglect is disclosed, assessed, or suspected
▪ Mandated reporters: nurses, health care professionals, etc.
o Must call protective services hotline
o Mandated reporter is protected by the state: if report is made in good faith, without malice
o Document call to protective services hotline.
▪ Reason for call; time of call; full name of who took call; response of call taker
Assessment of the Head, Eyes, Ears, Neck, Mouth, Oral Health and Throat (HEENOT)
- Subjective Data
o Health history and review of systems
▪ Have you ever experienced…
▪ Do you have a history of…
▪ Do you have a family history of…
o Health History
▪ Head:
● History of head injury/surgery
▪ Neck:
● History of thyroid disease/surgery or other neck surgery
● Thyroid medications
▪ Eyes:
● History of eye injury/surgery
● Use of glasses or contacts
● Last eye exam
● Medications
▪ Ears:
● Environmental noise
● History of ear surgeries (childhood/adult)
▪ Nose/Sinus:
● History of nasal trauma/surgery
▪ Mouth/Throat:
● History of oral surgery; oral/throat cancer
● Last dental examination
o Review of systems
▪ Assessing for negative and positive findings
▪ Chart negative findings as well
▪ For positive findings:
● OLDCARTS
o O – Onset
o L – Location
o D – Duration
o C – Character
o A –Aggravating/Alleviating Factors
o R – Relieving Factors/Radiation
o T – Timing
o S – Severity
▪ Head:
● Unusually frequent or severe headaches, head injury, dizziness, vertigo
▪ Neck:
● Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter
▪ Eyes:
● Decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, glaucoma, cataracts
▪ Ears:
● Earaches, infections, discharge and characteristics, tinnitus, vertigo, hearing loss
▪ Nose/Sinus:
● Discharge (characteristics), unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, change in sense of smell
▪ Mouth/Throat:
● Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or on tongue, dysphagia, hoarseness or voice change, altered taste
- Objective Data HEENOT
o Assessment techniques
▪ Inspection
▪ Palpation
▪ Percussion (direct)
▪ Auscultation
o Equipment
▪ Direct lighting and penlight
▪ Stethoscope
▪ Tongue blade
▪ Snellen chart or reading card (primary care)
o In general, the following found during inspection and palpation are abnormal and would require further assessment:
▪ Tenderness
▪ Enlargement
▪ Lumps or masses
▪ Edema or swelling
▪ Drainage
- HEAD
o Palpation
▪ Normal: free of deformities, lumps; no tenderness
▪ Abnormal: tenderness, enlargement, lumps, masses
o FACE
▪ Inspection:
▪ Facial expression
● Normal: relaxed, congruent with circumstances
● Abnormal: hostile, angry, tense, rigid (pain, anxiety)
▪ Color and texture (mouth, earlobes)*
● Normal: even tone (normal for ethnicity), smooth skin
● Abnormal: cyanosis, pallor
▪ Shape, symmetry, and movement
● Normal: symmetrical, no involuntary movements
● Abnormal: mask-like or moon face; drooping; tics or excessive blinking
▪ Edema
● Normal: no edema
● Abnormal: periorbital edema, myxedema
▪ Palpation
● Normal: free of deformities, lumps; no tenderness
● Abnormal: tenderness, enlargement, lumps, masses
▪ Temporomandibular joint
● Normal: smooth, full ROM
● Abnormal: crepitation, popping, locking, pain, limited ROM
o NECK
▪ Inspection:
▪ Symmetry
● Normal: head centered midline, erect and still; neck muscles symmetric
● Abnormal: head tilt, rigidity,
muscle weakness
▪ Range of motion
● Normal: fluid, full ROM in all
directions
● Abnormal: pain during movement, limited ROM
▪ Palpation
● Strength of cervical muscles
o Normal: shrug shoulders and turn
head side to side against resistance
o Abnormal: muscle weakness, stiffness
● Position of trachea
o Normal: midline
o Abnormal: tracheal shift
● Lymph nodes and tenderness
● Thyroid for nodules, enlargement
▪ Auscultation
● If the thyroid is enlarged, auscultate for a bruit
o Use bell of stethoscope
▪ Normal: no sound
▪ Abnormal: soft, pulsatile, whooshing sound (bruit)
● Auscultate for a carotid bruit in similar manner
o EYES
▪ Inspection:
▪ Eyebrows
● Normal: symmetric with symmetric movement
● Abnormal: unequal, absent movement
▪ Eyelids and eyelashes
● Normal: approximate when closed; no redness, swelling, lesions
● Abnormal: ptosis, periorbital edema, ectropion, entropion, lesions
▪ Sclera and conjunctiva
● Normal: eyeballs moist and glossy; clear conjunctiva with pink over lids and white over sclera
● Abnormal: general reddening of sclera; cyanosis of lower lids; pallor; jaundice; lesions
▪ Vision
● Normal: 20/20
● Abnormal: myopia, hyperopia, presbyopia, astigmatism
▪ Pupils – PERRLA*
● Pupils
● Equal
● Round and
● Reactive to
● Light and
● Accommodation
▪ Size of pupils – Left/Right
▪ Eye movement: whiskers test
o EARS
▪ Inspection:
▪ Size and shape
● Normal: equal bilaterally with no swelling or thickening
● Abnormal: microtia, macrotia, edema
▪ External auditory meatus
● Normal: No swelling, redness, or discharge, some cerumen
● Abnormal: yellow discharge; cerumen impaction
▪ Skin
● Normal: consistent with facial color
● Abnormal: reddened, red-blue, crusts and scaling, lesions
▪ Palpation
● Pinna and tragus
o Normal: non tender
o Abnormal: tender (swollen lymph nodes, otitis externa)
▪ Whisper test
● Loss of high frequency hearing (common in older men) – presbycusis
▪ Weber’s Test
● Should be equal bilaterally
● In conductive hearing loss, lateralizes to defective ear
● In sensorineural hearing loss, lateralizes to unaffected ear
▪ Rinne Test
● Air conduction (AC) should be twice as long as bone conduction (BC)
● In conductive hearing loss, BC > AC
● In sensorineural hearing loss, AC > BC
o NOSE & SINUSES
▪ Inspection:
● Symmetry and deformity
● Abnormal: deviated septum
▪ Palpation
● Nasal patency
● Abnormal: common cold, allergic
rhinitis, polyps
● Frontal and maxillary sinuses
o MOUTH & THROAT
▪ Inspection:
● Lips for color, moisture, cracking, lesions
o Abnormal: pallor, cyanosis
● Teeth and gums for abnormalities
o Abnormal: discolored (brown – fluoride; yellow – smoking); grinding, missing, decaying teeth; bleeding gums; gingival hyperplasia
● Tongue for color, surface characteristics, moisture
o Abnormal: beefy red and swollen, enlarged, small, fissures
● Buccal mucosa for color, moisture, nodules, and lesions*
o Abnormal: white patches, dry and cracked
● Tonsils for size, color, and surface characteristics
o Grading:
▪ 1+: Visible
▪ 2+: Halfway to uvula
▪ 3+: Touching uvula
▪ 4+: Touching each other
o Tonsillitis (acute, chronic)
▪ Bright red and swollen with acute infection
▪ White membrane may indicate mononucleosis, leukemia, or diphtheria
● Tongue deviation
o Cranial nerve XII damage; cerebral palsy
● Halitosis
o Poor oral hygiene; alcohol consumption; smoking; diabetic ketoacidosis
Cranial Nerves:
- Cranial Nerve I: Olfactory Nerve (Sensory)
o Not routinely checked
o Assess patency first (cannot test in someone with upper respiratory infection or sinusitis)
o Should identify odors bilaterally
o Older adults have decreased sense of smell
- Cranial Nerve II: Optic Nerve (Sensory)
o Visual acuity
o Confrontation
- Cranial Nerves III, IV, and VI: Oculomotor, Trochlear, and Abducens Nerves (Motor)
o Pupils – PERRLA
▪ Pupils
▪ Equal
▪ Round and
▪ Reactive to
▪ Light and
▪ Accommodation
o Size of pupils – Left/Right
- Cranial Nerves III, IV, and VI: Oculomotor, Trochlear, and Abducens Nerves (Motor)
o Eye Movement
o Whiskers test
- Cranial Nerves V: Trigeminal (Mixed) →
o Motor & sensory
- Cranial Nerves VII: Facial (Mixed)
o Motor
▪ Smile, frown, close eyes tightly, lift eyebrows, show teeth, and puff cheeks
o Sensory
▪ Acoustic or Vestibulocochlear Nerve (Sensory)
● Whispered voice test
- Cranial Nerves IX and X: Glossopharyngeal and Vagus Nerves (Mixed)
o Motor
▪ Depress tongue with tongue blade and have person say “aaah”.
▪ Note voice sounds, which should be smooth and not strained.
▪ Do not normally test gag reflex except in comatose person.
- Cranial Nerves XI: Spinal or Accessory Nerve (Motor)
o Head movement
o Shoulder shrug
- Cranial Nerves XII: Hypoglossal Nerve (Motor)
o Stick out tongue
o Say “light, tight, and dynamite”
- Pediatric Variations
o Toddlers and children
▪ Head and Neck:
● Examination and findings of head
▪ Eyes:
● Visual acuity of 20/20 achieved during toddler years
▪ Ears:
● Hearing evaluation of young child may be necessary if parent or nurse perceives that child has some type of lag related to child’s developmental milestones
● Behavioral manifestations may indicate hearing impairment
▪ Nose:
● Allergic salute
● Foreign bodies
▪ Mouth/Throat:
● Tooth eruption/oral hygiene
● Larger tonsils
- Older Adult Variations
o Eyes:
▪ Pseudoptosis, or relaxed upper eyelid, may be seen, with lid resting on lashes
▪ Orbital fat may have decreased so that eyes appear sunken, or may herniate, causing bulging on lower lid or inner third of upper lid
▪ Lacrimal apparatus may function poorly, giving eye a lack of luster
and making it dry
▪ Arcus senilis is common but not associated with any pathologic condition
▪ Abnormal findings include ectropion in which lower lid drops away from globe or entropion in which lower lid turns inward
o Vision:
▪ Decrease in vision can occur after age 70
▪ Acuity of 20/20 or 20/30 with corrective lenses is common; accommodation takes longer
▪ Color perception of blue, violet, and green may be impaired
▪ Presbyopia is farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age – problems reading
▪ Myopia: Near sighted - inability to see things clearly unless they are relatively close to the eyes – problems seeing road signs
o Ears and hearing:
▪ If patient wears hearing device, ear should be carefully examined and assessed for any skin irritation or sores
▪ Increased likelihood of cerumen impaction
▪ Presbycusis is hearing loss associated with aging
o Neck:
▪ A stiff neck in older adult may indicate cervical arthritis
o Mouth:
▪ Aging causes gum line to recede secondary to bone degeneration, causing teeth to appear longer
▪ Gums may become more friable and bleed with slight pressure
▪ Teeth may become darkened or stained
▪ Many older adults may become edentulous or have caps or bridges
- HEENOT Nursing Diagnosis
o Impaired verbal communication
o Impaired dentition
o Risk for falls
o Impaired oral mucous membrane
o Disturbed sensory perception
o Impaired swallowing
- HEENOT Assessment
o Head and Neck
▪ Safety
▪ Seatbelts
▪ Bicycle/motorcycle helmets
▪ Fall prevention
o Eyes
▪ Routine eye exams
▪ Vitamin A in diet
▪ Older adults and driving
o Ears
▪ Environmental
▪ Ear plugs or other appropriate ear covering for work noise
▪ Decrease volume when using headphones, stereos, etc.
▪ Older adults
▪ Hearing acuity tests
▪ Proper use and care for hearing aids
o Nose and Mouth
▪ Decreased sense of smell
▪ Good oral care
- Mental Health Assessment
o Begins immediately when you first encounter the patient
o Will occur simultaneously with SUBJECTIVE DATA collection (complete health history)
o Continues throughout the entire examination
o Mental health includes both EMOTION and COGNITIVE FUNCTION
o Components of assessment
▪ A – Appearance
▪ B – Behavior
▪ C – Cognition
▪ T – Thought processes
o Appearance
▪ Posture
● Normal: erect, relaxed
● Abnormal: tense, slumped, dragging
▪ Body movements
● Normal: deliberate, coordinated, smooth, even
● Abnormal: restless, bizarre gestures, facial grimaces
▪ Dress
● Normal: appropriate for setting, season, age, gender, and social group
● Abnormal: inappropriate, eccentric
▪ Personal hygiene
● Normal: clean, groomed, neat
● Abnormal: dirty, disheveled, poor repair
o Behavior
▪ Level of consciousness
● Normal: awake, alert, responds appropriately
● Abnormal: lethargic (somnolent), obtunded, stupor, coma
▪ Facial expression
● Normal: appropriate to situation, eye contact appropriate to culture
● Abnormal: flat, depressed, angry, sad, anxious, mask-like
▪ Mood and affect
● Normal: appropriate to place and condition, cooperative
● Abnormal: depressed, euphoric, anxious, fearful, hostile, irritable, angry, labile, inappropriate, ambivalent
▪ Speech
● Normal: quality, pace, articulation
● Abnormal: speech disorders (abnormal volume or pitch), monopolizes conversation, silent, pressurized speech, difficulty in speaking (aphasia)
o Cognition
▪ Orientation
● Normal: oriented to time, place, and person (oriented x3), oriented to situation also (oriented x4)
● Abnormal: disorientation (delirium or dementia) occurs typically first with time, then place, then person (rarely and in severe cases)
▪ Attention span
● Normal: concentrate on task at hand without wandering
● Abnormal: impaired in people who are anxious, fatigued, or drug intoxicated
▪ Recent memory
▪ Remote memory
▪ New learning*
▪ Higher intellectual function
● Calculation ability; abstract reasoning
▪ Judgment
▪ *Mini-Cog
● Three-
word recall
● Clock
drawing test
o Thought Processes and Perceptions
▪ Thought processes (do they make sense?)
▪ Perceptions (are they aware of reality?)
▪ Anxiety disorders (generalized, social, panic, PTSD?)
▪ Depression
▪ Suicidal ideation
o Pediatric Symptom Checklist
▪ Abuse
▪ Drug Abuse
▪ Puberty; initiation of sexual activity
- Mental Health Nursing Diagnosis
o Ineffective individual coping
o Altered thought processes
o Impaired social interaction
o Risk for suicide
o Sensory- perceptual alterations
HEENOT: Mouth
- 130 million US adults and children lack dental coverage
- 70% of adults aged > 65 lack dental coverage
- Up to 75% of pregnant women are declined dental services because of pregnancy
- ECC is the most common chronic disease of childhood in 5-to-17 year olds
- ECC is 5x more common than asthma
- 50 million school hours per year lost b/c of oral health related illness (pain, infection)
- Determine Risk: parents can be provided with an oral health questionnaire to help the child health professional determine the child’s oral risk health status. The child health professional can also ask key oral health questions during the examination.
- Provide Patient Education: the caregiver should be provided with good oral hygiene instructions.
- Conduct Oral Screening Examination: with a gloved hand, the child health professional should lift the lips, feel the soft tissues, and examine the health of the teeth and mouth. All tooth surfaces should be inspected using a mirror, and dental abnormalities and/or caries should be identified if present.
- Extra-Oral Examination: Inspection and Palpation
o Facial Symmetry
▪ Note any facial symmetry; differentiate salivary gland enlargement from lymphadenopathy and masseter hypertrophy
o Skin
▪ Examine the skin for ulcerations and pigmentations; ask the patient about any skin changes you identify; refer any unexplained abnormalities to dermatology
o Neck
▪ Lymph Nodes
● The extra examination includes cervical lymph nodes; our extra examination is a focused examination; these are the lymph nodes that drain the oral and oropharyngeal areas
▪ Middle Structure: Thyroid, Trachea
● Note any deviation of the trachea from the midline and include palpation of the thyroid area in your extra oral examination; however, these structures are outside our area of expertise; do not inform the patient that you are doing a thyroid examination; you will note and refer any abnormality noted in either of these structures
o TMJ Area
▪ Joint noises
▪ Pain
▪ Functional changes
- Oral- Systemic Connection
o Diabetes & periodontal disease
o Cardiovascular disease & inflammation and infections
o Maternal oral health & its relation to early childhood caries (ECC)
o Ventilator-Associated Pneumonia (VAP)
Assessment of the Respiratory System and Related Health Promotion
- Subjective Data
o Health history and review of systems
▪ Have you ever experienced…
▪ Do you have a history of…
▪ Do you have a family history of…
▪ Cough, sputum (color and amount), hemoptysis
▪ Shortness of breath (how much activity produces shortness of breath)
▪ Difficulty breathing while sleeping
▪ Chest pain with breathing
▪ Wheezing or noisy breathing
▪ Previous chest x-ray
o Health History
▪ History of respiratory infections or illnesses
▪ Medications for respiratory disorders
▪ Including inhalers
▪ Oxygen at home
▪ Environmental expose (home, work, travel)
o Older Adults
▪ Any shortness of breath or fatigue with daily activities?
▪ Usual physical activity?
▪ For those with history of COPD, TB, lung cancer:
● How are you getting along each day?
● Any weight change in past 3 months?
● How is your energy level?
● How does illness affect you at home or at work?
- Objective Data
System Assessment
iratory Breath Sounds CTA bilaterally Anterior, posterior
Shortness of Breath None, mild, severe
Work of Breathing Increased
Use of accessory muscles, retractions
Cough Weak, strong, productive
Sputum None, scant, moderate, copious Description
Equipment Chest tubes, CPAP, etc.
o Assessment techniques
▪ Inspection
● Shape and configuration of thoracic cage; anteroposterior (AP)/transverse (T) diameter
o Normal: 1:2 AP/T diameter; no abnormal curvatures
o Abnormal:
barrel chest scoliosis kyphosis
● Facial expression and level of consciousness
● Skin color and condition
o Normal: even tone (normal for ethnicity), smooth skin
o Abnormal: hyperpigmentation, hypopigmentation, rashes, lesions, cyanosis
● Quality of Respirations
o Normal: upright/erect, 12-20 breaths per minute, no retractions or use of accessory muscles
o Abnormal: tripod position, abnormal rate/rhythm, retractions, bulging, use of accessory muscles
● Anterior Chest
o Retractions
▪ Obstruction of respiratory tract
▪ Increased effort due to atelectasis
o Bulging
▪ Trapped air in forced expiration associated with asthma or emphysema
o Accessory muscles
▪ Acute airway obstruction or massive atelectasis
o Respiratory rate
▪ Normal: 12-20 breaths per minute, regular
▪ Abnormal Respiratory Rates
● Anterior Chest
Hyperventilation
Sigh
Tachypnea
Bradypnea Hypoventilation
Cheyne-Stokes Respiration Kussmaul’s Breathing
▪ Palpation
● Anterior Chest
Chronic Obstructive Breathing
o Normal: warm and dry; no tenderness, lumps or masses
o Abnormal: cold, moist, tenderness, enlargement, lumps, masses
▪ Percussion
● Anterior Chest
o Normal: resonance over healthy lung tissue
o Abnormal:
▪ Hyperresonance – too much air is present (emphysema or pneumothorax)
▪ Dullness – abnormal lung density such as in pneumonia, pleural effusion, atelectasis, or tumor
▪ Auscultation
● Anterior Chest
o Normal: bronchial, broncho-
vesicular, vesicular
● Abnormal Breathing
Sounds:
Fine Crackles
Coarse Crackles
Atelectatic Crackles
Friction Rub
Wheeze
Stridor Rhonchi
▪ Palpation
● Posterior Chest
o Normal: warm and dry; no tenderness, lumps or masses
o Abnormal: cold, moist, tenderness, enlargement, lumps, masses
▪ Percussion
● Posterior Chest
o Normal: resonance over healthy lung tissue
▪ Auscultation
● Posterior Chest
o Normal: breath sounds
o Equipment
▪ Stethoscope
- Pediatric Variations
o Adolescents
▪ Adolescent exam/normal findings are same as for adult
▪ Consider modesty for adolescent patients
- Older Adult Variations
o Kyphoscoliosis
o Chest wall stiffness
o Diminished strength of respiratory muscles results in reduced maximal inspiratory and expiratory force
o DOE – Dyspnea on exertion
o Problem with mucous clearance
o Dry membranes
- Respiratory Nursing Diagnosis
o Ineffective airway clearance
o Ineffective breathing pattern
o Impaired gas exchange
o Risk for aspiration
- Health promotion topics
o Appropriate work related equipment (masks, oxygen, etc.)
o Smoking cessation (second-hand smoke?)
o Identification and avoidance of triggers (asthma, COPD)
o Adherence to medication regimens
o Vaccinations – flu, pneumococcal
- 5 A’s for Smoking Cessation
o Ask- is the patient a smoker? How many cigarettes/packs per day x number of years
o Assess- describe the smoking pattern, use a screening test such as the Fagerstrom questionnaire.
o Advise- Tailor the discussion on health implications of smoking to his/her health or diagnosis
o Assist- ise motivational interviewing steps to help the patient evaluate interest, willingness to quit. Discuss non pharmacologic options and otc and prescription aides.
o Arrange- for follow up with a return visit or f/u call
- Smoking Cessation
o Communication: nonverbal behavior, acknowledge emotions feelings, accepting non-judgmental, uses open ended questions, allow patient to talk without interruption
o Motivational Interviewing: active listening, assess readiness motivation to engage in changing a specific behavior. Explore views- pros/cons of continuing your current behavior.
o Explores views pros/cons of changing your current behavior. Reflect back to the patient, the patient’s motivations for change
Assessment of Breasts
- Assessment of the Breast and Axillae and Related Health Promotion
o Subjective Data
▪ Risk factors
▪ Breast health and awareness
▪ Health promotion
▪ Common breast and axillary symptoms
o Lifespan Considerations
▪ Pregnant / Nursing women
▪ Children and adolescents
▪ Tanner staging
▪ Menarche
▪ Older adults
▪ Male breasts
▪ Cultural considerations
o Objective Data
▪ Comprehensive physical assessment
▪ Inspection
▪ Palpation
▪ Screening test results
- Guidelines for women at average risk of breast cancer
o Women with a personal history of breast cancer, a family history of breast cancer, a genetic mutation known to increase risk of breast cancer (such as BRCA), and women who had radiation therapy to the chest before the age of 30 are at higher risk for breast cancer, not average-risk.
o Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so. The risks of screening as well as the potential benefits should be considered.
o Women age 45- 54 should get mammography every year.
o Women age 55 and older should switch to mammograms every 2 years, or have the choice to continue yearly screening. Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer.
o
- Research does not show a clear benefit of physical breast exams done by either a health professional or by yourself for breast cancer screening. Due to this lack of evidence, regular clinical breast exam and breast self-exam are not recommended. Still, all women should be familiar with how their breasts normally look and feel and report any changes to a health care provider right away.
- Inspection
o Sitting position
o Arms at sides, overhead and then on hips
o Check symmetry
o Color
o Texture
- Palpation
o Palpate axillae while patient sits
o Palpate breast tissue while patient supine, arm raised overhead
o 2-3 minutes
o Different methods
▪ Vertical (often recommended)
▪ Circular and Wedge
- Assessment
o Conditions requiring further investigation
▪ Swelling of all or part of the breast
▪ Skin irritation or dimpling
▪ New breast or axillary lump
▪ Redness, scaliness or thickening of the nipple or breast tissue
▪ Nipple retraction or discharge other than breast milk
- Second major cause of death from cancer for women
- 5-year survival rate is 89% (racial gap)
- Men represent about 1-2% of breast cancer cases
- White women overall higher risk
- African-American women have highest death risk for any age
- Asian, American Indian, and Hispanic women have lower incidence and death rates than white and African-American women
- Non-modifiable risk factors
o Female gender
o Age > 50 years
o Mutation of BRCA1 and BRCA2 genes
o First-degree relative with breast cancer
o Early menarche (< 12 years)
o Late menopause (> 55 years)
o High breast tissue density
- Modifiable risk factors
o Nulliparity (never had a child) or first child after age 30 years
o Never breastfed
o Recent oral contraceptive use
o Recent and long-term estrogen and progestin use
o Alcohol intake of ≥ 1 drink daily
o Obesity (especially after menopause) and high fat diet
o Physical inactivity
- Overall Breast Health Promotion
o Support Breast Feeding
o Promote Breast Health Awareness
o Screening for Breast Cancer-Mammography
o Breast Cancer Risk reduction through – moderate alcohol consumption, good diet, adequate exercise
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