NCSBN – Lesson 3-C: Physical Assessment Study guide,100% CORRECT

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NCSBN – Lesson 3-C: Physical Assessment Study guide Assessment Overview Health Hx The health history usually begins with a review of the client's present state of wellness or illness ... and his or her general health status. If the client is ill, the nurse will ask about the onset of symptoms, the location of symptoms, the quality of pain or discomfort, duration of symptoms and if there were any precipitating or aggravating factors. The nurse will also review the following pertinent information in the client's chart: age, sex, race, medical and surgical history (including treatment and outcomes, allergies and immunization status), family history and risk factors (including lifestyle and genetics), social history, occupation and medications. The nurse must be sure to specifically ask the client about using any over-the-counter medications, complementary and integrative health therapies (including herbal remedies or dietary supplements) tobacco use and alcohol intake. Other assessments include asking about activity level (including leisure activities and any exercise regimen), sleep pattern and nutrition. General Assessment Before beginning the exam, the nurse will need to gather the appropriate equipment. The physical exam includes a general assessment of the client's appearance, including obvious signs of distress, body type, posture, gait, body movements, hygiene, personal attire or dress, affect, mood and speech. The nurse will measure temperature, pulse, respirations, blood pressure, height and weight. Height can be measured with the client standing on a scale or lying down (for infants); proxy measurements such as arm span may also be used for bedbound clients. Physical Exam Equipment • Platform scale with height attachment • Skinfold calipers • Sphygomomanometer • Stethoscope with bell and diaphragm endpieces • Thermometer • Flashlight or penlight • Otoscope/opthalmoscope • Tuning fork • Nasal speculum (if short, broad speculum not included with otoscope) • Tongue depressor • (Skin-marking) pen • Flexible tape measure and ruler (marked in centimeters) • Reflex hammer • Sharp object, e.g., sterile needle • Cotton balls • Bivalve vaginal speculum • Clean gloves • Lubricant • Fecal occult blood test materials • Gown and drapes for client • Eye chart General Assessment: Well-Child Care Well-child care (birth-6 years) includes routine care, comprehensive health promotion and disease prevention exams; vision and hearing screenings; routine immunizations; and whether the child is reaching developmental milestones. Height and weight measurements are recorded for all children; the nurse will measure the infant's head circumference. These measurements are plotted on growth charts to find the child's percentile compared with the national averages. Recommended vaccinations are given to protect against diphtheria, varicella, mumps, pneumococcal disease, pertussis, measles, Haemophilus influenza type b (Hib), rubella, hepatitis A and B, tetanus and polio. Preteens should receive the HPV vaccine to protect against cervical cancer. General Assessment: Adult Care Physical exams should be scheduled every year, depending on risk factors and health concerns. Recommended components of the exam should include hypertension screening, screening for and/or counseling for alcohol use, depression screening, tobacco use screenings and intimate partner violence. • Lab Tests o A baseline lipid panel, which includes total cholesterol, HDL, LDL and triglycerides, is performed at age 20 and every five years thereafter if it is normal o Type 2 diabetes screening with blood pressure ˃135/80 o Hepatitis C screening for high-risk clients born between 1945-1965 o Routine ECGs are no longer ordered routinely for adults who are at low risk for heart disease and are not experiencing chest pain. • Adult Immunizations o a yearly influenza vaccination and a tetanus booster with Td every 10 years. o The Center for Disease Control (CDC) recommends adults age 60 and older receive one dose of herpes zoster vaccine (HZV), regardless if they have had a prior episode of herpes zoster. o The CDC recommends adults who are immunocompetent and age 65 or older receive the 13-valent pneumococcal conjugate vaccine (PCV13) followed by 23- valent pneumococcal polysaccharide vaccine (PPSV23) at least one year after PCV13. • ECG Strips – Interpreting an ECG o Rhythm: determine if is regular or irregular, with or without patterns ▪ Ventricular rhythm: measure R to R intervals ▪ Atrial rhythm: measure P to P intervals o Rate: count the number of QRS complexes over a six second interval and multiply by 10 to determine the heart rate o P wave: represents atrial depolarization o PR interval: represents AV conduction o QRS interval: represents ventricular depolarization and contraction o T wave: represents ventricular repolarization o QT interval: represents the time of ventricular activity including both depolarization and repolarization ▪ Measure the beginning of the QRS complex to the end of the T wave ▪ Normal: 0.36 to 0.44 seconds (9-11 small boxes) – varies with gender, age and heart rate o ST segment: represents the early part of ventricular repolarization Assessment Techniques • IPPA Assessing the Cardiovascular System • Cardiovascular Anatomy o Layers of the Heart ▪ Pericardium – fibrous sac that encloses the heart ▪ Epicardium – covers surface of heart ▪ Myocardium – muscular portion of the heart ▪ Endocardium – lines cardiac chambers and covers surface of heart valves o Chambers of the Heart ▪ Right atrium – is the collecting chamber for the incoming systemic venous system ▪ Right ventricle – propels blood into the pulmonary system ▪ Left atrium – collects blood from the pulmonary venous system ▪ Left ventricle – is a thick-walled, high-pressure pump that propels blood into the system; the systemic circulation is responsible for cardiac output o Heart Valves – allow one-way blood flow ▪ Atrioventricular valves prevent backflow from the ventricles to the atria during systole. • Tricuspid valve is between the right atrium and the right ventricle (TINY RIGHT SIDE OF HEART) • Mitral (or bicuspid) valve is between the left atrium and the left ventricle (MIGHTY LEFT SIDE OF HEART) ▪ Semilunar valves prevent backflow from the aorta and pulmonary arteries into the ventricles during diastole. • Pulmonic valve is between the right ventricle and the pulmonary artery • Aortic valve is between the left ventricle and the aorta, which leads to central circulation o Blood Supply to the Heart ▪ Coronary Arteries • right coronary artery supplies the right ventricle and part of the left ventricle. • left coronary artery supplies the left ventricle and septum. ▪ Veins • Coronary sinus is a wide venous channel that drains five coronary veins into the right atrium. • The thebesian veins are the smallest coronary veins, which drain venous blood directly into the right atrium and right and left ventricles. o Conduction System ▪ Sinoatrial node/”pacemaker” • Located in Rt. Atrium • Intrinsic rate of 100 impulses/min. ▪ Atrioventricular node/Junctional tissue • has an intrinsic rate of 40-60 impulses per minute. ▪ Bundle branch/Purkinje system • heart's electrical system. • It is in the septum and in the cardiac tissues • It has an intrinsic rate of 20-40 impulses per minute. o Diastole – the phase of relaxation during which the chambers fill with blood; when the heart pumps, the myocardial layer contracts and relaxes o Blood Flow ▪ Blood then enters the right ventricle via the tricuspid valve. It travels through the pulmonic valve to the pulmonary arteries and lungs, where the exchange of oxygen and carbon dioxide gases occurs. ▪ Oxygenated blood returns from the lungs, flowing through the pulmonary veins into the left atrium, and enters the left ventricle through the mitral (bicuspid) valve. ▪ Finally, the blood from the left ventricle goes through the aortic valve into the aorta and into the systemic circulation to perfuse tissue. o Vascular System ▪ The vascular system is a continuous network of blood vessels. ▪ The arterial system consists of arteries, arterioles and capillaries and delivers oxygenated blood to tissues. ▪ Oxygen, carbon dioxide, nutrients and metabolic waste are exchanged at the capillary level. ▪ The venous system, comprised of veins and venules, returns the blood to the heart. ▪ The heart itself is supplied with blood by the left and right coronary arteries, which are found at the base of the aorta above the aortic valve. The Heart: Assessing the Cardiovascular System • Supine pos. or w/ HOB @ 45 degree • Aortic area — 2nd right intercostal space • Pulmonic area — 2nd left intercostal space • Erb's point — 3rd left intercostal space • Tricuspid area – 4th left intercostal space • Mitral (apical) area — 5th left intercostal space • Epigastric area — at the tip of the sternum Normal Heart Sounds • S1 is the closing of the mitral valve and is best heard at the apex of the heart. • The S2 is a high-pitched sound that is dull in quality due to the closing of aortic valve; it is best heard over the aorta, 2nd intercostal space. Abnormal Heart Sounds • Murmurs are extra sounds that occur between heartbeats. o Sometimes they sound like a whooshing or swishing noise. • Systolic Murmurs – occurs b/w S1 and S2 o Aortic Stenosis – Mild ▪ Loud murmur early in systole (musical murmur) ▪ Caused by turbulent blood flow into the aorta ▪ Listen using the diaphragm of the stethoscope with the client in a supine position • Diastolic Murmurs – occurs between S2 and S1 o Aortic Regurgitation – Mild ▪ Caused by a bicuspid (thickened) aortic valve ▪ Listen using the diaphragm of the stethoscope over Erb’s point with the client in a sitting position, leaning forward o Mitral Stenosis – Mild ▪ Commonly due to rheumatic heart disease ▪ Listen using the bell of the stethoscope over the mitral valve, with the client in a left lateral position • The first heart sound is increased in intensity • The second heart sound is normal and unsplit Vasculature: Assessing the Cardiovascular System • Prehypertensive individuals (systolic pressure 120-139 mm Hg and diastolic pressure 80- 89 mm Hg) should be counseled on lifestyle modifications, such as weight reduction, exercise, diet and smoking cessation. • Systolic pressure greater than 140 mm Hg and/or diastolic greater than 90 mm Hg should be referred to a health care provider for possible antihypertensive drug therapy. • Typical healthy men and women age 18 and older should be screened for high blood pressure at least once every 2 years • To assess for a pulse deficit, one nurse assesses the apical pulse rate while another nurse assesses the peripheral pulse rate. o If there is a difference between the two pulse rates, then this is the pulse deficit. o A pulse deficit is often associated with irregular cardiac rhythms and can be a sign of decreased cardiac output. • The nurse will check for jugular vein distension by placing the client in supine position and the head of the bed elevated 45°. o The client should then turn his head to one side while the nurse looks for a pulsation. A normal finding is no pulsation. Lymphatic System: Assessing the Cardiovascular System • retrieves excess fluid from tissue spaces and returns it to the bloodstream. Without lymphatic drainage, fluid remains in the interstitial spaces and produces edema. • Can be palpated in the groin, armpit, neck, under the jaw and chin, behind the ears and on the back of the head. • Lymph nodes help the body recognize and fight infections and foreign substances. • Infection is the most common cause of swollen lymph nodes (lymphadenopathy), but immune or autoimmune disorders (such as HIV or rheumatoid arthritis), cancer (such as leukemia and non-Hodgkin lymphoma) and some medications (such as phenytoin) can also cause swollen lymph nodes Findings in Older Adults: Assessing the Cardiovascular System As people age, the natural pacemaker (SA node) of the heart loses some cells and fibrous tissue and fat deposits contribute to a slightly slower heart rate. Additional normal changes seen with aging include lipofuscin deposits, degeneration of heart muscle cells and a thickening of the heart valves. A heart murmur may be heard. Baroreceptors become less sensitive in aging, which may explain why older adults may experience orthostatic hypotension. The aorta becomes thicker, stiffer and less flexible, which causes an increase in blood pressure and hypertrophy of the heart. The blood changes with age. Although the number of white blood cells stays the same, there is a reduction of neutrophils, which means a reduced ability to resist infection. The production of red blood cells produced in response to stress or illness is reduced, which creates a slower response to blood loss and anemia. Cells of the immune system act more slowly, which is why cancer is more common and some infections (such as pneumonia and influenza) are more common in older adults. Also, when an older adult has an infection, their body may not be able to produce a higher temperature. Assessing the GI System The gastrointestinal system consists of the gastrointestinal (or digestive) tract (upper and lower) and the liver, pancreas and gallbladder. UPPER GI System • Mouth — teeth, tongue, salivary glands • Pharynx — mucous-producing glands and skeletal muscles • Esophagus • Stomach LOWER GI System • Small Intestine – digests, absorbs, and mixes via peristalsis. Receives secretions from liver, pancreas, and gallbladder o Uodenum – the proximal section of the small intestine joins the pylorus of the stomach, divided by the pyloric sphincter, which is about 10 inches (25.4 centimeters) long o Jejunum – the middle section, which is about eight feet (2.4 meters) long o Ileum – the lower section, which is about 12 feet long (3.66 meters) • Colon – approx. 6 ft (1.8 m) long + absorbs water and sodium o Ascending o Transverse o Descending o Sigmoid o Rectum – the last 7-8 inches (17.8-20.3 centimeters) of intestine LIVER Lobes are divided into lobules by blood vessels and fibrous material Ducts – hepatic duct from liver; cystic duct from gallbladder; the common bile duct is formed by the joining of the hepatic duct and cystic duct and drains into duodenum MOUTH & PHARYNX Findings in Older Adults As people age, they may report a diminished sense of taste and decreased saliva production. When compared to the younger adult, the nurse will note the following age-related changes: mucosa appears drier, lips are thinner and shinier, teeth color is yellowed (and teeth may be missing) and the tongue is smoother. Dental exams and cleaning are used to identify any tooth or gum problems before they progress. These are scheduled every six months, starting within six months of a child's first tooth but no later than the first birthday. ABDOMEN • IAPP Findings in Older Adults As people age, the muscles of the esophagus contract less forcefully and food is emptied from the stomach more slowly, but these changes usually do not cause symptoms. However, slower movement of food by products through the large intestine contributes to constipation. The liver becomes smaller, and since there's less blood flowing through the kidneys and liver enzymes are less efficient, an older adult is less able to remove drugs and other substances from the body. Additional findings may include increased fat deposits over the abdominal area and less abdominal muscle tone. Recommended Screenings The stool is checked for occult blood (guaiac test) annually. This test is used to identify colon cancer or polyps in the colon or rectum. A colonoscopy is scheduled once every 10 years after turning 50 (unless there is a family history of polyps or colon cancer) to check for cancer or precancerous growths. Assessing the Genitourinary System The genitourinary system consists of the organs of the urinary system (kidneys and bladder) and male and female reproductive organs. • Urinary System o Kidney ▪ The structure of the kidneys include the: • Cortex (outer layer): composed of glomeruli, proximal and distal tubules • Medulla (middle layer): about eight renal pyramids formed by collecting ducts and tubules • Renal pelvis (innermost layer): composed of calyces where papillae move urine into the ureter by peristalsis • Nephron: a functional unit that filters, concentrates, reabsorbs and secretes to produce urine • Glomerulus (plural: glomeruli): filters fluid wastes out of the blood • Tubules: the site where fluid becomes urine (flow sequence: proximal convoluted tubule, loop of Henle and distal convoluted tubule) ▪ The kidney's functions include: • Balancing fluid and electrolytes • Buffering the body's acid-base balance with chemical (metabolic) buffers: phosphate ions and ammonia (NH3) • Regulating arterial blood pressure: hormones – renin, aldosterone • Excreting waste products: urea, creatinine • Producing erythropoietin o Ureters ▪ The ureters convey urine from the renal pelvis of the kidneys to the bladder. They are comprised of smooth muscles that move urine to the bladder by peristalsis. o Bladder ▪ The bladder is a muscular organ that stores urine. It contracts to expel urine from the body. o Urethra ▪ The urethra conveys urine from the bladder to the outside of the body. • Female Reproductive Systems o The ovaries are the main female sex glands. The functions of ovaries include: o Oogenesis ▪ Ovulation ▪ Secretion of progesterone and estrogen o Other female sex organs include the: ▪ Fallopian tubes, which conduct ova from the ovaries to the uterus ▪ Uterus, which has a function in menstruation and pregnancy ▪ Vagina ▪ Vulva • Male Reproductive Systems o The testes are the main male sex glands. o Each individual testis is encased in a fibrous capsule, which has partitions into the inner gland. Seminiferous tubules form spermatozoa and interstitial cells secrete testosterone. o Accessory male sex glands include: ▪ Seminal vesicles ▪ Prostate gland ▪ Bulbourethral glands, which secrete lubrication prior to ejaculation o Ducts: ▪ Epididymis conducts semen from testes to vas deferens ▪ Vas deferens conduct semen from each epididymis to an ejaculatory duct ▪ Ejaculatory ducts ▪ Urethra ▪ Scrotum ▪ Penis The nurse will ask the client about voiding, including frequency, pain, and difficulty starting or maintaining the stream of urine. The nurse will also ask if the client has any difficulty controlling his or her urine. Related questions include: medication, family history of diabetes and daily fluid intake. Inspection & Palpation The nurse will inspect the urine specimen for color and odor. The nurse can palpate a firm, distended bladder between the symphysis pubis and umbilicus. Kidneys are usually not palpable. Abnormal findings include symptoms of a urinary tract infection (UTI), including a burning sensation when voiding, frequent or intense urge to urinate and pain or pressure in the back or lower abdomen. The urine may appear cloudy, dark or foul smelling. Findings in Older Adults As people age, the kidneys become smaller and the number of nephrons decreases. Blood vessels supplying the kidneys can become hardened, which means that the kidneys are less able to filter blood. The wall of the bladder changes, the bladder muscles weaken and the bladder cannot hold as much urine as before. The urethra can become blocked, due to either a prolapsed vagina or enlarged prostate gland. In part, due to their susceptibility to infection, older adults are more likely to experience UTIs. A weakening of the muscles of the bladder and pelvic floor can lead to urine retention, due to incomplete emptying of the bladder and incontinence. • Female Reproductive System The nurse should review the client's reproductive history, including any information about sexually transmitted diseases, menstrual history, obstetrical history and contraceptive use. o Inspection ▪ The nurse will inspect the external genitalia for hair distribution, condition of the skin of the perineum, urethral orifice and vaginal orifice and anus. ▪ During the cervical exam, normal findings include pink skin that's smooth and firm; secretions should be odorless and creamy or clear. ▪ Skene's glands (located around the opening of the urethra) and Bartholin's glands (located in the vulva on either side of the opening to the vagina) should be non-tender with no discharge. ▪ The nurse will note any observed changes to the skin condition, including the presence of hemorrhoids. o Palpation ▪ The nurse may or may not be able to palpate the ovaries. They should feel firm, slightly tender, oval, mobile; about 4 centimeters in diameter. ▪ The uterus should be mobile and be palpable at the level of the pelvis. o Findings in Older Adults ▪ When compared to the younger adult, findings in the older adult include flattened labial folds and paler and shinier skin. ▪ The cervix decreases in size and the vagina shortens with age. ▪ The uterus also diminishes in size and may not be palpable. ▪ The ovaries atrophy with age. o Recommended Screenings ▪ No later than age 21 and performed YEARLY until age 30 • Pap smear: used to look for cervical and/or vaginal cells that are cancerous or precancerous • After 30 yo, screening can be 2-3 years (if before shit were normal) • 70 yo + = may no longer need pap tests. • Male Reproductive System o Inspection ▪ The nurse will inspect the external genitalia for distribution of hair and the skin of the penis, urethral meatus and scrotum. ▪ Expected findings include symmetry of the scrotum, with the left testicle slightly lower than the right. ▪ There should be no bulging in the inguinal canal. ▪ The skin of the perianal areas will be smooth and anal tissues will be moist and hairless. ▪ The nurse will note any abnormal or unusual findings, including an inguinal hernia or hemorrhoids. o Palpation ▪ The foreskin of uncircumcised penises should retract easily. ▪ The testicle should be ovoid in shape, smooth, rubbery and non-tender. ▪ Inguinal lymph nodes should not be palpable. ▪ The nurse will note the tone of the anal sphincter with digital palpation. ▪ The nurse will palpate the prostate gland through the anterior rectal wall. • A normal finding is a firm feeling, walnut-sized structure that protrudes less than 1 cm into the rectum. o Findings in Older Adults ▪ When compared to younger adults, the testes will feel softer, less firm and decrease in size. The scrotal sac may be somewhat pendulous. Pubic hair will be thinner and greyer, and the penis will decrease in size. o Recommended Screenings ▪ The prostate-specific antigen (PSA) lab test may be used to screen asymptomatic and symptomatic men for prostate cancer. • This test is usually combined with a digital rectal exam for men. • An elevated PSA level is associated with cancer, but it can also be caused by benign prostastic hyperplasia (BPH) and inflammation of the prostate. ▪ Men who are between the ages of 15-24 should visually inspect and palpate the skin on the scrotum and testicles in front of a mirror. Assessing the Integumentary System The integumentary system is comprised of the skin, hair, nails and exocrine glands. Along with periodic self-examinations, regular skin screening is included in a routine physical exam. Anatomy ▪ The skin is the largest organ in the body and has two layers: o Dermis – the connective tissue layer under the epidermis containing nerve endings, sensory receptors, capillaries and elastic fibers o Epidermis – contains keratin cells (a fibrous protein), basal cells and melanocytes, which produce the pigment melanin Physiology ▪ The skin is responsible for protection, temperature regulation, sensory reception, biochemical synthesis and absorption. Skin Condition Factors • Age • Hydration and nutrition • Soap, laundry detergents and topical products • Medications • Infectious processes (viral, bacterial and fungal) • Mechanical forces (tearing, friction and shearing) and vascular damage • Tape and adhesive products • Allergy • IV infiltration • Temperature • Bodily secretions: urine, stool, ostomy drainage and fistula Inspection and Palpation The skin is the largest organ in the body. The nurse will inspect the skin color and note any alterations in appearance, including any differences in color or pigmentation (such as hyperpigmentation, hypopigmentation, cyanosis or jaundice). The nurse will also inspect the skin for any lesions. The nurse will palpate the skin and make note of any moisture or excessive dryness, the skin's temperature and texture, noting any areas of roughness or thickening. The nurse can evaluate hydration by assessing skin turgor. The nurse will gently pinch the skin over the sternum or on the forehead for adults. Well-hydrated skin quickly returns to its original position. If it doesn't, the nurse should assess the client for other signs of dehydration. Part of the skin assessment is to inspect the hair and nails. Findings in Children • For light-skinned infants, the overall color is generally pink. For dark-skinned infants, the nurse will assess for Mongolian spots or café au lait spots. To check skin turgor on infants and children, the nurse can gently pinch a fold of skin over the abdomen. Findings in Older Adults • As people age, the skin becomes thinner and drier. o Skin turgor decreases with age. • Benign purple ecchymoses (senile purpura) typically affects older adults due to atrophy of dermal tissues and blood vessels becoming more fragile. • Other age-related changes include keratosis senilis, cherry angiomas, atrophic warts and "liver spots", which are small and flat brown macules. • Hair thickness changes and hair loss commonly occurs for both men and women. o Body and facial hair turn gray. • Fingernails and toenails become thicker, harder, more yellowed and opaque. o Lengthwise ridges in the nails may develop. o Other changes, such as pitting, horizontal ridges and other types of lines may be related to iron deficiency, kidney disease and nutritional deficiencies. • Normal body temperature is not as affected by aging, but it becomes more difficult to control temperature due to a decrease in the amount of fat below the skin and a decreased ability to sweat. Abnormal Findings – Lesions There are many different alterations of the skin. Various health conditions or diseases affect the color of skin. For example, liver disease is associated with jaundice and the yellowish coloring of the skin and cyanosis may indicate hypoxemia. Edema typically is the result of an underlying health issue, such as liver disease, kidney disease, lung disease or heart failure. Clubbed fingers is also a symptom of an underlying heart or lung disease. There are different types of skin lesions, which can be divided into three categories: primary, secondary and special skin lesions. For every lesion, the nurse should note the following eight aspects: color, location, texture, size, shape, type, grouping and distribution. • Primary Skin Lesions o Macules ▪ are flat, irregularly-shaped discolored spots that are either hypopigmented or hyperpgimented. o Nodules ▪ are solid, elevated lesions that extend deeper into the dermis than a papule. Examples include keratinous cysts, small lipomas, fibromas and a variety of neoplasms. Nodules often indicate an underlying systemic disease, such as syphilis, tuberculosis and roundworm infestation. o Papules ▪ are solid, elevated lesions about 0.5-1 cm or less in diameter. Many skin diseases start with papules, including warts, psoriasis, syphilis and acne. The color of the papule is affected by the disease. o Plaque ▪ is an area of the skin surface that is elevated above the surrounding skin surface. In psoriasis, papules form the plaque. o Pustules ▪ are pus-filled lesions, which can result from infection of vesicles or bullae. o Tumor ▪ is a general term for any mass (benign or malignant). A tumor is an elevated, solid lesion greater than 2 cm. o Vesicles and bullae ▪ are elevated, fluid-filled skin lesions. A vesicle is smaller than a bulla. These can be seen in impetigo and corneal pustular dermatosis. o Wheals – allergic rxns ▪ are elevated lesions with increased tissue fluid. They often itch and usually disappear within a few hours. Wheals may be an allergic response to an irritant or insect bite. • Secondary Skin Lesions o Atrophy ▪ One type of atrophy involves a thinning and wrinkling of the epidermis, which is common in older adults. ▪ Another type of skin atrophy is the stretch marks in women after pregnancy and in anyone who had a large weight loss. o Crust ▪ refers to the dry reside of fluid, blood or puss on the skin when vesicles or pustules burst. o Erosion ▪ is a loss of epidermis that does not extend into the dermis. It is often seen in herpes infections. o Fissure ▪ is a linear crack with sharp edges that extend into the dermis. o Keloid ▪ is a smooth overgrowth of fibroblastic tissue. It appears in an area of injury or just arises spontaneously. It is more common in African Americans. o Scales ▪ are shedding flakes of keratinized skin tissue o Scars ▪ are the fibrous healing of a wound. The healing replaces the damaged dermis and epidermis. o Ulcers ▪ are skin lesions involving destruction of the epidermis and the upper papillary dermis. There are many causes, including trauma, infections, parasitic infestations and tumors. An ulcer always results in a scar. • Other Skin Lesions o Other skin lesions include: ▪ comedo (blackhead) ▪ milia (whitehead) ▪ sebaceous cyst ▪ wen ▪ folliculitis (ingrown hair) ▪ furuncle (boil) ▪ carbuncle, abscess, telangiectasia, petechiae, ecchymosis, maceration, burrow and excoriation. • Edema o is an observable swelling from the accumulation of fluid in the interstitial spaces of body tissues. o Anasarca ▪ generalized accumulation of fluid in all the tissues and cavities of the body o Ascites ▪ fluid retention in the abdominal cavity o Dependent edema ▪ swelling that occurs when the limbs are hanging down and gravity pulls the fluid to the lower point o Peripheral edema ▪ swelling of the feet and ankles Assessing Musculoskeletal System The musculoskeletal system is comprised of the bones of the skeleton, muscles, cartilage, tendons, ligaments, joint and other connective tissue that supports and binds tissues and organs together. Functions • The function of the bones is to support and protect structures of the body. They anchor muscles and participate in the regulation of calcium and phosphorus. Some bones contain hematopoietic tissue which forms blood cells. Types • Long – legs, arms • Internal structure of bone o medullary cavity, cancellous bone and red marrow • Short o ankles, wrists ▪ they have less support than long bones and are more likely to break • Flat – shoulder blades • Irregular – face, vertebrae Joints • Bursa – an enclosed cavity containing a gliding joint • Synovium – the lining of joints which secretes lubricating fluid that nourishes and protects • Classification of joints – synarthrosis, amphiarthrosis and diarthrosis Cartilage • Connective tissue covering the ends of bones Muscles Muscles produce movement of the body and maintain posture and body position. • Types: o Striated – controlled by voluntary nervous system o Smooth – controlled by autonomic nervous system o Cardiac – controlled by autonomic nervous system Fascia Fascia surrounds and divides muscles: • Deep – dense fibrous connective tissue that surrounds muscles and bones • Visceral – suspends the organs and wraps them in connective tissue Tendons • Fibrous tissue between muscles and bones Ligaments • Fibrous tissue between bones and cartilage; supports muscles and fascia Inspection The nurse should review the client's risk factors for osteoporosis, impact of current problem on activities of daily living and involvement in sports and/or exercise routine. The nurse will observe the client's gait, posture, balance when walking and the client's extremities. Normal findings include smooth and rhythmic walking with the arms swinging freely at sides. The client should stand upright with parallel alignment of the hips and shoulders, feet aligned and toes pointing straight ahead. There should be a convex curvature to thoracic spine and a concave curvature to lumbar spine. The client should be able to stand still without swaying or tilting. The nurse should observe bilateral symmetry in length, circumference and alignment of the extremities. The nurse will note any abnormal or unusual findings, including kyphosis, lordosis or scoliosis. Palpation The nurse will palpate the muscles, bones and joints. Normal findings include firm and non- tender muscles and joints. The client should be able to move every joint through its normal range of motion, including abduction and adduction, flexion (and dorsiflexion) and extension (and hyperextension) and pronation and supination. The hand and arm on the client's dominant side is generally stronger than the nondominant side, but grips should be fairly equal on both sides. Findings in Older Adults As people age, they lose bone mass or density and the vertebrae lose some of their mineral content, making each bone thinner, and the disks gradually lose fluid and become thinner. The spinal column becomes curved and compressed and the arches of the foot become less pronounced. Bone spurs may develop. The joints become stiffer and less flexible and arthritic changes will cause inflammation, pain and deformity. Lean body mass decreases, muscles shrink and are less toned and able to contract. • All these changes result in: o Bones that break more easily o Overall decrease in height o Inflammation, pain, stiffness and deformity of the joints o Slower and more limited range of motion in the joints o Stooped posture o Slower and shorter gait o Unsteady walking o Decreased strength and endurance o Weaker grip Recommended Screenings Bone density screening is used to screen for osteoporosis. The test uses bones that are more likely to break due to osteoporosis, such as the hip and lower spine. A baseline test should be done at age 50 or at a time that coincides with menopause. Screening for scoliosis is typically scheduled at the onset of adolescence, to coincide with the growth spurt associated with puberty. Early detection and intervention is important because untreated scoliosis can lead to disfigurement, impaired mobility and cardiopulmonary complications. Assessing the Nervous System The nervous system has two components: the central nervous system and the peripheral nervous system. The central nervous system consists of the brain, spinal cord, sensory organs and nerves. The peripheral nervous system consists of nerves and ganglia outside of the brain and spinal cord. Assessment of the eyes and ears is included. The central nervous system (CNS) coordinates and controls body functions. Spinal Cord • The descending tract is the anterior portion of the spinal cord carrying motor information (associate "d"escending to "d"own impulses are carried to peripheral nerves). The ascending tract is the posterior portion of the spinal cord that carries sensory information up to the brain. • The spinal cord is made up of 31 segments: o Eight cervical – neck and upper extremities o 12 thoracic – thoracic and abdomen o Five lumbar – lower extremities o Five sacral – lower extremities, urine and bowel control o One coccygeal PNS • The peripheral nervous system contains cranial and spinal nerves that connect the CNS to sensory organs (eye and ear) and other organs, muscles, blood vessels and glands. • There are 12 pairs of cranial nerves. o 31 pairs of spinal nerves contain both sensory and motor neurons: ▪ 31 pairs – innervate area of skin called dermatome ▪ Eight cervical – neck and upper extremities ▪ 12 thoracic – thoracic area and abdomen ▪ Five lumbar – lower extremities ▪ Five sacral – lower extremities; urine and bowel control ▪ One coccygeal • The autonomic nervous system (part of the PNS) controls involuntary muscles, such as the smooth and cardiac muscles. • Sympathetic nerves control activities that increase energy expenditures (e.g., speed up the heart rate, dilate pupils and relax the bladder) and are involved in "fight-or-flight" response or stress response. • Parasympathetic nerves control activities that conserve energy expenditures (e.g., inhibiting the heart rate, constricting pupils, contracting the bladder and maintaining GI peristalsis). Assessments The nurse can use a number of different tools to assess the nervous system, determine a client's level of consciousness and to evaluate the client's mental status (using the Mini-Mental State Examination, also known as the Folstein test, to measure cognitive impairment). • Level of Consciousness o The most commonly used assessment at the point of care is to determine if the client is alert, which means s/he is oriented to time, person, place and situation and can respond appropriately to verbal, auditory, tactile and painful stimuli o Alterations in level of consciousness can range from alert to lethargic, obtunded, stuporous, semicomatose and comatose (when the client no longer responds to pain, there are no reflexes or muscle tone) o GCS  Traumatic Brain Injury • Cranial Nerves (See your poster) • Sensory Function Assessment o Sensory function assessment involves the client identifying objects visually, by sound, by smell and by touch (the client's vision is obstructed with a blindfold). o Some of the tactile assessments include asking the client to identify superficial pain, temperature, light touch and vibration. o Other tests may include the nurse tracing a number on the client's palm and asking the client to identify the number (graphesthesia) and asking a client to identify a familiar object such as a coin or paperclip (stereognosis). • Motor Function Assessment o Check kraft paper • Newborn reflexes o Check previous notes Inspection and Palpation The nurse will inspect and palpate the face and skull. To assess speech and language, the nurse will ask clients questions and listen to the responses. Normal assessment will include smooth, flowing speech, an ability to formulate words without difficulty, varied inflection and using vocabulary appropriate to their educational level. The nurse will expect the client to be able to write letters and numbers. Findings in Older Adults As people age, the brain and spinal cord lose nerve cells and nerve cells may pass messages more slowly than the younger adult. Plaques and tangles may form in the brain and a fatty brown pigment can build up in nerve tissue. The breakdown of nerves can affect the senses. These changes contribute to a reduction or loss of reflexes or sensation, which affects movement and the safety of older adults. The slowing of thought, memory and thinking is a normal part of aging; intelligence, however, remains the same throughout the lifespan. Eye Findings in Older Adults As people age, all the structures in the eye change and result in these more common changes: • The cornea is less sensitive • Pupils may decrease in size and react more slowly in response to light • The lens becomes yellowed, less flexible and slightly cloudy • Visual acuity declines and results in presbyopia • Less able to tolerate glare • More difficulty differentiating certain colors, especially blues and greens • Floaters or flashers may develop in the field of vision • Reduced peripheral vision • Less tear production These changes can all result in concerns about safety, especially if the older adult is still driving. Decreased tear production leads to dry eyes and if not treated, can result in infection, inflammation and scarring of the cornea. Ear The nurse will inspect the external ear and observe the size, shape and symmetry of both ears. The nurse will also inspect the skin for any lesions and the area behind the auricle for tophus. The nurse will inspect the ear canal for redness, swelling, discharge, crusting and foreign bodies. Hearing tests can detect signs of disease and issues associated with development or communication. These are scheduled every 10 years and then every three years after age 50. Assessing the Respiratory System The respiratory system is comprised of organs responsible for taking in oxygen and expelling carbon dioxide. Upper Respiratory System • Nose and sinuses o The nose and sinuses filter, warm and humidify air and are the first defense against foreign particles. In deep breathing, inhalation usually occurs through the nose and exhalation usually occurs through the mouth. • Pharynx o The pharynx is located behind oral and nasal cavities. The nasopharynx is behind the nose, soft palate, adenoids and Eustachian tube. o The oropharynx forms a soft palate to the base of tongue and the laryngopharynx extends from the base of the tongue to the esophagus. ▪ The oropharynx is where food and fluids are separated from air. It is considered the bifurcation of the larynx and the esophagus. • Larynx o The larynx is located between the trachea and pharynx and is commonly called the voice box. The vocal cords are responsible for voice, airway protection and control of airflow through the trachea. o The glottis is the opening between the vocal cords o the epiglottis covers the airway during swallowing, protecting against aspiration. o The thyroid cartilage is often called the "Adams apple." o The cricoid cartilage contains the vocal cords and is the only complete ring in the airway. Lower Respiratory System • Trachea o The trachea is found at the anterior neck in front of the esophagus and carries air to the lungs. • Mainstem Bronchi o The mainstem bronchi are located on both the right and left sides. In older adults, the right middle lobe is most likely to receive aspirate in clients who have difficulty swallowing. • Conducting Airways o Lobar Bronchi ▪ Surrounded by blood vessels, lymphatics and nerves lined with ciliated, columnar epithelial cells. o Bronchioles ▪ do not have supportive cartilage and collapse more easily. ▪ They do not contain cilia and are not involved in gas exchange. • Alveolar Ducts and Alveoli o The lungs contain approximately 300 million alveoli. The alveoli are surrounded by a capillary network. o Gas exchange happens at the alveolar-capillary membrane. ▪ Blood takes in oxygen (O2) and gives off CO2. o The alveoli are held open by surfactant, which decreases surface tension to minimize alveolar collapse. • Accessory Muscles of Respirations o If the client is using accessory muscles to breathe, this indicates additional effort is needed. ▪ Scalene muscles – elevate the first two ribs ▪ Sternocleidomastoid muscles – raise the sternum ▪ Trapezius and pectoralis muscles – stabilize the shoulders ▪ Abdominal muscles – put power into a cough and used most often with chronic respiratory problems and acute severe respiratory distress ▪ In infants – nasal flaring, sternal or intercostal retractions and grunting o Respiratory changes in older adults include stiffening and reduced function of respiratory structures, reduced capacity of respiratory defense mechanisms and less effective respiratory control. Respiratory Anatomy & Physiology - General • The respiratory system is comprised of the upper airway and lower airway structures. • The upper respiratory system filters, moistens and warms air during inspiration. • The lower respiratory system is the site of gas exchange, regulating the body's oxygen (PaO2) and carbon dioxide (PaCO2) levels and acid-base (pH) balance. • Gas-exchange in the respiratory system occurs in the alveoli and pulmonary capillaries. Physiology of Breathing • Inspiration is an active process and begins with the contraction of the intercostal muscles. The diaphragm expands the chest. The intrathoracic pressure decreases, drawing oxygenated air through the upper airway into the lungs. • Expiration is a passive process. The intercostal muscles relax, which increases intrathoracic pressure. Carbon dioxide, a waste product of metabolism, is exhaled from the lungs through the upper airway. • Gas exchange of oxygen and carbon dioxide occurs through diffusion across the alveolar- capillary membrane. Findings in Older Adults As people age, the muscles used in breathing tend to weaken and the lungs become less elastic. The number of alveoli and capillaries in the lungs decrease, which means less oxygen is absorbed. Cough tends to be weaker in older adults and the cells that are supposed to protect the airways are less efficient, which means that older adults may be less able to fight infection. Abnormal Findings • Alterations in breathing • Adventitious breath sounds • Pediatric Alterations o The pediatric client has an increased risk of obstruction from mucus, edema or a foreign body due to several factors, including a smaller, shorter and more pliable airway, underdeveloped supporting cartilage, a flexible larynx, a decreased ability to mobilize secretions and a less forceful cough. o Children with respiratory distress will sit up and lean forward to allow the accessory muscles to help with breathing. Children with epiglottitis will sit up with their neck extended and head forward, while drooling and breathing through the mouth. o Using auscultation, the nurse may hear adventitious breath sounds such as stridor, wheezing or crackles; decreased breath sounds; paradoxical movement of the chest wall; and accessory muscle use and nasal flaring. [Show More]

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