ADPIE-

Assessment is to collect subjective and objective data

Diagnosis is to analyze sub and obj data to make a nursing judgment…this is where you do your referrals, collaborative prob, and make a nursing dx

Planning is to determine the outcome criteria and develop a plan

Implementing is carrying out that plan

Evaluate is did it work or does your plan need advising

The purpose of the health assessment is to collect subj and object data to determine overall functioning to make a professional clinical judgment

The steps of assessment are as follows; subjective data, objective data, validation, and documentation.

Validation is crucial. Its serves to ensure the assessment process has NOT ended before relevent data have been collected and it helps prevent inaccurate data

Data analysis is the critical thinking. It has seven steps….Id normal strengths and data, clusters data, inferences, nursing dx, definining characteristics, confirm and rule out, document (this is what we did our concept map on)

Culture is learned, shared and associated with adaptation of environment and it’s universal

Review of symptoms are signs and symptoms of a current health problem (aka review body systems) it draws out current health problems, include only subjective data like a headache, fatigue, cramps.

When preparing for an exam the nurse must assess your own feelings before examine the client. The patient nurse relationship must also be established during the client interview before the physical exam can take place.

The general surgery is the first step in the head to toe assessment. It consists of the overall impression, mental status, and vital signs

Temperature 36.5-37.7

Pulse- 60-100 +1 is weak, +2 is normal +3 is bounding

Respiration is 12-20 breaths/ minute

Blood pressure- <120, and <80

Cold spa

C character- signs and symptoms

Onset- when it began

Location- where and does it radiate

Duration= how long and does it reoccur

Severity- how bad

Pattern- what makes it better or worse?

Associated factors- other symptoms that occur with it like (ROS)

Orthostatic HTN is caused by decreased bar receptors, sensitivity fluid volume, dehydration, medication like anti hypertensives.

The stages of hypertension are

1. D. 140-159; S.90-992. D. 160-179; S. 100-1093. D. >180, S> 110

The bell on a stethoscope is used to detect murmurs and soft sounds, like bruits.

Pain is an unpleasant sensory and emotional experience associated with tissue damage and is considered the fifth vital sign. The Must rely on the patients reporting of there pain.

When asking the patient the location of the pain it is important to know that the radiation of the pain can help ID it’s source. Example chest pain that radiates to arm is a MI

Different scales for pain

Wong baker scale is the faces

NRS 0-10

VAS- Visual and you pick the point where your pain is

VDS mild severe, moderate, worse

To check for patients hydration the nurse must assess for pitting edema, skin tenting, muscle and fat distribution, neck veins, tongue, lung sounds and venous fillings

The healthy bmi is between 19-24

25-30 is considered over weight

30 or more is obese

How you measure your height and weight on the bmi is for every 5 feet tall you are you you add 5 pounds for one inch of your height. For example I am 5’6 so my Ideal body weight would be about 130 lbs.

Well child development focuses on normal growth and development.

SKIN HAIR AND NAILS

Cyanosis (makes white skin appear blue-tinged, especially in the perioral, nailbed, and conjunctival areas. Dark skin appears blue, dull and lifeless in the same areas.Central cyanosis results from a cardiopulmonary problem whereas peripheral cyanosis may be a local problem resulting from vasoconstriction.To differentiate between central and peripheral cyanosis, look for central cyanosis in the oral mucosa Jaundace in light- and dark-skinned people is characterized by yellow skin tones, from pale to pumpkin, particularly in the sclera, oral mucosa, palms, and soles.Acanthosis nigricans (AN), a linear streak-like pattern in dark-skinned people, suggests diabetes mellitus is roughening and darkening of skin in localized areas, especially the posterior neck. Pallor (loss of color) is seen in arterial insufficiency, decreased blood supply, and anemia. Pallid tones vary from pale to ashen without underlying pink. Clammy skin is typical in shock or hypotension Cold skin may accompany shock or hypotension. Cool skin may accompany arterial disease. Very warm skin may indicate a febrile state or hyperthyroidismIncreased moisture or diaphoresis (profuse sweating) may occur in conditions such as fever or hyperthyroidism. Decreased moisture occurs with dehydration or hypothyroidism

Macule, Patch

Flat, non-palpable skin color change (skin color may be brown, white, tan, purple, red)

Macule: < 1 cm, circumscribed border Patch: > 1cm, may have irregular border

Freckles

Flat moles Petechiae Rubell Vitiligo Port wine stains Ecchymosis

Papule. Plaque

Elevate, palpable, solid mass; circumscribed border

Papules:

Elevated nevi Warts L

Nodule, Tumor

Elevated, solid, palpable mass

ichen planus Lipoma Squamous cell carcinoma Poorly absorbed injection Dermatofibroma

Vesicle, Bulla

Circumscribed elevated, palpable mass containing serous fluid

Vesicles:

Herpes simplex/zoster Varicella (chickenpox) Poison ivy Second-degree burn

Pustule

Pus-filled vesicle or bulla Acne

Lichenification

Thickening and roughening of the skin Accentuated skin markings May be secondary to repeated rubbing, irritation, scratching

Contact dermatitis, often resulting from exposure to aero allergens, chemicals, foods, and emotional stress

Petechia (Pl. Petechiae)

Round red or purple macule Small: 1–2 mm Secondary to blood extravasation Associated with bleeding tendencies or emboli to skin

Ecchymosis (Pl. Ecchymoses)

Round or irregular macular lesion Larger than petechia Color varies and changes: black, yellow, and green hues Secondary to blood extravasation Associated with trauma, bleeding tendencies

Cherry Angioma

Papular and round Red or purple Noted on trunk, extremities May blanch with pressure Normal age-related skin alteration Usually not clinically significant

When assessing moles follow the code ABCDE

Asymetry , border, color, diameter, and elevation

Head Neck and Lymphatic

Palpate the temporomandibular joint. To assess the temporomandibular joinNormally there is no swelling, tenderness, or crepitation with movement. Mouth opens and closes fully (3 to 6 cm between upper and lower teeth). Lower jaw moves laterally 1 to 2 cm in each direction.t (TMJ), place your index finger over the front of each ear as you ask the client to open her mouth, Limited range of motion, swelling, tenderness, or crepitation may indicate TMJ syndrome

Normal ly lymph nodes, which are round and smal ler than 1 cm, are not palpable. When lymph node enlargement exceeds 1 cm, the c l ient is said to have lymphadenopathy, which may be caused by acute or chronic in fect ion, an auto immune disorder, or metastat ic d isease

Neck pain may accompany muscular problems or cervical spinal cord problems. Stress and tension may increase neck pain. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation.

Drooping of one side of the face may result from a stroke—or cerebrovascular accident (CVA)—or a neurologic condition known as Bell's palsy (Fig. 12-6).A “masklike” face marks Parkinson's disease; a “sunken” face with depressed eyes and hollow cheeks is typical of cachexia (emaciation or wasting); and a pale, swollen face may result from nephrotic syndro

Palpate the thyroid gland. Locate key landmarks with your index finger and thumb. cases of diffuse enlargement; such as hyperthyroidism, Graves' disease, or an endemic goiter, the thyroid gland may be palpated. An enlarged, tender gland may result from thyroiditis. Multiple nodules of the thyroid may be seen in metabolic processes. However, rapid enlargement of a single nodule suggests a malignancy and must be evaluated further. soft, blowing, swishing sound auscultated over the thyroid lobes is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries

1. Tonisllar grading Grading Scale 1. Tonsil 0: Tonsils fit within tonsillar fossa 2. Tonsil 1+: Tonsils <25% of space between pillars 3. Tonsil 2+: Tonsils <50% of space between pillars 4. Tonsil 3+: Tonsils <75% of space between pillars 5. Tonsil 4+: Tonsils >75% of space between pillars

EYE

Redness or swelling of the eye is usually related to an inflammatory response caused by allergy, foreign body, or bacterial or viral infection. Discharge other than tears from one or both eyes suggests a bacterial or viral infection.

Myopia (impaired far vision) is present when the second number in the test result is larger than the first (20/40). Presbyopia (impaired near vision) is indicated when the client moves the chart away from the eyes to focus on the print.Asymmetric position of the light reflex indicates deviated alignment of the eyes. This may be due to muscle weakness or paralysis

Drooping of the upper lid, called ptosis, may be attributed to oculomotor nerve damage,

An inverted lower lid is a condition called an entropion, which may cause pain and injure the cornea as the eyelash brushes against the conjunctiva and cornea.Ectropion, an everted lower eyelid, results in exposure and drying of the conjunctiva

Protrusion of the eyeballs accompanied by retracted eyelid margins is termed exophthalmos

sunken appearance of the eyes may be seen with severe dehydration or chronic wasting illnesses.

Generalized redness of the conjunctiva suggests conjunctivitis (pink eye).Areas of dryness are associated with allergies or trauma.Episcleritis is a local, noninfectious inflammation of the sclera. The condition is usually characterized by either a nodular appearance or by redness with dilated vessels

Test for direct response by darkening the room and asking the client to focus on a distant object. To test direct pupil reaction, shine a light obliquely into one eye and observe the pupillary reaction. Shining the light obliquely into the pupil and asking the client to focus on an object in the distance ensures that pupillary constriction is a reaction to light and not a near reaction.

Hordeolum (stye), a hair follicle infection, causes local redness, swelling, and pain. A chalazion, an infection of the meibomian gland (located in the eyelid), may produce extreme swelling of the lid, moderate redness, but minimal pain

corneal scar, which appears grayish white, usually is due to an old injury or inflammation. Chalazion (infected meibomian gland). Blepharitis (staphylococcal infection of the eyelid). Not iceable wi th the

posi t ions test , paralyt ic s t rabismus is usual ly the resul t of weakness or paralys is of one or more extraocular muscles

EAR Earache (otalgia) can occur with ear infections, cerumen blockage, sinus infections, or teeth and gum problems.

Mouth nose sinuses

Dysphagia (difficulty swallowing) may be seen in esophageal disorders, anxiety, poorly fitting dentures, or a neurologic disorder. Dysphagia increases the risk for aspiration, and clients with dysphagia may require consultation with a speech therapist. Difficulty chewing, swallowing, or moving the tongue or jaws may be a late sign of oral cancer.uth nose sinuses

leukoplakia (thick white patches of cells). Leukoplakia is a precancerous condition. Leukoplakia is a precancerous lesion, and the client should be referred for evaluation. Whitish, curdlike patches that

scrape off over reddened mucosa and bleed easily indicate “thrush” (Candida albicans) infection. Koplik's spots (tiny whitish spots that lie over reddened mucosa) are an early sign of the measles

Clients who smoke, drink large quantities of coffee or tea or have an excessive intake of fluoride may have yellow or brownish teeth. Among possible abnormalities are deep longitudinal fissures seen in dehydration; a black tongue indicative of bismuth (PeptoBismol) toxicity: black, hairy tongue; a smooth, reddish, shiny tongue without papillae indicative of niacin or vitamin B12 Fruity or acetone breath is associated with diabetic ketoacidosis. Purulent nasal discharge is seen with acute bacterial rhinosinusitis.

LUNGS

Wheezing indicates narrowing of the airways due to spasm or obstruction. Wheezing is associated with congestive heart failure (CHF), asthma (reactive airway disease), or excessive secretions. Studies have shown that patients with asthma often have GERD (gastroesophageal reflux disease) or are more susceptible to GERD. Nonproductive coughs are often associated with upper respiratory irritations and early congestive heart failure. White or mucoid sputum is often seen with common colds, viral infections, or bronchitis. Yellow or green sputum is often associated with bacterial infections. Blood in the sputum (hemoptysis) is seen with more serious respiratory conditions. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia. Pink, frothy sputum may be indicative of pulmonary edema. An increase in the amount of sputum is often seen in an increase in exposure to irritants, chronic bronchitis, and pulmonary abscess. Clients with excessive, tenacious secretions may need instruction on controlled coughing and measures to reduce viscosity of secretions. Client leans forward and uses arms to support weight and lift chest to increase breathing capacity, referred to as the tripod position (Fig. 16-10). This is often seen in chronic obstruc-tive pulmonary disease (COPD). Crepitus, also called subcutaneous emphysema, is a crackling sensation (like bones or hairs rubbing against each other) that occurs when air passes through fluid or exudate. Use your fingers and follow the above sequence when palpating. fremitus (vibrations of air in the bronchial tubes transmitted to the chest wall). Unequal chest expansion can occur with severe atelectasis (collapse or incomplete expansion), pneumonia, chest trauma, or pneumothorax (air in the pleural space). Decreased chest excursion at the base of the lungs is characteristic of chronic obstructive pulmonary disease (COPD). This is due to decreased diaphragmatic function.

Resonance is the percussion tone elicited over normal lung tissue (Fig. 16-14). Percussion elicits flat tones over the scapula.

Hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax. Dullness is present when fluid or solid tissue replaces air in the lung or occupies the pleural space such as in lobar pneumonia, pleural effusion, or tumor

Adventitious lung sounds, such as crackles (formerly called rales) and wheezes (formerly called rhonchi) are evident. See Table 16-2 for a complete description of each type of adventitious breath sound.

Labored and noisy breathing is often seen with severe asthma or chronic bronchitis. Abnormal breathing patterns include tachypnea, bradypnea, hyperventilation, hypoventilation, Cheyne-Stokes respiration, and Biot's respiration Retraction of the intercostal spaces indicates an increased inspiratory effort. This may be the result of an obstruction of the respiratory tract or atelectasis. Bulging of the intercostal spaces indicates trapped air such as in emphysema or asthma. Hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax. Dullness may characterize areas of increased density such as consolidation, pleural effusion, or tumor

areas of extreme congestion or consolidation, crepitus may be pal-pated particularly in clients with lung disease.

Continuous coughs are usually associated with acute infections, whereas those occurring only early in the morning are often associated with chronic bronchial inflammation or smoking. Coughs late in the evening may be the result of exposure to irritant during the day. Coughs occurring at night are often related to postnasal drip or sinusitis. Orthopnea (difficulty breathing when lying supine) may be associated with heart failure. Paroxysmal nocturnal dyspnea (severe dyspnea that awakens the person from sleep) also may be associated with heart failure. Changes in sleep patterns may cause the client to feel fatigued during the day.

HEART

Extra Heart Sounds

S 3 and S 4 are referred to as d iasto l ic f i l l ing sounds or extra heart sounds, which resul t f rom

ventr icu lar v ibrat ion secondary to rapid ventr icu lar f i l l ing. I f present , S 3 can be heard ear ly in

d iasto le.

Chest pain can be cardiac, pulmonary, muscular, or gastrointestinal in origin. Angina (cardiac chest pain)

is usually described as a sensation of squeezing around the heart; a steady, severe pain; and a sense of

pressure. It may radiate to the left shoulder and down the left arm or to the jaw. Diaphoresis and pain

worsened by activity are usually related to cardiac chest pain.

Pulse Amplitude Scale

0 = Absent

1+ = Weak

2+ = Normal

3+ = Increased

4+ = Bounding

Apical pulse (fourth or fifth intercostal space at the midclavicular line)

A bruit, a blowing or swishing sound caused by turbulent blood flow through a narrowed vessel, is

indicative of occlusive arterial disease

Mitral valve insuffiency the SI will be dimished

Chestr pain Emegent, mi, aaa, phenmothorax

Non Emergent CHF, phnemonia, anxiety, gerds chronditis

Peripheral vascular

Know whre to assess all pulses, radial, ulner, popliae, femur, dorsal pedis, etc

Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, especially over the lower

legs, are associated with arterial insufficiency. Warm skin and brown pigmentation around the ankles

are associated with venous insufficiency.

Intermittent claudication characterized by cramping pain in the calves, thighs, or buttocks and weakness that occurs with activity and is relieved with rest may indicate arterial disease (Scherer & Regensteiner, 2004). Heaviness and an aching sensation aggravated by standing or sitting for long periods of time and is relieved by rest are associated with venous disease. Leg pain that awakens a client from sleep is often associated with advanced chronic arterial occlusive disease. However, the lack of pain may signal neuropathy in a diabetic client. Reduced sensation or an absence of pain can result in a failure to recognize a problem or fully understand the problem's significance

Arterial Insufficiency

Pain: Intermi t tent c laudicat ion to sharp, unrelent ing, constant

Pulses: Diminished or absent

Skin Character is t ics: Dependent rubor

Elevat ion pal lor of foot

Dry, shiny sk in

Cool- to-cold temperature

Loss of hai r over toes and dorsum of foot

Nai ls th ickened and r idged

Ulcer Character is t ics:

Locat ion: T ips of toes, toe webs, heel or other pressure areas i f conf ined to bed

Pain: Very painfu l

Depth of u lcer : Deep, of ten involv ing jo int space

Shape: Circular

Ulcer base: Pale b lack to dry and gangrene

Leg edema: Minimal unless extremity kept in dependent posi t ion constant ly to re l ieve

pain

Venous Insufficiency

Pain: Aching, cramping

Pulses: Present but may be d i f f icu l t to palpate through edema

Skin Character is t ics:

Pigmentat ion in gai tor area (area of media l and latera l mal leolus)

Skin th ickened and tough

May be reddish-blue in color

Frequent ly associated wi th dermat i t is

Ulcer Character is t ics:

Locat ion: Media l mal leolus or anter ior t ib ia l area

Pain: I f superf ic ia l , min imal pain; but may be very painfu l

Depth of u lcer : Superf ic ia l

Shape: I r regular border

Ulcer base: Granulat ion t issue–beefy red to yel low f ibr inous in chronic long-term ulcer

Leg edema: Moderate to severe

Right Upper Quadrant (RUQ)

Ascending and t ransverse colon

Duodenum

Gal lb ladder

Hepat ic f lexure of colon

Liver

Pancreas (head)

Pylorus ( the smal l bowel—or i leum—traverses a l l quadrants)

Right adrenal g land

Right k idney (upper pole)

Right ureter

Right Lower Quadrant (RLQ)

Appendix

Ascending colon

Cecum

Right k idney ( lower pole)

Right ovary and tube

Right ureter

Right spermat ic cord

Left Upper Quadrant (LUQ)

Lef t adrenal g land

Lef t k idney (upper pole)

Lef t ureter

Pancreas (body and ta i l )

Spleen

Splenic f lexure of colon

Stomach

Transverse descending colon

Left Lower Quadrant (LLQ)

Lef t k idney ( lower pole)

Lef t ovary and tube

Lef t ureter

Lef t spermat ic cord

Descending and s igmoid colon

Accentuated sharp pain that causes the client to hold his or her breath (inspiratory arrest) is a positive

Murphy's sign and is associated with acute cholecystitis. Pain or an exaggerated sensation felt in the RLQ

is a positive skin hypersensitivity test and may indicate appendicitis. Pain in the RLQ indicates irritation

of the obturator muscle due to appendicitis or a perforated appendix. Pain in the RLQ (Psoas sign) is

associated with irritation of the iliopsoas muscle due to an appendicitis (an inflamed appendix). Pain in

the RLQ during pressure in the LLQ (referred rebound tenderness) suggests appendicitis. Pain in the RLQ

during pressure in the LLQ is a positive Rovsing's sign. It suggests acute appendicitis. The client has

rebound tenderness when he or she perceives sharp, stabbing pain as the examiner releases pressure

from the abdomen (Blumberg's sign). It suggests peritoneal irritation (as from appendicitis). If the client

feels pain at an area other than where you were assessing for rebound tenderness, consider that area as

the source of the pain. In the client with ascites, you can feel a freely movable mass moving upward

(floats). It can be felt at the fingertips. A floating mass can be palpated for size. The spleen feels soft with

a rounded edge when it is enlarged from infection. It feels firm with a sharp edge when it is enlarged

from chronic disease.

Tenderness accompanied by peritoneal inflammation or capsular stretching is associated with splenic

enlargement. palpable spleen suggests enlargement (up to three times the normal size), which may

result from trauma, mononucleosis, chronic blood disorders, and cancers. The splenic notch may be felt,

which is an indication of splenic enlargement. hard, firm liver may indicate cancer. Nodularity may occur

with tumors, metastatic cancer, late cirrhosis, or syphilis. Tenderness may be from vascular

engorgement (e.g., congestive heart failure), acute hepatitis, or abscess.

A liver more than 1 to 3 cm below the costal margin is considered enlarged (unless pressed down by the

diaphragm).

Enlargement may be due to hepatitis, liver tumors, cirrhosis, and vascular engorgement. A wide,

bounding pulse may be felt with an abdominal aortic aneurysm. A prominent, laterally pulsating mass

above the umbilicus with an accompanying audible bruit strongly suggests an aortic aneurysm. A mass

detected in any quadrant may be due to a tumor, cyst, abscess, enlarged organ, aneurysm, or adhesions.

Involuntary reflex guarding is serious and reflects peritoneal irritation. The abdomen is rigid and the

rectus muscle fails to relax with palpation when the client exhales. It can involve all or part of the

abdomen but is usually seen on the side (i.e., right vs. left rather than upper or lower) because of nerve

tract patterns. Right-sided guarding may be due to cholecystitis. Tenderness elicited over the liver may

be associated with inflammation or infection (e.g., hepatitis or cholecystitis). Friction rubs are rare. If

heard, they have a high-pitched, rough, grating sound produced when the large surface area of the liver

or spleen rubs the peritoneum. They are heard in association with respiration.

A friction rub heard over the lower right costal area is associated with hepatic abscess or metastases.

A rub heard at the anterior axillary line in the lower left costal area is associated with splenic infarction,

abscess, infection, or tumor. hernia (protrusion of the bowel through the abdominal wall) is seen as a

bulging in the abdominal wall. Diastasis recti appears as a bulging between a vertical midline separation

of the abdominis rectus muscles. This condition is of little significance. An incisional hernia may occur

when a defect develops in the abdominal muscles because of a surgical incision. A mass within the

abdominal wall is more prominent when the head is raised, whereas a mass below the abdominal wall is

obscured. Bluish or purple discoloration around the umbilicus (Cullen's sign) indicates intra-abdominal

bleeding.

Assess for rebound tenderness and Rovsing's Sign. Abdominal pain and tenderness may indicate peritoneal

No rebound tenderness is present.

The client has rebound tenderness when he or she perceives sharp, stabbing pain as the examiner

irritation. To assess this possibility, test for rebound tenderness. Palpate deeply in the abdomen where the client has pain then suddenly release pressure (Fig. 20-31). Listen and watch for the client's expression of pain. Ask the client to describe which hurt more—the pressing in or the releasing—and where on the abdomen the pain occurred.

 Test for rebound tenderness should always be performed at the end of the examination because a positive response produces pain and muscle spasm that can interfere with the remaining examination.

releases pressure from the abdomen (Blumberg's sign). It suggests peritoneal irritation (as from appendicitis). If the client feels pain at an area other than where you were assessing for rebound tenderness, consider that area as the source of the pain (see test for referred rebound tenderness, below).

    Figure 20-29 Performing fluid wave test.   Figure 20-30 Performing ballottement with one hand

(A) and bimanually (B).

Palpate deeply in the LLQ. No pain is elicited.

Pain in the RLQ during pressure in the LLQ is a positive Rovsing's sign. It suggests acute appendicitis.

Test for referred rebound tenderness. Palpate deeply in the LLQ and, quickly release pressure.

No rebound pain is elicited.

Pain in the RLQ during pressure in the LLQ (referred rebound tenderness) suggests appendicitis.

 Avoid continued palpation when test findings are positive for appendicitis because of the danger of rupturing the appendix.

Assess for Psoas sign. Raise the client's right leg from the hip and place your hand on the lower thigh. Ask the client to try to keep the leg elevated as you apply pressure downward against the lower thigh (Fig. 20-32).

No abdominal pain is present.

Pain in the RLQ (Psoas sign) is associated with irritation of the iliopsoas muscle due to an appendicitis (an inflamed appendix).

Assess for Obturator sign. Support the client's right knee and ankle. Flex the hip and knee and rotate the leg internally and externally (Fig. 20-33).

No abdominal pain in present.

Pain in the RLQ indicates irritation of the obturator muscle due to appendicitis or a perforated appendix.

Test for Cholecystitis

Assess RUQ pain or tenderness, which may signal cholecystitis (inflammation of the gallbladder). Press your fingertips under the liver border at the right costal margin and ask the client to inhale deeply.

No increase in pain is present.

Accentuated sharp pain that causes the client to hold his or her breath (inspiratory arrest) is a positive Murphy's sign and is associated with acute cholecystitis.

MUSCULO

Test for carpal tunnel syndrome. Perform Phalen's test. Ask the client to place the backs of both hands against each other while flexing the wrists 90 degrees downward (Fig. 24-20A). Have the client hold this position for 60 seconds.Optionally test for Tinel's sign. With your finger, percuss lightly over the median nerve (located on the inner aspect of the wrist) (Fig. 24-20B).

No tingling, numbness, or pain result from Phalen's test or from Tinel's test.

After either test, client may report tingling, numbness, and pain with carpal tunnel syndrome.Median nerve entrapped in the carpal tunnel results in pain, numbness, and impaired function of the hand and fingers

Test for pain and injury. If the client complains of a “giving in” or “locking” of the knee, perform McMurray's test (Fig. 24-29). With the client in the supine position, ask the client to flex one knee and hip. Then place your thumb and index finger of one hand on either side of the knee. Use your other hand to hold the heel of the foot up. Rotate the lower leg and foot laterally. Slowly extend the knee, noting pain or clicking. Repeat, rotating lower leg and foot medially. Again note pain or clicking.

Neurological

Cerebellum i ts pr imary funct ions inc lude coordinat ion and smoothing of voluntary

movements, maintenance of equi l ibr ium, and maintenance of muscle tone

Cerebrummemory, percept ion, communicat ion, and in i t ia t ion of voluntary movements.

Frontal Directs voluntary, skeletal actions (left side of lobe controls right side of body and right side of lobe controls left side of body). Also influences communication (talking and writing), emotions, intellect, reasoning ability, judgment, and behavior. Contains Broca's area, which is responsible for speech.

Parietal Interprets tactile sensations, including touch, pain, temperature, shapes, and two-point discrimination.

Occipital Influences the ability to read with understanding and is the primary visual receptor center.

Temporal Receives and interprets impulses from the ear. Contains Wernicke's area, which is responsible for interpreting auditory stimuli.

I (olfactory) Sensory Carries smell impulses from nasal mucous membrane to brain

II (optic) Sensory Carries visual impulses from eye to brain

III (oculomotor) Motor Contracts eye muscles to control eye movements (interior lateral, medial, and superior), constricts pupils, and elevates eyelids

IV (trochlear) Motor Contracts one eye muscle to control inferomedial eye movement

V (trigeminal) Sensory

Motor

Carries sensory impulses of pain, touch, and temperature from the face to the brainInfluences clenching and lateral jaw movements (biting, chewing)

VI (abducens) Motor Controls lateral eye movements

VII (facial) Sensory

Motor

Contains sensory fibers for taste on anterior two thirds of tongue and stimulates secretions from salivary glands (submaxillary and sublingual) and tears from lacrimal glandsSupplies the facial muscles and affects facial expressions (smiling, frowning, closing eyes)

VIII (acoustic, vestibulocochlear)

Sensory Contains sensory fibers for hearing and balance

IX (glossopharyngeal)

Sensory

Motor

Contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the “gag reflex” when stimulatedProvides secretory fibers to the parotid salivary glands; promotes swallowing movements

X (vagus) SensoryMotor

Carries sensations from the throat, larynx, heart, lungs, bronchi, gastrointestinal tract, and abdominal visceraPromotes swallowing, talking, and production of digestive juices

XI (spinal accessory) Motor Innervates neck muscles (sternocleidomastoid and trapezius) that promote movement of the shoulders and

head rotation. Also promotes some movement of the larynx

XII (hypoglossal) Motor Innervates tongue muscles that promote the movement of food and talking

Lethargy: Client opens eyes, answers questions, and falls back asleep.Obtunded: Client opens eyes to loud voice, responds slowly with confusion, seems unaware of environment.Stupor: Client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep.Coma: Client remains unresponsive to all stimuli; eyes stay closed. Client with lesions of the corticospinal tract draws hands up to chest (decorticate or abnormal flexor posture) when stimulated (Fig. 25-8).Client with lesions of the diencephalon, midbrain, or pons extends arms and legs, arches neck and rotates hands and arms internally (decerebrate or abnormal extensor posture) when stimulated

Use the Glasgow Coma Scale (GCS) for clients who are at high risk for rapid deterioration of the nervous system (Display 25-2).

GCS score of 14 indicates an optimal level of consciousness.

GCS score of less than 14 indicates some impairment in the level of consciousness. A score of 3, the lowest possible score, indicates deep coma.

Test CN I (olfactory). For all assessments of the cranial nerves, have client sit in a comfortable position at your eye level. Ask the client to clear the nose to remove any mucus then to close eyes, occlude one nostril, and identify a scented object that you are holding such as soap, coffee, or vanillaAssess CN III (oculomotor), IV (trochlear), and VI (abducens). Inspect margins of the eyelids of each eye. Assess CN V (trigeminal).Test motor function. Ask the client to clench the teeth while you palpate the temporal and masseter muscles for contractionTest corneal reflex. Ask the client to look away and up while you lightly touch the cornea with a fine wisp of cottonTest CN VII (facial).Test motor function. Ask the client to

Smile Frown and wrinkle forehead (Fig. 25-15A) Show teeth

Test CN VIII (acoustic/vestibulocochlear). Test the client's hearing ability in each ear and perform the Weber and Rinne tests to assess the cochlear (auditory) component of cranial nerve VIIITest CN IX (glossopharyngeal) and X (vagus).Test motor function. Ask the client to open mouth wide and say “ah” while you use a tongue

depressor on the client's tongueTest CN XI (spinal accessory). Ask the client to shrug the shoulders against resistance to assess the trapezius muscleTest CN XII (hypoglossal). To assess strength and mobility of the tongue, ask the client to protrude tongue, move it to each side against the resistance of a tongue depressor, then put it back

Assess the strength and tone of all muscle groups (see Chapter 24).

Relaxed muscles contract voluntarily and show mild, smooth resistance to passive movement. All muscle groups equally strong against resistance, without flaccidity, spasticity, or rigidity.

Soft, limp, flaccid muscles are seen with lower motor neuron involvement. Spastic muscle tone is noted with involvement of the corticospinal motor tract. Rigid muscles that resist passive movement are seen with abnormalities of the extrapyramidal tract.

Elderly assessmentmajor threat to the heal th of a f ra i l e lder ly person is respiratory infect ion. Pneumonia is the most common cause of in fect ion-re lated deaths in e lder ly c l ients and is character ized as a “s i lent k i l ler

Decreased tear product ion by the lacr imal g lands of ten resul ts in dry eyes. ADLS Ability

to Telephone, shopping, food prep, house keep, laundry,

transportation, meds, financ

occurring with standing up and associated with dizziness may point to orthostatic hypotension and an adverse reaction to medication. If the client reports tripping or slipping in the absence of stiffness or weakness and any symptoms, an environmental basis such as shoes or floors with a slick surface or loose carpeting or rugs may be suspected. It’s pretty basic

Family assessment

The goal of the nurse to assess domestic violence is to Identify, Safety, and Referal.

Components of Family Assessment

StructureFami ly st ructure has three e lements: in ternal s t ructure, external s t ructure, and

context . Some theor is ts focus on a st ructura l–funct ional f ramework that , when appl ied

to fami ly assessment, examines the interact ion between the fami ly and i ts in ternal and

external envi ronment

DevelopmentLike indiv iduals, fami l ies go through stages of growth and development.

These stages of development are as important to the heal th and wel l -being of the fami ly

as they are to the indiv idual . In fact , a stat ic fami ly s t ructure is dysfunct ional

Funct iondef ined f ive basic fami ly funct ions: af fect ive, socia l izat ion and socia l

p lacement, reproduct ive, economic, and heal th care

The genogram (see Fig. 31-1 ) acts as a cont inuous v isual reminder to caregivers to “ th ink fami ly . ” In addi t ion, the ecomap (see Fig. 31-3 ) i l lust rates the fami ly 's in teract ions wi th outs ide

systemscomposition. Use a genogram and fill in as much information as possible. Ask the following questions:

What is the family type (nuclear, three generation, single-parent)? Who does the family consider to be family? Has anyone recently moved in or out? Has anyone recently died?

Community

Barriers to access to health care are public transportion

Study the history of the community. Look for this information at the local library or ask local residents. Use this information to gain insights into the health practices and belief systems of community members.

The community history should include initial development, any specific ethnic groups that may have settled there, past economic trends, and past population trends.

The history of some communities may include episodes that have had a disruptive influence on the people of the community such as relocation because of repeated flooding, a history of racial or ethnic problems, or the closing of a factory.

Infant assessment

Temperature is 97.5 to 99° F (36.4 to 37.2° C). Rate is 30 to 60 breaths/min. Pulse is regular and between 120 to 160 breaths/min (rate is 100 breaths/min if the infant is sleeping and 180 breaths/min if the infant is crying). Pulse is regular and between 120 to 160 breaths/min (rate is 100 breaths/min if the infant is sleeping and 180 breaths/min if the infant is crying).

Skin color ranges from pale white with pink, yellow, brown, or olive tones to dark brown or black. No strong odor should be evident, and the skin should be lesion free.Skin should be soft, warm, slightly moist with good turgor and without edema or lesions.Common newborn skin variations include

Physiologic jaundice Birthmarks Milia (Fig. 28-15) Erythema toxicum (Fig. 28-15) Telangiectatic nevi (stork bites) (Fig. 28-15)

Yellow skin may indicate jaundice or passage of meconium in utero secondary to fetal distress. Jaundice within 24 hours after birth is pathologic and may indicate hemolytic disease of the newborn. Blue skin suggests cyanosis, pallor suggests anemia, and redness suggests fever, irritation.

Head is normocephalic and symmetric. In newborns, the head may be oddly shaped from molding (overriding of the sutures) during vaginal birth. The diamond-shaped anterior fontanelle measures about 4 to 5 cm at its widest part; it usually closes by 12 to 18 months. The triangular posterior fontanelle measures about 0.5 to 1 cm at its widest part and it should close at 2 months of age.

Pregnancy