NURS 6512 Midterm exam study Guide
NURS 6512 Midterm exam study Guide
Communication techniques used to obtain a patient’s health history (found in Seidel’s guide to physical examination, chapter 1, pages 1-7)
Ask the patient how the prefer to be addressed
b. Ask open-ended questions. Ensure to let the patient have time to discuss their concerns.
c. Be courteous- Knock before entering, ensure confidentiality, meet and acknowledge others that may be in the room and level of participation, respect modesty, allow patient to dress after examination before follow-up discussion
d. Ensure comfort- ensure physical comfort, have minimal furniture, maintain privacy, comfortable room temperature, good lighting, and do not overtire the patient NURS 6512 Midterm exam study Guide
e. Establish a connection- Maintain good eye contact (if cultural preferences allow), avoid professional jargon, actively listen, establish the patients history and conduct the physical exam before viewing previous studies and tests to avoid a predetermined path, be flexible, watch nonverbal cues, define concerns completely (where, severity, length, context, soothers/aggravators)
f. Establish confidentiality- Have patient summarize the discussion, allow more discussion if the patient has other concerns by asking “anything else you would like to bring up,” follow-up if there are questions you are unable to answer right away, if you make a mistake own up to it and make every effort to repair it
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g. Ensure appropriate dress and grooming paying attention to clean fingernails, modest clothing, and neat hair.
h. Seek certainty if patients responses to questions are unclear
i. Be direct and firm when discussing sensitive issues and document after the discussion is over
Medical record should be complete and legible
Each patient encounter should include
Reason for encounter (Chief Complaint)
Relevant history, PE findings, and test results
Assessment, clinical impressions, or diagnosis
Plan of care
Date and legible identity of the observer
Why test was ordered
SOAP notes are a quick and efficient way to compile information and make decisions based on the information provided by the patient.
The information for SOAP notes can be found in the Sullivan Text
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
S-Chief Compliant (CC), history of present illness (HPI), Pertinent past medical history (PMH), Pertinent family history (FH), Pertinent psychosocial history (SH), any specialized history related to the chief complaint, and Pertinent review of systems (ROS) (Sullivan, pp.91-92).
O- Objective: includes the vital signs, a general assessment of the patient, physical examination findings, results from laboratory or diagnostic tests (Sullivan, p. 93)
A- Assessment: is an analysis and interpretation of the subjective and objective data to provide a diagnosis or a list of differential diagnoses (Sullivan, pp. 96-97).
P- Plan: this area includes diagnostic studies that will be obtained, referrals, therapeutic interventions, educational material, disposition of the patient, next visit (Sullivan, p. 99)
Subjective Data vs Objective Data (#4)
Information collection is a vital piece of any assessment process, regardless of whether it is for risk management, a health diagnosing, or an execution assessment. The emotional and target techniques for information accumulation are two conspicuous ones used to decide the kind of information gathered and the suspicions. While the previous is identified with verbal articulation of thought and the statements to take after, the last is identified with unquestionable and strong actuality.
Subjective data or abstract information is information that is gathered or acquired through personal interactions, i.e., talking, sharing, clarifying, and so forth.
It is gathered to make an assumption about what the reality may be, what occasion may have happened, what estimations must be done, and so on.
Subjective information can likewise be gathered by methods for judgment, doubt, or rumors
This information fluctuates from one person to another, with each circumstance, consistently.
It can’t be announced as reality, as it advances from such a large number of changed sources with various information sources.
Abstract dialect as a rule starts with, ‘I think’, ‘I require’, ‘I feel’, and so on
By definition, objective data is information that is gathered or acquired by means of established or obvious realities and sources.
It is gathered to affirm your doubts and suppositions – or only to accumulate trustworthy data. It is something that can be felt, contacted, smelled, seen, heard, and tasted.
Objective information will be the same from numerous sources and can be checked and portrayed precisely and affirmed.
This information does not fluctuate from one person to another or with each circumstance.
It tends to be proclaimed as evident information since it stays same and reliable regardless of whether numerous sources are included.
Objective dialect more often than not starts with ‘I said’, ‘I watched’, ‘I gauged’, and so forth.
Subjective Data Vs. Objective Data
Its underlying base is personal interpretation. Whatever is perceived is done so, upon communicating with the person about the same and believing what was said by the person/source. Its underlying base is observing what happened, observing the facts. The facts are straightforward or proved by means of a test/analysis/experiment, and are true and measurable.
It cannot be completely relied on for taking decisions. After all, personal opinions and beliefs vary, and may present an entirely new perspective of the same problem. In such a scenario, a level-headed decision cannot be taken. It is based on facts; hence, it is usually reliable for decision-making. Whatever decision is taken is done so in the light of what has actually happened, that which can be trusted upon, with experiments and facts.
Subjective data and analysis can usually be found on personal blogs, forums, Internet chat stations, biographies, editorials, etc. Objective data is not a discussion. It is found in important scientific papers, encyclopedias, textbooks, reference books, tutorials, etc.
It cannot be used for reporting any news. As it is collected through discussions and interpretations, it is not totally reliable; therefore, making a definite assumption about an event or subject is incorrect. It can be used for reporting information. Data collection is done through efficient methods and reliable, set procedures. It is dependable and can be reported.
When you have a cough and you go to the hospital, the doctor/nurse will ask you questions regarding your cough, like ‘When did it start?’, ‘Is it a dry cough or wet cough?’, ‘Did you eat/drink something cold?’, etc. The information obtained thus, is classified as subjective data. When you get a cough and go to the doctor, the doctor will examine you thoroughly, check your vital signs, conduct tests, and then, based on the test results, he will ascertain the problem you are suffering from (like bronchitis, pneumonia, etc.). This is objective data.
Ethical Decision Making and Beneficence
Four principles of medical ethics are autonomy, beneficence, non-maleficence, and justice. Beneficence is the principle of acting with the best interest of the other in mind, it is the basic premise that healthcare providers have a duty to be of a benefit to the patient as well as to take positive steps to prevent harm from the patient (Levitt, 2014). Ethics are moral principles that govern a person’s behavior. Ethical decision making is based on a person’s moral compass. Choosing to make the right decision is based on what a person believes is right.
Cultural Awareness (6)
*Cultural reflects the whole of human behavior including ideas and attitudes; ways of relating, speaking manners, products of physical effort, ingenuity and imagination.
*Cultural awareness- being knowledgeable of one’s thoughts, feelings, sensation and how these things affect interactions
Crossing the cultural divide helps, but skepticism is a barrier.
*Cultural humility- recognizing one’s limitation in knowledge and cultural perspective to be open to new perspectives; view each patient individually
*Seeleman et al framework- emphasizes on awareness of social context which specific ethnic groups live Social context in minority group means assessing stressors and support networks, sense of life control and literacy
*Campinha- Bacote’s process of Cultural Competence Model- includes (cultural competence dimensions): Awareness- self- examination and in -depth exploration of your biases, stereotypes, prejudices, and assumption
Knowledge- seeking and obtaining education
Skill- collecting culturally relevant data assessing in a cultural manner
Encounter- patient interactions used to validate, redefine or modify existing beliefs and practices and develop cultural desire or modify existing beliefs and practices and develop cultural desire awareness, skill, and knowledge
Desire- motivation to want engagement in being culturally competent
Socioeconomic, Spiritual and lifestyle factors affecting
Socioeconomic status is the social standing or class of an individual or group. It is often measured as a combination of education, income and occupation.
a. Diverse populations are often financially challenged, have educational limitations and have poor access to health care due to of lack of insurance or funding to pay for medication. The lack of health insurance reduces access to care and often results in poorer health outcomes (Bittoni et al, 2015). Healthcare providers must be sensitive to this factor and be knowledgeable about resources within the community to aid these populations to sustaining adequate healthcare (Ball et al, 2015 pg. 10).
b. Many patients want attention paid to spirituality and faith can be a key factor in the success of a management plan. When assessing spirituality continue to be sensitive and ask open ended questions such as:
i. What are your spiritual or religious beliefs?
ii. How do our religious beliefs affect your health care decisions (i.e. birth control)?
iii. Is there anyone from your faith that you would like to include in your healthcare needs (i.e. pastors, priest, or male family members)?
c. Lifestyle factors are the modifiable habits and ways of life that can greatly influence overall health and well-being. Many people of diverse populations have higher rates of engagement in factors that increase health risks such as smoking, poor diet, sedentariness, and poor sexual habits.
i. Assess dietary habits and make nutritional recommendations as needed.
ii. Encourage smoking and alcohol consumption modification or cessation.
iii. Encourage active lifestyle habits (vigorous exercise at least 30 min per day for cardiovascular health, and decreasing obesity)
iv. Assess the 5 Ps of sexual history
1. Partners, practices, protection, past history, and pregnancy prevention practices (Ball et al, 2015 pg. 12).
• Functional assessment is an attempt to understand your patient’s ability to achieve the basic ADL’s
• Should be made for all older adults and for any person who may be limited by disease or disability, acute OR chronic.
• Well-taken history and a meticulous physical exam can bring out subtle influences, such as tobacco and alcohol use, sedentary lifestyles, poor food selection, overuse of medications, and potentially emotional distress.
• Physical limitations such as cognitive ability or of the senses may be founded
• Keep in mind patients tend to overstate their abilities and obscure reality
When performing a functional assessment, consider a variety of disabilities: physical, cognitive, psychological, social, and sexual. It is just as important to understand a patient’s social and spiritual support system as it is their physical disabilities.
Disabilities include but are not limited to
• Difficulty walking standard distances: ½ mile, 2-3 blocks, across a room, etc.
• Difficulty with stairs- climbing or descending
• Problems with balance
Upper Extremity function
• Difficulty grasping small objects or opening jars
• Difficulty reaching out or up overhead (reaching a shelf)
• Heavy (scrubbing floors, vacuuming)
• Light (dusting)
• meal preparation
• medication use/set up
• money management
• bathing, dressing, toileting, moving from bed to chair or from sitting to standing, eating, walking inside the home, etc.
**Any limitations, even is perceived as mild, will affect the patient’s independence and autonomy. This leads to increased reliance on other people and/or assistive devices.
** These limitations indicate the loss of physical reserve and the potential loss of physical function and independence that indicate the onset of frailty
** The patient’s support system and material resources become an integral part of development of reasonable management plans
Growth and Development Ch 6 of text book
Growth Hormone-Releasing Hormone stimulates the pituitary to release the growth hormone.
70% of secretion of the growth hormone occurs during sleep
Critical brain growth between conception and 3 yrs old.
Puberty- Dependent on the GH and androgens (Sex Steroids). They stimulate and increase in the growth Hormone.
Lymphatic tissues reach adult size by 6 yrs old and double by 10-12 yrs old.
Child- 6-8lbs of wt blood-3-4lbs Maternal Fat/protein 4-6lbs
Uterus 2lbs breast 1-2 lbs
Fluid 2-3lb Amniotic fluid 2lbs
Physical Stature decrease at 50 yrs
60 yrs – decrease HT, WT, BMI
Increase Body Fat
Children and Adolescence
Sexual Maturation Girls
Early < 7 yrs Delayed > 13 yrs
Sexual Maturation Boys
Early <9 Delayed > 14
Malnourished < 18 Normal 18.5-24.9 Overweight 25-29.9 Obese 30-39.9 Extreme >40
Weight- Infants should be weight in Gm or KG to the nearest 10 gm
Normal newborn wt 2500-4000 gm * 5lbs 8oz – 8lbs 13 oz)
Lose 10 % of wt at birth and regain in 2 wks.
Birth weight doubles at 6 months and triples by 12 months
Wrap measuring tape at occipital protuberance and supraorbital prominence.
Measure to the nearest 0.4cm
Place on the growth curve and compare with the standard.
Compare to head size
Wrap at nipple line
5 months – the head is = or exceeds the chest size
5 months – 2yrs head = chest
2 yrs chest is > head.
A nutritional assessment is the interpretation of data to determine whether and individuals in nourished or malnourished.
Measurements – length, height, weight, BMI
Recent weight gain or loss?
Allergies and intolerances
Food preferences (likes/ dislikes)
Type and amount of food and beverages
Home prepared? Fast food?
Frozen meals? Meat? Vegetable? Dairy? Sweats? Fish? Grain?
Water? Coffee? Tea? Juice? Soda? Milk? Alcohol?
How much and how often?
Any special diet?
Do you eat breakfast, lunch and dinner?
Physical activity- Low? Moderate? High? How many days per week? How many minutes?
How often do you have a bowel movement? Any use of laxatives? Gas? Diarrhea? Constipation? N/V?
Women 2.7 liters or 91 ounces or 11.5 cups of total water (from food and beverage)
Men 3.7 liters of 125 ounces or 11.5 cups of fluids daily.
Calculation is BMR X Activity Factor = Total daily energy expenditure
Macronutrients vs Micronutrients – Seidel p 95 & 96
• Macronutrients are carbohydrates, protein and fat and the main sources of calories in the diet.
o Carbohydrates are mostly from plants and in milk and is the main source of energy 4 calories /gram.
o Protiens provide 4 calories /gram and is present in all animal and plant products and is a part of more than half of the organic matter in the body.
o Fat provides 9 calories/gram and present in fatty fish, animal, and some plant products particularly seeds. Main source of linoleic acid.
• Micronutrients – vitamins, minerals, and electrolytes required and stored in very small quantities by the body. Essential for growth, development, and hundreds of metabolic processes.
Food Diary (pg. 101)
• A food diary can help to determine if a patient’s diet is adequate.
• It should be recorded in real time and include at least one weekend day.
• Practitioners should use a food diary to assess the eating habits and if a nutrition consult would be effective.
• The food diary can help the patient and practitioner to see trends and make suggestions in problem areas.
• A good resource to help can be found at ChooseMyPlate.gov
BMI measurements for normal, overweight, obesity, morbid obesity in adults and children
-undernutritionl = <18.5 -normal appropriate weight for height = 18.5 – 24.9 -Overweight = 25 – 29.9 -obese = 30 – 39.9 -Extremely obese = >40
EXAMINATION TECHNIQUES AND EQUIPMENT
Tape measure – use to examine multiple raised lesions.
Transilluminate – An appropriate examination technique to assess vesicle in the skin. It also a source of light with a narrow beam.
Otoscope – use to visualize the lower and middle turbines of the nose.
Inspection – is applied throughout the entire examination and interview process.
Auscultation– is carried out last except when examining kidney or abdomen . it is also used to listen for sounds produced by the body
Fist – use for indirect finger percussion involves striking the middle finger of the nondominant hand
Deep abdominal palpation of the kidney is used to assess tenderness over the kidney.
Ulnar surface of the hand is used to palpate Mass in the skin
Diaphragm – pressed lightly against skin to detect high frequency.
Scoliometer- measures the degree of rotation of the spine to screen for scoliosis. Pg. 49 8th edition.
Pneumatic attachment of an otoscope – use to evaluate the cone of light reflex in adult and kids.
Red – free light -seen through the ophthalmoscope to estimate the size and location of lesion.
Dorsal surface of the hand – sensitive to vibration
Amsler grid– use to screen patient at risk for macular degeration
Pederson speculum– use for women with small vaginal opening
Near-vision (Rosenbaum) or Jaeger chart– Use for screening near vision
Dermatoscope– is a skin surface microscope used to inspect the surface of pigmented skin lesions
Bell of stethoscope– detects low frequency sound.
Wood lamp-black light used to detect fungal infection.
Pan-optic ophthalmoscope– larger field of view in eye examination.
Palpation- gathering information through touch.
Monofilament– help identify a patient with decreased sensation and increased risk for injury
Percussion Tone Expected
Lung with patient with Pneumonia-Dull
Abdomen with lung tumor-Dull
• Tuning Fork (p.45-46)- creates vibrations to produce frequencies of sound waves that can be expressed as cycles per second (cps) or Hertz (Hz).
o Auditory- Frequency of 500-1000 Hz is utilized. Activated by gently squeezing, or tapping on your knuckles.
o Vibration- use lower frequency between 100-400 Hz. Activated by tapping on heel of hand, and then applying the base to a bony prominence.
• Stethoscope (p. 39-40)- 3 basic types acoustic, magnetic, electronic with acoustic being most utilized.
o Acoustic- closed cylinder, the diaphragm has a frequency of 300 Hz, and is best for high pitched sounds such as the heart. The bell can pick up low frequency with light pressure, and high frequency with heavier pressure. (Stereophonic stethoscope has a dual channel with single tube, each ear piece picks up sound from its side of the bell.
o Magnetic- contains iron disk, and magnet. Contains dial to adjust from high to low frequency.
o Electronic- turns vibrations to sound, can record and store.
o Proper use- Hold between index and middle finger with firm pressure. To avoid unwanted noise, do not touch tubing during auscultation.
• Otoscope (p.45)- used for examining external auditory canal and tympanic membrane. Utilize the largest speculum that can fit comfortably in the patients ear.
• Ophthalmoscope (p.42-43)- Used to visualize interior eye structure. Some models offer a variety of apertures.
o Large Aperture produces large round beam, and is most often used.
o Small Aperture used for small pupils
o Red-free filter- produces green beam, and is used to evaluate the optic disc for pallor and small vessel changes. Can also detect retinal hemorrhages (blood appears as black),
§ Eye structure is examined by converting or diverging light through different magnification powers.
§ Magnification power is selected by moving the lens selector. Black numbers represent positive, while red represents negative.The use of different lenses can assist in compensation of the patient and examiner with hyperopia and myopia. (No compensation for astigmatism is available)
Skin lesion characteristics
Skin lesion can describe any pathologic skin changes and can be primary or secondary.
• Elevation or depression
• Attachment at base: pedunculated (having a stalk) or sessile (without a stalk)
• Annular (rings)
• Arciform (bow-shaped)
• Location and distribution
• Generalized or localized
• Region of the body
• Discrete or confluent
Documenting Skin Lesions using the ABCD Rule
Skin lesions are evaluated based on the ABCDE rule (Melanoma Research Foundation)
A=Asymmetry- i.e. irregular shape
B=Borders- not easy to define the margins of the border
C=Color- presence of multiple colors may be a sign of malignancy
D=Diameter- >6 mm can be a sign of malignancy (size of pencil eraser)
E=Evolution- changes over time
Pay attention to location of lesions- Box 8-6, (Seidel, p. 132)
Pay attention to any exudate- Box 8-5, (Seidel, p. 125)
Table 8-4 Primary Skin lesions (Seidel, p. 126-128)
Table 8-5 Secondary Skin lesions (Seidel, p. 129-131)
Anatomy and Physiology of Skin Layers
Protect against microbial and foreign substance invasion and physical trauma
Restrict body fluid loss
Sensory perception via nerve endings
Produce Vitamin D from precursors in skin
Contribute to blood pressure regulation through constriction
Repair surface wounds
Excrete sweat, urea, and lactic acid
Outermost portion of skin
Stratum Corneum : Protects body against harmful environmental substances and restricts water loss
Contains dead squamous cells that form a protective barrier
Cellular stratum: keratin cells are synthesized here
Contains stratum germinativum – keratinocytes matures here- then make way through stratum spinosum, stratum granulosum, into stratum corneum
Stratum germinativum contains melanocytes which synthesize melanin and give skin color
Stratum lucidum is only in thicker skin of palms and soles
Avascular- depends on dermis for nutrition
Richly vascular connective tissue layer that supports and separates the epidermis from the cutaneous adipose tissue
Papillae from this layer penetrate the epidermis to provide nourishment
Elastin collagen and reticulum fibers are found here and provide resilience, strength, and stability
Sensory nerve fibers are located here to provide sensation of pain, touch, and temperature
Additionally, found are autonomic motor nerves that innervate blood vessels, glands, and the arrectores pullorum muscles
A subcutaneous layer that is loose connective tissue filled with fatty cells
This adipose layer generates heat and provides insulation, shock absorption, and a reserve of calories
Eccrine sweat glands
Open onto the surface of the skin and regulate body temperature through water secretion
Everywhere except lip, eardrum, nail beds, inner surface of prepuce, and glans penis
Apocrine sweat glands
Only found in the axillae, nipples, areolae, anogenital areas, eyelids, and external ears
Emotional stimuli= these glands secrete a white fluid containing protein, carbs, and other substances; odorless; body odor is due to bacterial decomposition of apocrine glands
Secrete sebum that keeps the skin and hair from drying out
Secretory activity varies according to hormonal levels throughout the life span
Consists of root, shaft, and follicle
Papilla at the base of the follicle supplies nourishment for growth
Melanocytes in shaft provide color
Vellus hair: short, fine, soft, and nonpigmented
Terminal hair: coarser, longer, thicker, and pigmented
Three stages of hair
Epidermal cells converted to hard plates of keratin
Vascular nail bed gives nail its pink color
Stratum corneum layer of skin covering the nail root is the cuticle or eponychium, which pushes up and over the lower part of the nail body
Paronychium : soft tissue surrounding the nail border
ALL ABOVE INFORMATION FOUND IN SEIDEL’S GUIDE TO PHYSICAL EXAMINATION: EIGTH EDITION PAGES 114-116
Abnormal nail findings in older adults
Nail changes associated with aging are common in the elderly and include characteristic modifications of color, contour, growth, surface, thickness, and histology. The calcium content of the aging nail increases and iron decreases.
keratinocytes of the nail plate are increased in size with an increased number of ‘pertinax bodies’ (remnants of keratinocyte nuclei)
• nail bed dermis also shows thickening of the blood vessels and elastic tissue, especially beneath the pink part of the nail.
• Nail growth decreases by approximately 0.5% per year between 20 and 100 years of age.
• Prominent longitudinal ridges were the most common change
• Brittleness of the nail is a common condition related to aging.
• Onychauxis which is an age-associated thickening of the nail plate
• changes in nail contour, increased transverse curvature
White banding (Terry Nails) is a nail disorder that is specifically linked to age – p. 158.
Pathophysiology: associated with cirrhosis, CHF, adult-onset diabetes mellitus, and age.
Appearance: transverse white bands cover the nail except for narrow zone at the distal tip
Onychomycosis is a fungal infection that causes the nail plate to crumble – p. 156.
Pathophysiology: this is not specifically related to older adults but is associated with loss of manual dexterity (interfere with exercise or walking).
Appearance: distal nail plate turns yellow or white as hyperkeratotic debris accumulates, causing the nail to separate from the nail bed
PSORIATIC SKIN LESIONS
Psoriasis is a common skin condition that speeds up the life cycle of skin cells. It causes cells to build up rapidly on the surface of the skin. The extra skin cells form scales and red patches that are itchy and sometimes painful.
Psoriasis is a chronic disease that often comes and goes. The main goal of treatment is to stop the skin cells from growing so quickly.
There is no cure for psoriasis, but you can manage symptoms. Lifestyle measures, such as moisturizing, quitting smoking and managing stress, may help
here are several types of psoriasis. These include:
• Plaque psoriasis. The most common form, plaque psoriasis causes dry, raised, red skin lesions (plaques) covered with silvery scales. The plaques might be itchy or painful and there may be few or many. They can occur anywhere on your body, including your genitals and the soft tissue inside your mouth.
• Nail psoriasis. Psoriasis can affect fingernails and toenails, causing pitting, abnormal nail growth and discoloration. Psoriatic nails might loosen and separate from the nail bed (onycholysis). Severe cases may cause the nail to crumble.
• Guttate psoriasis. This type primarily affects young adults and children. It’s usually triggered by a bacterial infection such as strep throat. It’s marked by small, water-drop-shaped, scaling lesions on your trunk, arms, legs and scalp.
The lesions are covered by a fine scale and aren’t as thick as typical plaques are. You may have a single outbreak that goes away on its own, or you may have repeated episodes.
• Inverse psoriasis. This mainly affects the skin in the armpits, in the groin, under the breasts and around the genitals. Inverse psoriasis causes smooth patches of red, inflamed skin that worsen with friction and sweating. Fungal infections may trigger this type of psoriasis.
• Pustular psoriasis. This uncommon form of psoriasis can occur in widespread patches (generalized pustular psoriasis) or in smaller areas on your hands, feet or fingertips.
It generally develops quickly, with pus-filled blisters appearing just hours after your skin becomes red and tender. The blisters may come and go frequently. Generalized pustular psoriasis can also cause fever, chills, severe itching and diarrhea.
• Erythrodermic psoriasis. The least common type of psoriasis, erythrodermic psoriasis can cover your entire body with a red, peeling rash that can itch or burn intensely.
• Psoriatic arthritis. In addition to inflamed, scaly skin, psoriatic arthritis causes swollen, painful joints that are typical of arthritis. Sometimes the joint symptoms are the first or only manifestation of psoriasis or at times only nail changes are seen. Symptoms range from mild to severe, and psoriatic arthritis can affect any joint. Although the disease usually isn’t as crippling as other forms of arthritis, it can cause stiffness and progressive joint damage that in the most serious cases may lead to permanent deformity.
The cause of psoriasis isn’t fully understood, but it’s thought to be related to an immune system problem with T cells and other white blood cells, called neutrophils, in your body.
T cells normally travel through the body to defend against foreign substances, such as viruses or bacteria.
But if you have psoriasis, the T cells attack healthy skin cells by mistake, as if to heal a wound or to fight an infection.
Overactive T cells also trigger increased production of healthy skin cells, more T cells and other white blood cells, especially neutrophils. These travel into the skin causing redness and sometimes pus in pustular lesions. Dilated blood vessels in psoriasis-affected areas create warmth and redness in the skin lesions.
The process becomes an ongoing cycle in which new skin cells move to the outermost layer of skin too quickly — in days rather than weeks. Skin cells build up in thick, scaly patches on the skin’s surface, continuing until treatment stops the cycle.
Just what causes T cells to malfunction in people with psoriasis isn’t entirely clear. Researchers believe both genetics and environmental factors play a role.
Psoriasis typically starts or worsens because of a trigger that you may be able to identify and avoid. Factors that may trigger psoriasis include:
• Infections, such as strep throat or skin infections
• Injury to the skin, such as a cut or scrape, a bug bite, or a severe sunburn
• Heavy alcohol consumption
• Vitamin D deficiency
• Certain medications — including lithium, which is prescribed for bipolar disorder, high blood pressure medications such as beta blockers, antimalarial drugs, and iodides
Anyone can develop psoriasis, but these factors can increase your risk of developing the disease:
• Family history. This is one of the most significant risk factors. Having one parent with psoriasis increases your risk of getting the disease, and having two parents with psoriasis increases your risk even more.
• Viral and bacterial infections. People with HIV are more likely to develop psoriasis than people with healthy immune systems are. Children and young adults with recurring infections, particularly strep throat, also may be at increased risk.
• Stress. Because stress can impact your immune system, high stress levels may increase your risk of psoriasis.
• Obesity. Excess weight increases the risk of psoriasis. Lesions (plaques) associated with all types of psoriasis often develop in skin creases and folds.
• Smoking. Smoking tobacco not only increases your risk of psoriasis but also may increase the severity of the disease. Smoking may also play a role in the initial development of the disease.
If you have psoriasis, you’re at greater risk of developing certain diseases. These include:
• Psoriatic arthritis. This complication of psoriasis can cause joint damage and a loss of function in some joints, which can be debilitating.
• Eye conditions. Certain eye disorders — such as conjunctivitis, blepharitis and uveitis — are more common in people with psoriasis.
• Obesity. People with psoriasis, especially those with more severe disease, are more likely to be obese. It’s not clear how these diseases are linked, however. The inflammation linked to obesity may play a role in the development of psoriasis. Or it may be that people with psoriasis are more likely to gain weight, possibly because they’re less active because of their psoriasis.
• Type 2 diabetes. The risk of type 2 diabetes rises in people with psoriasis. The more severe the psoriasis, the greater the likelihood of type 2 diabetes.
• High blood pressure. The odds of having high blood pressure are higher for people with psoriasis.
• Cardiovascular disease. For people with psoriasis, the risk of cardiovascular disease is twice as high as it is for those without the disease. Psoriasis and some treatments also increase the risk of irregular heartbeat, stroke, high cholesterol and atherosclerosis.
• Metabolic syndrome. This cluster of conditions — including high blood pressure, elevated insulin levels and abnormal cholesterol levels — increases your risk of heart disease.
• Other autoimmune diseases. Celiac disease, sclerosis and the inflammatory bowel disease called Crohn’s disease are more likely to strike people with psoriasis.
• Parkinson’s disease. This chronic neurological condition is more likely to occur in people with psoriasis.
• Kidney disease. Moderate to severe psoriasis has been linked to a higher risk of kidney disease.
• Emotional problems. Psoriasis can also affect your quality of life. Psoriasis is associated with low self-esteem and depression. You may also withdraw socially.
Vesicular Skin Characteristics
o Vesicles are small, clear, fluid-filled blisters. (page 127)
o A vesicle is elevated, superficial and less than 1cm. The vesicle does not go into the dermis. (page 127)
o Examples of a vesicle are varicella (chickenpox) and herpes zoster (shingles) viruses. (page 127)
o A bulla is a vesicle (blister) that is greater than 1cm. (page 128).
Normal vs abnormal hair distribution during aging
Characteristics of Hair Distribution
Quantity and distribution of hair vary according to individual genetic makeup
Hair is commonly on the scalp, lower face, neck, nares, ears, chest, axillae, back and shoulders, arms, legs, toes, pubic area, and around the nipples
Hair loss is generalized or localized
Hair loss on toes may indicate poor circulation or nutritional deficit
Diffuse hair loss usually occurs without inflammation and scarring
Note if the hair shafts are broken off or completely absent
Scarring is helpful in diagnosis
During adulthood men who are genetically predisposed often display gradual symmetric hair loss on the scalp as a response to androgens
Asymmetric hair loss may indicate pathologic condition
Women in their 20s and 30s can also develop adrenal androgenic female pattern alopecia (hair loss), gradual hair loss from the central scalp
Fine vellus hair covers the body
Coarse terminal hair occurs on the scalp, pubic, axillary area, arms, legs (to some extent), and a man’s beard
Male pubic hair configuration is upright triangle with the hair extending midline to umbilicus
Female pubic hair configuration is an inverted triangle; hair may extend midline to the umbilicus
Assess for hirsutism in women- the growth of terminal hair in a male distribution pattern on the face, body, and pubic area. Hirsutism, alone or with other signs of virilization, may indicate an endocrine disorder
Ball et al., 2015, p. 133-134
Hair loss on lateral eyebrows and scalp may indicate a thyroid dysfunction
Dains et al., 2016, p. 251
Evaluate hair loss that is diffuse or localized and compare areas such as temporal and crown region to the occiput
Hair pull test will reveal any increased hairs shed with a gentle pull
Dains et al., 2016, p. 335
o Sudden, rapid, patchy loss of hair, usually from face or scalp
o Unknown cause may be triggered by genetic-environmental interactions
o Any hair may be affected
o Regrowth begins in 1-3 months
o Subjective data: sudden, rapid, patchy hair loss, may report nail pitting, may have family history
o Objective data: hair loss sharply defined round areas, hair shaft is poorly formed and break off at skin surface
Ball et al., 2015, p. 154
o Replacement of hair follicles with scar tissue
o Skin disorders of the scalp or follicles resulting in scarring and destruction of hair follicles and permanent hair loss
o Subjective data: may have other concurrent skin or systemic disorders
o Objective data: patchy hair loss, scalp may be inflamed, hair follicles may be pustular or plugged
Ball et al., 2015, p. 155
o Hair loss that is the result of prolonged tightly pulled hairstyles
o Prolonged tension of the hair from traction breaks the hair shaft
o Follicle is not damaged, loss is reversible
o Subjective data: history of wearing certain hairstyles: braids, hair rollers, or hot combs
o Objective data: patchy hair loss that corresponds directly to the area of stress
o Scalp may or may not be inflamed
Ball et al., 2015, p. 155
o Caused by high androgen levels (from ovaries or adrenal glands) or by hair follicles that are more sensitive to normal androgen levels, free testosterone causes hair growth
o Causes: genetic, physiologic, endocrine, drug-related, and systemic disorders
o Subjective data: excessive hair growth on face or body; onset, severity, and rate depend on underlying cause
o Objective data: thick dark terminal hairs in androgen-sensitive sites: face, chest, areola, external genitalia, upper and lower back, buttocks, inner thigh, and linea able; may or may not be accompanied by other signs of virilization
Ball et al., 2015, p.155
o Loss of scalp hair caused by physical manipulation
o Hair is twisted around the finger and pulled or rubbed until it breaks off; the act of manipulation is usually an unconscious habit
o Subjective data: may report tension, anxiety, emotional stressors
o Objective data: affected area has an irregular border, and hair density is greatly reduced, but the site is not bald
Ball et al., 2015, p. 163
Tinea capitits- the triad of hair loss, scaling, and lymphadenopathy in children
Crainial nerves associated with the HEENT system:
God gave you 1 nose (Olfactory) and 2 eyes (Optic). Nerves 3,4, and 6 make your eyes do tricks (3 Occularmotar, 4 Trochlear, and 6 Abducens). FIVE rhymes with TRI (5 Trigeminal). 7 is like an “F” backwards (F for Facial). 8 looks like earrings (8 Vestibulocochlear (Auditory)). “9 and10, under my chin” (IX Glossopharyngeal (Swallowing, saliva, taste), X Vagus (Control of PNS e.g. smooth muscles of GI tract) (just check gag reflex), 12 for swallowing (XII Hypoglossal (Tongue muscles – speech & swallowing)), and the number 11 looks like the neck (XI Accessory (Moving head & shoulders).
In the pic of the face attached, each part of the number 5 the crosses the face (3 lines) corresponds with the first, second, and third segments of the Trigeminal nerve (Forhead, maxila and mandible).
Here is a quick, meat and potatoes crainial nerve assessment video that is to point:
As the video suggests, the 1st crainial nerve is not tested during routine exam, but you could blindfold the patient and hold coffee, alchohol, etc under the nose and test like you would a taste for sugar and salt.
Now, to remember the order, a “clean” acronym for remembering the crainial nerve order would be,
“Oh Oh Oh To Touch And Feel Very Good Velvet, Such Heaven.” Take the first letter of this acronym for the order of the nerves.
There is another acronym that helps you determine whether the nerve is sensory, motor, or both. This acronym is, “Some Say Marry Money But My Brother Says Big Brains Matter Most.”
Where S=Sensory, M=Motor, and B=Both.
Lateral/inferior eye movement, motor
Face feeling, chewing, sensory/motor
Lateral eye movement, motor
Expressions (motor), taste (sensory)
Hearing and balance, sensory
Swallowing (motor), taste (posterior/sensory)
Heart, dig, respiratory (motor) / respiratory, voice, dig, (sensory)
Sternocleidomastoid, trapezius (motor)
Muscle of tongue (motor)
Normal Assessment Findings of an Adolescent’s (10-19years) Nose and Throat
*All information retrieved from Seidel’s Guide to Physical Examination 8th Edition-Chapter 12, pages 242-243 & 248-249*
Smooth skin, no swelling, & conforms to the color of the face
Columella should be midline and does not exceed diameter of a naris
Nares-oval in shape and symmetrically positioned
Nasal structures should feel firm and stable-no crepitus, tenderness or masses should be present
Nasal mucosa-should glisten and is deep pink in color
Clear discharge is normal on the septum
Hairs may be visible on the vestibula
Turbinates should be firm and same color as surrounding area
Septum-close to midline and fairly straight
Anterior septum is thicker than posterior septum
No perforations, bleeding or crusting
Tonsils-same pink color as pharynx & should fit within the tonsil pillars
Crypts may be present in tonsils-cellular debris and food collects here
Posterior wall of the pharynx should be smooth, glistening and pink
Some small irregular spots of lymphatic tissue and small blood vessels should be seen
FONTANELS Seidel’s guide (8th edition) says anterior fontanel closes by 12-15 months (page 186). In infant the cranial bones are separated by sagittal, coronal, and lambdoid suture. Please note that, some books refer that closure of the skull fontanel should occur by 24 months for sure or anterior fontanel can remain palpable till 24 months. So, I hope we don’t get a very complicated question about it in the test. NURS 6512 Midterm exam study Guide
Ossification of skull sutures is complete about 6 years old.
Posterior fontanel closes by 2 months.
Anterior fontanel by 12-15 months.
Torticollis (Wry neck): shortening or excessive contraction of sternocleidomastoid muscle (p. 200 of Seidel’s). Happens due to birth trauma.
Caput Succedaneum: (Seidel’s p. 195)
subcutaneous edema over presenting part of head at delivery.
Most common form of birth trauma and usually occurs over occiput and crosses suture lines. Poorly defined margins. Edema goes away in a few days.
The most common form of birth trauma of the scalp is
A. caput succedaneum.
C. cranial bossing.
E. dilated scalp veins.
Correct ans C
Cephalhematoma: subperiosteal collection of blood and is bound by suture lines.
Most common in parietal region and may not be obvious at birth. Firm and well-defined edges. Does not cross suture lines. NURS 6512 Midterm exam study Guide.
Question: Which of the following is true regarding a cephalohematoma?
a. It is bound by suture lines.
b. The affected part feels soft.
c. It is obvious at birth.
d. The margins are poorly defined.
Correct answer: A
Bossing: bulging of skull. Bossing is associated with prematurity, thalassemia, Paget disease, rickets.
Plagiocephaly: flattened spot on back or one side of head. Can result from premature fusion of sutures.
Examination findings of a patient with Hypothyroid and Hyperthyroid
Seidel’s guide to physical Examination eighth edition p. 190, 201- Table 10-1
• Excess thyroid hormone causes increase in metabolic rate
• Associated with increase in total body heat production and increased heart contractility, heart rate and vasodilation
• Multinodular goiter (Plummer disease
• Weight loss
• Heat Sensitivity
• Normal size thyroid. Goiter or nodules
• Fine hair
• Bridle nails
• Primary: Thyroid gland produces insufficient amounts of thyroid hormone.
• Secondary: Insufficient thyroid hormone secretion due to inadequate secretion of either thyroid-stimulating hormone (TSH) from the pituitary gland or thyrotropin-releasing hormone (TRH) from the hypothalamus
• More common than hyperthyroidism
• Weight gain
• Cold intolerance
• Normal size thyroid, goiter or nodules
NURS 6512 Midterm exam study Guide
Techniques for Examining the HEENT
Chapters 10, 11, 12 Seidel’s Guide to Physical Examination
HEAD 189: Observe position. Should be upright and still, no tilts or tremor
Skull/Scalp 189-192: Front to back
Symmetry by parting the hair -assess size, shape and for lesions during the above
Palpate for indents/depressions (should be smooth/fontanels undetectable p 6mo)
Palpate over sinuses (no tenderness) NURS 6512 Midterm exam study Guide
Scalp should move freely over skull
Special attention at hair line, crown and behind the ears
Palpate hair, noting texture, color, distribution (smooth, even, no split ends)
IF appropriate- auscultate & palpate temp arteries for thickness/hardness/tenderness
Facial Features 189: Includes eyelids/brows, palpebral fissures (under eye) nasolabial folds, mouth
Check Symmetry at rest (slight difference common w movement/expression)
Note unusual features (edema, bruising, bulging eyes, abn hair growth)
Tics (spasmodic movement)
Do features appear syndrome like? (characteristic facies)
Variation in skin color
Salivary Glands 192: inspect/palpate for asymmetry, size, flexibility, firmness
Transillumination of Infant skull 196: to check for fluid/decreased brain tissue
Neck 192-193: Inspect symmetry- slight hyperextension as patient swallows (obs muscle movement)
Observe trachea alignment and fullness
Palpate lower trachea w thumbs at each side to eval space between trachea and sternocleidomastoid muscles on each side (uneven indicates displacement)
Palpate movement with swallowing (smooth and nontender) movement of cartilages should be felt under finger
ROM 193/516/578: Flex, extend, rotation without pain, resistance or dizziness
Palpation for tenderness in the paravertebral musculature and spinous processes (upper/lower back) coupled with ROM of neck for eval of stiff neck
Take note of any mass, webbing, skin folds (excessive posterior cervical skin) NURS 6512 Midterm exam study Guide
Thyroid 194: inspection, palpation, and auscultation for bruit if enlarged
Gently extend neck, use water for swallowing, gentle touch
Can be done from front or behind (learn and be consistent with your method)
Palpation for size, shape, configuration, pain, nodules
Lymph nodes 174-175: Palpation (so much info pictures, I wasn’t sure how to break it down)
Eyes 208-209: Near vision- Rosenbaum pocket vision screen (14 inch from face)
Distant Vision- Snellen eye chart/Pin hole (no glasses first)
Peripheral Vision- Confrontation test (bringing fingers in from the side)
Eyebrows 210: Inspect texture, size, extension to temporal canthus
Eyelids 210-211: Open and closes completely?
Eyelash position (should curve away)
Ptosis (drooping eyelid)
Flakey, redness, swelling?
Palpate for nodules -closed lids w gentle push into orbit (should be no discomfort)
Pull lower lid down to assess for color, discharge, lacrimal gland punctum, pterygium
Orbits 210: Inspect for edema, puffiness, excess tissue
External Eye 212-214: Corneal clarity using a pen light
Corneal sensitivity using a cotton wisp (slight touch across the cornea)
Corneal arcus: circle around the cornea
Color of irises should be the same
Pupils should be round, regular, equal size, and reactive to light
Pupillary defect with swing flashlight test (checks optic nerve)
Nystagmus- have patient follow your finger to check for involuntary movement
Muscle balance & movement 214-216: Corneal light reflex 215: light source (used to check strabismus)
Cover-uncover test 215
Six cardinal fields of gaze: assess extraocular muscles and cranial nerves
Nasal- straight, up, and down
Temporal- straight, up, and down
Opthalmic examination 216-218: Give rest periods between tests using bright light
Dim the lights
Ophthalmoscope in the hand with corresponding eye (right hand-right eye)
Instill dilating medications as necessary
Ears 239: Inspect for size, shape, symmetry, landmarks, color, abnormalities.
Position- pull ear up and back
Palpate auricles and mastoid area for pain, swelling or nodules
Auditory canal 240: otoscope 1-1.5 cm depth- color, cerumen, abnormalities
Tympanic membrane 240-241: otoscope- movement (w positive pressure), color, landmarks, abnormalities
Hearing 240-242: Response to questions during history, whispered voice, and tuning forks (top of head and mastoid area)
Nose and Sinuses 242-244: Inspect external nose NURS 6512 Midterm exam study Guide
Palpate bridge and soft tissues of nose
Nares -nasal speculum and light source
Palpate maxillary and frontal sinuses for swelling or pain
Transillumination 244: of sinuses if tender or infection is present
Mouth 245-249: Inspect lips, teeth, and oral cavity for abnormalities
Palpate and inspect gingivae and buccal mucosa for color, lesions, and pain
Inspect and palpate the tongue
Elicit a gag reflex
Inspect tonsils and pharynx
#30 Examination findings for a patient with sinus symptoms
Seidel page 231, 243-244
Inspect the external nose, noting the shape, size, color, and nares.
Palpate the bridge and soft tissues of the nose, noting tenderness, displacement, and masses.
Evaluate the patency of the nares
Inspect the nasal mucosa and nasal septum for the following: color, alignment, discharge, selling of turbinates, or perforation.
Inspect the frontal and maxillary sinus area for swelling
Palpate the frontal and maxillary sinuses for any tenderness, pain, or swelling
NURS 6512 Midterm exam study Guide
Signs and Symptoms
Sinus infections often follow a cold and cause pain and pressure in your head and face. Palpating over the infected sinus will cause tenderness.
Sinusitis can be either acute or chronic. With chronic sinusitis, the infection or inflammation does not completely go away for 12 weeks or more.
Sinusitis can be caused by three things: viruses, bacteria, fungi. The same viruses that cause the common cold cause most cases of sinusitis.
-Viral Sinusitis: When the lining of the sinus cavities gets inflamed from a viral infection like a cold, it swells. The swelling can block the normal drainage of fluid from the sinuses into the nose and throat.
-If the fluid cannot drain and builds up over time, bacteria or fungi (plural of fungus) may start to grow in it. These bacterial or fungal infections can cause more swelling and pain.
-Nasal allergies or other problems that block the nasal passages and allow fluid to build up in the sinuses can also lead to sinusitis.
Other common symptoms of sinusitis may include: headache, bad breath, cough that produces mucus, fever, pain in your teeth and a reduced sense of taste or smell.
Viral infections normally resolve without antibiotics within 14 days. Bacterial infections may require antibiotics. OTC medications can be obtained to relieve discomforts and sinus symptoms. Fungal infections (less common) require anti-fungals, these infections can require additional interventions (surigal).
Transillumination of the sinuses:
A transilluminator or small, bright light can be used. Darken the room.
Maxillary sinuses: place the light source lateral to the nose, just beneath the medial aspect of the eye. Look through the patients open mouth for immunination of the hard palate.
Frontal sinuses: place the light source against the medial aspect of each supraorbital rim. Look for a dim red glow just above the eyebrow.
The sinuses may differ in degree of illumination
-Opaque: no transillumination
-Dull: reduced transillumination
-Glow (expected): transillumination.
-An opaque response may indicate the sinus is filled with secretions or never developed.
-Asymmetry of transillumination is a significant finding NURS 6512 Midterm exam study Guide.
#31 appropriate tuning fork frequencies to approximate vocal frequencies
Seidel page 241-242
Weber test: helps assess unilateral hearing loss. Place the base of the vibrating tuning fork on the midline of the patients head. Ask the patient if the sound is heard equally in both ears or is better in one ear. If the sounds is heard better in one ear, have the patient identify which ear.
-To test reliability have the patient occlude one ear. Repeat the test, the sound should be heard better in the occluded ear.
Rinne test: helps to distinguish if the patient hears better by air or bone conduction. Place the base of the vibrating tuning fork against the patients mastoid bone and ask the patient to tell you when the sound is no longer heard. Time this interval of bone conduction, noting the number of seconds. Quickly position the still vibrating tines 1-2 cm from the ear, and again ask the patient to tell you when the sound in no longer heard. Time the interval of sound conduction as well. Compare the seconds recorded for both bone and air conduction.
-Air conduction should be heard twice as long as bone conduction. (see figure 12-16 on page 242 in Seidel)
*Placing the base of a vibrating tuning fork on the midline vertex of the patient’s head is a test for? Lateralization of sound
*To approximate vocal frequencies, which tuning fork should be used to assess hearing?
Ans. 500 to 1000 Hz
Examining the oral mucosa-
*Careful examination of the oral cavity may reveal findings indicative of an underlying systemic condition, and allow for early diagnosis and treatment.
**A good light source is fundamental for a good intraoral examination. Any intraoral lesion should be described with respect to size, extent, thickness, color, texture, consistency, and tenderness. Major salivary gland should be palpated and milked to assess salivary gland duct orifices patency and salivary flow and to evaluate the quality of saliva (e.g., frothy versus serous). In a healthy individual unstimulated whole salivary flow rate ranges 0.3–0.4 mL/min, while chewing-stimulated whole salivary flow is 1.5–2.0 mL/min.
*Teeth should be examined to evaluate possible dental decays, fractures, mobility, defects in restorations, gingival recession and bone loss with inspection, palpation and percussion NURS 6512 Midterm exam study Guide.
**Examination should include evaluation for mucosal changes, periodontal inflammation and bleeding, and general condition of the teeth. Oral findings of anemia may include mucosal pallor, atrophic glossitis, and candidiasis. Oral ulceration may be found in patients with lupus erythematosus, pemphigus vulgaris, or Crohn disease. Additional oral manifestations of lupus erythematosus may include honeycomb plaques (silvery white, scarred plaques); raised keratotic plaques (verrucous lupus erythematosus); and nonspecific erythema, purpura, petechiae, and cheilitis. Additional oral findings in patients with Crohn disease may include diffuse mucosal swelling, cobblestone mucosa, and localized mucogingivitis. Diffuse melanin pigmentation may be an early manifestation of Addison disease. Severe periodontal inflammation or bleeding should prompt investigation of conditions such as diabetes mellitus, human immunodeficiency virus infection, thrombocytopenia, and leukemia. In patients with gastroesophageal reflux disease, bulimia, or anorexia, exposure of tooth enamel to acidic gastric contents may cause irreversible dental erosion. Severe erosion may require dental restorative treatment. In patients with pemphigus vulgaris, thrombocytopenia, or Crohn disease, oral changes may be the first sign of disease. NURS 6512 Midterm exam study Guide.
Ask patient to open mouth wide (use a pen light or otoscope if needed)
Inspect the surface of the tongue and the hard palate
Use a tongue depressor to allow movement of the oral cavity contents
Inspect the uvula and soft palate
Examine the buccal area and the gingivolabial (gingivobuccal) sulcus
Inspect lateral, superior, and inferior walls
Ask the patient to lift their tongue in the air
Inspect the floor of the mouth (use the tongue depressor if needed)
Use a tongue depressor to move the tongue down
Inspect the uvula, tonsillar tissue, palatal folds, and posterior pharyngeal wall NURS 6512 Midterm exam study Guide
Hearing loss findings when examining the elder patient
• Nearly 1/3 of adults over the age of 65 have hearing loss.
• Age-related hearing loss is associated with degerneration of hair cells in the organ of Corti, loss of cortical and organ of Corti auditory neurons, degerneration of the cochlear conductive membrane, and decreased vascularity in the cochlea.
• Sensorineural hearing loss-first occurs with high-frequency sounds and then progresses to tones of lower frequency. Loss of high frequency sounds usually interferes with the understanding of speech and localization of sound.
• Conductive hearing loss- may result from an excess deposition of bone cells along the ossicle chain, causing fixation of the stapes in the oval window, cerumen impaction, or a sclerotic tympanic membrane.
Risk Factors of hearing loss in adults (obtained in history portion of assessment)
• Exposure to industrial or recreational noise
• Genetic disease: Meniere disease
• Neurogenerative and autoimmune disorders
• Ototoxic medication use (Ex: aminoglycosides, gentamicin, streptomycin, quinine, salicylates, and furosemide.
Hearing loss findings
• Cranial nerve VIII is tested by evaluation of hearing
• Hearing screening begins when the patient responds to your questions and directions
• Asking patients if they have a hearing problem is associated with detecting a mild to moderate hearing impairment with audiometric assessment.
• Behaviors such as cupping hand behind ear or tilting an ear toward you when listening
• Excessive requests for repetition may indicate hearing loss
• Speech with a monotonous tone and erratic volume may indicate hearing loss
NURS 6512 Midterm exam study Guide
Check the patients response to your whispered voice, one ear at a time, while having the patient insert finger into opposite ear canal. Stand 1-2 d=feet away from the ear being tested and out of the patients line of vision. Whisper a random combination of three to six letters and numbers. EX. 3, T,8 and ask the patient to repeat what was heard. The patient should correctly repeat 50% of the sounds. Repeat process with other ear.
Examination techniques used to examine the trachea and thyroid
Please refer to pages in Siedel pp. 185-188, pp. 194-195, Hyper and Hypothyroidism (pp 200-201) and pg. 273
View video on YouTube demo: The Thyroid Exam (Stanford Medicine 25) on YouTube: https://www.youtube.com/watch?v=lmEus_ZDipg
View Video: Thyroid Status Examination – OSCE Guide: https://www.youtube.com/watch?v=ziaYBkgEZNU
View Video: Examination of the Trachea
Thyroid Anatomy: One gland two lobes, butterfly-shaped and joined by an isthmus at their lowest aspect (Seidel, p.185).
Thyroid Gland that straddles the trachea in the middle of the neck. Secretes T4 and T3. Has two lobes.
Thyroid is the largest endocrine gland in the body producing two hormones Thyroxine (T4) and Triiodothyronine (T3).
Thyroid feels: Rubbery and easier to feel on a long slender neck
What do you do if the thyroid is enlarged?: Listen over lateral lobes w/ bell and listen for thyroid bruit
Inspect Neck for range of motion, strength, trachea, thyroid, and lymph nodes.
Trachea: The trachea, colloquially called the windpipe, is a cartilaginous tube that connects the pharynx and larynx to the lungs, allowing the passage of air, and so is present in almost all air-breathing animals with lungs NURS 6512 Midterm exam study Guide
What techniques do you use to examine the neck?
inspection: inspect the neck in the usual anatomic position, in slight hyperextension as the patient swallows ( Seidel p. 193 see pictures).
palpation: palpate the trachea for midline position (Seidel p.192, see picture)
auscultation: when checking for bruits often noted in children and uncommon in neonates (Seidel p. 192).
Refer to Website: https://depts.washington.edu/physdx/thyroid/tech.html
Techniques: Thyroid Exam
There are several physical examination maneuvers described for examination of the thyroid described below that are at least moderately sensitive and specific. Much of the exam is based on physiological reasoning and tradition rather than on studies of reliability or precision. Combining the examination and association signs and symptoms increases the accuracy of the physical examination of the thyroid.
Goiter: Examination of the thyroid for size
Note: An enlarged thyroid is referred to as a goiter. There is no direct correlation between size and function- a person with a goiter can be euthyroid, hypo- or hyperthyroid.
A normal thyroid is estimated to be 10 grams with an upper limit of 20 grams or 2 to 4 teaspoons.
Examination for goiter can increase the possibility of thyroid disease in patients with symptoms of hypo- or hyperthyroidism, in determining the choice of treatment in hyperthyroidism and monitoring the response to therapy directed at decreasing the size of the thyroid in cases of symptomatic goiter. NURS 6512 Midterm exam study Guide.
The examination consists of three portions:
Synthesis of data from these techniques
In addition to palpating for size, also note the gland texture, mobility, tenderness and the presence of nodules.
Inspection: Anterior Approach
The patient should be seated or standing in a comfortable position with the neck in a neutral or slightly extended position.
Cross-lighting increases shadows, improving the detection of masses.
To enhance visualization of the thyroid, you can:
Extending the neck, which stretches overlying tissues
Have the patient swallow a sip of water, watching for the upward movement of the thyroid gland.
251KB video demo from Return to the Bedside
Inspection: Lateral Approach
After completing anterior inspection of the thyroid, observe the neck from the side.
Estimate the smooth, straight contour from the cricoid cartilage to the suprasternal notch.
Measure any prominence beyond this imagined contour, using a ruler placed in the area of prominence.
Note: There is no data comparing palpation using the anterior approach to the posterior approach so examiners should use the approach that they find most comfortable.
Palpation: Anterior Approach
The patient is examined in the seated or standing position.
Attempt to locate the thyroid isthmus by palpating between the cricoid cartilage and the suprasternal notch.
Use one hand to slightly retract the sternocleidomastoid muscle while using the other to palpate the thyroid.
Have the patient swallow a sip of water as you palpate, feeling for the upward movement of the thyroid gland.
454KB video demo from Return to the Bedside.
Palpation: Posterior Approach
The patient is examined in the seated or standing position.
Standing behind the patient, attempt to locate the thyroid isthmus by palpating between the cricoid cartilage and the suprasternal notch.
Move your hands laterally to try to feel under the sternocleidomstoids for the fullness of the thyroid.
Have the patient swallow a sip of water as you palpate, feeling for the upward movement of the thyroid gland.
Note: This traditional technique is based on physiological reasoning; data of effectiveness is lacking.
Synthesis of data from these techniques
Using the data from anterior and lateral inspection and from palpation, categorize the gland as:
goiter ruled out [normal or small (1 to 2 times normal) with lateral prominence <2 mm ], goiter ruled in [large (& 2 times normal) or lateral prominence >2 mm] or
See Evidence Base and Differential Diagnosis.
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Nodules: Examination of the thyroid for nodularity
Thyroid nodules are common (prevalence 4%). Half of the thyroids glands examined by ultrasound or direct visualization (surgery or autopsy) have nodules. Physical examination detects approximately 10% of the nodules found by these methods. Nodules increase in frequency with age and are four times more likely in women than men. Less than 5% of all nodules are cancerous.
The locationof the thyroid is identified by inspection.
Using the anterior or posterior approach, palpate the thyroid to identify nodules
Note the size and numberof nodules. NURS 6512 Midterm exam study Guide
Note the consistencyof the nodule.
Palpate regional lymph nodes for consistency and mobility.
Take a look at a teaching demo video.
Also called the digestive tract, the alimentary tract is composed of the following hollow organs: the mouth, the esophagus, stomach, small intestines, large intestines, and the anus. The solid organs of the tract include the liver, pancreas, and gallbladder.
#36- The correct assessment order for examining the abdomen is: 1) Inspect 2) Auscultate 3) Percuss 4) Palpate
Inspect the skin characteristics, contour, pulsations, and movement
Auscultate all 4 quadrants for bowel sounds. Auscultate the aorta and renal, iliac, and femoral arteries for bruits or venous hums.
Percuss all quadrants for tone. Percuss liver borders and estimate spans. Percuss left midaxillary line for splenic dullness.
Lightly palpate quadrants x4. Deeply palpate quadrants x4. Palpate right costal margin for liver border. palpate left costal margin for spleen. Palpate laterally at the flanks for left and right kidneys. Palpate midline for aortic pulsation. Test abdominal reflexes.
Finally, have the patient raise the head as you inspect the abdominal muscles. NURS 6512 Midterm exam study Guide.
ABDOMINAL EXAMINATION CORRECT SEQUENCE
WHEN YOU PERFORM a physical assessment, you’ll use four techniques: inspection, palpation, percussion, and auscultation. Use them in sequence—unless you’re performing an abdominal assessment. Palpation and percussion can alter bowel sounds, so you’d inspect, auscultate, percuss, then palpate an abdomen.
Seidel’s Guide to Physical Examination—Examination of the Liver pg. 385-386
Assessment YouTube Video: https://www.youtube.com/watch?v=DBif1jjAfKk
The lower edge of the liver can be palpable on inspiration about 3 cm below the right rib cage. The liver palpation can be performed with one hand or bimanually, and in the case of obese patients, the so-called “hooking” technique might be helpful as well.
One-hand liver palpation
Place your right hand on patient’s abdomen, lateral to the rectus muscle, well below the level of percussed border of liver dullness.
Orient your fingers towards the patient’s head or slightly diagonally towards the midline. Press your fingers firmly in and up (towards the patient’s head).
Ask the patient to take a deep breath. On inspiration, the liver descends, and its edge meets the fingertips of the palpating hand.
Continue palpating, moving your hand toward the coastal margin until you feel the liver edge (usually a few cm below right costal margin). Note liver edge texture and regularity. Slight tenderness on palpation is normal.
When your fingers meet the liver edge, slightly reduce the pressure on the abdominal wall while the patient is still taking a deep breath in. This maneuver allows the examiner to feel the anterior liver surface as it slips under the finger pads. Make a note of the consistency of the liver surface-nodes, granularity, etc. (Figure 2) NURS 6512 Midterm exam study Guide
Bimanual liver palpation
Place your left hand posteriorly at the level of the patient’s two lower ribs, and gently press upward to elevate the liver into a more accessible position.
Ask the patient to take a deep breath and perform palpation with your right hand as described above.
The “hooking” technique
This can be helpful when the liver is not palpable by the standard techniques.
Stand on the right of the patient, facing the patient’s feet.
Place your flexed fingers over the edge of costal margin.
Ask the patient to take a deep breath and try to feel the liver edge as you press downward and upward (towards the patient’s head). NURS 6512 Midterm exam study Guide
Signs and symptoms of liver disease include:
Skin and eyes that appear yellowish (jaundice)
Abdominal pain and swelling
Swelling in the legs and ankles
Dark urine color
Pale stool color, or bloody or tar-colored stool
Nausea or vomiting
Loss of appetite
Tendency to bruise easily
Examination findings associated with appendicitis
The incidence of appendicitis peaks at age 10 to 20 years, although it can occur at any age.
The patient reports sudden onset of colicky pain that progresses to a constant pain.
The pain can begin in the epigastrium or periumbilicus and later localize to the RLQ.
The pain worsens with movement or coughing. NURS 6512 Midterm exam study Guide
Vomiting after the onset of pain sometimes occurs.
On physical examination, the patient will be lying still and demonstrate involuntary guarding.
Classically, tenderness occurs in the RLQ.
The other tests for peritoneal irritation will be positive.
Rebound tenderness may be present.
Variation in presentation is common, particularly with infants, children, and the elderly.
Diagnostic testing includes complete blood count (CBC) with differential to confirm or rule out infection and the use of either ultrasonography, CT scan, or laparoscopy. NURS 6512 Midterm exam study Guide.
Psoas sign, McBurney point pain, rebound tenderness, and periumbilical pain that migrates to the right lower quadrant are signs of appendicitis.
Conditions that cause irritation of the obturator muscle are late findings usually associated with a ruptured appendix or pelvic abscess.
An accurate diagnosis based on history and physical examination can facilitate immediate surgical evaluation and definitive treatment and prevent unnecessary use of radiologic imaging.
In adults, historical symptoms that increase the likelihood of appendicitis are right lower quadrant (RLQ) pain, initial periumbilical pain with migration to the RLQ, and the presence of pain before vomiting.
The presence of rigidity, a positive psoas sign, fever, and/or rebound tenderness are physical examination findings that increase the likelihood of appendicitis.
Clinical Diagnosis of Appendicitis
In a review of clinical decision rules to assist in diagnosing appendicitis, the authors concluded that decision models that score combinations of findings from the history and clinical examination are more powerful than any single finding.
They point to the Alvarado model as one that balances accuracy with ease of use and familiarity to clinicians.
It combines the results for eight findings; a score of 7 or more out of a potential 10 indicates the need for surgical intervention.
The Alvarado model has a sensitivity of 81% and a specificity of 74%. NURS 6512 Midterm exam study Guide.
ALVARADO SCORE FOR EARLY DIAGNOSIS OF ACUTE APPENDICITIS
Migration of pain 1
Tenderness in RLQ 2
Rebound pain 1
Elevation of temperature 1
Shift to the left on differential (neutrophils >75%) 1
Maximum total score 10
Positive score ≥7*
*A score of 7 or more indicates the need for surgical intervention.
Examining Mc Burney’s Sign
Positive sign associated with appendicitis
+ tenderness at the RLQ (Mc Burney’s Point) Measure 1/3 between ASIS and umbilicus (Ball, Dains, Flynn, Solomon, & Stewart, 2015) pgs. 390-391
Video to assess for a positive Mc Burney’s sign –https://youtu.be/i7gbtgBfbrY (YouTube, 2016)
Assessment of abdominal pain in women
Auscultation should be done last when examining the abdomen
Example question found through Elsevier online: Your patient is complaining of acute, intense sharp epigastric pain that radiates to the back and left scapula with nausea and vomiting. Based on this history, your prioritized physical examination should be to: inspect for ecchymosis of the flank.
When assessing abdominal pain in college-aged women always ask when the first day of their last menstrual period was!!!
Before performing an abdominal exam have the patient empty their bladder!
After abdominal inspection then AUSCULTATE
Inspection of the abdomen should begin with the patient SUPINE
Advanced Health Assessment and Clinical Diagnosis in Primary Care (Dains, Baumann, & Scheibel: Chapter 3 pg. 11
Pg. 20: Perform a pelvic exam in women to rule out STI, PID, ovarian pain, ectopic pregnancy, and uterine fibroids. Cervical motion tenderness (CMT) is the hallmark of PID.
Pg. 28-32 table with common causes of acute abdominal pain
Examples for women:
Ectopic Pregnancy: women of childbearing age, sudden onset of spotting and persistent cramping in lower quadrant that begins shortly after missed period.
Physical findings: hemorrhage, shock, and lower abdominal peritoneal irritation, enlarged uterus, CMT, tender adnexal mass. (SURGICAL EMERGENCY) (Dains pg. 28) (Seidel pg. .391- Table 17.2)
Dysmenorrhea: typical premenstrual pain onset soon after menarche, gradually diminishes with age. Gynecology consult is needed with pelvic ultrasound. (pg. 30)
Uterine Fibroids: pain related to menses or intercourse. (
Physical Findings: Palpable myomas. Pelvic ultrasound is needed with gynecology consult (pg. 27, 31)
Ovarian Cyst: common with younger women. (pg. 27, 31)
Physical Findings: adnexal pain and palpable ovarian cysts especially later in cycle
Cholecystitis: more common in women. Pain located in RUQ and radiates to right scapular area, dark urine, N/V, light stools, and may be aggravated by certain foods. (pg. 29)NURS 6512 Midterm exam study Guide
Pelvic Inflammatory Disease (PID): common in women younger than 35 who are sexually active usually with more than one partner. Often caused by chlamydia trachomatis and Neisseria gonorrhoeae with onset occurring after menses. Patients present with lower abdominal pain that progressively becomes severe. Upon examination: tender abdomen, CMT, and adnexal tenderness. Patients may guard and have rebound tenderness, fever, irregular bleeding, vaginal discharge, and vomiting, WBC and ESR are usually elevated. (pg. 25)
Causes of lower abdominal or pelvic pain
Lower abdominal or pelvic pain, refers to discomfort that occurs at or below your belly button. Most women will experience pain in the lower abdomen from time to time. More often than not this is due to menstruation.
The bladder and reproductive organs are often where pelvic pain occurs. In many cases it is difficult to diagnose the exact cause of the pain, but noting certain symptoms will help come to a diagnosis.
The most common lower abdominal pain causes are:
A urinary disorder, such as bladder or kidney problems.
A bowel problem.
A problem with the reproductive system – the uterus, fallopian tubes and ovaries.
Abdominal pain arising from the urinary system
Urine infections are common and present symptoms, such as burning when you pass urine and going to the toilet more often.
Infection can spread to the kidneys (pyelonephritis) and can make you feel unwell with a high temperature and back pain.
If you have pain that spreads from your back down to your groin and is severe – your doctor may be more concerned that you have kidney stones. The doctor will test your urine if you have any of the above symptoms. NURS 6512 Midterm exam study Guide.
Abdominal pain arising from the digestive system
Pain arising from the large intestine is a particularly common cause of lower abdominal pain in both men and women. Features suggesting your pain may be to do with the bowel are:
Pain associated with bowel movement
A change in bowel habit
Blood with bowel movement
Both constipation and diarrhea can give you pain. The pain they are often associated with is described as crampy or ‘colicky.’ This means that it comes and goes in waves. Large bowel pain is characteristically relieved on opening the bowels.
Potential causes of pain arising from the bowel include irritable bowel syndrome (IBS), which can give you alternating diarrhea, constipation and bloating.
Other conditions include diverticular disease and its complications which are more frequent in older patients. Inflammatory bowel disease (ulcerative colitis or Crohn’s). A rare but important diagnosis is colorectal cancer.
Bloating and swelling is also a common symptom that people report and can be due to a problem affecting the bowels NURS 6512 Midterm exam study Guide.
Abdominal pain arising from the reproductive organs
Pain can originate from your uterus (womb), fallopian tubes or ovaries. It’s usually felt in the middle of the lower abdomen.
Pain that is felt more to the side can be more typical of a pain coming from the ovary.
Pain coming from the uterus is often worse during your period and is called dysmenorrhea.
Some conditions affecting the reproductive system can also cause pain during intercourse. This is called dyspareunia and it is important to let your doctor know if you are concerned.
Examples of conditions of the reproductive organs include:
Pelvic inflammatory disease
Problems related to the early stage of pregnancy, such as a miscarriage or ectopic pregnancy.
*Seek immediate medical assistance if your symptoms include a fever, vomiting blood, passing dark or bloody stools or acute and worsening pain.
Questions about a person’s emotional life-family, home, work and sex life are appropriate.
Further abdominal pain investigations
Depending on the exact symptoms and duration, referral to the appropriate specialist is often required. These may include:
Gynecological causes may require vaginal swabs, cervical smears or pelvic ultrasound examination. Ultrasound may also be performed from within the vagina. Specialized blood test for ovarian cancer, CA-125, are usually performed. More invasive tests will depend upon the doctor’s suspicion of the cause of the pain.
Urinary causes can be investigated by urine culture, ultrasound or CT scan.
Colonic causes may require internal endoscopic examination of the bowel by Flexible Sigmoidoscopy or Colonoscopy.
A CT (Computerized Tomography Scan) may be appropriate for all three major sites of pain. NURS 6512 Midterm exam study Guide
QUESTION #41 &42
Anatomic correlates of Nine regions of abdomen. Seidel p. 378-379
Right lobe of liver
Portion of duodenum
Hepatic flexure of colon
Portion of right kidney
Right adrenal gland
Portion of the liver
Tail of pancreas
Splenic flexure of colon
Upper pole of left kidney
Left adrenal gland
Lower half of right kidney
Portion of duodenum and jejunum
Lower part of duodenum
Jejunum and ileum
Lower half of left kidney
Portions of jejunum and ileum
Lower end of ileum
Right spermatic cord
Uterus (if enlarged)
NURS 6512 Midterm exam study Guide
Left spermatic cord
Characteristics of Bowel sounds heard during auscultation: (Seidel p. 381)
Range from 5 to 35 per minute
Borborygmi: loud prolonged gurgles
Increased bowel sounds may occur with gastroenteritis, early intestinal obstruction, or hunger.
High-pitched tinkling suggest intestinal fluid or air under pressure (in early obstruction)
Decreased bowel sounds occur with peritonitis and paralytic ileus.
*MUST auscultate in all four quadrants if there are any major concern and the absence of bowel sounds is the inability to hear ANY bowel sounds after 5 minutes of continuous listening; typically associated with abdominal pain and rigidity and is considered an EMERGENCY. NURS 6512 Midterm exam study Guide
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