CONCEPT OF MAN & HIS BASIC HUMAN NEEDS met by doing what’s realistic (by reasoning), responsible (fulfill

ic (by reasoning), responsible (fulfill needs but not deprive

st
others of fulfilling own needs), right
- forms 1 foundational component of nursing
 “self-actualization is essence of mental health”
- provide individualized, humane, holistic, ethical quality nursing care
MAN- capacity to think/conceptualize (abstract level); family formation
- tendency to seek & maintain territory THE FAMILY
- use verbal symbols as language (means to develop & maintain culture)
- related by blood, marriage, adoption; live together in 1 household (UN)
Study of Man - small social system w/persons related by strong reciprocal affections & loyalties;
2 approaches: ATOMISTIC- organism w/diff systems, organs, tissue cells permanent household persisting over years & decades
HOLISTIC- whole organism w/interrelated & interdependent parts - child’s perspective: everybody share/care each other, love in home, share in work
functioning to produced behavior acceptable/not to him/society
Unique Characteristics
Nursing Concepts of Man - membership is permanent commitment; relationships affectional in nature
- members have shared attributes: Genetic (physical & psychological)
a. as Biopsychosocial & Spiritual Being
Developmental (common bg, home, values)
- man is in constant contact w/his env
Family as Unit of Care
Biologic- like all other men: same basic human needs
a. Family is Social Context for Healthcare
: living org from birth destined die (responds to stimuli;
- disease transmission, acquired health behaviors, psychosocial stress, source of social
subordinate & superordinate system)
support, defines health & illness, makes health decisions
- organismic bhvior: respond as unified whole (not as series of integrated parts)
b. Patient’s problems are family’s problems
Psychosocial- like no other man (unique, irreplaceable, one-time being) c. Patient’s family is present in most patient’s interview
Characteristics: rational, sometimes irrational limited & unlimited nature - family influence their personality, value, belief, experience
mature w/core of immaturity usually indecisiveness
- union known by society
Social- like some other men; group have common attributes
- separate dwelling from relatives; economically independent
Spiritual- like all other men; due to intellect & will, has w/faith, hope, charity
Fam of Orientation: into one is born, reared, socialized (father, mother, brother/sister)
- all believe in Supreme Power (seek meaning/purpose, consolation)
“ “ Procreation- established by person by marriage(husband, wife, son/daughter)
b. as an Open System (Roy)
EXTENDED- 2 nuclear fams; economically/socially related; atleast 3 generations, fam-centered
- const interaction w/changing env; allow input/output to & form boundary (exchange)
- affected by: Matter (food, medicine, microorg) Energy (pain, fever, inflammation) Structures (Nuclear/Extended)
Information (diagnosis; pregnancy; death of relatives) Conjugal—spouse & offspring more important
Closed System- doesn’t allow input/output; no exchange; unaffected by factors - relatives comparatively unimportant; marriage bond emphasized
Consanguineal- blood relatives more important than spouse & children
c. as a Unified Whole
- focus on relationships formed w/blood kin in childhood
- (Rogers): interdependent & interrelated parts; no organ/system functions on its own
- adequate oxygenation needs respiratory, cardiovascular, nervous system CORPORATE/COMMUNAL- formed for specific ideological/societal purpose; group living
- alternative for those alienated from predominantly economically
d. composed of Subsystems & Suprasystems
privileged society; w/set rules for daily life
(Rogers) Sub: cells/Tissue, organ, organ system Supra: family, community, society
SINGLE-PARENT- < 17 y/o living w/single parent, relative, nonrelative
e. Whole, Complete, Independent w/14 Needs (refer to Henderson) - from loss of spouse, birth out-of-wedlock, adoption
Need- desirable, useful, necessary
BLENDED- couple & children from existing/previous relationships; stepparents/children
Principles: physio/psycho (to achieve state of health/wellbeing)
EMPTY SHELL- couples w/no sexual/emotional ties; marriage in name but w/separate lives
Maslow Rank: Physio- sex isn’t for individual survival but for mankind survival - less effective interaction, lack basic family function, live alone together
Safety, Love/Belonging, Esteem (well-thought of by oneself & others) - professionals in shifting sched
Self-Actualization
COHABITATION- unmarried couples w/children
Characteristics: universal (all have same needs); stimulated by int/external factors;
GAY/LESBIAN- w/w/o children (adoption)
priorities can be altered (adolescents have higher priorities to studies);
deferred (patient foregoes need for privacy & independence); based on Family Name/Surname
interrelated; met differently (routes of feeding) PATRONYMIC/MATRONYMIC- surname of father (Filipino)/ mother (Spanish)
f. w/ Parts Greater than & Different from Sum of Parts (Rogers) based on Decent
g. w/ Vital Reparative Processes to deal w/disease & desirous of health but passive PATRILINEAL/MATRILINEAL- affiliation w/group related through father/mother
in influencing env/nurse (Nightingale) - child has relationship w/other side but seek closer bond when in need
h. Unity viewed as Functioning Biologically, Symbolically, Socially; initiates self-care BILATERAL- affiliates through both fams of child’s parents
on own behalf in maintaining life, health, wellbeing (Orem) based on Authority
PATRIARCHAL/MATRIARCHAL- oldest male/female in family speaks for entire group
Self-Actualization (Maslow)- realistic, see life clearly, objective on observations
EQUALITARIAN/EGALITARIAN- husband & wife share equal authority
- judge correctly, superior perception, more decisive, clear notion
- accurate in predicting future; understand art, politics, philosophy MATRICENTRIC- father’s prolonged absence gives mother more dominant position
- humility; dedicated; flexible, spontaneous, courageous, open - father still shares in decision-making
- self-confident; low self-conflict, integrated personality, private based on Residence
- can be remote & detached; problem-centered; accepting PATRILOCAL/MATRILOCAL- newly married stays with/near domicile of their parents
- “self-actualized person is a mentally healthy person”
BILOCAL- couple stays either side depend on wealth, status, personality preference
Mentally Healthy (Marie Jahoda) NEOLOCAL- couple reside independently of either side
1. Positive self-attitude (self-reliant, confident, accepting)
2. Aware of action meanings by introspection (behavior accessible to consciousness) Family Role in Illness
3. Self-concept is similar to how others sees him - client’s beliefs interrelated w/family beliefs (psycho & spiritual belief on acceptable
4. Accept oneself; sense of identity w/few doubts gender/generational role affects its members’ approach to prevention/care)
5. Changes & grows; acts in unified manner, consistent
2 Needs fulfilled by mentally healthy person (William Glasser)
- Need to love & be loved - Need to feel ones Is worthwhile to self & others
 RAPID EXPANSION IN NURSE ROLE Black- dead (expectant) Red- resuscitation (addressed right away!)
Yellow- less urgent (max 60 mins until given attention; walking wounded)
Home Health Nursing- independent diagnosis, referrals, collaborative care Green- non- urgent (max 180 mins. until given prior attention; walking wounded)
- median salary: $78 983 ($34-41/hr)
 hospital owns PATIENT CHAR T; doctor: father of healthcare team
Public Health “ – community needs & monitor children growth/health
- median salary: $56 111 ($24-29/hr)
SUBJECTIVE- what patient tell you; symptoms & history, from CC by Review of Systems
School “ – (same as public health) median salary: $49 168 ($21-25/hr) Ex: A 54 y/o hairdresser who reports her left chest “like an elephant sitting there”
Hospice “ – assess needs of terminally ill clients & their families; $71 654 ($31-37/hr)
OBJECTIVE- what you detect on physical exam, lab info, test data; signs
Acute Care “ – extensive focused a assessments; $73 500 ($31-38/hr)
Ex: An older, overweight white female who’s cooperative, Height 5’4”, weight 150
Forensic “ - “ “ (reversed process); $81 800 ($35-42/hr)
lbs, BMI 26, BP160/80, temp 97.5F
Critical Care Outreach “ –assess clients outside structured intensive car env
- $62 822 ($27-32/hr) Scopes
Ambulatory Care “ – assess & screen clients to determine need for referrals COMPREHENSIVE ASSESSMENT- for new patients; give funda & personalized knowledge
- $78 983 ($34-41/hr) on patient; strengthen clinician-patient relationship
- identify/rule out physical causes related to patient concerns
- baseline for future assess; platform for health promotion by educ &
NURSING PROCESS SUPPLEMENTALS counseling; develop proficiency in skills of physical exam
Nursing Process- systematic & rational method of planning & providing nursing care FOCUSED ASSESS.- for established patients during routine/urgent care visits
- analyze & synthesize data; make judgment on nsg interv
- address focused concerns; assess symptom restricted to specific body sys;
effectiveness, evaluate client care outcomes apply exam method relevant to assessing concern as carefully as possible
Phases
Assessment Process
1. Assessment- Collect, Organize, Validate, Document, Record subj/objective data
- heart: sounds of closure of 4 valves, extra sounds from blood flow into atria &
2. Diagnosis- analyze data, formulate nsg statement, identify health problem ventricles, murmurs; detect bruits/turbulence on arterial vessels
- to make prof nsg judgment (diagnosis, collaborative problem, referral)
3. Planning- prioritize dx, formulate goals, select nsg interv, objectives
- determine outcome criteria & develop plan DATA SOURCES
4. Implementation/Intervention- apply, document nsg act, supervise delegated care Nursing Health History Reason (CC) Psycho Data, Pattern of Health Care
- carry out plan Biographic Data Illness History (past, fam) Social Data/Lifestyle
5. Evaluation- collect data on outcome (goal met? Partially met?) PRIMARY- directly from patient (interview, physical assessment); subjective
- assess if outcome criteria have met; revise plan as necessary - unless too ill, young, can’t talk
ASSESSMENT- systematic & continuous collection, validation, communic of client SECONDARY- client’s family, SO (chart, other healthcare team, next of lein (relative)
- purpose: establish data base - support system, client records (lab results, therapy records; lit (journal)
Types: Initial- specified time (nurse admission assessment) Data Validation- double-checking
Problem-focused- specific problem (nurse check intake & output) Purpose: ensure complete data, subj/obj, avoid jumping to conclusion
Emergency- rapid assessment (physiologic crisis) CBQ: accurate documentation- hallmark of nsg responsibility; factual, nonjudgmental
Time-lapsed- assessment months after initial assessment; to compare condition Inference- nurse’s interpretation/conclusion based on cues
Data Collection: Data Organization: Maslow’s Hierarchy of Needs
Subjective cue/symptom- verbal; client statement covert (covered) data (learn client) Body Systems Model
- ex: pain, dizziness Gordon’s Functional Health Problems
Objective cue/signs- overt; detected, observed, measured; ex: vital sign, pallor Gordon’s 11 Functional Health Patterns
Method: Interview- planned, purposeful, convo to get info - Health Perception/Mngmt - Activity/Exercise - Self-Perception/Concept
Observation- use 5 senses & instruments - Nutritional/Metabolic - Sleep-Rest - Role/Relationship
Examination- cephalocaudal (head-to-toe); body system approach (all body); - Elimination - Cognitive/Perceptual - Sexuality/Reproductive
review of system (particular area) - Copin g/Perceptual - Value/Belief
How to examine: Compare: a. Vital Signs b. Weight & Size c. Lab Values
INSPECTION- close observ on appearance, behavior, movement, skin condition, thorax Communicate/Record/Document- record all data (health status), factual manner (not as
symmetry, abdominal contour, gait interpreted, verbalization of client
PALPATION- tactile pressure from palmar fingers/fingerpads to assess skin elevation,
depression, warmth, tenderness, lymph node, pulse, contour, size of
APPROACHING PATIENTS
organs, crepitus in joints st
INFANCY (1 4 wks)- touch & hold (security) TODDLER (1-12 mos)- offer choices
PERCUSSION- use striking/plexor finger (3rd finger) to deliver rapid tap on distal
rd PRESCHOOLER (3-5 y/o)- offer single demonstration
pleximeter finger (distal 3 finger of left hand) laid against
chest/abdomen to evoke sound wave (resonance/dullness) from SCHOOL-AGE (6-12)- offer single explanation
tissue/orga/give tactile vibration against pleximeter finger ADOLESCENT/ADULT (13-21)- offer privacy, brief & concise (matured level)
AUSCULTATION- use diaphragm (high-pitch) & stethoscope bell (low) to detect heart,
lung, bowel sounds (location, timing, duration, pitch, intentisty)
Abdominal pain: Inspection, Auscultation, Percussion, Palpation
Significance of Health Assessment
- allow nurse to formulate nsg dx that require nsg care
- identify collaborative problem (interdisciplinary care)
- identify problems requiring immediate referral (prioritization)

Triage:
1ST Level Priority- Airway, Breathing, Circulation
Conscious: airway (priority), breathing, circulation
Unconscious: C, A, B; perform high quality CPR
2ND “ “ - mental status change, acute pain, acute urinary elimination problem,
abnormal lab value, risk for infection, medical prob; require immediate
attention
3rd “ “ - health prob (not included in 1st & 2nd); lack knowledge, rest, activity,
fam prob, w/o coping, triage (to classify)
 PATIENT POSITIONING STETHOSCOPE- auscultation; Korotkoff sounds (BP), bowel sound (abdominal)
heartbeats (apical), pulse (peripheral)
SUPINE- allow abdominal muscle to relax; easy access to peripheral pulse
- areas: head/neck, chest & lungs, breast/axillae, heart, abdomen, all extremity SPHYGMOMANOMETER- BP: systolic (80-120) & diastolic (60-80)
- ask client to lie down w/legs together on bed on back; small pillow under head AHA: >130 = hypertension Placement: 1 in above antecubital fossa
- if client has trouble breathing, elevate bedhead Size of BP cuff: 2/3 of arm circumference Position: sitting/supine
- (Dillon) Areas assessed Pros/Cons WATCH W/SWIFT SECOND HAND- timing heart, pulse, respiratory pulse, RR
- anterior chest for respiratory - trouble breathing: semi- fowler’s FLEXIBLE TAPE MEASURE- circumference: mid-arm, abdominal girth, fundic height
cardiac, breast exam - semi-fowler (semi-sitting w/knees PIECE OF SMALL GAUZE- grasp tongue for examining oral cavity
- pulse & extremities flexed, supported by pillows)
THERMOMETER-
PRONE- best for spina bifida (meningocele); lie down on abdomen w/head on side Rectal (reliable, accurate; check core temp); failure: imperforate anus [37-38 C (plus 0.5)]
- assess hip joint, back; not for problems in cardiac & respiratory systems Oral (most convenient, accessible) [36.5-37.5 C (minus 0.5)]
- (Dillon) Area Assessment Pros/Cons Axillary (safest, most common) [36-37 C (minus 0.5)] Tympanic (fastest) (37-38 C)
- musculoskeletal system - hard for many, w/respiratory disease
SKINFOLD CALIPERS- measure skinfold thickness of subcutaneous tissue
SITTING- max lung expansion; upright on edge of bed; alt: lie down w/ head PLATFORM SCALE W/HEIGHT- derive factors in calculating BMI
elevated - underweight <18.5. Normal 18.5-24.9 OW 25-29.9
- for head/neck, chest & lungs, back, breast/axillae, heart, extremities - Obese Class I 30-34.9 CII 35-39.9 CIII >40
- head & neck - good visualization RULER W/CENTIMETER- size of skin lesions, surgical specimens
- anterior & posterior chest - full lung expansion & respiratory - MAGNIFYING GLASS- enlarge visibility of lesions
(respiratory, cardiac, breast exam) assessment (DilSMALL CUP OF WATER- test swallow reflex of head/neck/thyroid gland
- vital signs & upper extremities - those w/weakness/paralysis may lon PENLIGHT- test pupillary constriction (brain function)
have difficulty & need assistance ) SNELLEN CHART- measure distance vision; normal 20/20; 20/200 legally blind
Area Assessment Pros/Cons OTOSCOPE- view ear canal & tympanic membrane
DORSAL RECUMBENT- relax abdomen muscle, OB procedure OPHTHALMOSCOPE- view red-orange reflex, exam retina
- lie down, knees bent, legs separate, feet flat; more comfy for back/stomach pain COVER CARD- test strabismus
- don’t assess abdominal muscle contraction ROSENBAUM POCKET SCREENER- test near vision
- for head/neck, chest/lungs, heart, breast/axillae, extremity & peripheral pulse TUNING FORK- compare air & bone conduction
- abdomen (supine w/knees fully - flex knees more comfy if w/abdomen TONGUE DEPRESSOR- view mouth & throat; transilluminate sinus
bent to relax abdomen) pain
PILLOW- placed under knees & head for relaxation of abdominal muscles
- female pelvic are if she cant do - older patients cant do lithotomy
VAGINAL SPECULUM- inspect cervix through vaginal canal
lithotomy/Sim’s
LUBRICANT- reduce friction, pressure, pain during rectal/vaginal exam
- same w/lithotomy but legs & feet on stirrup
COTTON-TIPPED APPLICATOR- obtain sample/scrape endocervical/vaginal tissue
- (Dillon) Area Assessment Pros/Cons SPECIMEN CONTAINER- collect/maintain integrity/sterility of specimen
SIM’S LATERAL- advanced leg (sim’s); left sim’s: enema insertion to retain fluid REFLEX HAMMER- test deep tendon reflex/sensation
- left side lying: best on pregnancy; wont cause compression of vena
cava
- lie on side, lower arm behind, upper arm flexed at shoulder & elbow, lower CULTURE, SPIRIRTUALITY, FAMILY
leg slightly flexed at knee, upper leg flexed at sharper angle & pulled forward - all are systems; difficult to separate (constantly interact, change based on interaction)
- female pelvic & rectal area - hard for arthritic patient
CULTURE- Lt “competere” (to strive together)
- best alternative if patient cant - contraindicated if patient has total
- totality of transmitted behavioral pattern, value, products of human work/thought
do lithotomy hip replacement
- characteristic of a population that guide their world view & decision-making
- elderly & w/joint problems assisted on rectal & vaginal area
- frame of reference in interpreting/understanding world
- (Dillon) Area Assessment Pros/Cons - values & norms (verbal & behavioral systems that transmit meaning)
Characteristics
Learned- by life experiences & contact w/ other cultural groups
- transmitted in generations by socialization
LEFT LATERAL - (Dillon) chest: - cardiac auscultation (S3 & S4) - not for w/respiratory Shared- norms for behavior, values, beliefs; shared by a group to great extent
Associated w/Adaptation to Env- group change to improve survival due to env change
- male rectal & prostate area - alternative (bend over table) is hard
Phases: Hunter & Gatherer, Agricultural, Industrial, Information
& embarrassing
Universal- vary in groups; we cant exist
murmurs problem
Constructs of Cultural Competence
CULTURAL ASSESSMENT- systematic appraisal of individual beliefs, values, practices
- spine & joint (ROM), musculoskeletal area - for weak, disabled, paralyzed
- neurological exam; gait & cerebellar function “ Competence- complex integration of knowledge, attitudes, skills
- enhance cross-cultural communic; meaningful interactions w/patients
- provide culturally appropriate, congruent, relevant health care
KNEE-CHEST- kneel on bed, weight supported by chest & knees, 90o between body &
hips, arms above head turned to 1 side, small pillow; for rectum exam Purnell & Paulanka Process
- uncomfy & embarrassing; limit time amap; not for w/cardiopulmonary problem Components:
- (Dillon) Areas assessed Pros/Cons CULTURAL AWARENESS- deliberate, cognitive process where healthcare provider becomes
STANDING- normal, comfy, resting posture; check posture, balance, gait, male genital appreciative & sensitive to value, belief, practices of client’s culture
- (Dillon) Areas assessed Pros/Cons - sensitive to patient culture & identify own values, prejudices
LITHOTOMY- lean on back, hips at edge of bed, feet on stirrups, well-draped stages: unconscious incompetence  conscious incompe  C Compe  Uc Compe
- exposed position may be embarrassing; need assistance; not for elderly UC Incompe- unaware that one lacks cultural knowledge
- for female genitals, reproductive tracts, rectum; must perform exam quickly - unaware that cultural difference exists
C Incompe- aware that one lacks knowledge on another culture
- aware that cultural difference exists
EQUIPMENT USED IN PHYSICAL ASSESSMENT - doesn’t know how to communicate w/client from diff culture
GLOVES- for body fluids, open wounds, excreta, contaminated items; universal C Compe- consciously learning client culture; give culturally relevant interv
- aware of culture difference; interact effectively
 UC Compe- automatically give culturally congruent care to clients
- experienced w/many cultural groups
CULTURAL SKILL- collect relevant cultural data on client’s health history & present problem
- accurately perform physical assessment; perform cultural knowledge PHYSICAL ASSESSMENT
- efficient in PA & collecting of further info Systematic (step by step)
CULTURAL KNOWLEDGE- seek & obtain sound educational foundation Comprehensive Collection, Validation (communication) of Client data
Continuous (ER to ward to ICU) Use methods
- concerned w/ world views of cultures (Immersion vs reading)

“ Encounter- allow healthcare provider to engage directly in cross-cultural interaction Pertinent Pos/Negatives from History & Physical Exam formulating Differential Diagnosis
- actual experience  knowledge & awareness
- f2f encounter; refine nurse’s belief on culture to prevent stereotyping
“ Desire- motivation: engage in intercultural encounter, acquire cultural competence

Culture & Illness

Cause of Illness: Biomedical Naturalistic (Yin/yang theory, Hot/cold theory of illness)
Magico-Religious (faith healing, witchcraft, healing ritual)
Culture-based syndrome: perceived to be separate illness in culture
Illness defined by specific culture group but interpreted
diff/not perceived as illness by other groups
Component of adult HA
LATIN (AMERICAN/MEDITERRANEAN) 1. IDENTIFY DATA (client name, age, gender, occupation, marital status)
a. source of history – (written report) (patient ideally, can be family, friend, letter of
ataque de nervios (from stress/buildup of anger; shout, cry, tremble, heat in chest
referral from another hospi/ambulance, clinical record)
rising to head)
b. source of referral (written report)
Empacho (children; soft food adhered to stomach wall; confirmed by rolling egg over
stomach & egg appears to stick to an area) 2. RELIABILITY- vary acc to patient’s memory, trust, mood
- benevolent deception (no absolute confidentiality)
mal de ojo/evil eye (children, women; stranger’s touch; crying w/o cause)
3. CHIEF COMPLAINT- shortness of breath (SOB); assess: IAPerPA
mal puesto,brujeria (illness are supernatural/voodoo’GI complaint, fear of being killed)
- 1 or more symptoms/concern; cause patient to seek care
susto (“fright”; due to natural/cultural stressor/supernatural/sorcery; anorexia,
insomnia, muscle tics, listlessness) 4. PATIENT HEALTH HISTORY- present illness: history of present illness (HPI)
- amplify chief complaint (describe each symptom developed)
caida de la mollera (“fallen fontanel”; due to midwife failing to press palate after
- get patient’s thought, feelings on illness
delivery; fell on head, remove nipple from baby’s mouth, not put
- pertinent positives (pos findings) & negatives
cap on newborn head; diarrhea, vomit, cry)
- review of systems; medication & allergies (tobacco, alcohol)
AFRICA & AFRICAN ORIGIN IN AMERICA 5. PAST MEDICAL HISTORY- list of childhood illness; adult illness (medical, surgical,
Falling/Blackout- preceded dizziness, spinning; eyes open but cant see, cant interact psychiatric, obstetric)
Rootwork- illness are supernatural; GI complaint, fear of being poisoned - health maintenance practice (immunization, screening test, lifestyle
Spell- talk w/dead/spirit; personality change; pathologic in culture of origin issues, home safety)
High Blood- thick/excessive blood rising; due to overly rich food 6. FAMILY HISTORY (age/health of members; cause of death; present condition:
Low Blood (lack/weak blood due to diet) hypertension, diabetes mellitus, cancer, vehicular accident)
Blood (blood contaminated; due to STI) 7. examiner follow certain sequence in HA (IPPA, IAPerPa)
Boufee Deliriante (Haiti) (panic disorder w/sudden agitated outburst; confusion, 8. include only findings w/medical significance
hallucination, paranoia) 9. findings shouldnt only focus on symptoms present but also pertinent negatives
10. results should be objective
NATIVE AMERICAN 11. neurologic exam is always part of physical exam
Ghost Sickness (Navajo) (feeling of danger, futility, suffocate; preoccupation w/death 12. when examining patient of opposite sex, always have a companion w/same sex
Hi-wa-itck (Mohave) (unwanted separation from loveone; depression, appetite loss w/patient (mortality = death; morbidity = illness)
suicide) 13. patient has right to refuse to be examined
Pibloktoq/Arctic Hysteria (Greenland Eskimo) (extreme excitement for 30 min fllowed 14. physical findings may change from time to time
by seizure/coma for 12 hrs w/amnesia of event; tear clothes, 15. Begin always at patient’s right side
break furniture, shout obscenities, eat feces during attack) 16. Right kidney more palpable
17. Jugular vein pressure more reliable
Wacinko (Oglala Sioux) (reaction to disappointment; awithdrawal, mutism, immobility,
attempted suicide)
Approach to Client
MIDDLE EASTERN Comfortable: sitting, supine (lung expansion)
Zar (spirit possession; laughing, weeping, hit head on wall; apathetic, refuse food; Complete exposure of part to be examined ONLY (drape the rest)
longterm relationship w/possessing spirit; not pathologic in culture) Cephalocaudal principle (head-to-tail assessment)
Compare findings of both sides
ASIAN (SOUTH/EAST) Cooperation (encouraged, explain all procedures; avoid alarming patient)
Amok (Malaysia) (20-45 y/o male after slight insult; homicidal, persecution; amnesia,
exhaustion, return to previous state) Preparing the Patient
Koro (Malaysia, SEA) (fear of genitalia retract to body; inappropriate sex, eat swine- 1. Introduce self 2. state purpose 3. inform client that examination takes time
flu-vaccinated pork as cause) 4. explain every procedure/technique
5. consider age of patient: Neonate (1st 4 weeks) Infant: 1-12 mos Toddler (1-3 y/o)
Latah (Malaysia) (after trauma/surprise; exaggerated startle response in women;
Preschool (3-5) School Age (6-12) Adolescent (13-21)
hysterical laughter, imitate people, hypersuggestibility)
Pregnant Client
Taijin Kyofusho (Japan (dread of offending others; by body odor; social phobia)
Bladder: empty= leopold’s; amniocentesis Ful = ultrasound/USD of abdomen (↑ OFI)
Shen Kui (China), Dhat (India) (from belief that semen/vital essence is lost; sexual
complaint, guilt, sexual dysfunction, no physical findings) a. assess both fetus & mother
b. fundic height (gestational age): preterm (< 37 wks), term (38-42 wks),
Wild Illness- fear of wind/cold; loss of Yang energy) post term/post mature (> 42 wks)
NORTH AMERICA/WESTERN EUROPE GDM- gestational diabetes mellitus
Anorexia Nervosa (intense fear of obesity; restrict calorie intake) c. normal changes during pregnancy  best position: left side lying
Bulimia Nervosa (binge-eat, self-induced vomiting; use laxative, diuretics) d. pay attention to nutritional assessment
 last term: difficulty in switching position  uterus is very large Avoid listening through clothing
e. hormonal swings
THERAPEUTIC COMMUNICATION
Disabled/Physically Challenged Client
Listening- active listener
1. identify disability Rephrase- own words, same thought
2. focus on ability (functional & mental capacity)
3. modify assessment based on needs (deaf: sign language, written instruction)
4. be alert & sensitive (unable to communicate verbally)

FIRST TOPIC NOTES NURSING- client-centered; ASH:

INSPECTION- visual exam/observe at the person or body part Art = Therapeutic Use of Self (active listening, silence, broad opening)
Vision, Smell, Hearing  normal (document), abnormal (manage) Science- theoretical body of knowledge
Shape, size, color, gait, position, posture: (Lordotic = lordosis; Kyphotic = kyphosis) Health- (WHO) OLOF (Optimum Level Of Functioning)
Begins admission  referral, ER-ward; precedes other techniques (priority) (Claude Bernard) maintain internal milieu
Eyes: Ophthalmoscope Ears: Otoscope (Walter Cannon) “ homeostasis
Guidelines: Room- comfy (accurate temp) (alter bwehavior, appearance if extreme) (Nightingale) use every power to its extent
(Henderson) hospice care (care of dying patients)
Lighting- no fluorescence (alter skin true color) dim
Tangential- cast across body ; highlight contour elevation & depression V/Q= 15-30 min bc its just by inhalation; no general anesthesia
- JAT (Jugular venous pulse, Apical pulse, Thyroid gland) MRI- use radiowaves than radiation Plural Tap- remove air/fluid in lungs
Perpendicular- shadows are reduced; subtle undulation; diffused light Radioisotopes in CAT scan- Barium radioisotope-
Look & Observe before touching (alter appearance)
Expose completely only parts to be examined TECHNIQUES
Note important characteristic (color, pattern, size, consistency, symmetry, GI- IAPerPa
movement, behavior, odor, sound) Musculoskeletal- I, Pa, Per
Compare appearance of symmetric body parts (upper/lower extremity) Cardiac- I, Pa, A,

PALPATION- touch w/ different parts of your hands, using diff degrees of pressure
HAIR, SKIN, & SCALP
-deep/light; pressure; temp (dorsal of hand/palm w/sensitive/receptors) Anatomy & Physiology of Skin
Determine: Texture (rough/smooth) Moisture (wet/dry) Mobility (fixed/movable) SKIN- major function: keep body in homeostasis (despite daily assaults from env)
Consistency (hard/fluid-filled) - 16% of total body weight; 1.2-2.3 sq m in area
Pulse Strength/Amplitude: 0 (absent), +1 (barely palpable) - vit D synthesis; body temp modulation; boundary for fluids
- protects underlying from: microbes, harmful substance, radiation
+2 (easily palpated/normal)
+ 3 (full) +4 (Apneustic) Layers:
Shape (reg/irreg) Tenderness (degree/level of pain) 1. Epidermis- 2 layers: outer keratinized cells & inner cellular layer (melanin & keratin form)
Hands: finger pad- body before finger tip (pulse, texture, size, consistency, crepitus, - cell migration from inner to outer takes 1 month
shape) - depends on dermis for nutrition (diffusion)
Ulnar & palmar surface- vibration, thrills, fremitus, temp 2. Dermis-rich in blood vessels (blood supply); merges w/subcutaneous layer
Dorsal- back of palm - contains: connective tissue, sebaceous gland, sweat gland, hair follicle
Bruits- swooshing, based on auscultation Thrill- palpation, vibrating 3. Subcutaneous
Types- depend on structure & thickness) Skin Color
Light- use dominant hand; little to no depression (depth: <1 cm) Melanin- # genetically determined; increased by sun exposure
- circular motion; for pulse, tenderness, moisture) Carotene- golden-yellow; found in subcutaneous fat & heavily keratinized area (palm/sole)
Moderate- dominant hand (1-2 cm); size, consistency, mobility Hemoglobin- in RBC & carry O2;
Deep- 2 hands: dominant on surface, nondomi on top (1-2 in) 2 forms: oxyhemoglobin- bright red; conc in artery & capillaries
- for organs (covered by thick/large muscle)6 - ↑ blood flow reddens skin; ↓ blood flow produce pallor
Bimanual- 2 hands: 1 apply pressure, 2nd feel structure; - pale people”: redder areas in palms, soles, face, neck, upper chest
- size, shape, consistency, mobility; for breast, uterus, spleen deoxyhemoglobin- darker & blue; made when oxyh. pass in capillary, losing O2
- ↑ in tissue = cyanosis
PERCUSSION- tap fingers/hands quickly & sharply against body parts toto produce
Propensity to Tan & Burn
sound to: elicit pain/reflex know location/size/shape/density/abnormal mass
types: Direct- 2nd, 3rd, 4th finger to strike directly
Indirect- most common; plexor + pleximeter; sound varies acc to density
- tap middle finger of pleximeter & release plexor immediately
Blunt- detect tenderness over organs (both hands: 1 hand flat, 1 hand as fist)
Sounds(quality): Resonance- hollow (normal lung)
Hyperresonance- booming (COPD)
Tympany- drum-like (gastric bubbles)
Dullness- thud-like (for diaphragm, liver)
Flatness- flat (for muscle, bone, sternum, thigh)
Skin Assessment
AUSCULTATION- listens to sounds within the body; use stethoscope - palpate skin temp (compare both sides); Note skin turgor
- intensity, pitch, duration, quality - note location of skin lesions on body surface diagram (drawing)
Guidelines: eliminate noise/distracting sound (quiet room) - “ color uniformity
Expose body part to be examined only PALLOR- decreased redness (anemia); inspect: fingertips, lips, mucosa
Use stethoscope (diaphragm: high-pitched; breath/bowel sounds)
CYANOSIS- bluish
(bell: low-pitch; bruit, korotfkoff)
Diaphragm: 1.5 in wide types: central- ↓O2; in COPD, congenital heart disease
Bell: 1 in wide peripheral- normal O2; when blood flow & rate ↓, tissue extract more O2 from
Stetho guidelines: warm diaphragm & bell before placing on skin blood (venous obstruction); response to anxiety; cold env
Explain auscultation purpose JAUNDICE- yellow in sclera, Palpebral conjunctivae, skin; bc of liver disease, hemolysis of RBC
Don’t apply too much pressure using bell CAFÉ-AU-LAIT SPOTS- slightly uniformly pigmented macule/patch); irregular border
 - 0.5 – 1.5 cm; benign; if > 6 spots, consider neurofibromatosis
Skin Lesions
ACANTHOSIS NIGRICANS- roughening & darkening of skin in localized areas (posterior- Inspect, palpate, describe skin lesions; use gloves as needed
neck)
ALBINISM- loss of pigmentation (total lack/decreased tyrosinase enzyme act) PRIMARY- original lesions
- extraordinary vulnerability to damage from sunlight
Macule- flat, variable size & shape; differs from skin; < 1 cm (freckles, petechiae)
VITILIGO- chalk-white lesions; due to autoimmune destruction of melanocytes (by T-cells)
Patch- large macules; coalescence macules; ≥ 1 cm (Pityriasis rosea, vitiligo)
ERYTHEMA- ↑ redness & skin warmth; due to: inflammation allergy; trauma; ↑ blood flow
Papule- small, solid, elevated, ≥ 1 cm (chickenpox/varicella, psoriasis (guttate type
CAROTENEMIA
Plaque- broad-based papules; occupies relatively large surface area (height above
` skin level); > 1 cm (psoriasis, ringworm)
HAIR Nodule- palpable, firmer/deeper than papule; round/spheroid (marble-like); center may
2 types: Vellus- short, fine, inconspicuous, relatively unpigmented bge at dermis/subcutaneous tissue (surfer’s nodule, boxer’s knuckle pad)
Terminal- coarse, thick, conspicuous, pigmented (scalp, eyebrows, pubes)
Wheal- irregular, transient, superficial, localized edema, flat-topped papule (mosquito
bite, skin text/Mantoux test)
NAIL- protect fingers/toes distal end; fingernails grown 0.1 mm daily (toenails slower)
Parts: Lunula- whitish moon Cyst- epithelial cell-lined sac; w/liquid (cells, cell products) (ganglion/sebaceous)
Nail Plate- firm, rectangular, curving; attachment site of nail bed Vesicle- w/serous fluid; elevated; ≤1 cm (shingles, bullous pemphigoid)
nd
Cuticle- extend from nail fold; seal/protect space in fold & plate from moisture Bullae- larger than vesicle; ≤1 cm (2 deg burn; foot bullae)
Lateral Nail Fold- cover sides of nail plate Pustule- elevated, w/pus (exudate) (pustular acne, psoriasis)
Proximal “ “ - covers ¼ of nail plate/root
Free Edge- 0.1 mm day/slower if toenail SECONDARY- “ “ that continued to full dev’t/modified by regression, trauma, etc
Scale- thin flaze of exfoliated epidermis (dandruff, scalp psoriasis)
SEBACEOUS GLANDS- make fatty substance in hair follicles; absent in palms & soles Crust/Scab- dried residue of serum, pus, blood; mixed w/epithelial & bacterial debris
Apocrine- body odor (bacterial decompose apocrine sweat) (cutaneous anthrax, impetigo)
Excoriation- epi superficial excavations; linear/punctuate; from scratching
Hair Assessment
Fissure- linear crack on skin (athlete’s foot; fissure-in-ano/anal fissure)
- Wear gloves
Erosion- superficial epi loss; moist surface but doesn’t bleed (chickenpox, wound)
- Inspect hair (natural color), evenness of growth evenness on calp, texture & oiliness
- Note infections/ infestation (part hair & check behind ears, hairline, neck) Ulcer- epi/dermis deeper loss; bleed & scar (bedsore, venous insufficiency)
N: scalp free from flaking; no nits/ lice Scar- new connective tissue (fibrous) replaced lost substance (in dermis or deeper)
AbN: excessive scaliness (dermatitis); raised lesions (tumor/inflammation) - from injury/scratch; normal reparative process (hypertrophic/keloid)
- Inspect # body hair
N: hair distribution on body (bbiologic sex & physiologic function)
Skin Condition
AbN: excessive hairiness in females (imbalance in adrenals) DRYNESS- consider hypothyroidism/dehydration
OILINESS- acne-prone SWEATING- hyperthermia/hyperthyroidism
- Note excessive hairloss (infect, nutrition lack, hormone disorder, thyroid/liver
disease, drug toxicity, hepatic/renal failure, radiation/chemo) Skin Integrity
Hair Conditions - assess skin pressure point areas (sacrum, hips, elbows)  rpone to decubitus ulcers
N: intact, no redness
ALOPECIA- male-pattern hairloss (diffuse, patchy, total) AbN: (+) skin breakdown, redness, warmer than other body parts
ALOPECIA AREATA- demarcated round/oval patches; children/young adults
- No visible scarring/inflammation Skin Texture
TRICHOTILLOMANIA- due to pulling, plucking, twisting hair; Hair shafts are broken - note any rough, flaky, dry skin (hypothyro idism); obese clients have dry/ itchy skin
- children (lead to hair being consumed) Skin Thickness
INFECTION- ringworm (tinea capitis) - note for calluses: epi rough, thickened parts; seen in parts w/constant pressure
NUTRITIONAL DEFICIENCY (KWASHIORKOR)- flag sign, copper-red N: thin skin w/o callus
CANCER TREATMENT- radiotherapy (localized), chemo (total) AbN: very thin skin (arterial insufficiency/steroid therapy)
ADRENAL IMBALANCE/HIRSUTISM
THYROID DISORDER- hyper (fine, silky), hypo (sparse) Skin Temp
- compare hands & feet bilaterally (using dorsal hand)
Lifespan Consideration N: uniform and within normal range
Neonate/Newborn- little/many body & scalp hair AbN: generalized hyperthermia (fever) & hypothermia (shock)
Children- axillary & pubic hair; measured by Tanner scale localized “ (infection) & “ (arteriosclerosis)
Elderly- loss of scalp, pubic, axillary hair; hair on eyebrow, ear, nostrils (bristle, coarse)
Parts of Hands to Use
Fingerpads- fine discrimination (pulses, texture, size, consistency, shape, crepitus)
SCALP Ulnar & Palmar surface- vibrations/Thrills/Fremitus
mnemonic: Dorsal surface- temperature
Factors to be Assessment Part of Hand
Fine discriminations: pulses, texture, size,
Skin
Fingerpads Turgor
consistency, shape, and crepitus?
Vibrations? Thrills? Fremitus? Ulnar/Palmar surface -
Temperature? Dorsal surface elasticity
(how
quickly it returns to original shape after pinching)
- mobility (how easily skin can be pinched)
Edema (Pitting) Assessment - assessed: lift skin fold, noting its ease w/which it lifts up
- let patient sit w/ legs dangling - where: child/adult (forehead, chest, abdomen, extremity; elderly (chest, abdomen)
- palpate skin over tibia, press between thumb & index finger (30-60 secs) - findings: pinched easily & immediately return to original place
- run finger pads over area pressed & note indentation Elder: ↓ elasticity & collagen fibers (sag/wrinkle skin in face, breast, scrotal area)
Scale Measurement Duration Edema (↓ mobility); dehydration (↓ tugor, >30 secs)
4+ > 7mm > 2 min
Documentation for Skin Findings
3+ > 5-7 mm < 60 secs Diagram- draw location, size, describe skin lesions on body surface diagram
2+ 2-4 mm (indentation) < 15 secs
1+ 2 mm (barely noticed) immediate Lifespan Consideration
NEONATE/NEWBORN- physiologic jaundice at 2-3 days after birth (lasts 1 week)
 - pathologic jaundice appears 24 hrs (lasts > 8 days)
- note fore: milia (whiteheads), small nodules on nose & face, vernix caseosa
(white, cheesy, greasy)
: (premature) lanugo (fine, downy hair on shoulder & back)
: (dark-skinned) hyperpigmentation (sacral area), Mongolian spots
: diaper rash (diaper dermatitis); skin turgor (abdomen)

CHILDREN- minor skin lesions on arm & leg (other parts are sign of disease/abuse) MELANOMA
- secondary lesions from scratch/expose primary lesions to staph. spp categories: SURFACE- better, not invade into body/not getting depth; chance of
- oil glands/acne metastasizing is < 5%
DEPTH- metastasize >5%
ELDERLY- changes in fairer skin people occur earlier than dark-skinned
- wrinkles on face/ neck (abundant in collagen & elastic fibers)
- thin, translucent skin due to loss of dermis & subcutaneous tissue
- dry/flaky skin on extremities (less active sebaceous & sweat gland)
- ↓ tugor (assess for hydration over sternum/clavicle)
- Senile lentigines (melanotic freckles) (Flat, tan-brown, macules areas exposed
to the sun (back of hand; 1-2 cm)

MIDTERM
Physical Assessment
- systematic - comprehensive
- continuous collection - validation & communication of client data

TOO TALL TOO TALL

MARFAN’S SYNDROME GIGANTISM
- connective tissue disorder - enlarged soft tissue (pituitary gland)
- genetic defect - excessive growth hormones

DWARFISM
- person w/short stature
Cause: unknown (constitutoned delayed growth)
Bone & metabolic disease
Gonadal dysgenesis
Chronis abuse & neglect (most common if child abuse)
Genetic mutation (achondroplasia: most common form; avg size portion torso)
: proportionate (same size all over: hypothyroidism)
RA 9288: NEWBORN SURVEY ACT
Specimen: blood
Site: outer head (finds easily, ↑ blood flow)
Disorders in newborn screening: CCGGKM (CC GAGA KA MAR)
CONGENITAL ADRENAL HYPERPLASIA - death
CONGENITAL HYPOTHYROIDISM
GALACTOSEMIA- death
G6PD (GLUCOSE-6-PHOSPHATE DEHYDROGENASE- anemia; avoid peanuts
PKU (PHENYLKETONURIA)- brain damage
MAPLE SYRUP URINE DISEASE
Worst: congenital adrenal hyperplasia & galactosemia

Body types
STHENIC- avg ht, well developed musculature, wide shoulders, flat abdomen
- oval face, muscular, thick set, broad chest, high diaphragm
- stomach lies transverse; gallbladder high in abdomen; high transverse colon
HYPERSTHENIC- short, stocky, maybe obese, broader chest, thicker abdominal wall
- rectangular face, very muscular, thick-set
ASTHENIC- long, thin chested, lean; exaggeration of hyposthenic
- lower positioned diaphragm, stomach, gallbladder, transverse
(stomach & transverse colon descend into pelvis)
HYPOSTHENIC- tall, willowy, poorly developed musculature, saggy abdomen
- triangular face, similar asthenic
Other disorders
CACHEXIA- profound & marked malnutrition; marked wasting (muscle); ill-health
DEBILITATED- weak, feeble, lack strength; profound weakness, energy loss
FTT (FAILURE TO THRIVE/GROW)- physical/dev’t delays/retardation; infant & children

Body types acc to BUILT & WEIGHT

BMR (BASAL METABOLIC RATE)
ECTOMORPH- tall w/long lean limbs; ↑BMR; ↑intelligence; schizophrenia
MESOMORPH- muscular; husky; avg BMR; models, artist
ENDOMORPH- stocky, prominent abdomen; slowest BMR; depression
> 6mm
In documenting:
Moles freckles,: numerous light brown macula
< 6mm- papule
Change in size of moles/warts= skin cancer
Nails: nail bed must be pink, nail shape roundish
Toenail base is pink; aging= thicker, yellowish nails
Inspect fingernail plate shape to determine its curvature and angle.
N: Convex curvature; angle of nail plate about 160°
ABN: Spoon nail, clubbing (180° or greater)
Spoon nails (Koilonychia) sign of IRON DEFECIENCY ANEMIA
CLUBBING OF FINGERS is a sign of chronic HYPOXIA (decreased O2 in body tissue)

Asymmetry
Border
Color
Diameter

HEAD FACE NECK

Normal cephalic-
Face dropping- stroke
Bell’s palsy-
Lymph node: size, location, consistency
Crisscross method-
Ishihara Test- for colorblindness
Obstruct LEFORT I: slight swelling of upper lip; + ecchymosis (bluish disc; buccal sulcus under each
Inhale zygomatic arch, malocclusion mobility of teeth)
Occlude LEFORT II: step deformity at infraorbital margin, mobile midface, paresthesia of cheek
Inhale LEFORT III: tenderness & separation at frontozygomatic suture; lengthing of face, depression
Choanal Atresia- nasopharynx obstruction of ocular levels; hooding of eyes (enophthalmos; affected teeth, incisors, posterior
CN IX & CN X- teeth)

SKULL & FACE ASSESSMENT ANTERIOR FONTANELLE POSTERIOR FONTANELLE

1. Assess shape & symmetry- to assess fracture, deformities - close: 12-18 mos - close: 2-3 mos
2. Inspect facial features- determine paralysis (loss of facial tone); Bell’s palsy - size: 2-3 mm - size: 1 mm
3. Inspect eyes for edema & hollowness- - shape: diamond - shape: triangle
Edema: signify fluid shifting (eye swelling); nephrotic syndrome; allergy
Hollowness (sunken)- sign of dehydration NAIL ASSESSMENT
4. Inspect facial symmetry & movement Children- bent, bruised, ingrown; nailbiting
5. Palpate skull for nodules, masses, depression
Nodule- if bulging: hydrocephalus (increased CSF in brain) Common problems
Sunken fontanelle- dehydration BANDS ACROSS NAILS- protein deficiency WHITE SPOTS- zinc deficiency
SPOON-SHAPED NAILS- iron deficiency anemia CLUBBING FINGER: chronic hypoxia
SKULL & FACE ANATOMY
Normal ICP (INTRACRANIAL PRESSURE): 5-15 mmHg/ 7.5-20 cmsH2O Growth: 0.1 mm/day (toenails slower)
Earliest sign: Altered LOC (LEVEL OF CONSCIOUSNESS): Complete replacement: Damaged finger nails: 4-6 mos
dizziness, drowsiness, headache, projectile vomiting (3-4 ft) Toe nails: 12-18 mos
late sign: CUSHING’S TRIAD Equipment
(SHOCK) - acetone (remove polish to clearly see nail bed) & cottonball
“HYPOTACHYTACHY” (early):
Hypotension Assessment
Tachycardia (1st sign of bleeding, increased heartrate) a. Inspect fingernail: shape, plate, curvature, angle
Tachypnea b. Inspect fingernail/toenail for texture
c. Inspect fingernail & toenail: color, lesions, deformities
Increased ICP: HYPERBRADYBRADY (late):
Hypertension (widened Pulse pressure) Properly groomed?
Bradycardia N: clean, manicured
Bradypnea (Cheyne stroke respiration; waxing & waning w/shorter period of apnea Abn: dirty, jagged
Apnea- cessation/absence of breathing N: pink, some longitudinal ridging; freckles, pigments (dark skinned)
Abn: pale/cyanotic (hypoxia, anemia)
SKULL ASSESSMENT
Hydrocephalus: Non-Communicating- most common Splinter Hemorrhage
Communicating- less common (APPEARS IN MIDTERMS!!) Yellowish Discoloration- fungal infection; psoriasis
Ex vacuo-
Normal Pressure SCHAMROTH’S TECHNIQUE- use ring finger (ring fingernails together)
N: diamond shape (window)
Abn: no diamond shape (finger clubbing  chronic hypoxia: low O2 in surrounding tissue)
 normal: document; abnormal: refer to physician
CBQ (angle): 180- early clubbing spongy sensation
>180- late clubbing (chronic hypoxia)

Developmental Consideration
NEWBORN- nails grow quickly, extremely thin 7 tears easily
CHILDREN- bent; bruised/ingrown (shoes too tight)
ELDERLY- nail biting; grow slower & thicker; tend to split
- toenail fungus (more common & difficult to eliminate)
ICTERIC- yellowish eyes
Larger pupils = more dead lmao

warning signs for stroke: “BE FAST”

Balance
Eyes (loss of vision)
Facial Droop TRUE=Both hypothyroidism and hyperthyroidism present with goiter
Arm drifting FALSE=Normal hearing is classified as “negative” in the Weber test.
Slurred speech TRUE=The eyebrows and scalp hair are considered terminal type of hair.
Time to call 91 FALSE=Albinism is due to autoimmune destruction of melanocytes by T-cells.
TRUE=Varicella infection can present as a papule, erosion, or fissure
CLEFT LIP- common for boys
CLEFT PALATE – common for girls

Ptosis- droopy eyelid

Myasthenia gravis- descending paralysis
Guillaine Barre Syndrome- ascending paralysis’
Thumb- to depress eyelids
Cataract/Milky Eye- opacity of lenses
Anisocoria- unequal pupil reaction

ASSESSMENT OF MOUTH/TEETH
Rule out- make sure that something is not the illness of a client

6 solid food introduction: cereals (w/vit B1/thiamin)

ELDERLY- drier oral mucosa; decreased salivation

- 1st thing to be lost: sweet & salty; Sluggish swallowing/gag reflex
(MIDTERM)Caviar spots- tiny, purplish/bluish swollen areas under tongue
(varicosities)
(TRUE/FALSE) teeth: stain, erosion, chipping, abrasion; dentin loss (under enamel)

NEWBORN- extra maternal calcium/EPSTEIN PEARLS (pearly white nodule)

- milk teeth; deciduous teeth
INFANT- inspect palate (rule out) & uvula; cleft palate = common in girls
- 1st teeth eruption (lower incisors) in 6 months
1st molars- eruption at 6 y/o (permanent)
Fluoride- 6 months (0.3 ppm/parts per mil)
 use soft bristled toothbrush/soft cloth
CHILDREN- tooth dev’t must be:
tonsils appropriate for age; tonsils normally larger than adults
white spots on teeth (fluoride ingestion)
drooling is common at 2 y/o; 2 ½ y/o (dependent toothbrushing)

ELDERLY- drier oral mucosa due to ↓ salivary gland activity

- ↓ salivation due to meds
- extreme dryness associated w/dehydration
- ↓ taste sensation: antropy of taste buds
- loss of smell
- ↑ Na- hypertension; ↑ glucose- diabetes mellitus ↓ insulin
- caviar spots (tiny, purplish, bluish, swollen areas (varicosities under tongue)
- teeth: staining, erosion, chipping, abrasion (loss of dentin)
- teeth loss & sluggish gag reflex (risk for aspiration: chem pneumonia)
 pedia & elderly
 DIGOXIN/FENTANYL APICAL (DOC: Bone Cancer)
ARRYTHMIA APICAL

CHEST- symmetrical, elliptical in cross section, AP (Transverse) Diameter: 1:2 Abdomen: IAPerPa; IPPA  leads to false (+)
- Hutchinson’s Index: measure transverse diameter BOWEL SOUND- heard easily; 5-20/sec or 5-30/min
Subcostal angle- 90o; more acute in males than females Hypoactive- normal in sleep; 1-2 in 2 min  constipation
Hyperactive- 5-6 in less than 30 secs 
Lung assessment: IPPA Absent- no sound in 3-5 min
Position: sitting position (conscious), side lying (unconscious, seizure)
- Upper body undressed
- Exhalation is PROLONGED than inhalation PELVIS:
INSPECTION PRIVACY!!
- yield signs of pulmonary conditions (Barrel Chest- sign of emphysema) Px HISTORY: bright red – lower GI
N: RR= 13-21 cpm; Morphine=16-20cpm black/tarry- upper GI
- altered respiratory rate: best position: RECTUM & ANUS
 imbalances in inspiration & expiration (n: I:E = 1:2) ADULT LEFT LATERAL/SIM’S POSITION
 signs of dyspnea (intercostal retardation/notable use spinal accessory muscle: FEMALE ADULT DORSAL RECUMBENT/LITHOTOMY
sternocleidomastoid, trapezius, MALE ADULT STANDING POS (BENT OVER)
N: Resonant Below the level- dull sound upon percussing: both sides
 start cranially “HARD” width lateral to spine & moves caudally alternating both side STOOL: N: brown color Abn: Mucoidal, blood, black & tarry
result: dullness (= effusion/tumor) Hyperresonance (COPD/Emphysema, Pneumothorax stercobilin (adds color to stool)
urobilinogen (add color to urine)
exhalation: both hands on lateral thorax & apply mild pressure to create skin fold
Inhalation: should vanish bilaterally DIGITAL RECTAL EXAMINATION- gloved hand
if not: a. atelectasis (lung collapse post-surgery) N: intact perianal skin, slightly more pigmented than buttocks skin
asymmetrical in nature
b. pneumothorax anal skin- more pigmented, coarser, moistened
Abn: presence of fissure, ulceration, excoriation, inflammation, abscess, hemorrhoids,
PNEUMOTHORAX- presence of air lumps, tumors, fistula, rectal prolapse
 assess for tactile fremitus; px say “99” w/deep voice (Rectum & Anus)
N: mild vibration (8-10th rib) a. Hemorrhoids- when severely constipated; treat with HOT SITZ BARTH
↑tactile fremitus = ↑ sound conduction (Dse: Pneumonia/inflamed lung parenchyma) - pregnancy (bc of progesterone which relaxes smooth muscle ,
↓ “ “ = ↓ sound conduction (effusion (pleural) causing venous dilation)
- types: INTERNAL- painless; swollen tributaries of superior rectal vein
BRONCOPHONY- whisper “66” EXTERNAL- painful; of “ “ inferior rectal vein
Louder- ↑ conduction = pneumonia b. Skin tags
Quieter/disappear – ↓ conduction c. ANAL FISSURES- tear in lining of lower rectum/anal canal
- painful during bowel movement, prone to infection
AUSCULTATION (heart sounds): Stethoscope d. ANAL WARTS- by causative agent Condyloma acuminata (anogenital wart)
LUB- produced by contraction of ventricles & closure of both atrioventricular valves - by HPV 6 & HPV 8 (common in 90%); rarely cancerous
DUB- shorter, produced by sharp closure of aortic & pulmonic valves
N: MURMURS Amebiasis- causative agent: Entamoeba histolyca
Aortic RMCL 2ND IC5 - stomach pain, loose stools, crampy (amoebic dysentery)
Pulmonic LMCL 2ND IC5 Helminthiasis-
Tricuspid RMCL 5TH IC5 https://www.youtube.com/watch?v=QKndv13bXHA
Mitral LMCL 5TH IC5 https://www.youtube.com/watch?v=JcGSFif1eyg  STUDY EVERYTHING HERE!!!!
Erb’s Point LMCL 3RD IC5 |
v
RESPIRATORY RATE (?????) fingers around the penis then into the head
min avg max look for discharge on meatus
INFANCY 100 120 140 feel for vas deferens to top of scrotum to feel epididymis
TODDLER 90 110 130
PRESCHOOLER 80 100 120 right hand right side of testicle to invaginate scrotum to the point of inguinal ring.
SCHOOL AGE 70 90 110
ADOLESCENT/ADULT 60 80 100 https://www.youtube.com/watch?v=zMczd4H91nM  STUDY EVERYTHING HERE!!

UNCONSCIOUS Best Pulse

ADULT CAROTID
CHILD CAROTID/FEMORAL
INFANT BRACHIAL
NEONATE APICAL
 locate pulse = moderate pressure, warm/clean hands, 3 middle fingers
Pulse Strength/Amplitude: 0 (absent), +1 (barely palpable)
+2 (easily palpated/normal)
+ 3 (full)
+4 (Aneurysm)/bounding) = sign of bleed, shock)

other best pulses

BP: SUPINE: STANDING: SYSTOLIC (<20), DIASTOLIC (<10)
ORTHOSTATIC HYPOTENSION RADIAL (DOC: Heart Failure)