Fundamentals of Nursing

EVOLUTION OF NURSING
Period of Intuitive Nursing
(Prehistoric to early Christian era)
Nursing was untaught and instinctive
Performed out of comassion for others and desire to he! others
"e!iefs and Practices of Prehistoric #an
Nursing was a function that $e!onged to women ta%ing care of the
chi!dren& the sic% and the aged'
"e!ieved that i!!ness causes the invasion of evi! sirit through the
use of $!ac% magic or voodoo'
"e!ieved that medicine man was ca!!ed shaman or witch doctor
having the ower to hea! using white magic'
The( a!so racticed )trehining* or dri!!ing a ho!e in the s%u!! with a
roc% or stone without anesthesia as a !ast resort to drive evi! sirits
from the $od('
+ontri$utions to #edicine and Nursing
"a$(!onia
o +ode of ,ammura$i - rovided !aws that covered ever(
facet of "a$(!onian !ife inc!uding medica! ractice and
recommended secific doctors for each disease and gave
each atient the right to choose $etween the use of
charms& medications or surgica! rocedures'
Eg(t
o Introduced the art of em$a!ming
o .eve!oed the a$i!it( to ma%e %een o$servation and !eft a
record of /01 recogni2ed diseases
o S!aves and atient3s fami!ies nursed the sic%
Israe!
o #oses was recogni2ed as the )Father of Sanitation* and
wrote in O!d Testament which4
Emhasi2ed the ractice of hosita!it( to strangers
and acts of charit(
Promu!gated !aws of contro! on the sread of
communica$!e disease and the ritua! of
circumcision of the ma!e chi!d
Referred to nurses as midwives& wet nurses or
chi!d3s nurses whose acts were comassionate
and tender
+hina
o "e!ieved that in using gir!3s c!othes for ma!e $a$ies %ee
evi!s awa( from them
o Prohi$ited the dissection of dead human $od( as a
worshi to ancestors
o The( gave the wor!d %now!edge of materia! medica
5harmaco!og(6
India
o #en of medicine $ui!t hosita!s& racticed an intuitive
form of asesis and were roficient in the ractice of
medicine and surger(
o Sushurutu made a !ist of function and 7ua!ifications of
nurses' This was the first reference to nurse3s ta%ing care
of the atient3s'
8ncient Greece
o Nursing was the tas% of untrained s!ave
o Introduced caduceus& the insignia of medica!
rofession toda(
o ,iocrates was given the tit!e of )Father of Scientific
#edicine*' ,e made ma9or advances in medicine $(
re9ecting the $e!ief that diseases had suernatura!
causes' ,e a!so deve!oed assessment standards for
c!ients& esta$!ished overa!! medica! standards&
recogni2ed a need for nurses'
Rome
o The Romans attemted to maintain vigorous hea!th&
$ecause i!!ness was a sign of wea%ness
o +are of the i!! was !eft to the s!aves or Gree%
h(sicians' "oth grous were !oo%ed uon as inferior
$( Roman societ('
o Fa$io!a made her home the first hosita! in the
+hristian wor!d through the he! of #arce!!a and Pau!a
Period of Apprentice Nursing
(Founding of religious nursing orders to 183 !hen "aiser!erth Institute for the
training of #eaconesses in $ermany !as esta%lished)
8!so ca!!ed the eriod of )on the 9o$* training'
Nursing care was erformed without an( forma! education and $( eo!e
who were directed $( more e:erienced nurses
Re!igious orders of the +hristian church were resonsi$!e for the
deve!oment of this %ind of nursing'
+rusades
#i!itar( re!igious orders esta$!ished hosita!s staffed with men
;nights of La2arus was founded and rimari!( for the nursing care of !eers in
<erusa!em after the +hristians had con7uered the cit('
Rise of Secu!ar Orders
Re!igious ta$oos and socia! restrictions inf!uenced nursing at the time of the
Re!igious Nursing orders
,osita!s were oor!( venti!ated and the $eds were fi!th(
There was overcrowding of atients4 = or > atients regard!ess of diagnosis or
whether dead or a!ive& ma( have shared one $ed'
Practice of environmenta! sanitation and asesis were non?e:istent
O!der nuns ra(ed with and too% good care of the sic%& whi!e (ounger nuns
washed soi!ed !inens& usua!!( in the rivers'
St' +atherine of Siena' The first )Lad( with a Lam*' She was a hosita! nurse&
rohetess& researcher and a reformer of societ( and the church'
In @A
th
centur(& hosita!s were esta$!ished for the care of the sic% where hosita!s
were g!oom(& cheer!ess& air!ess and unsanitar(' Peo!e entered hosita!s on!(
under comu!sion or as a !ast resort'
#ar& Period of Nursing
(1'
th
to 1(
th
century)
There were no rovisions for the sic%& no one to care for the sic%
Nursing $ecame the wor% of the !east desira$!e of women???women who too%
$ri$es from atients& who sto!e the atient3s food and who used a!coho! as a
tran7ui!i2er'
The( wor%ed seven da(s a wee% s!et in cu$$(ho!e near the hosita! ward or
atient and ate scras of food when the( cou!d find them'
Period of )ducated Nursing
(From *une 1+, 18( !hen Florence Nightingale -chool of Nursing !as opened
until .orld .ar II)
The deve!oment of nursing during this eriod was strong!( inf!uenced $(
trends resu!ting from wars& from an arousa! of socia! consciousness& from the
emanciation of women and from the increased educationa! oortunities
offered to women
Pou!ari2ation of the hi!osoh( of the Nightinga!e S(stem
o Imortance of nursing education
o ,osita! affi!iation
o Nurses teaching students
o ,ea!th teaching as critica! resonsi$i!it(
o Enforced written h(sician orders
o E:ansion in no' of schoo!s to North 8merica
o Secia!i2ation deve!oed
Facts a$out F!orence Nightinga!e
o Recogni2ed as the )#other of #odern Nursing*
o ;nown a!so as the )Lad( with a Lam*
o Raised in Eng!and and !earned !anguages& !iterature& mathematics
and socia! graces
o .eve!oed he se!f?aointed goa!4 )to change the rofi!e of nursing*
o +omi!ed notes of her visits to hosita!s& her o$servation of the
sanitar( faci!ities and socia! ro$!ems of the !aces she visited
o Noted the need for reventive medicine and good nursing
o 8dvocated the care of those aff!icted with diseases caused $( !ac% of
h(gienic ractices
o 8t age =@& she entered the .eaconess Schoo! of ;aiserworth
o Bor%ed as suerintendent for Gent!ewomen during i!!ness
o .isaroved of the restrictions on admission of atients and
considered this unchristian and incomati$!e with hea!th care
o Ugraded the ractice of nursing and made nursing an honora$!e
rofession for gent!ewomen
o Led the nurses that too% care of the wounded during the +rimean war
o Put down her ideas in two u$!ished $oo%s4 Notes on Nursing and
Notes on ,osita!s
Period of Contemporary Nursing
(Period after .orld .ar II up to present)
Scientific and techno!ogica! deve!oments as we!! as socia! changes mar%
this eriod
Esta$!ishment of B,O
Use of atomicCnuc!ear energ( for medica! diagnosis and treatment
Uti!i2ation of comuters
Use of sohisticated e7uiment for diagnosis and thera(
,ea!th is erceived as a fundamenta! human right
Nursing invo!vement in communit( hea!th is great!( intensified
.eve!oment of the e:anded ro!e of nurses
Professiona!i2ation of nursing
Nursing in the Phi!iines
Ear!( "e!iefs and Practices
"e!iefs a$out causation of disease 5evi! sirits& enem( or a with6
Peo!e $e!ieved that evi! sirits cou!d $e driven awa( $( ersons with owers
to e:e! demons
Peo!e $e!ieved in secia! gods of hea!ing& with the riest?h(sician and
,er$o!arios
Suerstitious $e!iefs and ractices in re!ation to hea!th and sic%ness such as
,er$men or ,er$icheros as one who racticed witchcraft
Persons suffering from diseases without identified cause were $e!ieved to $e
$ewitched $( )mang%u%u!am*'
Sanish Period
The re!igious orders e:erted their efforts to care for the sic% $( $ui!ding
hosita!s in the different arts of the Phi!iines
Ear!iest hosita!s esta$!ished4
,osita! rea! de #ani!a 5@0DD6 - $ui!t to care for the Sanish %ing3s
so!diers
San La2aro ,osita! 5@0DE6 - $ui!t e:c!usive!( for atients with !eros(
,osita! de Indio 5@0EA6 - esta$!ished $( Franciscan OrderF service
was in genera! suorted $( a!ms and contri$utions from charita$!e
individua!s'
,osita! de 8guas Santas 5@0G16 - founded $( "rother <' "autisita of
the Franciscan Order'
San <uan de .ios ,osita! 5@0GA6 - Founded $( the "rotherhood of
#isericordia and administered $( the ,osita!!iers of San <uan de
.iosF suort was derived from a!ms and rentsF rendered genera!
hea!th service to the u$!ic'
Nursing during Phi!iine Revo!ution
Prominent ersons invo!ved in nursing wor%s
<sehine "rac%en - insta!!ed a first hosita! in an estate house in
Te9erosF rovided nursing care to the wounded night and da(
Rosa Sevi!!a de 8!vero - converted their house into 7uarters for the
Fi!iino so!diers& during the Phi!iine?8merican Bar that $ro%e out in
@EGG'
.ona ,i!aria de 8guina!do - wife of Emi!io 8guina!doF organi2ed
Fi!iino Red +ross under the insiration of 8o!inario #a$ini
.ona #aria 8gonci!!o de 8guina!do - econd wife of Emi!io 8guina!doF
rovided nursing care to Fi!iino so!diers during revo!ution' President
of Fi!iino Red +ross $ranch in "atangas
#e!chora 87uino - Nursed the wounded Fi!iino so!diers and gave
them she!ter and food
+aitan Sa!ome - a revo!utionar( !eader in Nueva Eci9aF rovided
nursing care to the wounded when not in com$at
8gueda ;aha$agan - revo!utionar( !eader in Laguna& a!so rovided
nursing services to her troos
Trinidad Tecson - )Ina ng "iac na "ato*& sta(ed in the hosita! at "iac
na "ato to care for the wounded so!diers'
Fi!iino Red +ross
#a!o!os& "u!acan was the !ocation of the nationa! head7uarters
Functions4
o +o!!ection of war funds and materia!s through concerts& charit(
$a2aars& and vo!untar( contri$utions
o Provision of nursing care to wounded Fi!iino so!diers
Re7uirements for #em$ershi
o 8t !east @> (ears o!d& age re7uirement for officer was /0 (ears
o!d
o Of sound reutation
,osita!s and Schoo!s of Nursing
I!oi!o #ission ,osita! Schoo! of Nursing 5I!oi!o +it(& @G1A6
It was run $( the "atist Foreign #ission Societ( of 8merica' In #arch&
@G>>& // nurses graduatedF in 8ri! @G>> graduate nurses too% the first
Nurses "oard E:amination at the I!oi!o #ission ,osita!'
St Pau!3s ,osita! Schoo! of Nursing 5#ani!a& @G1D6
Esta$!ished $( the 8rch$isho of #ani!a& the #ost Reverend <eremiah ,art(
under the suervision of the Sisters of St' Pau! de +hartes' It was !ocated in
Intramuros and it rovided genera! hosita! services with free disensar( and
denta! c!inic
Phi!iine Genera! ,osita! Schoo! of Nursing 5@G1D6
8nastacia Giron?Tuas& the first Fi!iino nurse to occu( the osition of chief
nurse and suerintendent in the Phi!iines
St' Lu%e3s ,osita! Schoo! of Nursing 5Hue2on +it(& @G1D6
#ar( <ohnston ,osita! and Schoo! of Nursing 5#ani!a& @G1D6
Phi!iine +hristian Institute Schoo!s of Nursing
Sa!!ie !ong Read memoria! ,osita! Schoo! of Nursing 5Laoag& I!ocos Norte&
@G1=6
#ar( +hi!es ,osita! Schoo! of Nursing 5#ani!a& @G@@6
Fran% .unn #emoria! ,osita! 5Vigan& I!ocos Sur& @G@/6
San <uan de .ios Schoo! of Nursing 5#ani!a& @G@=6
Emmanue! ,osita! Schoo! of Nursing 5+ai2& @1@=6
Southern Is!ands ,osita! Schoo! of Nursing 5+e$u& @G@E6
First +o!!eges of Nursing in the Phi!iines
Universit( of Santo Tomas +o!!ege of Nursing 5@G>A6
#ani!a +entra! Universit( +o!!ege of Nursing 5@G>D6
Universit( of the Phi!iines +o!!ege of Nursing 5@G>E6
Nursing Leaders in the Phi!iines
8nastacia Giron?Tuas - First Fi!iino nurse to ho!d the osition of +hief Nurse
SuerintendentF founder of Phi!iine Nurses 8ssociation
+esaria Tan - First Fi!iino to receive a #asters degree in Nursing a$road
Socorro Siri!an - ioneered in hosita! socia! service
Rosa #i!itar - a ioneer in schoo! hea!th education
Sor Ricarda #endo2a - ioneer in nursing education
+onchita Rui2 - first fu!!?time editor of the new!( named PN8 maga2ine IThe
Fi!iino Nurse*
Loreto Tua2 - .ean of the Phi!iine NursingF F!orence Nightinga!e of I!oi!o
/ealth
8' .efinitions of hea!th var(
@' Traditiona! definition4 freedom from disease
/' @G0E Bor!d ,ea!th Organi2ation defined hea!th as Jstate of
com!ete h(sica!& menta! and socia! we!!?$eing and not mere!(
the a$sence of disease and infirmit(J
"' ,ea!th $e!ief mode!
@' Ps(cho!ogica! and $ehaviora! theor(
/' 8ttemts to e:!ain individua! hea!th $ehaviors
=' ,ea!th $ehaviors are $ased on three factors
a' the individua!s ercetion of susceti$i!it( of i!!ness
$' the individua!s ercetion of seriousness of the i!!ness
c' the !i%e!ihood that the erson wi!! ta%e reventive action
>' #odif(ing factors
a' cu!tura! $e!iefs
$' economics
c' o!itica! factors
d' socia! factors
e' ersona! $e!iefs
/ealth Promotion
+' .efinitions
@' /ealth promotion %ehavior is $ehavior in which the c!ient views
hea!th as a goa! and engages in $ehaviors designed to achieve or
maintain that goa!'
/' /ealth care inc!udes revention& ear!( detection& treatment and
reha$i!itation for c!ients with otentia! for or e:isting i!!ness or
disa$i!it('
=' /ealthy lifestyle can increase or maintain c!ientKs !eve! of
we!!ness and functiona! a$i!it('
>' /ealth screening 5for ris% factors or i!!ness6 can revent or
minimi2e i!!ness and disa$i!it('
0' #isease prevention %ehaviors are $ehaviors designed to
decrease the !i%e!ihoodCris% of i!!ness'
a' rimar( revention
I' hea!th romotion and disease revention
II' a!ied to c!ients considered h(sica!!( and
emotiona!!( hea!th(
III' e:am!e4 e:ercise rograms& hea!th( diet
$' secondar( revention
I' ear!( detection of i!!ness
II' focuses on individua!s who are e:eriencing hea!th
ro$!ems and i!!nesses and who are at ris% for
com!ications
III' activities are directed at diagnosis and romt
treatment
IV' e:am!e4 $reast se!f e:amination& cho!estero!
screening
c' tertiar( revention
I' revention of further deterioration in disease or
disa$i!it(
II' occurs when a defect or disa$i!it( is ermanent and
irreversi$!e
III' activities are directed at reha$i!itation
IV' e:am!e4 a!coho!ics anon(mous
.' Primar( hea!th care
@' 8ccessi$!e& communit(?$ased or wor%?$ased hea!th care services
$ased on rinci!e of universa! access& which ensures hea!th care
for a!! individua!s regard!ess of em!o(ment or insurance status
/' ,ea!th Securit( 8ct of @GG= offered universa! access to $asic
hosita!& reventive& h(sician and !ong?term services' It inc!uded
these seven services4
a' h(sica! e:aminations
$' screening tests
c' diagnosis and treatment of common acute i!!nesses
d' management of chronic i!!nesses
e' !iaison with communit( resources
f' rovision of renata! care
g' identification of need for secia!t( referra!s
=' Providers inc!ude h(sicians& and advanced ractice nurses& such
as4 nurse midwives and nurse ractitioners
>' Services rovided through a managed care mode!
0' Secia!t( services rovided and reim$ursed on!( after referra!
from the rimar( care rovider
A' Primar( care settings inc!ude
a' hea!th maintenance organi2ations 5,#Os6
$' u$!ic hea!th deartments
c' occuationa! hea!th c!inics
d' schoo!s
e' nurse managed c!inics
f' co!!a$orative ractice settings
E' ,ea!th( Peo!e /1@1
@' The US .eartment of ,ea!th and ,uman Services re!eased
,ea!th( Peo!e /1@14 Nationa! Promotion and .isease Prevention
O$9ectives
/' Statement of nationa! hea!th o$9ectives designed to identif( the
most significant reventa$!e threats to hea!th and to esta$!ish
nationa! goa!s to reduce these threats
=' The goa!s of the ro9ect are4
a' increase 7ua!it( and (ears of hea!th( !ife
$' e!iminate hea!th disarities
F' ,ea!th romotion mode!
@' .eve!oed $( No!a Pender
/' ,ea!th romotion deends on seven factors of cognition?
ercetion
a' importance of hea!th to the erson
$' erceived control of hea!th
c' erceived self0efficacy
d' definition of hea!th
e' erceived health status
f' erceived hea!th %enefits from the hea!th?romoting
$ehavior
g' erceived %arriers to the hea!th?romoting $ehavior
G' Ris% factors ? ro$a$i!it( of ac7uiring a articu!ar hea!th ro$!em
@' Varies with age& race& ethnicit(& gender
/' Ris% increases with certain !ifest(!e choices& such as smo%ing&
occuation& diet& environment
=' #odifia$!e ris% factors inc!ude occuation and diet
>' Non?modifia$!e ris% factors inc!ude race and age
0' E:am!es4 ris% factors are imortant in
a' coronar( arter( disease
$' cancer
c' co!on cancer
I' over 01 (ears of age
II' fami!( histor( of co!on o!(s or cancer
III' ur$an !iving
IV' diet high in fats and !ow in fi$er
d' tu$ercu!osis
I' histor( of e:osure to erson with T"
II' histor( of trave! or !iving outside United States
III' histor( of rison time
IV' ,IV infection
V' cancer chemothera(
VI' ma!nutrition
VII' home!essness
VIII' histor( of IV drug use
IL' medica! wor%ers
e' dia$etes4 candidates for screening
I' strong fami!( histor( of dia$etes me!!itus
II' mar%ed!( o$ese
III' o$stetrica! histor( of $a$ies weighing over nine
ounds at $irth
IV' o$stetrica! histor( of miscarriage or feta! death
V' regnant women $etween />?/E wee%s gestation
VI' histor( of gestationa! dia$etes
,' Screening recommendations for the average 8merican
/ealth Promotion Programs and /ealth -creening
8' "!ood ressure screening
@' Screening shou!d $e done annua!!( $eginning at age /@ for $oth ma!es and fema!es
/' Screening for chi!dren and ado!escents is a!so recommended $ut otima! interva! has (et to $e
determined
=' 8uscu!tator( method with a roer!( ca!i$rated and fitting cuff shou!d $e used
>' Person shou!d $e seated 7uiet!( in a chair for at !east five minutes with feet on the f!oor and
arms suorted at heart !eve!
0' 8t !east two measurements shou!d $e done& two minutes aart
A' Pre?h(ertensive individua!s 5S"P @/1?@=G and ."P E1?EG6 shou!d $e counse!ed on !ifest(!e
modifications such as weight reduction& e:ercise& diet& and smo%ing cessation
D' S"P M @>1 and C or ."P M G1 shou!d $e referred to a hea!th care rovider for antih(ertensive
drug thera(
"' "reast se!f?e:aminations
@' Shou!d $e started $( age twent(
/' .one at the same time of the month ? refera$!( seven da(s after onset of the menstrua! c(c!eF
if no menstrua! c(c!es& do at the same time each month
=' Techni7ue shou!d $e reviewed $( a hea!th care rovider to ensure effectiveness
>' Limited effectiveness& $ut when done regu!ar!( he!s a woman understand how her $reasts
norma!!( fee!
0' #ost changes are $enign& $ut unusua! or sontaneous changes shou!d $e chec%ed $( a hea!th
a' !um or thic%ening 5$reast or underarm6
$' red or hot s%in
c' orange ee! s%in
d' dim!ing or uc%ering
e' itch or rash& esecia!!( in ni!e area
f' retracted ni!e
g' change in direction of ni!e
h' $!ood( or sontaneous discharge
i' unusua! ain
9' a sore on the $reast that does not hea!
+' Ris%( $ehaviors ? assist in assessment of $ehaviors that imact the hea!th of individua!s in the
fo!!owing deve!omenta! stages
@' 8do!escents 5age @=?@G6
a' eating disorders
i' anore:ia nervosa ? restrictive eating
ii' $u!imia nervosa ? $inge eating fo!!owed $( urging
$' in9ur( revention
i' wearing of seat $e!ts
ii' wearing of he!mets
iii' sorts in9uries
iv' homicide and suicide
c' su$stance a$use
i' to$acco
ii' underage drin%ing
iii' i!!icit drug use
d' se:ua! $ehavior
i' num$er of se: artners
ii' use of contracetion
iii' unintended regnanc(
iv' e:osure to se:ua!!( transmitted diseases
/' Noung adu!t 5age /1?=06
a' eating disorders ? onset of o$esit(
$' in9ur( revention
i' motor vehic!e accidents
ii' occuationa! ha2ards
iii' homicide and suicide
c' su$stance a$use
i' to$acco
ii' a!coho! use
iii' i!!icit drug use
d' se:ua! $ehavior
i' se:ua!!( transmitted disease ? use of condoms
ii' unintended regnanc(
e' stress
i' changing ro!es
marriage
$eginning a new fami!(
starting a new 9o$
ii' deression
=' midd!e adu!t 5age =0?A06
a' o$esit(
$' !ac% of e:ercise
c' su$stance a$use
i' to$acco
ii' a!coho!ism
iii' i!!icit drug use
d' !ac% of reventative hea!th care
e' stress
i' 9o$
ii' fami!( C divorce
iii' accetance of aging
>' o!der adu!t 5age A0 and o!der6
a' o$esit(
$' !ac% of e:ercise
c' su$stance a$use
i' to$acco
ii' a!coho!ism
iii' i!!icit drug use
d' in9ur( revention
i' fa!!s
ii' seat$e!ts
iii' suicide
iv' mu!ti!e medications
@' +ho!estero! ? once ever( five (ears if norma! age >0 and o!der
/' In women4 mammograh(
.' Sco!iosis screening
@' Recommendations var( $ut genera!!( acceted to erform screening at onset of
ado!escence
/' Significant!( more reva!ent in gir!s than $o(s
=' Ear!( intervention imortant $ecause untreated sco!iosis can !ead to disfigurement& imaired
mo$i!it(& and cardiou!monar( com!ications
>' Techni7ue4 c!othing shou!d $e removed from uer $od(
a' whi!e standing& chec% ado!escent for as(mmetr( of shou!ders& scau!a& his& or
waist
$' assess for misa!ignment of sinous rocesses ? !atera! curvature and conve:it( of
thoracic sine indicate sco!iosis
c' with feet together and !egs straight& have ado!escent $end forward unti! $ac% is
ara!!e! to f!oorF chec% for rominence of ri$s on one side on!( and hi and !eg
as(mmetr( ? chest wa!! on side of conve:it( is rominent and scau!a on side of
conve:it( is e!evated
0' 8$norma!ities are to $e fo!!owed u $( a hea!th care rovider and referra! to orthoedist
ma( $e necessar( for severe curvatures
E' Testicu!ar se!f?e:aminations
@' #onth!( se!f?e:amination shou!d $egin in ado!escence& since this is the highest ris% grou
/' "est time to erform e:am is during or after a $ath or shower when the scrotum is re!a:ed
=' Limited research to determine if regu!ar e:aminations reduce death rate $ut the( are
strong!( encouraged for men with ris% factors such as
a' fami!( histor( of testicu!ar cancer
$' cr(tochidism
c' revious germ ce!! tumor in one testic!e
>' Findings that shou!d $e reorted to a hea!th care rovider inc!ude
a' hard !ums or nodu!es
$' change in si2e& shae& or consistenc( of the testes
1iming of 2ammograms
The Nationa! +ancer Institute 5N+I6 and the 8merican +ancer Societ( differ in their recommendations for
schedu!ing of mammorgrams'
The N+I recommends 5/11/64
Bomen in their >1s shou!d $e screened ever( one to two (ears with mammorgrah('
Bomen aged 01 and o!der shou!d $e screened ever( one to two (ears'
Bomen who are at higher than average ris% of $reast cancer shou!d see% e:ert medica! advice a$out
whether the( shou!d $egin screening $efore age >1 and the fre7uenc( of screening'
The 8+S guide!ines for the detection of $reast cancer in as(mtomatic women 5/11/64
Bomen >1 (ears of age and o!der shou!d have a mammogram ever( (ear'
Bomen >1 and o!der shou!d have a h(sica! e:amination of the $reast ever( (ear& erformed $( a hea!th
care rofessiona!& such as a h(sician& h(sician assistant& nurse or nurse ractitioner' This e:amination
shou!d ta%e !ace near and refera$!e $efore& the annua! mammogram'
Bomen /1?=G shou!d have a h(sica! e:amination of the $reast ever( three (ears& erformed $( hea!th
care rofessiona! such as a h(sician& h(sician assistant& nurse or nurse ractitioner'
"SE is an otion for women starting in their /1s' Bomen shou!d $e to!d a$out the $enefits and !imitations of "SE'
Bomen shou!d reort an( $reast changes to their hea!th rofessiona! right awa('
=' In women4 the first aanico!au smear at the onset of se:ua!
activit( andCor over age @E& annua!!(
>' In men4 rostate?secific antigen ? annua!!( 01 (ears of age or at
age >1 for those at ris%
0' For co!on cancer
a' digita! recta! e:am ever( (ear after the age of >1
$' guaiac test for occu!t $!ood ever( (ear after the age of 01
c' roctosco( ever( three to five (ears after the age of 01
after two negative annua! e:ams
d' co!onosco(
A' Tu$ercu!osis s%in tests4 intraderma! in9ection of antigen
D' .ia$etes4 fasting !asma g!ucose& idea!!( eight to @/ hours fast
E' Vision4 after age =G& medica! e(e e:am ever( three to five (ears
G' ,earing4 candidates for screening inc!ude4
a' fami!( histor( of chi!dhood hearing imairment
$' erinata! infection 5ru$e!!a& heres& c(tomega!ovirus6
c' !ow $irth weight infants
d' chronic ear infection
e' down s(ndrome
I' +om!iance
@' .efinition4 adherence to rimar( or secondar( revention
recommendations
/' Factors inf!uencing com!iance
a' ersona! meaning and ercetions4 %now!edge& va!ues&
$e!iefs& outcome e:ectations
$' socia! factors4 environmenta! conte:t& socia! re!ationshis&
socia! suort& societa! norms& economic resources
c' deficiencies in the hea!th care s(stem4 access& costs& wait
time& mono!ingua! services
<' Noncom!iance
@' 8n individua!Ks informed decision not to adhere to a theraeutic
recommendation
/' Individua! una$!e or unwi!!ing to a!ter ha$itua! $ehaviors or adot
new $ehaviors necessar( to a rescri$ed theraeutic regimen
/ealth Assessment
;' ,ea!th assessment in genera!
@' Puroses of hea!th assessment
a' data co!!ection
$' su!ement& confirm or refute historica! data
c' identif( changes in c!ientKs status
d' eva!uate the outcomes of care
/' +omonents of hea!th assessment4 histor( and h(sica!
a' histor(
I' chief com!aint
!ocation
7ua!it(
7uantit(
reciitating or aggravating factors
duration
associated findings
II' genera! hea!th status
III' medica! histor(
IV' fami!( histor(
V' socia! histor(
VI' occuation
VII' activit( !eve!
VIII' s!ee
IL' nutrition
L' medicationsF inc!uding su$stance useCa$use
LI' s(chosocia! factors
$' h(sica! e:am4 s%i!!s
i' insection
rocess of o$serving the differences
$etween norma! h(sica! signs and
deviations
re7uires %now!edge of norma! h(sica! signs
throughout the !ifesan
rinci!es of Insection
o in good !ighting and with who!e $od(
art visi$!e
o o$serve each area for si2e& shae&
co!or& and osition
o comare $od( arts $i!atera!!( for
s(mmetr(
ii' a!ation
.use touch to assess resistance& resi!ience&
roughness& te:ture and mo$i!it(
. a!ation ma( $e either !ight or dee in
ressure
i. use !ight a!ation to
determine tenderness
ii. dee a!ation usua!!(
deresses the area $( @ to / inchesF
use it to e:amine secific organs
. use a!mar surface of fingers to determine
osition& te:ture& si2e& consistenc(& and
u!sationF a!so resence and shae of mass
. use $ac% of hand to test temerature
. use a!m of hand to sense vi$ration
ii' ercussion
ta the $od( with fingertis4 to detect f!uid&
or to assess !ocation& si2e& densit( and
$orders of organs'
taing the $od( roduces vi$ration and
sound waves which (ou hear as ercussion
tones
methods
i' direct4 stri%ing the $od( surface with two
fingers
ii' indirect4 stri%ing the midd!e finger of the
nondominant hand on the $ac% surface with
the fingers of the dominant hand rather than
the $od( surface& whi!e %eeing the a!m
and remaining fingers off the $od(
character of ercussion sounds deends
on the densit( of the tissue $eing ercussed
C/A3AC1)3 4F P)3C5--I4N -45N#-
T(man(4
.rum!i%e& !oud& high itch& moderate durationF usua!!( found over saces
containing air such as the stomach
Resonance4 ,o!!ow sound of moderate to !oud intensit(F !ow itch& !ong durationF Usua!!(
heard over !ungs
,(erresonance4 "ooming sound of ver( !oud intensit(F ver( !ow itch& !ong durationF Usua!!( heard
in the resence of traed air 5such as emh(sematous !ung6
F!atness4 F!at sound of soft intensit(F high itchF short durationF Usua!!( heard over musc!e
.u!!ness4
Thud?!i%e sound of soft intensit(F high itchF moderate durationF Usua!!( heard
over so!id organs 5such as heart& !iver6
iii' auscu!tation
!istening 5with unassisted ear or stethoscoe6 to
sounds made $( the $od(
assess resence of sounds and their character
o fre7uenc( 5high or !ow itch6
o !oudness 5!oud or soft6
o 7ua!it( 5$!owing& gurg!ing& $ooming&
thud!i%e& ho!!ow& f!at6
o duration 5short& moderate& !ong6
v' o!faction
use of sense of sme!! to differentiate common $od(
odors from a$norma! ones
common odors inc!ude
o urine4 ammonia
o s%in4 $od( odor
o $od( wastes4 feces& vomitus
o mouth4 ha!itosis
v' h(sica! e:am
e7uiment
c!ient ositions
reorting genera! aearance and $ehaviors
o gender and race
o age
o o$vious signs of distress
o $od( t(e
o osture
o gait
o $od( movements
o h(giene
o dress
o affect and mood
o seech
)65IP2)N1 N))#)# F43 P/7-ICA8 )9A2
+!ient Gown
.raes
Stethoscoe
G!oves
Percussion ,ammer
Sh(gmomanometer 5"!ood Pressure gauge and cuff6
Thermometer
Tae measure
+otton swa$s
F!ash!ight
Tongue deressor
Sca!e
Lu$ricant
E(e chart
#isce!!aneous4 safet( in& ru!er& aer towe!s
vita! signs
height and weight
$od( temerature
o range4 =A to =E degrees +e!sius 5GE'A to
@11'> degrees Fahrenheit6
o measure core temerature4 rectum&
t(manic mem$rane& esohagus& or urinar(
$!adder
o measure surface temerature4 s%in& a:i!!a&
or mouth
o $od( temerature norma!!( varies with
age
e:ercise
hormone !eve!
circadian rh(thm 5time of
da(6
stress
environment
/ealth Assessment %y :ody Part
:; )ye
@' ,istor(
a' current findings
$' ast ro$!ems
c' fami!( histor( ? g!aucoma& cataracts
d' harmfu! e:osure ? chemica! sun!ight
/' Ph(sica! e:am
a' vision test
$' e:traocu!ar musc!e functions 5EO#Ks6
c' e:terna! e(e structures
d' interna! e(e structures and red ref!e:
e' otic disc
f' retina! vesse!s
=' Geriatric a!terations of e(e
a' arcus seni!is ? Oa7ue white ring a$out the eriher( of the
cornea& seen in aged ersonsF caused $( the deosit of fat
granu!es in the cornea or $( h(a!ine degeneration'
$' ui!s often miotic 5sma!!er6 with s!ower di!ation
c' iris ma( aear a!er
d' retina ma( aear a!er
e' disc ma( $e s!ight!( sma!!er and more oa7ue
f' res$(oia
g' co!or ercetion ma( $e dimmed
C; )ar
@' ,istor(
a' resenting ro$!em or in9ur(
$' resence of hearing !oss
c' use of hearing assist
d' associated findings
e' onset
f' reciitating factors
g' aggravating and a!!eviating factors
h' !ifest(!e factors4 swimming& musician
i' medica! histor(
9' fami!( histor( of a!!erg( or hearing disease
%' medications
/' Insection ? e:terna! ear
a' o$serve si2e& shae and s(mmetr( of $oth ears
$' auric!es are norma!!( !eve! with each other& and uer oint
of attachment is in a straight !ine with the !atera! canthus of
the e(e
c' insect ear s%in for co!or& !esions& rash and sca!ing
d' insect area $ehind auric!e for tohus 58 deosit of sodium
$iurate in tissues near a 9oint& in the ear& or in $one in gout6
=' Pa!ation
a' a!ate auric!e& tragus and mastoid area for tenderness
and e!evated !oca! temerature
$' norma! findings4 auric!e is norma!!( smooth without !esions
c' estimate si2e of e:terna! auditor( meatus
>' Otoscoic e:amination
a' adu!t4 gras auric!e and u!! up and $ac% to straighten
e:terna! ear cana! $efore inserting otoscoe
$' chi!d4 gras auric!e and u!! do!n and $ac%
c' insect ear cana! for redness& swe!!ing& discharge& crusting
and foreign $odies
d' e:ect a sma!! amount of moist& usua!!( orange cerumen
5ear wa:6' +erumen is usua!!( dr( in 8sians& Native
8mericans& and the e!der!(
e' t(manic mem$rane
i' norma! finding4 trans!ucent& shin(& !ight gra(& taut
dis%F free from tears or $rea%s
ii' test its mo$i!it(4 as% c!ient to sa( JahJ or swa!!ow'
Intact mem$rane wi!! vi$rate s!ight!(
0' ,earing acuit(4 four tests
a' gross hearing is tested $( c!ientKs resonse to norma!
conversation
$' whisered word or tic%ing watch test
c' Be$er test4 tuning for% of 0@/ cs is set to vi$rate and
!aced erendicu!ar!( on the mid!ine verte: of the s%u!!'
+!ient as%ed to reort in which ear sound is heard' If heard
in one ear& susect sensorineura! !oss in the other
d' Rinne test ? comares sound conduction4 air versus $one
i' set tuning for% to vi$rate
ii' !ace on mastoid rocess
iii' as% c!ient whether the sound is heard and when it
can no !onger $e heard' Note how !ong the sound
can $e heard'
iv' when c!ient states that sound is gone& immediate!(
move the tuning for% to a$out / cm from auditor(
cana!
v' as% the c!ient again whether there is sound and
when it stos
vi' norma! finding4 !atter sound shou!d $e heard twice
as !ong as that of mastoid sound
A' Geriatric a!terations
a' ear !o$es ma( aear endu!ous
$' res$(cusis
#; 2outh and pharyn<
@' Insection4 norma! findings
a' temoromandi$u!ar 9oint4 smooth 9aw e:cursionF eas(
mo$i!it(
$' !is and $ucca! mucosa4 s(mmetrica!& in%F smooth and
moist
c' teeth and gums4 =/ adu!t teethF in% gums
d' tongue4 s(mmetr(F in%F moistF ai!!a resent
e' hard and soft a!ate4 hard a!ate is a!e& immova$!e with
transverse rugaeF soft a!ate is in% and mova$!e
f' Orohar(n:4 s(mmetrica!F mid!ine uvu!a& tonsi!s ma( $e
resent on either side
/' Geriatric a!terations
a' mucosa ma( $e drier
$' sense of taste ma( $e diminished
c' decreased sa!iva
d' !is thinner& shin(
e' teeth ma( aear (e!!owish
f' tongue ma( aear smoother
); -&in
@' Genera! aearance ? insection
a' co!or
i' varies with $od( art& and from erson to erson
ii' co!or ranges
JwhiteJ s%in4 Ivor( or !ight in% to rudd( in%
dar% s%in4 !ight to dar% $rown or o!ive
a' a!terations in s%in co!or
i' h(erigmentation
ii' h(oigmentation
iii' c(anosis
iv' 9aundice
v' er(thema
$' moisture
c' temerature
d' te:ture4 varies from art to art
i' smooth or rough
ii' su!e or tight
iii' indurated
e' turgor
i' norma!!( decreases with age
ii' decreased in deh(dration
f' vascu!arit(
i' in o!der eo!e& cai!!aries are more fragi!e
ii' etechiae
g' edema
h' !esions
i' norma! finding4 free of !esions
ii' age?re!ated changes inc!ude %eratosis seni!is&
cherr( angiomas& and atrohic warts'
iii' rimar( !esions
macu!e ? .isco!ored sot or atch on the
s%in& neither e!evated nor deressed& of
various co!ors& si2es& and shaes
au!e ? 8 sma!!& red& e!evated area on the
s%in& so!id and circumscri$edF a im!e
atch ? 8 sma!! circumscri$ed area distinct
from the surrounding surface in character
and aearance'
!a7ue ? 8 atch on the s%in or on a mucous
surface
vesic!e O 8 sma!! sac or $!adder containing
f!uid' P8 $!ister!i%e sma!! e!evation on the
s%in containing serous f!uid'
$u!!a O 8 !arge $!ister or s%in vesic!e fi!!ed
with f!uidF a $!e$
ustu!e ? 8 sma!! e!evation of the s%in fi!!ed
with !(mh or us
nodu!e ? 8 sma!! node'
iv' secondar( !esions 5arise from rimar(6
sca!e
crust
!ichenification
scar
e:coriation
u!cer
fissure
%e!oid
erosion
v' for ever( !esion& note eight asects4
co!or
!ocation
te:ture
si2e
shae
t(e
grouing
distri$ution
i' hair
i' hirsutism
ii' a!oecia
9' nai!s
%' factors affecting s%in condition
i' h(giene
ii' nutritiona! status
iii' under!(ing disorders
!' geriatric changes in s%in 5$esides wrin%!ing& and
!ossCgra(ing of $oth head and $od( hair6
i' thinner s%in
ii' more frec%!es
iii' h(oigmented atches
iv' s%in is drier& esecia!!( on !ower e:tremities
v' !ess ersiration
vi' a!! s%in $ecomes !ess e!asticF hanging arts sag
vii' toenai!s ma( $e thic%& distorted& and (e!!owish
viii' !esions4 cherr( angiomas& seni!e %eratosis& atrohic
warts
F; /eart
@' 8ssess the heart through the anterior thora: 5front chest6
/' Insection and a!ation
a' c!ient in suine osition or with head e!evated at >0
degrees
$' anatomica! !andmar%s of the heart
i' second right intercosta! sace ? aortic area
ii' second !eft intercosta! sace ? u!monic area
iii' third !eft intercosta! sace ? Er$Ks oint
iv' fourth !eft intercosta! sace ? tricusid area
v' fifth !eft intercosta! sace ? mitra! 5aica!6 area
vi' eigastric area at ti of sternum
c' aica! imu!se
i' fourth or fifth !eft intercosta! sace& midc!avicu!ar
!ine
ii' ma( or ma( not $e seen
iii' norma!!( a short& gent!e ta
=' 8uscu!tation
a' c!ient ta%es three ositions4 sitting& suine& !eft !atera!
recum$ent
$' use stethoscoe to auscu!tate heart sounds
c' S@
i' c!osing of the mitra! va!ve
ii' after !ong diasto!ic ause and
iii' $efore short s(sto!ic ause
iv' heard $est at ae:
d' S/
i' c!osing of aortic va!ve
ii' after short s(sto!ic ause and
iii' $efore !ong diasto!ic ause
iv' heard $est over aorta ? second right intersace
v' high itched& du!! in 7ua!it(
e' u!se deficit
f' murmurs
i' grading s(stem
ii' as(mtomatic or s(mtomatic
iii' thri!!
iv' s(sto!ic murmur occurs $etween S@ and S/
v' diasto!ic occurs $etween S/ and S@
$; =asculature
@' "!ood ressure
a' ref!ects re!ationshi $etween cardiac outut& erihera!
vascu!ar resistance& $!ood vo!ume and viscosit(& and
arteria! e!asticit(
C8A--IF7IN$ /)A31 253253- :7 IN1)N-I17
Grade I4 .ifficu!t to hear& even with stethoscoe
Grade II4 Huiet& heard with stethoscoe
Grade III4 #oderate!( !oud& no thri!!
Grade IV4 Loud& ma( have a thri!!
Grade V4 Ver( !oud& heard with a stethoscoe artia!!( off chestF has thri!!
Grade VI4 +an $e heard with a stethoscoe off chestF has a thri!!
$' factors inf!uencing $!ood ressure
i' age
ii' stress
iii' race
iv' drugs
v' diurna! 5da(?night6 variations
vi' gender
c' a!terations in $!ood ressure
i' h(ertension
ii' h(otension
d' range of norma! $!ood ressure
i' chi!d under age / weighing at !east /D11g4 use
f!ush techni7ue& =1?A1mg ,g
ii' chi!d over age two4 E0?G0C01?A0 mm ,g
iii' schoo! age4 @11?@@1C01?A0 mm ,g
iv' ado!escent4 @@1?@/1CA0?E0 mm ,g
v' adu!t4 Q@=1 mm ,g S(sto!ic C QE0 mm ,g diasto!ic
/' Interna! carotid arteries in nec%
a' a!ate each searate!( a!ong margin of
sternoc!eidomastoid
$' norma! findings4 strong thrusting u!se
c' auscu!tate $oth sides
d' norma! findings4 no sound heard
e' constriction causes $ruit
=' <ugu!ar veins
a' c!ient in suine osition with head e!evated at >0 degrees
$' norma! findings4 u!sations not evident
c' 9ugu!ar venous ressure 5<VP64 not to e:ceed = cm a$ove
!eve! of sterna! ang!e
>' Perihera! arteries and veins
a' u!se
i' !ocations
:844# P3)--53) (:P)
Common 2ista&es during 5pper )<tremity :P Chec&s
Too wide a $!adder or cuff roduces fa!se !ow reading
Too narrow a $!adder or cuff roduces fa!se high reading
+uff wraed too !oose!( roduces a fa!se high reading
.ef!ating cuff too s!ow!( roduces fa!se high diasto!ic reading
.ef!ating cuff too 7uic%!( roduces a fa!se !ow s(sto!ic and fa!se high diasto!ic reading
Inaccurate inf!ation !eve! roduces a fa!se !ow s(sto!ic reading
Ta%ing the $!ood ressure in !ower e:tremities
Peripheral :P 2easurement in the legs
Use the o!itea! arter( $ehind %nee as a stethoscoe auscu!tator( site
Position the c!ient rone or sitting with %nees s!ight!( f!e:ed
Use wide& !ong cuffF wra it so that the $!adder is over the osterior asect of midthigh
S(sto!ic $!ood ressures in !egs are /1?>1 mm,g higher than in the $rachia! arter(
.iasto!ic ressure in the !egs is a$out the same as in the $rachia! arter(
84CA1I4N- 4F P58-)-
/ead 0 Nec&
@' Temora!4 over temora! $one !atera! to e(e
2. +arotid4 over the carotid arter( in nec%
Chest
=' 8ica!4 $etween >th and 0th intercosta! sace usua!!( mid?c!avicu!ar !ine
Arm
>' "rachia!4 in the antecu$ita! area of arm
0' Radia!4 on thum$ side of wrist
A' U!nar4 media! wrist
8eg
D' Femora!4 $e!ow the inguina! !igament
E' Po!itea!4 $ehind the %nee
G' Posterior ti$ia!4 on inner side of each an%!e
@1' .orsa!is edis4 a!ong to of foot
ii' norma! range of erihera! u!ses
infants4 @/1 to @A1 $eatsCminutes
todd!ers4 G1 to @>1 $eatsCminutes
reschoo!Cschoo!?age4 D0 to @@1 $eatsC
minute
ado!escentCadu!t4 A1 to @11 $eatsCminute
iii' factors affecting rate
e:ercise
temerature
stress
drugs
hemorrhage
ostura! changes
u!monar( conditions causing oor
o:(genation
$' rh(thm ? regu!ar 5norma!6 or irregu!ar
c' strength
i' ref!ects vo!ume of $!ood e9ected with each $eat
ii' grading s(stem
d' e7ua!it(
e' a!terations
f' d(srh(thmias
g' tissue erfusion
i' temerature
ii' co!or4 c(anosis
iii' c!u$$ing
iv' edema
P58-) $3A#IN$ -CA8)
No u!se
O 1
Bea% u!se
O @R
.ifficu!t to a!ate O /R
Norma! O =R
O >R
v' s%in and nai! te:ture
vi' hair distri$ution on !ower e:tremities
vii' resence of u!cers
/; 8ungs
@' ,istor(4 smo%ing& infections& ain& discomfort& d(snea& activit(
into!erance& fever
/' Insection
a' genera! aearance4 resirations
i' $reathing shou!d $e 7uiet and eas(
ii' resiration invo!ves venti!ation& diffusion& and
erfusion of gases
iii' factors inf!uencing resirations
e:ercise
ain
an:iet(
stress
anemia
osture
drugs4 narcotics& amhetamines
iv' norma! rates of resiration
new$orn4 =0 to >1 $reathsCminute
infant4 =1 to 01 $reathsCminute
todd!er4 /0 to =0 $reathsCminute
schoo! age4 /1 to =1 $reathsCminute
ado!escentCadu!t4 @> to /1 $reathsCminute
adu!t4 @/ to /1 $reathsCminute
v' deth4 dee& norma!& sha!!ow
vi' rh(thm4 regu!ar& irregu!arF Norma! finding4 regu!ar
vii' s%in co!or
viii' chest wa!! configuration
norma! findings4 s(mmetrica! with $i!atera!
musc!e deve!oment
a? to transverse ratio range4 @ to 04 / to D
=' Pa!ation
a' fee! for a$norma!ities such as masses& !esions& scars&
swe!!ing& creitus& as(mmetr(
$' creitus indicates air in su$cutaneous sace 5in thoracic
area& usua!!( due to neumothora:6
c' voca! fremitus
i' vi$ration fe!t when atient sea%s
ii' increased over areas of conso!idation
>' Percussion ? norma! findings4 resonance heard throughout !ung
fie!ds
0' 8uscu!tation
a' norma! findings4 7uiet $reathing throughout a!! !ung fie!ds
$' whisered ectori!o7u(
i' c!ient whisers Jone& two& threeJ
ii' over norma! areas of the !ung& on!( faint sounds are
heard
iii' over conso!idated areas& the words are more
distinct
c' egohon(
i' c!ient sa(s JEJ
ii' over conso!idated areas& the sound is a nasa! J8J
A' 8!terations in !ung function
a' cough
$' e:ectoration
c' d(snea
d' $rad(nea
e' tach(nea
f' h(ernea
g' anea
h' +he(ne?Sto%es resiration
i' ;ussmau!Ks $reathing
9' "iotKs $reathing
%' grunting
!' retractions
m' hemot(sis
n' ain
o' accessor( musc!e use
' c(anosis
7' adventitious sounds
r' ursed?!i $reathing
i' ro!onged e:ha!ation
ii' $reathing out through uc%ered !is
s' !eura! friction ru$
i' grating sound roduced $( inf!amed !eura ru$$ing
together
ii' usua!!( heard !oudest over !ower !atera! anterior
chest at end of insiration
D' Pediatric differences
a' sma!!er& shorter& more !ia$!e airwa(s&
$' underdeve!oed suorting carti!age
c' a$ove two factors increase the ris% of o$struction due to
mucus& edema& or foreign $od(
d' f!e:i$!e !ar(n: more susceti$!e to sasm
e' immature immune s(stem
f' incom!ete m(e!ini2ation
g' increased $asa! meta$o!ic rate
h' decreased a$i!it( to mo$i!i2e secretions
i' !ess forcefu! cough
I' "reasts
@' Insection 5erformed with c!ient in !(ing& sitting& or standing
osition6
9' si2e4 var( from conve: to endu!ous
%' s(mmetr( 5the !eft $reast is common!( !arger than the
other6
!' s%in4 co!or& venous attern& ossi$!( a few hairs around
areo!a
m' a!terations
I' retraction
II' dim!ing
III' !esions
IV' edema
V' inf!ammation
VI' a!terations with regnanc( and !actation
I' en!argement of $reasts
II' soreness of ni!es during !actation
III' ossi$!e striae
n' ni!e and areo!a
I' si2e
II' co!or4 ranges from in% to $rown
III' shae
I' areo!a4 round or ova!
II' ni!es4 everted
IV' s(mmetr(4 norma!!( s(mmetrica!
V' direction4 norma!!( ni!es oint in same direction
VI' a!terations
I' discharge
II' inverted ni!es
III' $!eeding
/' Pa!ation ? $reast
a' !(mh nodes ? norma! findings4 not a!a$!e
$' $reast tissue
@' c!ient in suine osition with hand !aced $ehind
nec%
/' methods of e:amining $reast tissue
c!oc%wise or counterc!oc%wise circ!ing
$reast from ni!e outward
$ac% and forth with fingers moving u and
down each $reast
=' consistenc(4
varies wide!( from erson to erson
norma! findings4 dense& firm and e!astic
>' a!teration ? fi$roc(stic disease of the $reast
0' geriatric a!terations
re!a:ed $reasts
ma( aear e!ongated or endu!ous
decrease in g!andu!ar tissue
*; A%domen
@' ,istor(
a' ain& $owe! ha$its& dietar( ro$!ems& weight change&
difficu!t( swa!!owing& f!atu!ence& $e!ching& heart$urn&
nausea& vomiting& craming
$' changes in micturition inc!uding4 change in amount and
co!or of urine& irritation of the !ower urinar( tract&
o$struction of the urinar( tract& urinar( incontinence&
urinar( tract ain
/' Insection
a' !andmar%s
i' :ihoid rocess4 mar%s uer $oundar( of
a$domen
ii' s(mh(sis u$is4 mar%s !ower $oundar(
iii' a$domen divided into four 7uadrants4 RUH& RLH&
LUH& LLH
$' norma! findings
i' s%in te:ture and co!or shou!d $e consistent with rest
of $od(
ii' stria ma( $e resent
iii' um$i!icus is norma!!( f!at or concave midwa(
$etween :ihoid and s(mh(sis u$is
iv' a$domen ma( $e f!at& concave or conve:F a!! three
are norma! if there is s(mmetr(
v' (ou ma( note erista!sis movement or aortic u!se
vi' voiding4 stead(& straight stream with no ain or ost
void dri$$!e
=' Percussion
a' norma! findings4 t(man( over stomach and intestinesF
du!!ness over !iver& s!een& ancreas& %idne(s and
distended 5M@01cc6 $!adder
$' !iver $order
i' usua!!( noted in the 0th& Ath or Dth intercosta! sace
ii' distance $etween uer and !ower $orders shou!d
range $etween A to @/ cm at right midc!avicu!ar !ine
c' s!een
i' !eft osterior mida:i!!ar( !ine4 du!!ness at Ath to @1th
ri$
ii' !eft intercosta! sace in anterior a:i!!ar( !ine4
t(man(
>' Pa!ation
a' norma! findings4 soft with no a!a$!e masses& no
tenderness or rigidit(
$' $!adder noted as a $u!ge in a$domen when fi!!ed with more
than 011cc of urine
c' dee a!ation ma( roduce tenderness ? !iver& %idne(s&
s!een inguina! nodes genera!!( not a!a$!e
0' 8uscu!tation
a' $owe! moti!it( ? norma! findings4 audi$!e in a!! 7uadrants
$' vascu!ar sounds ? norma! findings
i' no vascu!ar sounds over aorta or femora! arteries
ii' rena! arter( $ruits can $e heard
A' 8!terations
a' distention
$' ascites
c' ara!(tic i!eus
d' $or$or(gmus
e' guarding 5musc!es contract6
f' tenderness
g' ain
D' Geriatric a!terations
a' increased fat deosits over a$domina! area
$' musc!e tone more !a:
"; Female reproductive system
@' ,istor(4 se:ua!!( transmitted disease& menstrua! histor(& o$stetrica!
histor(& contracetion
/' Insection
a' e:terna! genita!ia ? norma! findings
i' hair distri$ution4 varia$!eF usua!!( inverted triang!e
starting at s(mh(sis u$is
ii' s%in of erineum smooth& c!ean& s!ight!( dar%er than
other s%in
iii' !a$ia ma9ora4 ma( $e c!osed or gaing
iv' c!itoris4 a$out / cm in !ength and 1'0 cm in width
v' urethra! orifice4 intact& in% without irritation
vi' vagina! orifice4 ranges from thin& vertica! s!it to !arge
orifice with moist tissue
vii' anus4 moist and hair!ess4 s%in more dar%!(
igmented
$' interna! genita!ia
i' cervi: ? norma! findings4 in%F mid!ineF usua!!( a$out
two to three cm in diameterF smooth& firm& rounded
or ova!F odor!ess& cream( or c!ear secretions
ii' Paanico!aou 5a6 smear
iii' vagina4 in% throughoutF c!ear or c!oud(& odor!ess
secretionsF a$out @1 to @0 cm in !ength
=' Pa!ation
a' ovaries ma( or ma( not $e a!a$!eF firm& s!ight!( tender&
ova!& mo$i!eF a$out > cm in diameter
$' uterus4 mo$i!eF roundedF a!a$!e at !eve! of e!vis
c' S%eneKs g!ands and "artho!inKs g!and ? norma! findings4
nontender& no discharge
>' Geriatric a!terations
a' !a$ia! fo!ds f!atten
$' s%in a!er& shin(
c' meatus usua!!( more osterior
d' cervi: decreases in si2eF ma( aear a!er
e' scant( cervica! discharge
f' vagina shortens with age
g' decreased vagina! secretions
h' uterus diminishes in si2eF ma( not $e a!a$!e
i' ovaries atroh( with age
8; 2ale reproductive system
@' ,istor(4 se:ua! histor(& se:ua!!( transmitted disease&
contracetion& surger(& associated urinar( ro$!ems
/' Insection
a' e:terna! genita!ia
$' hair distri$ution4 variesF hair e:tends from $ase of enis
over s(mh(sis u$isF coarse and cur!(
c' enis shaft& corona& reuce& g!ans
d' urethra! meatus is s!it !i%e oening ositioned on ventra!
surface& mi!!imeters from ti of g!ansF oening shou!d $e
g!istening and in%
e' scrotum
i' s%in more dar%!( igmentedF more wrin%!edF usua!!(
!oose
ii' s(mmetr(4 !eft testic!e is !ower than right
iii' si2e4 changes with temerature
f' inguina! cana! ? norma! finding4 no $u!ging
=' Pa!ation
a' enis
i' fores%in shou!d retract easi!(
ii' sma!! amount of thic% white secretion $etween
g!ans and fores%in is norma!
iii' testic!e4 ovoidF ranges from / ? > cm in diameter&
smooth and ru$$er(F nontender
$' inguina! cana!
i' norma! finding4 inguina! !(mh nodes not a!a$!e
>' Geriatric a!terations
a' increased $ogginess of rostate
$' testes softer
0' Rectum and anus
a' insection of eriana! areas
i' s%in4 smooth and uninterruted
ii' ana! tissues4 norma!!( moist and hair!ess
$' digita! a!ation
i' ana! shincter4 note tone
ii' recta! wa!!s4 smooth and even
iii' rostate g!and
I' a!ate through anterior recta! wa!!
II' sma!! wa!nut?si2ed& heart shaed structure
III' ranges from /'0 to > cm in diameter
IV' norma! findings4 firm& rotrudes Q @ cm into
rectum
c' a!terations
i' hemorrhoids
ii' fissures
iii' fistu!as
iv' o!(s
v' ain
2; 2usculos&eletal
@' ,istor(4 articiation in sorts& ris% factors for osteoorosis& imact
of current ro$!em on activities of dai!( !iving
/' Insection
a' gait ? norma! findings4 c!ient wa!%s with arms swinging
free!( at sidesF coordinated and smoothF rh(thmic with
ush off and swing through
$' osture and $a!ance ? norma! findings
i' uright stance with ara!!e! a!ignment of his and
shou!ders
ii' feet a!ignedF toes ointing straight ahead
iii' conve: curve to thoracic sine
iv' concave curve to !um$ar sine
v' can stand sti!! without swa(ing or ti!ting
c' e:tremities
i' norma! findings4 $i!atera! s(mmetr( in !ength&
circumference& a!ignment& osition and num$er of
s%in fo!ds
=' Pa!ation
a' a!! musc!es& $ones& 9oints
$' norma! findings4 musc!es firm& non?tender
>' Range of motion ? norma! findings4 a$!e to move 9oints through
re7uired range of motion
a' a$duction ? Latera! movement of the !im$s awa( from the
median !ane of the $od(& or !atera! $ending of the head or
trun%
$' adduction ? #ovement of a !im$ or e(e toward the median
!ane of the $od( or& in the case of digits& toward the a:ia!
!ine of a !im$'
c' dorsif!e:ion ? #ovement of a art at a 9oint to $end the art
toward the dorsum& or osterior asect of the $od('
d' eversion ? Turning outward
e' e:tension ? 8 movement that $rings the mem$ers of a !im$
into or toward a straight osition
f' f!e:ion ? The act of $ending or condition of $eing $ent in
contrast to e:tension'
g' h(ere:tension ? E:treme or a$norma! e:tension'
h' inversion ? 8 turning inside out of an organ 5e'g'& the
uterus6'
i' !antar f!e:ion ? E:tension of the foot so that the foreart is
deressed with resect to the osition of the an%!e
9' ronation ? The act of !(ing rone or face downward'
%' suination ? The condition of $eing on the $ac% or having
the a!m of the hand facing uward or the foot turned
inward and uward
0' #usc!e strength and s(mmetr( ? norma! findings4 arm on dominant
side genera!!( stronger
A' 8!terations
a' %(hosis ? 8n e:aggeration or angu!ation of the norma!
osterior curve of the sine& giving rise to the condition
common!( %nown as hum$ac%& hunch$ac%& or PottKs
curvature'
$' !ordosis ? 8$norma! anterior conve:it( of the !um$ar sine'
c' sco!iosis ? 8 !atera! curvature of the sine
d' ain
D' Geriatric a!terations
a' stance !ess uright with head and nec% forward
$' !um$ar curvature !ess ronounced
c' height decreased
d' gait s!ower to initiate and sto
e' !ess %nee and an%!e !ifts
f' stes ma( $e shorter and more raid
g' ma( need to ho!d onto furniture as age increases
h' musc!es atroh( with disuse
i' wea%er gri
9' active range of motion ma( $e s!ower and !imited in one or
more 9oints
%' 9oints aear !arger than surrounding tissueF ma( $e stiff
N; Neurological system
@' ,istor(
/' #enta! status
a' #ini?#enta! Status E:am 5##SE6 ? 8 common!( used
assessment too! to 7uantif( a ersonKs cognitive a$i!it(' It
assesses orientation& registration& attention and
ca!cu!ation& and !anguage' Scoring is from 1 to =1& with =1
indicating intact cognition
=' Emotiona! status ? norma! findings4 affect matches seech
>' +rania! nerve function
C3ANIA8 N)3=) F5NC1I4N
@' O!factor( 5+N I6
+an identif( variet( of sme!!s
.eviation4 Ina$i!it( to identif( aroma
/' Otic 5+N II6
,as visua! acuit( and fu!! visua! fie!ds
Fundoscoic e:am revea!s no atho!og(
.eviation4 Ina$i!it( to identif( fu!! visua! fie!ds ? tota! or artia! $!indness of one or $oth e(es
=& >& A' Ocu!omotor 5+N III6& troch!ear 5+N IV6& and a$ducens 5+N VI6
Fo!!ows u to si: cardina! ositions of ga2e
Pui!s are unremar%a$!e
E:hi$its no n(stagmus and no tosis
.eviation4 one or $oth e(es wi!! deviate from its norma! osition
0' Trigemina! 5+N V6
+!enches teeth with firm $i!atera! ressure
,as no !atera! 9aw deviation with mouth oen
Fee!s a cotton wis touched to forehead& chee% and chin
.ifferentiates shar and du!! sensations on face
+ornea! ref!e:F $!in%s when cotton is touched to each cornea
.eviation4 8$sent or one?sided $!in%ing of e(e!ids
D' Facia! 5+N VII6
,as facia! s(mmetr( with and without a smi!e
+an raise the e(e$rows s(mmetrica!!( and grimace
+an shut e(es tight!(
+an identif( sweet& sour& sa!t or $itter on the anterior tongue
.eviation4 Irregu!ar and une7ua! facia! movements
.eviation4 Ina$i!it( to taste or identif( taste
.eviation4 Ina$i!it( to taste or identif( sa!t& sweet& sour& or $itter su$stances on the anterior two?thirds of the
tongue
.eviation4 Ina$i!it( to smi!e s(mmetrica!!(
E' 8coustic 5+N VIII6
+an hear a whiser at @?/ feet
+an hear a watch tic% at @?/ feet
.oes not !atera!i2e the Be$er test
+an hear 8+ 5air conduction6 $etter than "+ 5$one conduction6 in the Rinne test
.eviation4 Ina$i!it( to hear so%en word
G& @1' G!ossohar(ngea! 5+N IL6 and Vagus 5+N L6
Swa!!ows and sea%s without hoarseness
Pa!ate and uvu!a rise s(mmetrica!!( when atient sa(s JahJ
"i!atera! gag ref!e:
+an identif( taste on the osterior tongue
.eviation4 Une7ua! or a$sent rise of uvu!a and soft a!ate as the c!ient sa(s& JahJ
.eviation4 8$sent gag ref!e:
.eviation4 ina$i!it( to taste or identif( taste on the osterior tongue
@@' Sina! accessor( 5+N LI6
Resists head turning
+an shrug against resistance
.eviation4 Bea% or a$sent shou!der and nec% movement
@/' ,(og!ossa! 5+N LII6
+an stic% tongue out and move it from side to side
+an ush tongue strong!( against resistance
.eviation4 Tongue deviates to side
0' Leve! of consciousness 5LO+6 ? norma! findings
a' a!ert
$' resonds aroriate!( to visua!& auditor(& tacti!e and
ainfu! stimu!i
c' a$!e to carr( out sim!e commands
d' G!asgow +oma Sca!e
e' a!terations in LO+
A81)3A1I4N- IN 8)=)8 4F C4N-CI45-N)--
8!ert
@' 8wa%e and aware of erson& !ace& time& and situation
/' Resonds aroriate!( and to ver$a! stimu!i
Lethargic
@' S!ees $ut easi!( aroused
/' Sea%s and resonds s!ow!( and aroriate!(
O$tunded
@' .ifficu!t to arouse
/' Returns to s!ee 7uic%!(F ma( resond inaroriate!(
Stuorous
@' 8roused on!( through ain
/' No ver$a! resonse
Semicomatose
@' Resonds on!( to ain
/' Gag and $!in% ref!e:es intact
+omatose
@' No resonse to ain
/' No ref!e:es or musc!e tone
Note4 d(ing c!ients wi!! roceed through these !eve!s in this a$ove?!isted se7uence'
A' Sensor( function ? norma! findings
a' visua!4 recogni2es o$9ects
$' auditor(4 identifies sounds
A--)--2)N1 4F -)N-437 N)3=) F5NC1I4N
(done !ith client>s eyes closed)
Suerficia! ain
Pric% with steri!e need!e
,ave c!ient identif( whether shar or du!!
Temerature
Two test tu$es4 one fi!!ed with hot water& the other with co!d water
+!ient identifies hot versus co!d sensation and where it is fe!t
Light touch
+otton $a!!F a!( !ight wis of cotton to different surface ointsF
+!ient identifies when touched
Vi$ration
Low itched tuning for%
8!( to dista! interha!angea! 9oint of finger then toe&
+!ient identifies when vi$ration stos
Position
Gras c!ientKs finger or great toe& ho!ding $( its sides
+!ient identifies if moving u or down
Two?oint discrimination
Two safet( ins
8!( !ight!( and simu!taneous!( to two different !aces on s%inKs surface'
Usua!!( start with finger ads&
Find minima! distance at which c!ient can discriminate one from two oints& norma!!( Q0mm
on finger adsF
+!ient identifies when can discriminate one from two oints
Stereognosis
Use coin or aer c!i or an( fami!iar o$9ect with c!ientKs e(es c!osed
+!ient identifies o$9ect to identif( $( touch and maniu!ation
Grahesthesia 5num$er identification6
Num$er is traced on the c!ientKs a!m $( a $!unt o$9ect
+!ient identifies num$er
E:tinction
+orresonding areas on $oth sides of $od( are simu!taneous!( stimu!ated
+!ient identifies where touched
c' tacti!e4 identifies o$9ects through $!ind touchF erceives
ain& hot and co!d and vi$rationF two?oint discrimination
d' o!factor(4 identifies fami!iar sme!!s
D' +ere$e!!ar function ? osition and $a!ance
E' Seech and !anguage ? norma! findings
a' smooth f!owing seech
$' a$!e to formu!ate words without difficu!t(
c' varied inf!ection
d' a$!e to write !etters and num$ers to dictation
e' voca$u!ar( aroriate to educationa! !eve!
G' Inte!!ectua! ? norma! findings
a' memor(4 immediate reca!! and remote reca!!
$' oriented to erson& !ace and time
c' a$!e to a$stract
d' demonstrates consistent insight and ercetion of se!f
@1' Ref!e:es ? assessment and grading
a' ediatric considerations
C)3):)88A3 F5NC1I4N
Rom$erg test4 tests osition sense& note c!ientKs a$i!it( to stand uright when standing with feet
together and e(es c!osed for /1?=1 seconds
,o in !ace4 maintains $a!ance whi!e hoing on one foot
;nee $ends4 maintains $a!ance whi!e $ending at %nees
Tandem wa!%ing4 wa!%s hee! to toe in straight !ine
Raid s%i!!s4
@' Pronates and suinates hands raid!( with e7ua! timing and urosefu! movement
/' Touches a!ternate finger to nose rh(thmica!!( with e(es oen and c!osed
=' #oves finger a!ternate!( from nose to e:aminerKs finger in coordinated fashion
>' Runs contra!atera! hee! down shin with $i!atera! coordination
One?foot $a!ance
@' #aintains $a!ance on one foot for at !east five seconds
/' "i!atera! resonse with e(es oen and c!osed
1)-1- F43 3)F8)9)-
.ee tendon ref!e:es with se!ected site stimu!us
@' "ices ref!e: 5+0& +A64 f!e:ion of arm at e!$ow
/' Trices ref!e: 5+A& +D64 e:tension of arm at e!$ow and contraction of trices musc!es
=' "rachioradia!is 5suinator6 ref!e: 5+0& +A64 f!e:ion at e!$ow and ronation of forearm
>' Huadrices 5%nee?9er% or ate!!ar6 ref!e: 5L/& L=& L>64 e:tension of !eg at %nee and
contraction of 7uadrices
0' 8chi!!es 5an%!e?9er%6 ref!e: 5S@& S/6
Suerficia! ref!e:es
@' Phar(ngea! ref!e: 5+N IL& +N L6
/' Uer 8$domina! ref!e: 5TE& TG& T@164 uward movement of um$i!icus toward stimu!us
a$ove um$i!icus
=' Lower 8$domina! ref!e: 5T@1&T@@&T@/64 downward movement of um$i!icus toward
stimu!us $e!ow um$i!icus
>' +remasteric ref!e: 5T@/& L@6 E!evation of isi!atera! testic!e 5the side stimu!ated6
0' G!utea! ref!e: 5L>?S=64 contraction of ana! shincter with g!oved finger insertion
Patho!ogic ref!e:es in adu!ts ? documented as Jositive for SSSJ
@' "a$ins%i ref!e: 5P!antar6 5L>?S/64 stro%ing !atera! so!e of foot causes dorsif!e:ion of great
toe with fanning of other toes 5norma! e:ectation in chi!dren u to age @E months on the
average6
/' +haddoc% ref!e: 5L>?S/64 stro%ing $e!ow !atera! ma!!eo!us causes dorsif!e:ion of great toe
with fanning of other toes
=' 8n%!e +!onus4 "ris% dorsif!e:ion of foot with %nee f!e:ed causes u and down movement
of footF found in severe reec!amsia
>' Oenheim4 stro%ing ti$ia! surface causes great toe fans out
0' Gordon4 s7uee2ing ca!f musc!eF great toe fans out
A' ,offmann4 f!ic%ing midd!e finger downF f!e:ion of the thum$
+ommon e:ected ref!e:es ? norma! for a!! ages
@' Gag
/' +ornea!
@@' Geriatric a!terations in neuro status
a' !onger resonse time to sensor( stimu!ation
$' ma( resist new ideas or change
c' thought atterns ma( $ecome more concrete
d' %inesthesia diminishes ? The a$i!it( to erceive e:tent&
direction& or weight of movement
e' suerficia! and dee ref!e:es ma( $e diminished or a$sent
9; Client?Family )ducation
8' 8du!t !earning theor(
@' Se!f?directed
/' Reservoir of e:erience
=' 8du!ts refer mutua! !anningCgoa! setting
>' Interna!!( motivated
0' Esta$!ished orientation to !earning
A' Educator is faci!itator of !earning
D' E:erientia! rather than didactic
E' #ust $e immediate!( a!ica$!e to !ife
"' TeachingC!earning rocess
@' 8ssessment
/' Identification of !earning needs
=' Outcome 5goa!6 setting
>' Educationa! offerings
0' Eva!uation of outcomes
+' Learning st(!es
@' Var( with individua!s
/' Learners can $e visua!& auditor(& or tacti!e 5%inesthetic6
.' Teaching strategies
@' .emonstration C return demonstration
/' Programmed instruction
=' Ro!e !a(ing
>' Simu!ation
0' +ase stud( ana!(sis
A' #a( $e individua!i2ed or in grous
D' #a( $e comuteri2ed
E' #a( $e media?$ased or rint
E' Lega! im!ications
@' 8merican ,osita! 8ssociation issued the Patient "i!! of Rights in
@GD= that guaranteed c!ients the right to information necessar( to
give informed consent $efore treatment $egins'
/' Individua!i2ed teaching must $e documented in c!ientKs chart
3)F8)9 $3A#IN$
1 O no resonse
@R O s!uggish or diminished resonse
/R O norma!
=R O $ris%er than norma!
>R
O h(eractive and ver( $ris% 5ma( $e
associated with sina! cord disorder6
=' 8!terations for geriatric c!ients
a' ma%e sure c!ient has g!asses or hearing aid
$' face the c!ient and use a !ower itched voice
c' su!ement ora! resentation with rint materia!s
d' use !arge rint
e' rovide good !ighting
f' some c!ients have a hard time seeing co!orF use $!ac% on
white or (e!!ow aer
g' %ee sessions short and wor% with surviva!?!eve!
information initia!!(
h' reeat often for c!ients rone to memor( !oss
i' $rea% down !earning into sma!! stes
9' use secific& ste?$(?ste directions and have the c!ient
redemonstrate them
%' get fre7uent feed$ac% regarding c!ientKs !eve! of
understanding
>' ,ea!th Insurance Porta$i!it( and 8ccounta$i!it( 8ct 5,IP886?
signed into !aw in @GGA' This !aw inc!udes imortant new
rotections for mi!!ions of wor%ing 8mericans and their fami!ies
who have ree:isting medica! conditions or might suffer
discrimination in hea!th coverage $ased on a factor that re!ates to
an individua!Ks hea!th' ,IP88 !aces re7uirements on em!o(er?
sonsored grou hea!th !ans& insurance comanies and hea!th
maintenance organi2ations 5,#Os6' ,IP88 inc!udes changes that4
a' !imit e:c!usions for ree:isting conditions
$' rohi$it discrimination against em!o(ees and deendents
$ased on their hea!th status
c' guarantee renewa$i!it( of hea!th coverage to certain
em!o(ers and individua!s
d' rotect man( wor%ers who !ose hea!th coverage $(
roviding $etter access to individua! hea!th insurance
coverage'
0' The first?ever federa! rivac( standards to rotect atientsK
medica! records and other hea!th information rovided to hea!th
!ans& doctors& hosita!s and other hea!th care roviders too%
effect on 8ri! @>& /11=' .eve!oed $( the .eartment of ,ea!th
and ,uman Services 5,,S6& these new standards rovide
atients with access to their medica! records and more contro!
over how their ersona! hea!th information is used and disc!osed'
A' The new rivac( regu!ations ensure rotection for atients $(
!imiting the wa(s that hea!th !ans& harmacies& hosita!s and
other covered entities can use rotected medica! records and to
other individua!!( identifia$!e hea!th information& whether it is on
aer& in comuters or communicated ora!!(' ;e( rovisions of
these new standards inc!ude4
a' access to medica! records
$' notice of rivac( ractices
c' !imits on use of ersona! medica! information
d' rohi$ition on mar%eting
e' stronger state !aws
f' confidentia! communications
g' com!aints
Points to 3emem%er
/ealth Promotion@ /ealth Assessment
#easure vita! signs when the c!ient is at rest
+omare $oth sides of the $od( for s(mmetr(
8ssess the s(stems re!ated to the c!ient3s ma9or com!aint first
Offer rest eriods if c!ient $ecomes tired
+u!ture and re!igious $e!iefs ma( !a( a ro!e in o$served differences
Barm hands and e7uiment such as stethoscoe $efore touching c!ient
Te!! c!ient what (ou are going to do $efore touching c!ient
Norma! variations e:ist among c!ients and there is a range of norma!c( for a!!
h(sica! findings
#aintain the c!ient3s rivac( throughout the e:amination
+ontro! for environmenta! factors which ma( distort findings
+hec% e7uiment rior to e:am for functioning
+onsider growth and deve!omenta! needs when assessing secific age grous
Integrate c!ient teaching throughout the e:am
=asculature
+omare $!ood ressure in arms !eft versus right
+omare $!ood ressure with c!ient !(ing& sitting and standing
8ungs 0 Air!ay
8nemic atients ma( never $ecome c(anotic
Po!(c(themic atients ma( $e c(anotic& even when o:(genation is norma!
+ough resu!ts from stimu!ation of irritant recetors& with im!ications of either
acute or chronic etio!og('
+(anosis indicates decreased avai!a$!e o:(gen' Etio!og( can $e either erihera!
or centra! in origin'
Bhee2es indicates narrowingCinf!ammator( rocess of !ower airwa(s
Stridor harsh sound roduced near !ar(n: $( vi$ration of structures in uer
airwa(' +!assic J$ar%( coughJ
+rac%!es or ra!es adventitious sounds& usua!!( on insiration and indicating
inf!ammation
:reast
"reast tissue shrin%s with menoause
Teach c!ient $reast se!f e:amination
A%domen 0 3eproductive -ystem
8uscu!tation shou!d $e erformed $efore a!ation to revent distortion of $owe!
sounds
Tightening of a$domina! musc!es hinders accurac( of a!ation and auscu!tation
Barm hands $efore touching c!ient3s a$domen'
#en $reathe a$domina!!(F women $reathe costa!!('
8uscu!tate a!! four 7uadrants for $owe! sounds
8uscu!tate a$domen $etween mea!s
2usculos&eletal
O!der adu!ts wa!% with sma!!er stes and need a wider $ase of suort
Neurological
G!asgow +oma Score
o not va!id in atients who have used a!coho! or other mind?a!tering drugs
o ossi$!( not va!id in atients who are h(og!(cemic& in shoc%& or
h(othermic 5$e!ow =>+6
o shou!d $e comared to tota! of @1 when c!ient is intu$ated
Ref!e:es are norma!!( !ess $ris% or even a$sent in o!der c!ients
Ref!e: resonse diminishes in the !ower e:tremities $efore the uer e:tremities
are affected
8$sent ref!e:es ma( indicate neuroath( or !ower motor neuron disorder
,(eractive ref!e:es suggest an uer motor neuron disorder
1eaching client and family
Teaching?!earning rocess mirrors the nursing rocess
Se!ect teaching strategies that are comati$!e with the c!ient3s !earning st(!e& age&
cu!ture& !eve! of education
+!ient teaching shou!d $e mu!ti?sensor(
8!wa(s confirm the c!ient3s understanding of the information resented
Teaching must $e geared to the !eve! of the !earner
Reeat %e( information and summari2e main oints at interva!s
E:!ain medica! termino!og( in !a( terms
.etermine the c!ient3s !earning st(!e and gear teaching methods to using that
st(!e
Se7uence information the wa( the c!ient wi!! use it
"e concrete and use the sim!est words and the shortest sentences when
teaching !ow !iterac( c!ients& or an( c!ient under stress