HEALTH ASSESMENT EXAM Objectives

Exam 1
Chapter 1
1. Explain how assessment skills are needed for every situation the nurse encounters.

Assessment lays the foundation for the nursing process, but it is an ongoing collection/analysis and
interpretation of data.

2. Differentiate between a holistic nursing assessment and a physical medical assessment.

-Holistic Nursing Assessment- collect holistic subjective & objective data to determine client overall level of
functioning in order to make a professional clinical judgement (nursing diagnosis) purpose is to make
diagnosis/judgement

-Physical medical assessment- physician focuses primarily on the client’s physiologic status

3. Describe how assessment fits into the total nursing process.

Assessment and Evaluation are both ongoing processes if outcome not as anticipated need to reassess all steps
collect new data and formulate adjustments to care plan

4. List and describe the steps of the nursing process: subjective data collection; objective data collection;
validation of data, documentation of data, and analysis of data.

Assessment- collect subjective/objective data and validation of data collected

Diagnosis- analyzing subjective/objective data to make a professional nursing judgement (nursing
diagnosis/collaborative problem/or referral)
Planning- Determining outcome criteria and developing a plan
Implementation- carrying out the plan
Evaluation- assessing whether outcome criteria have been met and revising the plan as necessary

5. Describe the steps of the analysis phase of the nursing process.

Identify abnormal data and strengths, cluster the data, draw inferences and identify problems, propose possible
nursing diagnoses, check for characteristics of those diagnoses, document conclusions

6. Compare and contrast the four basic types of nursing assessment: (a) initial comprehensive, (b) ongoing
or partial, (c) focused/problem-oriented, and (d) emergency.

a) initial comprehensive- collect subjective data about client’s perception of health, all body parts/systems,
past medical history, family history and lifestyle
b) Ongoing/Partial assessment- Data collection that occurs after comprehensive database is established
c) Focused/Problem oriented- thorough assessment of a particular problem which does not cover areas not
related to the problem
d) Emergency- rapid assessment performed in life-threatening situations
7. Explain how the nurse’s role in assessment has changed over the past century. Discuss what the nurse’s
role might be 25 years from now.

-19th century- inspect/observe ambulation, detect changes in color, nutrition, output, palpate to measure pulse
rate/quality & pregnant women fundus
-20th century- worked in public health, community health, and occupational settings
-1970’s/1980’s- role expansion to conduct health histories and perform physical/psychological assessments
-1990-Present- acute to community setting; critical pathways/care maps guide plan and progression of care;
New advanced practice role- Nurse practitioner and Clinical nurse specialist
-2010- assess populations across the continuum of health, role in telecommunication systems—with online data
retrieval/communication; perform in depth physiologic/psychosocial assesments while integrating technological
date

Chapter 2
For Interviewing:
1. Describe the three phases of an interview.
1) Introductory: Pre-intro- review health record; explain purpose of interview, assure client of
HIPAA/confidentiality, assure client comfort, develop trust
2) Working: elicit as much data about health status you can- biographical data, reason for seeking
care, HPI, PMH, Family Health History, ROS (body systems) for current health problems,
lifestyle and developmental level; Listen, observe cues, use critical thinking to interpret and
validate date; collaborate with client to identify client goals and problems
3) Summary and Closing: end gracefully not abruptly, summarize info from working phase,
validate problems/ goals, identify/discuss possible plans to resolve client problem, ask about any
other concerns/questions

2. Describe the use of nonverbal communication during an interview.

Appearance- professional, Demeanor- warm, Facial Expression- neutral/friendly, Silence- reflection, Listening-
ACTIVELY, Posture- same level as client, Attitude-accepting, non-judgmental
Avoid- excessive/insufficient eye contact, distraction, distance, standing
3. Describe the use of effective verbal communication during a client interview.
Open-Ended Questions/Statements, Close ended questions to keep interview on course of clarify info from
open-ended questions, Laundry list, Rephrasing, Well-Placed Phrases, Inferring, Providing Information
4. Describe the types of verbal communication that should be avoided in client interviews.
Biased/Leading Questions, Rushing interview, False reassurance, Unwanted advice, Using authority,
Professional jargon, Taking too much, Interrupting, Using ‘Why’ questions
5. Describe how communication should be varied to communicate with parents of newborns, infants, and
children, with adolescents, and with elderly clients.
-Childbearing Women- accurate prenatal history
-Parents of newborns/infants- friendly non-judgmental approach
-Children- include child as part of interview as appropriate
-Adolescents- Privacy is essential—allow private room for sensitive issues and maintain confidentiality;
exception in legal matters; use health teaching opportunities
-Older adults- assess vision and hearing focus on positives of clients health
6. Describe how ethnicity can affect communication.
Cultural variations- may be reluctant to share personal info; variation with verbal/nonverbal language, with
disease/illness perception, in time orientation (past/present/future), family role
7. Describe appropriate ways to modify communication with clients who have emotional conditions.
-Anxious- information provided is simple and organized, explain role/purpose, simple concise questions, don’t
hurry or become anxious, decrease external stimuli
-Angry- approach in calm reassuring in-control manner, allow them to vent, avoid arguments/touching client,
obtain help from HCP if need, allow space
-Depressed- express interest/understanding respond neutrally; don’t communicate in upbeat encouraging
manner
-Manipulative- provide structure/limits, differentiate between manipulation and reasonable request, obtain
objective opinion from colleagues
-Seductive- set firm limits don’t respond to subtle seductive behavior encourage appropriate coping methods
-Sensitive issues- be aware of own thoughts/feelings ask simple nonjudgmental questions allow time for client
to vent, if uncomfortable may refer patient as appropriate

For Taking the Health History:

8. Identify the major categories of a complete health history.
Health History- Biographical data, reason for care, HPI, Past history, Family history, ROS for current problem,
lifestyle, developmental level
9. Describe the key sources of biographic data.
Client is primary source all others are secondary (In some cases family/caregiver may give more accurate info)
10. Describe the types of biographic data to be collected.
See above
11. Obtain an accurate nursing history of a client, omitting (at this time) the review of systems.
CC in patient words and history of COLDSPA analysis

12. Use the COLDSPA format to collect information about a health concern.
COLDSPA
13. Identify the information to be obtained in a review of body systems.
Skin/Hair/Nails, Head/Neck, Eyes, Ears, Mouth/Throat/Nose/Sinuses, Thorax/lungs, Breasts/ Regional
lymphatics, Heart/Neck vessels, Peripheral vascular, abdomen, genitalia, anus/rectum/prostate,
musculoskeletal, neurologic
Each system addressed to find out current health problems or problems from the past that may still affect
them or recur—ONLY subjective information; description of health and denial of
signs/symptoms/disease/problems

14. Describe the relationship of the lifestyle and health practices profile with health status.
Description of typical day—nutrition, weigh management, activity level/exercise, sleep/rest, medication,
tobacco, alcohol, self-concept/self-care, coping and stress, social activities, relationships, values/belief system,
education/work, environment.
15. Analyze data from the subjective data collected in the client interview to formulate valid nursing
diagnoses, collaborative problems, and/or referrals.
Chapter 8
1. Prepare the client for a survey of general health status.

Observe posture/movement/overall appearance/ ensure comfort on exam table/chair, explain procedure

2. Describe an accurate general survey of their health status.

-OBSERVE-client and environment for abnormalities (skin color, dress, posture, hygiene, gait, physical
development, body build, apparent age, gender, obvious distress)—if abnormalities seen can perform in depth
assessment
-Vital signs-cardio/neuro/peripheral vascular, respiratory system information

3. Describe an accurate general survey.

-Physical development/body build, gender/sexual development, apparent and developmental age vs reported
age, skin condition/color (light to dark beige-pink, tan, dark brown, olive), dress/hygiene, posture/gait
(erect/comfortable, rhythmic gait/coordinated arm swinging, Full ROM), level of consciousness, behaviors,
body movement/affect, facial expression, speech, distress
-Subjective- High fevers, alterations in heartbeat, difficulty breathing, pain—COLDSPA if needed
Usual BP awareness of heart variations and normal health/family/lifestyle histories.
Physical development/body build/fat distribution
-HEENT- symmetry in face, eyes can see/follow, ears. can heat and converse, nose/throat- patents airway and
able to swallow
-Vital Signs

4. Assess accurate vital sign measurements.

-Temperature (96.0-99.9)
-increases with exercise, stress, ovulation
-lowest in AM highest in late evening
-Hypothermia < 96.0- prolonged cold exposure, hypoglycemia, hypothyroidism, starvation/
neuro dysfunction/shock
-Hyperthermia > or equal to 100 viral/bacterial infection, malignancies, trauma,
blood/endocrine/immune disorders
- Oral 96.6-99.5 not for client with ET tube or wired jaw
-Tympanic 98.0- 100.9
-Temporal 97.4- 100.3 affected by diaphoresis
- Axillary 95.6-98.5 1 degree lower than oral
-Rectal- 0.7- 1 degree higher than oral temperature 1 inch into rectum
-Pulse- normal 60-100 apical/radial/pedal. radial gives good picture of overall health status –lateral wrist count
for 30 seconds if regular for full minute if irregular then verify with apical pulse.
-Bradycardia < 60 can be seen in healthy athletes
-Tachycardia >100 occurs with fever, stress, dysrhythmias
-Rhythm- evaluate for regularity (equal time between beats) or if sinus arrhythmia. If Irregular—
determine if regularly irregular or irregularly irregular
-Amplitude- intensity & contour/elasticity; 0-Absent, 1+ Weak, diminished easy to obliterate, 2+
normal- Obliterate with moderate pressure, 3+ Bounding- unable to obliterate or requires firm pressure.
-Arterial elasticity—resilient and springy
-Doppler can assess unpalpable pulses especially in extremities and assess tissue perfusion
-Respirations- count for 30 seconds then multiple x 2;12-20 in adults—assess rhythm, depth, and effort
-Blood Pressure- Pressure exerted on artery walls; Stroke Volume/Pulse pressure is the amount of blood
pumped in each beat PP/SV= SPB-DBP. Factors affect BP- Cardiac output (blood volume ejected each minute)
increases with exercise; Peripheral Vascular resistance- with circulatory disorders; Circulating blood volume
more blood higher BP less blood lower BP, Blood viscosity/thickness—associated with polycythemia and
increased BP; Elasticity of vessel walls i.e. atherosclerosis and higher BP. Lower in Am higher in evening,
coffee, alcohol, nicotine, intake, exercise, emotions, muscle tension, bladder distention, pain, noise,
temperature, arm position, body position, gender, race, age, weight can all affect blood pressure
High BP especially in adolescent take thigh pressure to check for coarctation of the aorta normal thigh pressure
is 10-40 higher

-Normal BP <120/<80
-Pre-Hypertension 120-139/ 80-89
-Hypertension Stage 1 140-159/90/99
-Hypertension Stage 2 160 or higher/100 or higher
-Hypertensive Crisis Higher than 180/Higher than 110

on anti-HTN medications of history of fainting—assess orthostatic BP measure BP in supine position then with
client standing or sitting drop of <20 is normal > 20 SBP or >10 DBP may indicate orthostatic hypotension—
which may be related to fluid volume deficit or certain medications

5. Assess for the presence of pain as a “fifth vital sign.”

Observe comfort level ask if pain rate on 0-10 then use coldspa

6. Describe the findings frequently seen when assessing general status and vital signs in individuals across
the lifespan.
Childbearing- pre-pregnancy weight/optimal gain depends on height and weight—low pregnancy
weight/inadequate weight fain contribute to intrauterine growth retardation and low birthweight; 1st trimester 2-
4 lbs., 2nd 3rd trimester 11-12 lbs. (total 25-35 lbs.); BP range 90-134/60-89 decreases during 2nd trimester
returns to baseline by 32-34 weeks; pulse may be 60-90 (10-15 beats higher than pre-pregnant levels);
temperature- 97-98.6 > 100 may indicate infection. 1st T ambivalent, 2nd T energetic, 3rd T restless possible
labile moods small child on scale to closes 0.5 oz; older child to nearest 0.25 lbs.

Newborn- Birth weight, length, head circumference—assess adequate nutrition/growth Head circumference
greater than chest at birth by 2cm; by age 6 head is 90% of adult size—pulse, resp, temp., BP avoid times or
crying apical pulse for full minute (NB- 1 month 120 160 bpm, 6 months-1 year 110 bpm, 3 months -2 years
80-150 bpm 2 years – 10 years 70-110 bmp, 10 years- adult 55-90. Respirations 30-60/ min, 6 months- 2 years
20-30, 2 years to 10 years- 20-28, 10-18 years 12-20. rectal temp most accurate no further than 2 cm—99.4 is
normal

Older adults- temp is lower 95.0-97.5 may not have infections with elevated temp or be considered hypothermic
below 96. Pulse – arteries more rigid/bent, proximal pulses may be easier to palpate due to loss of
surrounding/supporting tissue, distal pulses may be more difficult to palpate or nonpalpable; respirations may
be from 15-22 – may increase with shallower inspiratory phase because of decreased vital capacity and
inspiratory reserve volume. BP- rigid arteriosclerotic arteries account for higher SBP—take BP to detect
actual/potential orthostatic hypotension and fall risk

7. Differentiate between normal and abnormal general survey and vital sign findings.
Abnormal
-Physical- malnutrition obesity (exogenous- even distribution; Endogenous= Cushing’s),
dwarfism/gigantism, acromegaly/Marfan’s syndrome, appears older (hard life, manual labor, chronic
 illness, alcoholism, smoking, sun exposure), gender/sexual development (delayed/precocious puberty/or
opposite gender characteristics)
Skin- pallor, flushed, yellow; dark skin- loss of red tones, ashen gray cyanosis
-Dress/Grooming- inappropriate for weather/occasion, ill fitting (weight loss/or gain possible)
-Hygiene- poor hygiene with dementia or self-care deficit
-Posture and gait- lordosis, scoliosis, kyphosis, Parkinson’s gait
-Dwarfism- decreased height and skeletal malformations
-Acromegaly- overgrowth of bones in face head and hands
-Gigantism- excessive growth hormone if occurs before growth plates—increased height
-Anorexia Nervosa- emaciated appearance, psychosocial issues
-Exogenous obesity- excessive body fat related to excessive caloric intake
-Marfan’s syndrome- tall, thin stature, elongated arms and fingers, arm span greater than height
-Cushing’s Syndrome- Endogenous obesity- centralized weight gain

8. Analyze data from the interview and a client’s general survey and vital signs to formulate valid nursing
diagnoses, collaborative problems, and/or referrals.

 
Chapter 3

1. Describe the ways to prepare the physical environment and make it conducive to a physical
examination.

-Practice Competence Confidence

-Comfort, warm temp, private area without interruptions, quiet, adequate lighting, firm exam table,
height that prevents stooping/bending, bedside table to hold equipment

2. Explain the ways to prepare a client for a physical examination.

-Establish nurse-client relationship, explain procedure and assessment, respect client requests,
explain importance, reassure client.

3. Describe the various positions used to perform a physical examination.

Sitting
Supine
Dorsal Recumbent
Sim’s
Standing
Prone
Knee- Chest
Lithotomy

4. Describe the correct method used for inspection during a physical examination.

Good lighting, look/observe before touching; expose areas being examined keep other areas covered
– note color, patterns, size, location, consistency, symmetry, movement, behavior, odors, sounds,
compare symmetrical appearance when possible

5. Explain the purpose and differences between light, deep, and bimanual palpation

Palpation- for texture, temperature, moisture, mobility, consistency, strength of pulses, size, shape,
degree of tenderness, swelling, crepitus, lumps/masses
- Finger pads- fine discrimination0 pulses, texture, size, consistency, shape, crepitus
- Ulnar/Palmar surface- vibrations/thrills
- Dorsal (back surface)- temperature
-Light palpation- one hand (dominant) less than 1 cm—little or no depression deep surface structure
using circular motion (pulses)m tenderness, texture, temperature and moisture
-Moderate- 1-2 cm easily palpable organs/masses
-Deep- 2 hands dominant hand on skin surface non-dominant hand on top of dominant hand (not
routinely performed by nurse)

6. Explain the correct use of a stethoscope and the purpose of the bell and the diaphragm.

-Percussion tap boy to produce sound waves/vibrations—purpose to elicit pain, determine

size/location/shape, determine density air/fluid/solid, detect abnormal masse, elicit reflexes (with
percussion hammer)
-Resonance- hollow sound over normal lung
-Dullness thud-like sound over organ (normal); pleural effusion—abnormal
-Flatness- flat sound heard over bone/ muscle

-Auscultate—heart, lungs, bowels; warm diaphragm and bell before use

Diaphragm for high pitched sounds use firm pressure; lung/bowel/normal heart sounds
Bell for low pitched sounds use light pressure; abnormal heart sounds- murmurs/bruits

7. Survey the various pieces of equipment used to perform a physical examination.

Chapter 6

1. Discuss the concepts of mental health, mental disorders, and factors that affect both.

2. Discuss the risk factors for mental health disorders and substance abuse across cultures and
ways to reduce one’s risks.

3. Describe an accurate history of mental status and risk for substance abuse.
Be alert to verbal and non-verbal cues; explain purpose; in depth history including sensitive issues,
sexuality, dying, spirituality, Normal health history with info on mental health hospitalizations/issues. Mental
status exam incorporated with health history. Much of objective also involves questions/verbal tests. Perform
MSE (mental status exam) early to determine validity of client’s information. Perform Full MSE if screening
suggests anxiety, depression, cognitive impairment; family concern related to behavioral changes—memory
loss, inappropriate social interaction etc. appropriate moderately paces speech; Positive feelings about
future/positive coping mechanisms; observe clarity/content/perception—full free flowing thoughts, follow
directions accurately, realistic perceptions, deny suicidal thoughts; Assess orientation person/place/time—time
is lost first person is lost last; ability to stay focused; evenly distributed weight, toes point straight
CUT- Have you ever tried to cut back on your use?
Annoyed/Angered- Have you ever been annoyed/angered when questioned about your use?
Guilt- Have you ever felt guilt about your use?
E- Eye-Opener Have you ever had an eye-opener to get started in the morning?
 One Yes- possible alcohol problem more than one—highly likely that a problem exists

AUDIT- alcohol use screening questionnaire

4. Describe an accurate mental health and risk for substance abuse assessment.
Posture/gait- relaxed, shoulders back erect when sitting/standing; gait rhythmic/ coordinated.
Behavior- cooperative, purposeful interactions
Hygiene- clean/groomed per developmental/socioeconomic/cultural

5. Correctly use the Glasgow Coma Scale (GCS) for clients who are at high risk for rapid
deterioration.
Score anywhere between 3-15.
<7 is considered coma
<10 needs medical attention
(not used in intubated or aphasic patients)
E- Best EYE Response
(4 open normal blinking 3 open to verbal command/shout 2 open to pain  1 None )
V-Best VERBAL response
(5 oriented  4 confused but answer q’s  3 incorrect response words discernible  2
incomprehensible speech 1 None)
M- Best MOTOR response
(6 Obeys movement command 5 purposeful movement to pain  4 withdraws from pain  3
abnormal spastic flexion Decorticate posture 2 extensors rigid response decerebrate posture  1
None)

Lethargy: opens eyes, answers questions, and falls back asleep

Obtunded: opens eyes to loud voice, responds slowly with confusion, and seems unaware of environment.
Stupor: awakens to vigorous shake or painful stimuli but returns to unresponsive sleep.
Coma: remains unresponsive to all stimuli; eyes stay closed.

6. Be familiar with commonly used depression screening tools used to assess for depression.

7. Describe the seven warning signs to assess for Alzheimer disease.

1) Asking same questions over and over again
2) Repeat same story over and over word for word
3) Forget how to cook, make repairs, play cards, things they used to do
4) Lose ability to pay bills/balance check-book
5) Get lost in familiar surroundings/ misplace household objects
6) Neglecting to bathe/wear same clothes over and over
7) Relying on someone else to make decisions/answer questions they didn’t before
8. Correctly use Suicide Risk tool to assess for suicide risk.
Clients who are suicidal may share past attempts of suicide, give plan, verbalize worthlessness of
self, joke about death frequently
Clients who are depressed/ feel hopeless are at higher risk for suicide
HIGHEST RISK--- person with a realistic plan and means to carry plan out

Sex
Age
Depression
Previous attempt
Ethanol abuse
Rational thinking loss
Social supports lacking
Organized plan
No spouse
Sickness
*Sometimes A- Availability of means

9. Differentiate between normal and abnormal findings of a mental health status and substance
abuse assessment.
Abnormal
-Slumped posture- may indicate powerlessness, depression or organic brain disease
-Bizarre movements- may be seen in schizophrenia or as medication side effect
-Reduced eye contact- in depression or apathy; extremes of emotions—happy/angry/frightful with anxious
patients
-Mask like face- Parkinson’s
-Inappropriate facial expressions when expressing different thoughts may indicate mental illness
-Drooping/marked facial asymmetry with Bell’s Palsy/Stroke
-Slow/repetitive speech- depression/Parkinson’s
Loud/Rapid speech- manic phase of Bipolar disorder
-Dysarthria (difficulty forming words)- neurologic disorder
-Client can’t name objects/read/write sentences – refer for neurologic assessment for cortex problems
-Flat affect, euphoria, anxiety, fear, ambivalence, irritability, depression, rage—altered mood i.e. depression,
manic episodes, anxiety, OCD etc.
-Client with depression early in life have a two-fold risk for dementia
Depression Symptoms- Fall asleep, Wake too early, Sleep too much, Sad, Decreased/Increased appetite or
weight, concentration issues, thoughts of death/suicide, energy level, restlessness etc.
-Repetition of thoughts, invention of words, flight of ideas, rhymes, delusions, compulsions/obsessions,
confabulation
-Distraction/Unable to focus- anxiety/fatigue/attention deficit/impairment
- Trouble recalling recent events- Delirium/dementia/depression/anxiety
-trouble recalling past events- cerebral cortex disorders
-New learning (4 unrelated words recall at 5/10/30 min)- unable- anxiety/depression/Alzheimer’s
-Abstract reasoning- unable to compare/contrast- schizophrenia/mental retardation/delirium/dementia
-Impaired judgement-organic brain syndrome/emotional disturbances/ mental retardation/schizophrenia
-Visual/Perceptual/Constructional ability (draw face of clock)- unable mental retardation/dementia/ parietal lobe
dysfunction
-Alzheimer’s: easy onset (genetic), slow onset but irreversible chronic progressions, early depression, speech
intact until later, get lost in familiar places, recent is lost first then remote memory.
-Vascular Dementia- Cardio/Cerebrovascular disease, abrupt onset following CVA/TIA, chronic irreversible
with fluctuating progression, mood is labile, may have aphasia, lost in familiar places, recent is lost first then
remote memory.
-Delirium- drug toxicity and interactions/acute disease/ trauma/ chronic disease/fever/fluid electrolytes; rapid
acute onset due to variety of illnesses; symptoms fully reversible with treatment, mood is variable and
speech/orientation fluctuate; impaired recent and remote memory

Chapter 24

1. Describe the structure and functions of the bones, skeletal muscles, and joints.

-Bones- Store calcium, produce blood cells and serve as levers

-Muscles- Skeletal, Smooth, Cardiac
-Skeletal under conscious control
-Tendons- attach muscle to bone
-Joints
-Fibrous joints- immovable
-Cartilaginous joints- between vertebrae
-Synovial joints- contain synovial fluid promote sliding movement at ends of bones
-Ligaments- strong bands of connective tissue; join bones in synovial joints
-Bursae- small sacs filled with synovial fluid to cushion joints
TMJ opens/closes mouth; side to side; projects & retracts jaw
Elbow flexes and extends forearm; supination/pronation
Shoulder flexion & extension, abduction & adduction, circumduction and rotation
Wrists flexion/extension, hyperextension, adduction, radial/ulnar deviation
Finger flexion/extension, hyperextension, abduction, circumduction
Thumb: flexion, extension & opposition
Vertebrae: flexion, hyperextension, lateral bending, & rotation
 Hip: flexion with knee flexed & extended, extension and hyperextension,
circumduction, internal & external rotation, abduction, adduction
Knee: Flexion and extension
Ankle: plantar flexion and dorsiflexion
Foot: inversion and eversion
Toes: flexion, extension, abduction, adduction

2. Discuss the incidence of osteoporosis across cultures and ways to reduce one’s risks.

RF: Bone Density-: Men > Women; African American > Caucasian;
Caucasian> Chinese/Japanese/Eskimo
-Modifiable RF: Alcohol, Smoking, low BMI, poor nutrition, Vit D deficiency, eating disorder,
insufficient exercise, sedentary lifestyle
-Non-Modifiable RF: gender, age, body size, ethnicity/race, history of bone fractures,
menopause/hysterectomy, long term glucocorticoid therapy, rheumatoid arthritis

3. Describe the teaching opportunities to reduce risks for osteoporosis and promote joint health.

Nutrition Vitamin D, weight bearing exercises, no smoking, no drinking, assess fall risk, decrease
fracture risk, adequate calcium

4. Describe a nursing history of the client’s muscles, joints, and bones.

HPI- weight gain/chewing pain/ muscle or bone pain stiffness swelling/ limited ROM
Past Hx- problems/injuries, immunization, dx of diabetes, sickle-cell, lupus or osteoporosis
Fam- Hx- rheumatoid arthritis, gout, osteoarthritis
Lifestyle- activities, meds, tobacco, alcohol, caffeine, diet—including milk/calcium supplements,
exercise, posture, ADL’s, MS problems, bone density screening

5. Describe a physical assessment of the musculoskeletal system using the correct techniques of

inspection, auscultation, palpation, and percussion.

JOINTS
-Inspect size, shape, symmetry; Note masses, deformities, atrophy bilaterally
-Palpate for edema, heat, tenderness, pain, nodules, or crepitus bilaterally
-Teach each joint’s ROM through normal motions—passive then active

MUSCLES
-Test muscle strength move each extremity through full ROM against resistance; for prime mover
muscle groups of each joint should be equal B/L and hold against opposing force
If unable to move against resistance, ask to move against gravity if not more passively
Active- stabilize proximally observe for limitations
Passive ROM- assess tenderness/pain/crepitation, if limited anchor with one hand use other to move
joint to its limits—limited ROM most sensitive sign of joint disease
Inspect/Palpate TMJ move jaw side-to-side/ snapping/clicking may be heard in normal clients
CTL Spine double S curve symmetrical shoulder/iliac crests, test ROM, and asses pain, leg length,
straight spine
Shoulder/Arms/Elbows symmetrical w/out redness/swelling/tenderness, equal strength full ROM
Symmetric knees with hollows on both sides of patella no swelling/deformity; aligned with upper leg;
no bulge or fluid on medial sign of knee
Neurovascular Assessment- assess circulation, motor, sensation

Muscle Strength
5- Active motion against full resistance – Normal
4- Active motion against some resistance—Slight Weakness
3- Active motion against gravity—Average Weakness
2- Passive ROM (gravity removed+assistance)—Poor ROM
1- Slight flicker of contraction—Severe Weakness
0- No muscular contraction—Paralysis

-Cast/Restrictive Bandages? CRITICAL CMS ASSESSMENT

Circulation, Motor, Sensation
The 5 (or 6-7 P’s)
Pain
Paralysis (Movement)
Paresthesia (Sensation)
Pulses (or pulselessness) and capillary refill
Pallor and Temperature
Poikilothermic/Polar “Cold”
Pressure (ability to detect)
-Recognize and prevent Compartment Syndrome—pressure in muscle builds, decreased blood flow, oxygen
can’t reach nerve—medical or surgical emergency!

6. Differentiate between normal and abnormal findings of the musculoskeletal system.

Abnormal
-Uneven weight bearing, limping, shuffling, wide-based gait
-Falling backward seen with cervical spondylosis and Parkinson’s
-Crepitus- crunching sensation with joint movement; cartilage wear
-Arthritis- decreased ROM, swelling, tenderness, crepitus
-TMJ- decreased ROM, clicking, popping, grating sound
-Scoliosis lateral curvature or T spine; If leg length/hip height unequal asses for scoliosis
-Lordosis- exaggerated lumbar curve
-Kyphosis exaggerated thoracic curve seen in older adult with osteoporosis
-Shoulder/Arms: Dislocation less rounded; Nerve/muscle damage muscle atrophy; shoulder strain or
DJD tender, swollen, hot to touch; Rotator cuff tear pain limited abduction and weakness; Tendinitis
chronic pain; Nerve Damage unable to shrug shoulders to resistance
-Elbow: Bursitis/Arthritis redness, heat, swelling; RA firm nontender nodules; Tennis elbow
tenderness or pain in lateral epicondyle related to repetitive movements
-Disease/Injury decreased ROM or strength
-Carpal Tunnel Syndrome- Phalen’s/Tinel’s if tingling/numbness/shocking/pain positive test
-RA- chronic systemic inflammatory disease of joint and surrounding connective tissue, inflammation
of synovial membrane leads to thickening, then fibrosis which limits motion and eventually to bony
ankylosis (fixation) swelling/tenderness/nodules in wrist, ulnar deviation with limited ROM; finger
stiffness; fatigue, weakness, anorexia, weight loss, low grade fever; Pain and stiffness worse in the
morning when waking up and after rest period- Movement decreased pain
-Ganglion Cyst- nontender round enlarged fluid filled uncertain cause RF- wear/tear/arthritis/injury
-Fracture-tenderness, pain, limited ROM
-Lateral/Medial Epicondylitis- pain with extension against resistance
-OA- non inflammatory localized progressive disorder involving deterioration of articular cartilages
and bone and formation of new bone at joint surfaces; often affects hands, knees, hips,
lumbar/cervical spine; stiff joints swelling hard bony protuberances, pain with motion and limited
ROM; OA is worse later in the day movement increases pain. Heberden’s & Bouchard’s Nodes—hard
and painless nodules; decreased ROM, synovial thickening and crepitus
-Muscle/Joint Disease- decreased strength
-Hip Fracture- instability, inability to stand/ and or deformed hip area
-Groin pulls/Hamstring Strains—athletes
-Bursitis of the Hip- Limited ROM/strength
-Genu Valgum- Knock knees
-Genu Varum- Bowed legs
-Hallux valgus- laterally deviated great toe with bunion on medial side
-Flat feet, high arches, corns/calluses, warts/plantar warts
-Gouty arthritis- tender, painful, red, hot, swollen toe

7. Describe the expected aging changes of the bones, skeletal muscles, and joints.
8. Describe the findings frequently seen when assessing the musculoskeletal system in
individuals across the lifespan.
9. Analyze the data from the interview and physical assessment of the musculoskeletal system to
form nursing diagnoses, collaborative problems, and/or referrals. 
 

Chapter 4

1. Define validation of data.

Validation is confirmations that date are reliable and accurate (whether it is objective or subjective) to avoid
assessment errors that result in incorrect diagnosis and ineffective plans.
2. Describe the steps of the validation process.
First- What data needs validation?
Any data you have a doubt about. Data that is inconsistent subjective vs objective, inconsistent patient
statements, highly abnormal values and values inconsistent with other values.
Second- How are you going to validate? Recheck findings, redo the assessment, ask patient more questions, ask
other professional to assess patient, compare objective and subjective findings repeat labs
Third-Identify gaps in data that need to be filled in.

3. Describe conditions or situations that require data to be rechecked and validated.

-Patient denies pain but taking pain medication; Denies smoking but drops cigarette or smells of
smoke. Lab values don’t match findings of physical assessment. Lab values show signs of edema but
forgot to assess for edema.
4. Discuss several ways to validate data.

-See above.

5. Describe the purposes of documenting assessment data.

Standard of care mandated by professional organizations/regulatory bodies; Important for insurance. Promoted
interdisciplinary communication, safe/efficient car, identify health problems/nursing diagnosis, formulate/plan
interventions. Ongoing documentation of patient progress, information easy to access by everyone, basis for
diagnosing new problems, helps determine educational needs, and determine eligibility for care and
reimbursement. Serves as legal record of care, epidemiological tool (trace a disease), compliance with
legal/accreditation requirements, patient acuity systems (say how much staff a nursing unit is allowed).
6. Describe the general guidelines and rules for documenting data.

2009 HITECH encourages HER and meaningful use of health information technology; Can pull up and
resolve medication issues when issued by multiple providers/dispensed by multiple pharmacies etc. EHR-
better care coordination, less likely to lose/overlook date, less medication/treatment error, more
comprehensive reports/discharge summaries.

-Subjective Date- What the patient tells you- Biographical, CC, History-Health/Family/Lifestyle
-Objective Date- What you observe through inspection, palpation, percussion, auscultation. Make notes,
concise documentation, avoid nondescriptive/unmeasurable terms (good/fair/satisfactory) instead use
measurement or descriptive terms.

-Guidelines- Keep all charting information confidential, document legible/ nonerasable ink if paper
document; careful grammar, spelling, avoid wordiness- use phrases instead of sentences. Record findings
not method obtained (Hypoactive all 4 quadrants vs auscultated RUQ, LUQ, RLQ, LLQ etc.) Enter
information objectively NO judgements. Record client perception of problem with complete information—
support objective data with specific observations. (NO INFERENCES)
7. Describe various types of standardized assessment forms used for documenting data.
-Initial Assessment Form on arrival;
Open ended (traditional)- has categories (ex neuro heart lungs) you write in whatever desired under categories;
require skilled nurse/provider or may not be informative/sufficient; list topics/ open ended notes on each area,
individualized high risk for gaps with less experienced nurses.
Cued/Checklist form- check off- alert/somnolent/ check a category etc. Keep you on track fast/easy;
standardizes documentation, cues nurse, prevents missed questions, easy/quick, form itself may have gaps.
Integrated Cued- selecting certain options will cause other boxes/screens to pop up/ prompt for more
information; helps cluster data, combines data with selected diagnosis, promotes interdisciplinary care
Nursing minimum data set used in nursing homes- cued format specialized to older adults- functional status,
sensory ability, cognitive ability etc. standardized documentation helpful to research
-Frequent and Ongoing assessment form- less comprehensive form/ includes flowsheet- vital
signs/intake/output/weight etc.
-Focused/Specialty area Assessment used in dedicated areas or situations ex catheter or GI lab or used for risk
screening/specific assessments.

-Verbal Communication- verbal report to other providers, handoff reports, SBAR; Eye contact, close the loop-
validate information was communicated effectively and correctly interpreted/understood.

8. Document assessment findings, using a variety of assessment forms (e.g., narrative progress
notes, flow sheets).
SEE Above

9. Discuss the significance of documentation as specified by your state nurse practice act and
TJC standards.
10. Discuss the importance of documenting assessment findings in the legal record.
SEE ABOVE

11. State advantages and disadvantages of electronic documentation.

12. Summarize “Disciplinary Sanctions for Lying and Falsification” from the Texas Board of
Nursing as it applies to honesty, accuracy, integrity and documentation.

13. Discuss key principles of honest and accurate documentation. 

Chapter 14

1. Describe the structures and functions of the skin, nails, and hair.
Skin used for protections against, bacteria, trauma, UV rays and dehydration. It also assists with
temperature, fluid & electrolyte balance, absorption, excretion, sensation, immunity and synthesis of
Vitamin D. Epidermis top layer replaced 3-4 weeks contains calls that make melanin and keratin.
Dermis middle layer is vascular and thin made of mostly collagen because it provides support resist
tearing and allows resilient elastic tissue. Subcutaneous bottom layer is loose connective tissue that
stores fat for future energy and insulates to conserve internal body heat. Sebaceous glands- produce
oil/sebum for waterproof hair/skin. Sweat glands are eccrine for sweat and thermoregulation or
apocrine when around hair follicle like armpit, perineum and areolas Sweat + Bacteria= Body Odor!
Hair vellus is short/pale/fine and covers most of body, terminal on scalp and eyebrows is long dark
and coarse after puberty terminal hair grows on armpits perineum and legs.
Nails hard transparent keratinized epidermal cells.
2. Discuss the risk factors for skin cancer and METHICILLIN-RESISTANT STAPHYLOCOCCUS
AUREUS and ways to reduce one’s risks.
Types Skin Cancer Melanoma is most serious type greatest risk from recurrent sun exposure or UV radiation
reaches melanocytes in dermis; usually bigger than pencil eraser, multicolored, changes in size and shape with
asymmetric and uneven borders. Basal Cell Carcinoma is most common on sites with moderate exposure (trunk
or women’s lower legs) cuts into dermis some; can look like a shiny bump, a pink growth, a scar-like area or an
open sore that doesn’t heal easily; very little goes past epidermis and into dermis. Squamous cell carcinoma
most common on body parts with heavy sun exposure; common look like warts/scaly patches/open sores and
rapidly growing bumps with persistent bleeding.

MRSA Hospital acquired risk factors include invasive devices and living in a long-term care facility.
Community acquired risk factors include contact sports, sharing personal items, immunosuppression, and
unsanitary/crowded living conditions; Others include healthcare workers, antibiotics in the last 3-6 months,
young/old age, men sexually active with men. Reduction factors include covering wounds, not sharing personal
items, avoiding unsanitary/unsafe nail care, not stopping treatment until fully recovered, avoid contaminated
body fluids and use PPE, washing hands, and cleaning sports equipment between uses.

3. Describe an accurate nursing history of the skin, nails, and hair.

4. Discuss a physical assessment of the skin, nails, and hair using the correct techniques.
Identify prior skin issues for baseline (rashes, lesions, dryness, oiliness, drainage, bruising, swelling,
pigmentation, birthmarks, moles). Identify changes in appearance (color/size/shape), sensation
(pain/pressure/touch/temperature changes), pain/itching/tingling/numbness, hair/nail loss or changes,
body odor problems. Subjective obtain medication list, personal history (severe sunburns as child,
hospitalizations, surgeries), family history, lifestyle (sun/chemical/extreme temperature exposure,
daily care or skin/hair/nails, diet & exercise, stress, piercings/tattoos). Objective inspect and palpate
lesions, scars, hair and nails in outpatient in hospital focus is on skin integrity and preventing
pressure ulcers-; examine IV site for color intactness, swelling, drainage. Edema use thumbs- skin of
feet/ankles and check for swelling related to fluid accumulation. Mobility/Turgor- easily pinched?
Elasticity returns normal shape? Assess mucous membranes for moisture or lesions. Ask client to put
on gown remove clothes and jewelry (sit comfortably, ensure privacy, maintain comfortable room
temperature, good lighting, penlight, gloves, centimeter ruler, and assessment scales Braden).
Assess color (normal even skin tone and tanning behavior, striae or scar, distinctive odors; pallor-
loss of color and red/pink tones can be pale or ashen and can be due to arterial insufficiency, anemia;
erythema- redness and warmth can be inflammation, allergic reaction, trauma, fever, blushing—
darker skin can’t see redness feel for warmth; Cyanosis white skin is blue tinged especially around
mouth, on nails and conjunctival areas) dark skin may be blue or dull and lifeless can be due to
oxygen deficiency/ in peripheral cyanosis may be problem with vasoconstriction, central cyanosis
seen in oral mucosa indicates cardiopulmonary problem; jaundice- yellow skin can indicate hepatic
dysfunction (hepatitis, cirrhosis, sickle-cell) in light skin yellow tone especially sclera, oral mucosa,
palms and soles could be normal in 3-4 day Newborn), temperature, moisture, skin integrity(no
redness check pressure point areas (occiput, ears, scapula, elbows, sacrum, hip, ischial tuberosities,
medial condyle of tibia, fibular head, medial/lateral malleolus and heels ) obese under breasts.), look
for lesions (note color, shape, size, location, distribution & configuration- i.e. linear, annular, cluster,
discrete, nummular, confluent), ( (acanthosis nigricans darkened rough line behind neck) and check
condition or hair and nails start with hands/nails. Obese? Carefully inspect limbs, under breasts,
between skin folds and in groin (perspiration and friction). Remove socks inspect feet, nails, folds
between toes and areas patient can’t see themselves. Prevent Skin integrity issues bathe with mild
soap limit friction, use moisturize, clean incontinent skin, avoid vigorous massage over bony
prominences, frequent repositioning, mattress/lifting devices, nutritional supplements
5. Describe how to perform a self-assessment of the skin, hair, and nails.

ABCDE: Asymmetry, Border, Color, Diameter, Elevation

6. Differentiate between normal and abnormal findings of the skin, hair, and nails.
Normal: Lesions like stretch marks, healed scars, freckles, moles, and birthmarks. Dry flaky skin
could be normal OR hypothyroidism; Thickening of normally think skin-callus. Temperature warm and
equal may be moist-dry.
-Nails- in darker skin may see freckles or pigmented streaks in nails. Nail angle normally 160 degrees
between nail base and skin; smooth, firm, immobile, nail plate firmly attached to nail bed. Capillary
refill < 2 seconds to assess perfusion
-IV Site- sin intact no redness, swelling or phlebitis

Abnormal: Abnormal Lesion may indicate local or systemic problem.

-Butterfly rash across nose/cheeks seen in lupus
-Very thin skin can be arterial insufficiency or steroid
-Infected lesion tender to touch, non-mobile/fixed may be cancer
-Cold skin with shock or arterial disease
-Warm skin with fever or hyperthyroidism
-Fluid retention
Abnormal- pain, redness, swelling, red streak or rope-like appearance of vein, cool skin if cannula
begins infusing into the tissues
-Psoriasis- scaly erythematous plaque with silvery scales on top- common elbows/knees, immune
mediated
-Eczema- erythematous papules and vesicles with weeping, oozing and crusts inside arms and back
of knees related to allergy
Primary Skin Lesion- palpate lesion for size, mobility, consistency and tenderness, observe
drainage.
-Nodule/Tumor- elevated solid, palpable mass extends deeper into dermis—tumors are larger than
nodules
-Vesicle/Bulla- elevated mass contains serous fluid, vesicle less than 0.5 cm
-Wheal- elevated mass with irregular borders(urticaria).
-Pustule- pus filled vesicle
-Cyst- encapsulated fluid filled, semi-solid mass in subcutaneous or dermis
-Macule/Patch-small, flat, non-palpable color change macule is <1cm patch > 1 cm
-Papule/Plaque- elevated, palpable, solid mass papule is < 0.5 cm plaque is > 0.5 cm).
Secondary Skin Lesion- changes in lesions over time or trauma to a primary lesion -Erosion- loss of
superficial epidermis, depressed/moist area—ruptures vesicle/scratch mark
-Scar- skin mark left after wound heals color varies on time and healing
-Ulcer- skin loss extending past epidermis with necrotic tissue loss, venous stasis ulcer/pressure ulcer
-Fissure- linear crack in skin, painful may extend to dermis, chapped lips/athlete’s foot.
Vascular Skin Lesion- associated with bleeding, aging, circulatory conditions, diabetes, pregnancy
and hepatic disease.
-Purpuric Lesions- blood flow out of breaks in the vessels (difficult to see in darker skin)
Include two types (Petechia and Purpura)
-Petechia- round red/purple macule 1-2 mm due to bleeding tendencies
-Purpura- confluent extensive patch of petechiae and ecchymoses > 3mm flat red/purple macular
hemorrhage
-Ecchymosis- round irregular macular lesion seen with trauma
-Hematoma- Local collection of blood due to trauma
-Cherry angioma- popular and round normal age-related finding
-Spider angioma- red arteriole lesion on face, neck, arms and trunk seen with liver disease,
pregnancy and Vitamin B deficiency

Pressure Ulcer: appears on skin over bony prominence when circulation is impaired
Risk factors- prolonged pressure especially bony prominences, decreased/absent sensation,
impaired mobility, increased moisture, nutritional changes, friction/shearing forces, fragile tissue/skin
due to age/vascular incompetence, diabetes or body weight.
Stage 1- intact skin non blanchable redness
Stage 2- partial thickness loss of dermis, shallow ulcer
Stage 3- full thickness ulcer, extends into subcutaneous tissue
Stage 4- full thickness tissue loss with exposed bone, tendon or muscle
Unstageable- full thickness loss, base of ulcer covered by slough (dark dead tissue can’t stage until
eschar i.e. dead skin is remove)

Skin Cancer risk varies by culture Asians are less susceptible White Australians most; More susceptible white
males, older than 50, chemical exposure, HPV, long term skin inflammation, alcohol/smoking, inadequate
niacin in diet, depressed immune system. Causes of all sun, UV radiation, medical therapies, family
history/genetics, moles, pigment irregularity (e.g. albinism and burn scars), fair skin that burn/freckles easily,
light hair, age. Reduce risk by reducing sun exposure, using sunscreen, wear long sleeves and hats, have yearly
skin check and adequate niacin (Vitamin B3)

Hair abnormality
-Excessive generalized hair loss can be seen with infection, nutritional deficiencies or hormone
disorders
-Patchy hair loss seen with scalp infections, chemotherapy
-Hirsutism seen in Cushing’s or as effect of steroids
-Lice eggs/nits ovals on hair shaft
-Tinea capitis- ringworm

Nail Abnormality
-Longitudinal ridging (no known cause)
-Pitting seen with psoriasis
-Koilonychia- spoon shaped nails seen with trauma, iron deficiency anemia, endocrine or cardiac
disease
-Pale cyanotic nails seen with hypoxia/anemia
-Clubbing change in nail angle related to hypoxia (indicates chronic cyanosis/hypoxia)
-Paronychia local infection
-Blue-Black nailbed seen with nail-bed hemorrhage

7. Describe the findings frequently seen when assessing the skin, hair and nails in individuals
across the lifespan.

-Mongolian spots- bluish pigment seen in sacrum Asian, African American Native American and
Mexican American infants
-Darker skinned patients- deeper nail pigment
-African American- coarser hair

8. Analyze data from the interview and physical assessment of the skin, hair, and nails to
formulate nursing diagnoses, collaborative problems, and/or referrals.
Chapter 14

1. Describe the structures and functions of the skin, nails, and hair.
Epidermis

The epidermis (Fig. 14-1B), the outer layer of skin, is composed of four distinct layers: the stratum corneum,
stratum lucidum, stratum granulosum, and stratum germinativum. The outermost layer consists of dead,
keratinized cells that render the skin waterproof. (Keratin is a scleroprotein that is insoluble in water. The
epidermis, hair, nails, dental enamel, and horny tissues are composed of keratin.) The epidermal layer is
almost completely replaced every 3 to 4 weeks. The innermost layer of the epidermis (stratum germinativum)
is the only layer that undergoes cell division and contains melanin (brown pigment) and keratin-forming cells.
The major determinant of skin color is melanin. Other significant determinants include capillary blood flow,
chromophores (carotene and lycopene), and collagen.

Dermis

The inner layer of skin is the dermis (see Fig. 14-1B). Dermal papillae connect the dermis to the epidermis.
They are visible in the hands and feet, and create the unique pattern of friction ridges commonly known as
fingerprints. The dermis is a well-vascularized, connective tissue layer containing collagen, elastic fibers, nerve
endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles.

Sebaceous Glands

The sebaceous glands (see Fig. 14-1A) are attached to hair follicles and, therefore, are present over most of
the body, excluding the soles and palms. They secrete an oily substance called sebum that waterproofs the
hair and skin.

Sweat Glands

The two types of sweat glands (see Fig. 14-1A) are eccrine and apocrine glands. The eccrine glands are located
over the entire skin. Their primary function is secretion of sweat and thermoregulation, which is accomplished
by evaporation of sweat from the skin surface. The apocrine glands are associated with hair follicles in the
axillae, perineum, and areolae of the breasts. Apocrine glands are small and nonfunctional until puberty, at
which time they are activated and secrete a milky sweat. The interaction of sweat with skin bacteria produces
a characteristic body odor. In women, apocrine secretions are linked with the menstrual cycle.

Subcutaneous Tissue
Beneath the dermis lies the subcutaneous tissue, a loose connective tissue containing fat cells, blood vessels,
nerves, and the remaining portions of sweat glands and hair follicles (see Fig. 14-1A). The subcutaneous tissue
stores fat as an energy reserve, provides insulation to conserve internal body heat, serves as a cushion to
protect bones and internal organs, and contains vascular pathways for the supply of nutrients and removal of
waste products to and from the skin.

Hair

Hair consists of layers of keratinized cells, found over much of the body except for the lips, nipples, soles of
the feet, palms of the hands, labia minora, and penis. Hair develops within a sheath of epidermal cells called
the hair follicle. Hair growth occurs at the base of the follicle, where cells in the hair bulb are nourished by
dermal blood vessels. The hair shaft is visible above the skin; the hair root is surrounded by the hair follicle
(see Fig. 14-1A). Attached to the follicle are the arrector pili muscles, which contract in response to cold or
fright, decreasing skin surface area and causing the hair to stand erect (goose flesh).

There are two general types of hair: vellus and terminal. Vellus hair (peach fuzz) is short, pale, fine, and
present over much of the body. Terminal hair (particularly scalp and eyebrows) is longer, generally darker, and
coarser than vellus hair. Puberty initiates the growth of additional terminal hair in both sexes on the axillae,
perineum, and legs. Hair color varies and is determined by the type and amount of pigment (melanin and
pheomelanin) production. A reduction in production of pigment results in gray or white hair.

Vellus hair provides thermoregulation by wicking sweat away from the body. Hair on the head protects the
scalp, provides insulation, and allows for self-expression. Nasal hair, auditory canal hair, eyelashes, and
eyebrows filter dust and other airborne debris.
Nails

The nails, located on the distal phalanges of fingers and toes, are hard, transparent plates of keratinized
epidermal cells that grow from the cuticle (Fig. 14-2). The nail body extends over the entire nail bed and has a
pink tinge as a result of blood vessels underneath. The lunula is a crescent-shaped area located at the base of
the nail. It is the visible aspect of the nail matrix. The nails protect the distal ends of the fingers and toes,
enhance precise movement of the digits, and allow for an extended precision grip.
 2. Discuss the risk factors for skin cancer and METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS and
ways to reduce one’s risks.
14-1

EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION: METHICILLIN-RESISTANT

STAPHYLOCOCCUS AUREUS INFECTIONS

INTRODUCTION

Methicillin-resistant Staphylococcus aureus (MRSA), first noted in 1961, is a type of infection that is resistant
to methicillin, as well as to many other antibiotics. MRSA can be categorized into hospital-acquired or
community-acquired infections. Hospital-acquired MRSA occurs in individuals who are or have been
hospitalized within the past year, receive care in a same-day surgery center or ambulatory outpatient care
clinic, or are residents of long-term care facilities. MRSA hospital-acquired infections (HAIs) are associated
with invasive medical devices, such as urinary catheters, as well as with surgical incisions, pneumonia, and
bloodstream infections. Community-acquired MRSA occurs in individuals who have had recent medical
procedures and may be otherwise healthy.

HAIs, MRSA, and other organism-based infections are a growing concern to health care professionals. Various
processes to control HAIs have been put in place by US hospitals. The greatest success has been the “MRSA
bundle” approach of the Veterans Administration hospitals and long-term care facilities, where MRSA
infections between 2009 and 2012 fell by 69% for VA hospitals and 36% for long-term care facilities. The
“MRSA bundle” includes nasal swabbing and testing for MRSA colonization in patients, contact precautions,
hand hygiene, and an institutional culture of infection control for all personnel in contact with patients. The
“MRSA bundle” has also been successful in detecting other pathogens and the VA’s success in reducing HAIs
generally is notable (Veterans Administration Health Services Research & Development, 2015).

HEALTHY PEOPLE 2020 GOAL

Prevent, reduce, and ultimately eliminate health care–associated infections (HAIs).

SCREENING

Some acute care institutions screen for MRSA, particularly in the case of ICU admissions. More institutions are
using protocols for MRSA and other HAI screening since the VA “MRSA bundle” has worked so well, even
though this is not a universally recommended/implemented practice.

RISK ASSESSMENT

The greatest risk factor for MRSA is impaired skin integrity.

Assess for Hospital-acquired MRSA Risk Factors

Having an invasive medical device

Residing in a long-term care facility

Presence of a MRSA-positive person in the facility

Assess for Community-acquired MRSA Risk Factors

Participating in contact sports

Sharing personal items such as towels or razors

Suppression of the immune system function (e.g., HIV, cancer, or chemotherapy)

Residing in unsanitary or crowded living conditions (dormitories or military barracks)

Working in the health care industry

Receiving antibiotics within the past 3 to 6 months

Young or advanced age

Men having sex with men

Hemodialysis

CLIENT EDUCATION

Teach Clients

Keep wounds covered.

Do not share personal items.

Avoid unsanitary or unsafe nail care practices.

If treatment has been started, do not stop until recovery is complete.

Use Universal Precautions when touching others to avoid contact with contaminated body fluids. Wash your
hands.

Clean sports equipment between uses to avoid spread of infection.

Wash clothes, sheets, towels, razors, and other personal items before and after use.

Clean hands often.

14-2

EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION: SKIN CANCER

INTRODUCTION

Skin cancer is the most common of cancers. It occurs in three types: melanoma, basal cell carcinoma (BCC),
and squamous cell carcinoma (SCC). BCC and SCC are nonmelanomas. Precursor lesions occur for some
melanomas (benign or dysplastic nevi) and for invasive SCC (actinic keratoses or SCC in situ), but there are no
precursor lesions for BCC.

BCC is the most common skin cancer in Caucasians, whereas SCC is the most common in darker skin. Asians
are less susceptible to skin cancers. African Americans, Asians, and Hispanics, although less susceptible than
Caucasians, are susceptible to melanoma (The Skin Cancer Foundation, 2015d). Asian Americans and African
Americans tend to present with more advanced disease at diagnosis than do Caucasians. The Foundations also
note that African Americans, Asians, Filipinos, Indonesians, and native Hawaiians develop melanomas on
nonexposed skin with less pigmentation, such as on palms, soles, mucous membranes, and nail regions.

Nonmelanocyte skin cancers are the most common worldwide and are also increasing in populations heavily
exposed to sunlight, especially in areas of ozone depletion. Malignant melanoma is the most serious skin
cancer, and it is expected to account for 76,380 cases in 2016 (American Cancer Society, 2016).

HEALTHY PEOPLE 2020 GOALS

Reduce melanoma cancer death rate.

Increase participation in reducing exposure to harmful UV irradiation, sunburn, and use of artificial sources of
UV light for tanning.

Increase participation in protective measures that may reduce the risk of skin cancer.

SCREENING

According to the American Cancer Society (2015a), American Academy of Dermatology (2015), the National
Cancer Institute (2015b), the Skin Cancer Foundation (2015a), and a number of other organizations, all people
over 20 years of age should have a periodic examination of their skin by a primary care provider, and all should
do routine self-examinations (see Box 14-1) for oneself or of a child. These recommendations are not
supported by the U.S. Preventive Health Task Force report (U. S. Preventive Services Task Force, 2009), which
provides broad reviews of studies showing insufficient evidence to support the benefits or harm of using a
whole-body skin examination either by a primary care provider or self-examination for the early detection of
cutaneous melanoma, BCC, or SCC in the adult general population.
RISK ASSESSMENT

Assess for the Following Risk Factors

Sun exposure, especially intermittent pattern with sunburn; risk increases if excessive sun exposure and
sunburns began in childhood. Intermittent exposure to the sun or UVR is associated with greatest risk for
melanoma and for BCC, but overall amount of exposure is thought to be associated with SCC. SCC is most
common on body sites with very heavy sun exposure, whereas BCC is most common on sites with moderate
exposure (e.g., upper trunk or women’s lower legs)

Nonsolar sources of UVR (tanning booth, sunlamps, high-UV geographical areas). Indoor tanning has been
shown to raise the risk of developing melanoma by 74% (The Skin Cancer Foundation, 2015c)

Medical therapies such as PUVA and ionizing radiation

Family or personal history and genetic susceptibility (especially for malignant melanoma)

Moles, especially atypical lesions

Pigmentation irregularities (albinism, burn scars)

Fair skin that burns and freckles easily; light hair; light eyes

Age; risk increases with increasing age

Actinic keratoses

Male gender (for nonmelanoma cancers), especially white men over 50

Chemical exposure (arsenic, tar, coal, paraffin, some oils for nonmelanoma cancers)

Human papillomavirus (nonmelanoma cancers)

Xeroderma pigmentosum (rare, inherited condition)

Long-term skin inflammation or injury (nonmelanoma)

Alcohol intake (BCC); smoking (SCC)

Inadequate niacin (vitamin B3) in diet

Bowen disease (scaly or thickened patch) (SCC)

Depressed immune system

CLIENT EDUCATION
Teach Clients

Reduce sun exposure; seek shade.

Always use sunscreen (SPF 15 or higher) when sun exposure is anticipated.

Wear long-sleeved shirts and wide-brimmed hats.

Wear sunglasses that wrap around.

Avoid sunburns.

Understand the link between sun exposure and skin cancer and the accumulating effects of sun exposure on
developing cancers.

Examine the skin for suspected lesions. If there is anything unusual, seek professional advice as soon as
possible.

Ensure that diet is adequate in vitamin B3 (M.D. Anderson Cancer Center, 2015).

3. Describe an accurate nursing history of the skin, nails, and hair.

Preparing the Client

To prepare for the skin, hair, and nail examination, ask the client to remove all clothing and jewelry and put on
an examination gown. To respect the client’s modesty or desire for privacy, provide a long examination gown
or robe. In addition, ask the client to remove nail enamel, artificial nails, wigs, toupees, or hairpieces as
appropriate.

Have the client sit comfortably on the examination table or bed for the beginning of the examination. The
client may remain in a sitting position for most of the examination. However, to assess the skin on the
buttocks and dorsal surfaces of the legs properly, the client may lie on the side or abdomen.

During the skin examination, ensure privacy by exposing only the body part being examined. Make sure that
the room is a comfortable temperature. If available, sunlight is best for inspecting the skin. However, a bright
light that can be focused on the client works just as well. Keep the room door closed or the bed curtain drawn
to provide privacy as necessary. Explain what you are going to do, and answer any questions the client may
have. Wear gloves when palpating any lesions because you may be exposed to drainage.
Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the
same sex as the client.

Equipment

Examination light

Penlight

Mirror for client’s self-examination of skin

Magnifying glass

Centimeter ruler

Gloves

Wood light

Examination gown or drape

Braden Scale for Predicting Pressure Sore Risk

Pressure Ulcer Scale for Healing (PUSH) tool to measure pressure ulcer healing

Physical Assessment

When preparing to examine the skin, hair, and nails, remember these key points:

Inspect skin color, temperature, moisture, texture.

Check skin integrity.

Be alert for skin lesions.

4. Discuss a physical assessment of the skin, nails, and hair using the correct techniques.

SEE pages 258-264 Blue Box

5. Describe how to perform a self-assessment of the skin, hair, and nails.

SELF-ASSESSMENT: HOW TO EXAMINE YOUR OWN SKIN
Examine head and face using one or both mirrors. Use a blow dryer to inspect scalp.

Check hands, including nails. In full-length mirror, examine elbows, arms and underarms.

Focus on neck, chest, torso. Women: check under breasts.

With back to the mirror, use hand mirror to inspect back of neck, shoulders, upper arms, back, buttocks, legs.

Sitting down, check legs and feet, including soles, heels, and nails. Use hand mirror to examine genitals.

6. Differentiate between normal and abnormal findings of the skin, hair, and nails.
SEE PAGES 258-264 Blue Box

7. Describe the findings frequently seen when assessing the skin, hair and nails in individuals across the
lifespan.
SEE pages 258-264 Blue Box

8. Analyze data from the interview and physical assessment of the skin, hair, and nails to formulate
nursing diagnoses, collaborative problems, and/or referrals.
SEE pages 258-264 Blue Box

Chapter 15

1. Describe the structures and functions of the head and neck.

-Cranium- house and protect the brain and major sensory organs (frontal, parietal, occipital, temporal,
ethmoid and sphenoid joined together by immovable sutures)
-Face- facial expressions/reflect mood;14 facial bones, temporal artery, parotid glands, includes
eyebrows, ears, eyes, nose, mouth, palpebral fissures and nasolabial folds
-Neck-muscles sternomastoid & trapezius; vertebra prominens C7; blood vessels- internal jugular
veins & carotid arteries; Thyroid gland- large endocrine gland that surrounds the thyroid; lymph
nodes- <1cm filter lymph not palpable or feel like small beads
2. Discuss the risk factors for head and neck disorders across cultures and ways to reduce one’s
risks.

3. Describe an accurate nursing history of his/her head and neck.

Subjective Date- Headache, neck pain, medications, limited ROM, lumps, lesions, cough/difficulty
swallowing, head injury/loss of consciousness, blurred vision, head/neck trauma,
dizziness/lightheadedness/vertigo, change in energy level and skin/hair/nails, palpitations,
weakness/numbness in face/arms/legs, Past history, Family History, Lifestyle.
4. Describe a physical assessment of the head and neck using the correct techniques

Inspect/Palpate head size/shape/consistency- normocephalic: hard, smooth, symmetrical, no lesions.

Head still and upright no involuntary movements. Temporal artery is elastic & nontender. TMJ has full
ROM non-tender no crepitus.
Inspect face for symmetry, features, movement, expression and skin condition no abnormal
movements, inspect palpebral fissures and nasolabial folds.
Inspect/Palpate neck for symmetry/position/masses/and movement of neck structures- symmetric
with head centered no masses thyroid cartilage moves symmetrically; cervical vertebrae inspection
C7 visible & palpable; Full ROM and strength CN XI – spinal accessory.
Palpate lymph nodes bend head slightly toward side you are palpating to relax those muscles,
palpate with finger pads slow walking/gentle/circular motion, compare bilaterally; Normal size round <
1 cm not palpable if are document location; delimitation (position/boundary normally discrete),
consistency- normally soft, mobility- side to side and up and down, normally nontender; FAMILIAR
with direction of drainage patterns up lymph nodes if abnormal check area they drain for source of the
problem also explore upstream of abnormal node; Enlarged hard node on L may be metastasis;
Locations-Pre/Postauricular, Occipital, Tonsillar, Submandibular, Submental, Superficial cervical,
Posterior cervical, Deep cervical, Supraclavicular

5. Differentiate between normal and abnormal findings of the head and neck.

Abnormal

-Migraines- nausea, vomiting light sensitivity, visual disturbances, vertigo, tinnitus, numbness/tingling
(around eyes, temples cheeks, foreheads); last up to 3 days precipitated by emotions, anxiety,
alcohol, cheese, chocolate; throbbing/severe may receive relief from rest
- Cluster headaches- stabbing, tearing, lid dropping, red eye, runny nose; sudden onset precipitated
by alcohol, localized eye and orbit—radiates to face/temporal region, intense; movement/walking may
relieve
-Tension Headache-dull/tight; stress/anxiety/depression, frontal temporal occipital area lasts
days/months/years; aching relieved with local heat/massage
-Tumor related- aching/steady, neurologic/mental symptoms, nausea/vomiting, aggravated by
coughing/sneezing/sudden movement; commonly occur in AM last several hours
-Sinus Headache- deep/constant/throbbing pain often in one area of face/head (behind the eyes);
occurs with cold/acute sinusitis/nasal drainage/fever/congestion; pain worse with sudden head
movements; lasts until underlying condition improves
-Other- Meningitis or encephalitis see nuchal rigidity and fever; Hypertension fever;
Medications/Substances- oral contraceptives, bronchodilators, alcohol, nitrates, carbon monoxide

Involuntary Movements
-Microcephaly/Acromegaly- jerking or nodding movements
-Head tilt- shortening of sternomastoid muscle, malignant lumps, parotid enlargement
-Temporal Arteritis- tortuous hard tender temporal artery
-TMJ- limited ROM, swelling, crepitus
-Parotid Enlargement/Abscess/Tumor-facial asymmetry
-CVA/Bell’s Palsy- Facial drooping/weakness/paralysis
-Bell’s Palsy- lower motor neuron, CN VII complete paralysis of half of face, usually unilateral, can’t
wrinkle forehead, raise eyebrows, close eyes, whistle, or show teeth on affected side, can start
suddenly & peak within 48 hours often occurs in pregnancy
-CVA- upper motor neuron, neurological deficit, paralysis of lower facial muscles/upper half is not
affected.
-Parkinson’s mask-like face
-Cachexia- sunken face, depressed eye & hollow cheeks
-Nephrotic Syndrome- pale swollen face
-Meningitis- late symptom= stiff neck
-Arthritis- neck stiff, rigid and limited ROM
-Atelectasis (collapsed lung)- trachea pulled from midline to affected side
-Pneumothorax (abnormal air collection between lung/chest wall) - trachea pulled from midline to
unaffected side
-Lymphadenopathy- acute/chronic infection, autoimmune disorders, metastatic disease; Regional- 1
or 2 groups; Generalized- 3 or more groups persist more than 3 months may indicate HIV infection;
chronic infection lymph nodes merge (confluent); Hard, firm, unilateral nodes that are fixed in place
seen in metastatic cancers; tender enlarged nodes suggest acute infection
-Cushing’s Syndrome excessive ACTH secretion or chronic steroid use- round moonlike face,
prominent jowls, red cheeks, hirsutism on upper lip/lower cheeks/chin/acne type rash on chest
-Scleroderma- “hard skin” connective tissue diseases chronic hardening and shrinking degenerative
changes in skin, blood vessels, skeletal muscles—can occur in skin, heart, esophagus, kidney and
lung. Can see hard shiny skin on forehead and cheeks, thin pursed lips, muscle atrophy on face &
neck, absence of expression
-Acromegaly- enlarged facial features especially nose and ears due to increase in growth hormone
after skeleton/organs finish growing often due to benign pituitary tumor
Enlarges masses/nodules with enlarged thyroid gland or lymph nodes.
Asymmetric movement of thyroid gland.

6. Describe the findings frequently seen when assessing the head and neck in individuals across
the lifespan.

Hypothyroidism- increased sensitivity to cold, constipation, depression, fatigue, heavier menstrual

periods, pale/dry skin, thin/brittle hair/nails, weakness, unintentional weigh gain. Untreated may cause
decrease taste/smell, hoarseness, puffy face/hands/feet, slow speech, thickening of skin, thinning
eyebrows; Myxedema- deficient thyroid hormone severe will cause nonpitting edema puffy face,
around eyes, coarse facial features, dry skin, and dry coarse hair/eyebrows.
Hyperthyroidism (Myxedema) - sudden weight loss without change in appetite, increased appetite,
tachycardia/arrythmia, nervousness/anxiety/irritability, tremors in hands/fingers, sweating, changes in
menstrual patterns, increased sensitivity to heat, changes in bowel patterns (more frequent), enlarged
thyroid gland (goiter), fatigue insomnia, muscle weakness; Graves is most common cause- goiter and
exophthalmos
Traumatic Brain Injury- bump/jolt/ blow or penetrating injury to the head- fall, MVA, assault, struck
by/against solid surfaces. Risk- Age, transportation accidents, violence, falls, excessive ETOH,
infant/elderly, being cared for by a caregiver. Education- seatbelt/car seat, avoid DUI,
helmet/headgear with risky activities (contact sports, skateboards, baseball, horseback riding, skiing),
seniors remove trip hazards, use nonslip mats, install grab bars

7. Analyze the data from the interview and physical assessment of the head and neck to
formulate valid nursing diagnoses, collaborative problems, and/or referrals.
 Chapter 5

1. Describe how critical thinking relates to diagnostic reasoning.

Critical Thinking/Data Analysis- 2nd step of nursing process.

Critical thinking is when nurses use knowledge, past experiences, intuition, and cognitive abilities to formulate
nursing diagnoses to make clinical judgement.
Diagnostic phase/Clinical Reasoning is used to interpret data.

2. Determine your own ability to think critically.

Have you collected all information? Can you support opinion with data/rational/literature? Have you
explored alternatives? Can you distinguish between fact/opinion/cue/inference? Do you ask for client
for clarification when needed? Can you validate your information and judgements with experts in the
field? Do you use past knowledge/experiences to analyze date and avoid past mistakes? Do you try
to avoid biases? Could you be wrong?

Set Priorities!

1) 1st level problems are emergent and life-threatening. ABC’s and vital sign concerns
2) 2nd level problems require prompt intervention (MUAAAR). Mental status change, untreated
medical problems requiring immediate attention, acute pain, acute urinary elimination
problems, abnormal labs, risks—safety, infection, or security

3. Describe seven essential critical thinking characteristics.

1) Keep an open mind

2) Use rationale to support opinions or decisions
3) Reflect on thoughts before reaching a conclusion
4) Use past clinical experiences to build knowledge
5) Acquire an adequate knowledge base that grows
6) Be aware of the interactions of others
7) Be aware of the environment

4. List the six essential components of the diagnostic phase of the nursing process.

1) Group and organize date

2) Validate data/compare with normal findings/values
3) Cluster data to make inferences
4) Generate hypotheses regarding client’s problems
5) Formulate a professional clinical judgement
6) Validate the judgement with the client

5. List the seven distinct steps used in this textbook to perform data analysis.

1) Step One- Identify abnormal date and strengths

 2) Step Two- Cluster date (related abnormal findings)
3) Step Three- Draw influences “hunches”
4) Step Four- Propose possible nursing diagnoses (actual, risk, promotion)
5) Step Five- Check for defining characteristics use references i.e. NANDA
6) Step Six- Confirm or rule out diagnosis (Validate)
7) Step Seven- Document conclusions (nursing or risk diagnosis)

6. Define and give examples risk and actual nursing diagnoses.

Nursing diagnosis is the problem the client is currently experiencing. Three-part diagnosis.

1) The diagnosis (ex. Ineffective breathing pattern)

2) The cause (ex. related to impaired chest wall expansion)
3) The evidence/symptoms (ex. RR 28, nasal flaring, tripod position)

Risk Nursing Diagnosis- a situation in which an actual diagnosis will likely occur if the nurse does not
intervene; problem has not occurred written in a two-part statement.
Risk _____ and Risk Factors

Wellness/Health Promotion Diagnosis- client does not have a problem but is at a point where they can attain a
higher level of health. “Readiness for enhanced—diagnostic label related to cause as evidenced by or as
motivated by symptoms.

7. Define and give examples of collaborative problems.

Collaborative Problems/Referrals should be documented as risk for complications. RC:______

(problem stated); Goals for this problem should be documented as what should be monitored and
how often it should be monitored; Indicate is PCP needs to be notified, identify interventions to
prevent complications and when referrals are needed.
8. Explain why experienced expert nurses have an advantage over novice nurses in making
accurate diagnoses.
9. Discuss the common “pitfalls” of diagnostic reasoning.
10. Explain the ways to increase the accuracy of your diagnostic reasoning skills.
Chapter 9

1. Identify pain as the fifth vital sign.

Patient right to pain assessment/management; screen and periodically assess pain, record assessment and
reassessment results, assess/educate staff in pain management, establish organizational policies, educate
patient/families, address patient needs/collect data.

Seven Dimensions of Pain

1) Physical- anatomical; is current diseases or another disease causing pain

2) Sensory- qualitative/quantitative descriptions
3) Behavioral- verbal/nonverbal behaviors
4) Sociocultural- social/cultural backgrounds- can ask patient how they typically respond to pain; can vary
based on cultural expectations
5) Cognitive- belief/attitude/intentions r/t pain; Pain is weakness, a part of aging or a form of
punishment,concern for worsening condition or addiction to pain medication
6) Affective- feelings/emotions r/t pain
 7) Spiritual- meaning and purpose r/t pain

2. Explain the pathophysiology of pain.

Pain is whatever/wherever the person says it is—and is an unpleasant sensory/emotional experience. Pain is
often undertreated; inadequate treatment can cause physiologic, psychological and emotional distress with leads
to chronic pain.

Pathophysiology- the source of pain stimulates nerve endings (nociceptors- peripheral ends of nerve endings).
Nerve ending transmit sensations to CNS. Nociceptors- sense temperature (hot/cold) and pain (noxious stimuli);
are located in the body, skin, subcutaneous tissue, skeletal muscle, joints, peritoneal surface, pleural
membranes, dura mater, and blood vessel walls.

Nociception (transmission from periphery to CNS); Transduction- noxious stimulus causes tissue injury—
release of neurotransmitters. Transmission- pain impulse  spinal cord  brainstem  thalamus  cortex.
Perception- Conscious awareness of painful sensation (emotional response- parietal lobe). Modulation-
changes/inhibits pain message relay in the spinal cord.

Location: Cutaneous- skin or subcutaneous tissue; Visceral- abdominal cavity, thorax, cranium; Parietal-
ligaments, tendons, bones, blood vessels, nerves
3. Classify pain into acute and chronic pain.

Acute- Recent injury, related to trauma; Short term dissipates after injury heals; self- protective
purpose- warns of actual/potential tissue damage. Nonverbal behavior- guarding, grimacing, restless,
diaphoresis, change in VS.

Chronic- non-malignant cause/injury persists > 6 months, related to long term process; pain continues
after recovery; can adapt to chronic pain, use tools to asses intensity and effect on life. Nonverbal
behavior- adaptation/bracing, rubbing, diminished activity, sighing, change in appetite/sleeping,
irritability.

Cancer Pain- may reflect all pain types at same or different times—can be caused by cancer, its
treatment or it’s metastasis. Can be sudden & severe—acute or longer than 3 months—chronic; pain-
somatic/visceral/neuropathic, can cause breakthrough pain and can depend on cancer stage; may be
triggered by blocked blood vessel or pressure on a nerve from tumor; Side effect of treatments—
surgery, radiation, and chemotherapy include pain. 90% with advanced cancer experience severe
undertreated pain related to blocked blood vessels, bone fracture from metastasis,
infection/inflammation, psychological problems, treatment side effects; or tumor pressure on a nerve.

Neuropathic Pain- Abnormal processing of pain message from past damage (peripheral or CNS)
related to neurochemical levels; no predictable path—difficult to treat; perceived after healing; poorly
controlled nociceptive pain can become neuropathic (e.g. Diabetic neuropathy, shingles, HIV/AIDS,
sciatica, trigeminal neuralgia, phantom limb pain, and chemotherapy)

Additional Pain Classification

-Radiating- perceived at source extending to other tissues
-Referred- perceived in body areas away from the pain source
-Phantom- perceived by nerves left by missing/amputated/paralyzed body part
-Intractable- high resistance to pain relief

4. Name the different physiologic responses to pain.

Anxiety, fear, suicide, state pain—cry, moan, frown, grimace, decreased cognitive function—confusion, pupil
dilation, Increased heart rate/blood pressure/respirations, sputum retention— (Increased spit plus RR can cause
infection and atelectasis) muscle spasms, decreased gastric & intestinal motility, decreased urinary output
(retention), increased hormone response—hyperglycemia.

5. Describe a client experiencing pain, collecting subjective and objective data.

Subjective Data- Self report is best, Use COLDSPA, open ended questions; listen to patient and quote
terms used, effect on activities of daily living/mood/sleep/appetite/concentration/joy, facial
expressions/grimace DON’T put words in client’s mouth and BELIEVE client expression of pain.

6. Discuss a physical assessment on a client who is experiencing pain, with consideration to

those across the lifespan

Objective
-Observe Posture; normal upright appears comfortable
(Abnormal- slumped, inattentive, agitated, guarding, distress, breathing problems)
-Observe Facial Expression; normal client smiles and maintains eye contact
(Abnormal distress/discomfort, poor eye contact, may frown/moan/cry/grimace)
-Inspect Joints/Muscles; Normal without edema relaxed muscles
(Abnormal joint edema—indicated injury; muscle tension may indicate pain)
-Observe skin for scars, lesions, rashes, changes, discoloration; Normal no
inconsistency/wounds/bruising notes
(Abnormal bruising, wounds, edema can signify injury/infection—cause pain)
-Vital signs- HR, RR, BP
(Abnormal increased HR,RR, BP and possibly irregular/shallow breathing)

7. Discuss the purposes and uses of pain assessment tools, for all populations, and those for
specific populations.

Choose tool based on purpose, time to administer and patient comprehension. (Multidimensional vs
unidimensional, use standardized tools)

Tools for patient without cognitive impairment

-Visual Analog Scale (vertical vs. horizontal) 10 cm baseline (No pain --- Worst Pain)
-Numeric Pain Intensity Scale (baseline with tic mark-- 0 No Pain 5 Moderate 10 Worst)
-Numeric Rating Scale (best for older adults without impairment)
-Categorical Rating Scale- None—0, Mild—1, Moderate—2, Severe—3
-Simple Descriptor Scale (Baseline with No Pain, Mild Pain, Moderate Pain, Severe Pain, Very Severe Pain and
Worst Possible Pain tic marks)

Nonverbal/Preverbal Patients (Adults with cognitive impairment/dementia; infants/preverbal toddlers;

intubates/unconscious patients)
-Try to get a self-report, search for cause of pain, observe patient behaviors, use surrogate reporting
(parent/caregiver etc.) of pain and behavior changes, note discrepancies, observe for changes in self-report after
analgesics.
-Faces Pain Scale Revised—best for cognitively impaired adults. Also use VAS (Visual Analog Scale) and
Verbal descriptor scale.
Patients with Addictive diseases

8. Analyze data from client interview and physical assessment of a client experiencing pain to
formulate nursing diagnoses, collaborative problems, and/or referrals.
Chapter 19

1. Describe the structures and functions of the thorax and lungs.

Anterior Landmarks: Clavicles; Sternum- suprasternal notch, manubrium, body, xyphoid, sternal
angle (Angle of Louis), costal angle, 12 pairs of ribs & costal spaces

Posterior Landmarks: Vertebra Prominens C7, Spinous Processes, Scapula

Anterior:
Apex- highest point above 3rd clavicle
Base- lower border diaphragm, 6th rib, MCL
Laterally:
Lung tissue apex of axilla down to 8th rib
Posterior:
Apex- C7
Base- T10 mostly lower L lobe

Right lung is shorter Liver)

Left lung narrower (Heart)
Lung & Mediastinum
-Mediastinum- contains trachea, bronchi, esophagus, heart and great vessels
-Trachea- anterior to esophagus at level of sternal angle bifurcates into R/L main bronchi
bronchioles alveoli (Inspired air travels through trachea into bronchi, bronchioles, alveoli)
-Alveolar sacs: gas exchange
-Pleurae- thin double layered serous membranes; Lubricating serous fluid between layers allows
friction-free movement.
1) Parietal Pleura- lines the chest cavity
2) Visceral Pleura- covers the external lung surface

Lungs allow respiration! – Supply Oxygen for energy production, removes Carbon Dioxide, Acid/Base
Balance in body

Thorax

2. Identify the thoracic landmarks in relation to underlying structures of the thorax.

Vertical Reference Lines

-Anterior chest- mid-sternal, R/L mid-clavicular lines
-Posterior thorax- vertebral line, R/L scapular lines
-Lateral Thorax- midaxillary line, A/P axillary lines

3. Discuss the risk factors for lung cancer across cultures and ways to reduce one’s risks.
-RF- Smoking, 2nd hand smoke, asbestos/radon exposure, history of radiation exposure, family history
of lung cancer
-Education- Avoid smoking/2nd hand smoke, cessation program, older house checked for
asbestos/radon, seek medical assessment for symptoms

4. Describe the teaching opportunities to reduce risks and promote health of the thorax and
lungs.
5. Describe a client for an accurate nursing history of the thorax and lungs. 
Subjective:
-Dyspnea/SOB- difficulty taking a break, feels like suffocating (activity/exertion/at rest), how many
pillows/sleep position, associated factors- edema/angina/orthopnea/PND/sleep apnea
-Chest Pain- with cold/fever/deep breathing, pleuritis, respiratory vs cardiac origin.
-Cough- time of day, non-productive vs productive (Sputum color), wheezing with cough
-GI symptoms- heartburn, frequent hiccups, relation of asthma to GERD
-Family History- lung cancer, emphysema, asthma, viral/bacterial infection, second-hand smoke
-Lifestyle- poor nutrition, smoking, environmental conditions, difficulty with ADL’s, Stress,
herbals/alternative treatment.
6. Discuss a physical assessment of the thorax and lungs using the correct techniques of
inspection, auscultation, palpation, and percussion.
Remove clothing from wait up put on gown.
-Inspect nasal flaring, pursed lip breathing (not normally observed)
(Abnormal Nasal flaring/labored breathing in hypoxia)
(Abnormal pursed lip breathing with asthma/emphysema or CHF)
-Observe color of face, lips & chest (normally even colored skin)
(Abnormal ruddy to purple with COPD or CHF due to polycythemia)
(Abnormal cyanosis if client is cold or hypoxic)
-Color/Shape of nails—normally pink tones with 160-degree angle
(Abnormal pale/cyanotic/clubbing with hypoxia)
-Inspect Posterior chest- configuration—symmetric non-protruding scapulae, horizontally equal
shoulder/scapulae; AP to transverse diameter 1:2; spinous process straight, symmetrical thorax,
downward sloping ribs 45-degree angle in relation to spine
(Abnormal spinous process lateral deviation- scoliosis; ribs horizontal or > 45-degree angle with
increased AP/transverse diameter (Barrel chest—with emphysema or lung hyperinflation); accessory
muscles/trapezius or shoulder muscles used with acute or chronic airway obstruction or atelectasis)
(Abnormal- tripos position with COPD)
-Client position/posture/ability to support weight—sitting up relaxed breathing easily
(Abnormal with inflamed fibrous connective tissue, tender/painful areas over intercostal spaces may
affect position; rib pain—fractured rib especially osteoporosis)
-Palpate tenderness/sensation/masses/lesions; palpate for crepitus—crackling sensation when air
passes through fluid or exudate (normally none present and equal temp B/L; seen with air escape into
subcutaneous tissue with open thoracic injury—around a chest tube/tracheostomy or in areas of
consolidation
-Hand on T9/T10 press together with small skin fold should move apart symmetrically with equal
expansion
(Abnormal; unequal expansion with atelectasis/pneumonia/ pneumothorax/trauma)
-Posterior chest percussion (NOT ROUTINELY PERFORMED) Patient sits slightly forward arms
across lap C7-T10 not over bone– Resonance- sound predominant in healthy lung tissue in the adult
(Abnormal: Hyper-resonance (trapped air in emphysema or pneumothorax) Dull with pneumonia,
effusion, atelectasis or tumor) DULLNESS over breast tissue and heart and liver is normal; tympany
noted over L side gastric space.
-Inspect Anterior Chest- configuration and slope of ribs AP less than transverse 1:2; Ribs slope downward
symmetric intercostal spaces, costal angle within 90-degrees; no intercostal retractions or bulges
-Sternum position midline and straight no sternal retraction
-Respirations relaxed, effortless with regular rhythm 10-20 per minutes.
-Palpate apices supraclavicular

7. Differentiate between normal and abnormal findings of the thorax and lungs.
Breath sounds are considered normal ONLY in the area specified
-Bronchial (Tracheal) Loud, high-pitched, over trachea & thorax
-Broncho-vesicular Moderate pitch & amplitude; heard posteriorly & anteriorly around upper
sternum in 1st and 2nd intercostal spaces
-Vesicular Low-pitched, soft heard over all peripheral fields

Abnormal Breath Sounds

-Diminished/Absent- little or no air flow; obstruction of bronchial tree (seen with pleural thickening, pleural
effusion, pneumothorax or hyperinflation (due to emphysema))
-Increased/Louder- when consolidation/compression results in denser lung enhancing sound transmission
(pneumonia)
-Adventitious sounds- added sounds superimposed over normal breath sounds—if heard ask client to cough
then listen again
-Fine Crackles: high-pitched crackling/popping heard during inspiration not cleared by cough; inhaled
air opens small deflated air passages coated/sticky with exudate. In late inspiration
with pneumonia and CHF; in early inspiration with bronchitis, asthma or emphysema
-Coarse Crackles: loud low-pitched bubbling, moist sounds; inhaled air collides with
secretions in trachea and bronchi; In pulmonary edema, pneumonia or with pulmonary fibrosis
(Atelectatic crackles- not pathological occur when alveoli not fully aerated in aging adults,
bedridden people or people aroused from sleep; should clear with cough or disappear after a few
breaths)
-Wheezes (Sibilant/Sonorous): Sibilant- high pitched musical squeaking sound mostly heard in
expiration, but MAY occur in both. Air passes through constricted passages caused by swelling secretions or
tumor; seen in asthma or chronic emphysema; Sonorous wheeze- low- pitched snoring/moaning sound
primarily heard through expiration but may occur in both. May clear with cough. Air passes through
constricted passages; In bronchitis or obstruction and snoring before episodes of sleep apnea.
-Stridor: harsh honking wheeze; High-pitched inspiratory crowing sound with severe
broncholaryngospasm; In croup & epiglottis foreign body—Emergency
-Pleural Friction Rub- coarse low-pitched grating when pleurae are inflames, lose lubrication and
rub together—pleuritis
-Pectus excavatum- breastbone sinks “caves” into chest
-Pectus carinatum- pigeon/keel chest. chest protrudes out; cartilage connecting ribs grows out flat along the
chest
-Hyper/Hypoventilation
-Tachypnea >24 breaths/min; Bradypnea < 10 breaths per minute
-Cheyne-Stokes respiration- deeper breathing followed by shallow breathing that increases CO2 linked like heart
failure, stroke, traumatic brain injury and intra cranial pressure
 -

COPD (i.e. Emphysema, Chronic Bronchitis)-

lung diseases that block airflow as you exhale and make it difficult to breathe; abnormal inflammatory
response that reduces airflow, airways constrict after the air is in the lungs exhalation is difficult.
-RF: cigarette smoking, 2nd hand exposure, occupational exposure to dust/ chemicals, older
than 40, RARELY- genetics
-Education- Avoid smoking/join cessation program; occupational exposure- wear mask or
modify environment if possible

-Pneumonia- infection in lung parenchyma leaves alveolar membrane edematous and porous, RBCs
and WBCs pass from blood to alveoli; alveoli become consolidated with bacteria/debris/fluid;
decreased surface area of respiratory membranes results in hypoxemia; Increased breath sounds,
crackles and increased respiration rate. (Subjective- cough with sputum, dyspnea, possible chest
pain, fever; Objective- increased respiratory rate, decreased chest expansion on affected side,
crackled, possible hypoxemia, may have increased breath sounds; children may have sternal
retraction, nasal flaring and diminished breath sounds)
-Bronchitis- excessive mucus secretion, inflammation of bronchi; hacking, rasping cough, mucoid
sputum, crackles or wheezes
-Tuberculosis- inhalation of tubercle bacilli into alveolar wall caused inflammatory response and scar
tissue; cough with purulent sputum and crackles.
-Emphysema- permanent enlargement of air sacs—increased airway resistance AP to lateral
increase to 1:1 use of accessory muscles, diminished sounds or wheezes also crackles especially
long-term COPD
-Asthma/Reactive Airway Disease- allergic hypersensitivity to pollen/irritant/stress/exercise;
bronchospasm, inflammation, edema in walls of bronchioles and secretion of viscous mucus into the
airways, increased airway resistance; wheezing chest tightness; diminished air movement
(Subjective- dyspnea, chest tightness; Objective- audible wheezes, use accessory muscles, possible
cyanosis, labored breathing, breath sounds decreased )
-Atelectasis- Collapsed, shrunken section of alveoli or entire lung, lag on chest expansion of affected
side; breath sounds decreased or absent over area
-Heart Failure- pump failure with increased pressure of cardiac overload results in pulmonary
congestion, increased respiration rate, sob on exertion, orthopnea, PND; crackles at lung bases
-Pneumothorax- Free air in pleural space—complete or partial lung collapse; unequal chest
expansion, decreased or absent sounds
-Pulmonary Embolism- thrombus from legs or pelvis occludes pulmonary vessels; chest pain
restlessness, tachycardia, crackles, wheezes
-Pleural Effusion- excess fluid in the intrapleural space with compression of overlying tissue (protein
pus or blood); fluid subdues lung sounds—decreased breath sounds
8. Describe the findings frequently seen when assessing the thorax and lungs in individuals
across the lifespan.
Size of thorax affects pulmonary function and differs by race
9. Analyze the data from the interview and physical assessment of the thorax and lungs to
formulate nursing diagnoses, collaborative problems, and/or referrals.
 Nursing Diagnoses
-Activity Intolerance- related to imbalance between oxygen supply and demand secondary to COPD as
evidenced by respiration 24 per minute and report of inability to walk to end of driveway and back
-Ineffective airway clearance- related to excessive and tenacious secretion as evidenced by thick yellow-green
sputum

Exam 2
Chapter 21
1. Describe the structure and functions of the heart and neck vessels.
-Superior/Inferior Vena Cava- returns blood
-Pulmonary artery- carries blood to the lungs
-Pulmonary veins- returns oxygenated blood
-Aorta- transport oxygenated blood
-Heart- hollow muscular, four chambers
-Precordium- anterior chest wall over the heart and great vessels
-Pericardium- outer most double walled pericardial sac with fluid friction free
-Myocardium- middle contracting heart muscle
-Endocardium- inner most thin layer of endothelial tisue
-Atrioventricular Valves- Entrance into the ventricles
-Tricuspid Valve- Right Ventricle
-Bicuspid (Mitral) Valve- Left Ventricle
-Semilunar Valves- Exit from the ventricles
-Pulmonic Valve- Right Ventricle
-Aortic Valve- Left Ventricle
* Chordae tendineae: Anchor the AV valves to papillary muscle
-S1- beginning of systole- when AV valves (mitral and tricuspid) shut best heard over apex; coincides with
carotid arterial pulse
-S2- end of systole beginning of diastole- when semilunar valves (aortic and pulmonic) shut; heard best at base
over pulmonic area

-Carotid Artery Pulse- between trachea and sternocleidomastoid (SCM) muscle, coincides with ventricular
systole S1; smooth rapid upstroke and gradual downstroke
-Jugular Venous Pulse- Return blood to the heart; Jugular venous pressure reflects central venous
pressure; -Increased JVP indicates right-sided heart failure
-Internal JV: deep, medial to SCM
-External JV: superficial, lateral to SCM

2. Discuss the risk factors for coronary artery disease (CAD) across cultures and ways to reduce one’s
risks.
RF: nearly ½ of all African Americans slightly more females; 1/3 of key RF—HTN, high cholesterol,
smoking; Other RF- socioeconomic status, obesity; 1 in 4 women die by heart diseases—with almost 2/3 dying
suddenly of heart disease with no previous symptoms
RF: High blood pressure, High cholesterol, Smoking, Diabetes, Poor diet, Physical inactivity, Overweight/obese

3. Describe an accurate nursing history of the heart and neck vessels.

4. Discuss a physical assessment of the heart and neck vessels using the correct techniques of inspection,
auscultation, palpation, and percussion.

Exam preparation
• Supine position
• Head elevated about 30 degrees
• Auscultation & palpation of neck vessels
• Inspection, palpation and auscultation of precordium
• Auscultation of heart on supine, left lateral and then sitting up leaning forward positions
• STAND ON THE PERSON’S RIGHT side
• Environment: warm room temperature; privacy; drape female breast; ask client to pull her breast upward and
to her side when auscultating
-Inspect the Jugular Venous Pulse (JVP) Supine with 30˚-45˚, Neck rested and turn to left, Apply tangential
light, Inspect suprasternal notch or around clavicles for internal jugular pulsation, Check distention, protrusion,
or bulging (2-4 cm elevated from angle of Luis is normal), Full distension above 45˚; ventricular failure,
pulmonary hypertension, pulmonary embolism or cardiac tamponade
-Auscultate Carotid Arteries- In older clients or CVD suspected auscultate before palpation to
avoid slowing the heart by triggering vagal stimulation, Ask pt. to hold breath after exhalation; Use the bell for
bruits; Bruit (Blowing, swishing sound): Stenosis of carotid arteries; May hear aortic
stenosis murmur-Risk of TIA, Stroke
-Palpate Carotid Arteries- Palpate one at a time! Use index and middle fingers medial to the
SCM muscle on the neck; Avoid vagal stimulation; Equal pulse strength (0-3+ scale) smooth contour, elastic
and no thrills
-Abnormal is unequal pulses, weak, or bounding; loss of elasticity may indicate arteriosclerosis; thrills
may indicate narrowed arteries
-Bruit (blood vessels) vs murmur (heart valves & structures)
- Inspect Precordium; Inspect and Palpate Apical Impulse (PMI): Supine at 30-45°patient’s right side
Use tangential lighting-may visible, Palpate the apical impulse (PMI) (Left lateral position), Hold breath after
exhalation; use 1-2 finger pads, 4th-5th ICS & MCL
-Abnormal is a heave or lift (upward thrust), Double impulse Displaced under 5th ICS or
laterally rotated- hypertrophic cardiomyopathy
- Palpate Across the Precordium- Use palmar aspect of 4 fingers to feel other pulsations, thrills; Apex- Left
sternal border-Base; Normally no lifts, heaves or thrills
Abnormal: Lift/heave – visible upward thrust of the heart against chest wall at LSB – Right
ventricular hypertrophy (RVH); Thrill-palpable vibration with murmur; turbulent blood flow
-Percussion- Not commonly done – used to outline the heart’s borders if enlarged; Ineffective due to female
breast, thick SQ tissue or muscular chest wall; Right sternal margin, RSB, LSB, Apex
-Auscultation- clean stethoscope, stand on client’s right side; auscultate rate and rhythm. Sound- resonance
areas not physical locations—listen all over chest as areas overlap cover the precordium; Rhythm varies with
breathing/sinus arrhythmia; Check pulse deficit if irregular: Palpate the radial pulses & the apical pulse at the
same time for 1 full minute. pulse deficit (Apical –radial ) indicates a-fib, a-flutter—REFER for further
evaluation; sounds (S3, S4) on apex- listen will bell for extra heart sounds; Listen with the bell for murmurs;
timing, intensity and location. Listen on other positions (left
lateral, sitting up leaning forward).

5. Differentiate between normal and abnormal findings of the heart and neck vessels.
-Split S1- increased venous return during inspiration delays T1 best heard at tricuspid area supine, diaphragm
-Normal split S1 in children/adolescents, young adults and 3rd trimester of pregnancy
-Pathologic split S! in delayed conduction with RBBB right bundle branch block or A-Fib
-Split S2- increased venous return during inspiration delays P2
-Normal physiologic split S2 on inspiration
-Pathologic Split S2 indicated RBBB, pulmonary hypertension, pulmonic stenosis, mitral
regurgitation/ventricular septal defect, atrial septal defect
-S3- ventricular gallop heard during early diastole- ventricular resistance to rapid filling (ineffective
contraction); best heard apex with BELL in lateral position (S1, S2, S3)
-Normal- children, 3T pregnancy, well-trained athletes
-Pathologic- CHF, volume overload r/t vascular disease
-S4- atrial gallop during late diastole (S4, S1, S2),forced contraction due to noncompliant LV (ineffective relax)
Best heart at apex on left lateral and supine position
-Normal- well trained athletes after exercise
 -Pathologic- CHF, systemic HTN, CAD, acute MI
-Pericardial Friction Rub- during systole and diastole; rubbing sounds between two surfaces of inflames
pericardial sack due to pericarditis; high pitched scratch and scraping sounds
Auscultation- sit upright & lean forward hold breath in expiration – at Erb’s point with diaphragm
-Heart Murmurs- turbulent blood flow through incompetent or stenotic valves increases blood velocity,
decreases blood viscosity; sounds like swishing or blowing
-Timing-systolic vs diastolic; locations- landmarks; intensity- soft or loud; RT inspirations vs LT
expiration; duration- short long or holosystolic; pitch- low medium or high pitch; shape- crescendo,
decrescendo, diamond or rectangular
-Physiologic Murmur- pregnancy, hyperthyroidism, exercise and anemia with temporarily
increased blood flow early systolic, auscultate pulmonic area on supine with bell or diaphragm;
usually soft best at 2nd or 3rd ICS disappears with sitting
-Pathologic murmur- increased velocity of blood, structural valve defects, valve malfunction,
abnormal chamber opening (septal defect)
-Mid-Systolic Murmur- Aortic/Pulmonic Valves between S1 and S2, medium to high pitched heard at aortic
or pulmonic area at supine with bell or diaphragm
-Physiologic- pregnancy, hyperthyroidism, exercise and anemia
-Pathologic- Aortic stenosis, pulmonic stenosis, hypertrophic obstructive cardiomyopathy, and
atrial septal defects
-Heart Murmurs Systolic- -High-pitched murmur best heard at apex
-Pathologic: Mitral or tricuspid valve prolapse -usually mitral valve prolapse(MVP); -MVP with mid-
systolic click followed by high-pitched murmur
-Holosystolic (Pansystolic) Murmur -High-pitched rectangular shape during entire systole
-Pathologic: mitral regurgitation, or tricuspid regurgitation, ventricular septal defect
-Mitral regurgitation (MR); high-pitched “blowing” murmur best heard at apex
-Tricuspid regurgitation(TR); high-pitched murmur best heard at left lower sternal
border during inspiration
-Heart Murmur Diastolic- between S2 and S1
-Pathologic -Valve incompetence: aortic regurgitation, pulmonic regurgitation
-Filling Murmur: mitral stenosis, tricuspid stenosis
-Aortic Regurgitation -High-pitched decrescendo murmur during the first half of
diastole; Best heard at Erb’s point on sitting up and leaning position with holding
breath after expiration
-Mitral Stenosis- Rheumatic fever; low-pitched sounds during diastole best heard at
apex on left lateral position with bell

6. Describe the findings frequently seen when assessing the heart and neck vessels in individuals across the
lifespan.
7. Analyze the data from the interview and physical assessment of the heart and neck vessels to formulate
nursing diagnoses, collaborative problems, and/or referrals.

Heart Disease
-Subjective Data- Chest pain/tightness, dyspnea/orthopnea, tachycardia/palpitations, fatigue, cough,
cyanosis/pallor, edema, dizziness, nocturia, heartburn, cardiac history/defects (murmurs or surgery), EKG,
blood lipids, medications, family cardiac history, personal habits/risk factors
COLDSPA Chest Pain
 Character – crushing, stabbing, burning, squeezing, tightness
 Onset – when, how long, had this type before
 Location: where, radiation
 Duration: how long, how often
  Severity: 0-10 pain scale
 Patterns: Brought on by activity, rest, sex, weather, position, relieved by rest or nitro
 Associated Factors: Dyspnea, Diaphoresis, Pale clammy skin, Nausea/vomiting, Heart skips a beat or
speeds up
COLDSPA Dyspnea
 Characteristics: What type of activity now vs. 6 months ago
 Onset: when, how long, had this type before
 Location
 Duration: How long, how often
 Severity: ex. Modified Medical, Research Council (MMRC) Dyspnea scale 0-4, Awaken you from
sleep, Interfere with ADLs
 Pattern: DOE (Dyspnea on exertion), PND (Paroxysmal nocturnal dyspnea) , affected by position
 Associated factors: with chest pain, anxiousness, fatigue, dizziness, cough; Orthopnea - # of pillows,
Upright position to breath
COLDSPA Cough
 Characteristics: Dry, hacking, barky, hoarse, congested, productive, (mucus, blood), odor, blood-tinged
 Onset: when, how long, had this type before,
 Location:
 Duration: How long, how often
 Severity: ex) Visual analogue scales (VAS) 0-5 score
 Pattern: Made better/worse by activity, position, anxiety, talking, nocturnal or relieved by rest or med
 Associated factors: with chest pain, wheezing, runny nose, sore throat, night sweat, difficulty
swallowing

Female Heart Attack:

- Chest pain or discomfort (not always); More frequently pain in the neck/jaw/throat, arms, upper abdomen or
back, indigestion, heartburn, nausea/vomiting, Extreme fatigue, Shortness of breath
• Easy to ignore

Heart Failure
-Decreased cardiac output, increased circulation backed up and congested
-Hearts inability to pump/insufficient blood for systemic circulation increased blood volume and venous
return worsening congestion; kidney compensation by Renin-Angiotensin system
-Symptoms: Dilated pupils, skin pale/gray/cyanotic, dyspnea SOBOE is early symptom, orthopnea,
crackles/wheeze, cough, decreased blood pressure, nausea/vomiting, ascites, dependent pitting edema, anxiety,
falling O2 saturation, confusion, jugular vein distention, infarct, fatigue, S3 gallop, tachycardia, enlarged
spleen/liver, decreased urine output, weak pulse, cool moist skin

Myocardial Infarction
- Interruption of blood supply to the heart; Blockage of coronary artery, Ruptured plaque, Blood clotting, Heart
muscle injury or death
-Signs/Symptoms/Treatment- Obtain detailed history; Dx tests –EKG, enzymes; Chest pain, N/V, fatigue,
diaphoresis, palpitations, anxiety; MONA – Oxygen, Nitroglycerin, Aspirin, then Morphine if pain still present.

Nursing Diagnosis
• Activity Intolerance R/T compromised oxygen supply as evidenced by exertional angina
• Acute Pain R/T tissue ischemia AEB reports of chest pain7/10 (0-10 scale), change in pulse and BP
• Anxiety R/T threat of death AEB fearful attitude, restlessness
• Risk for Ineffective Tissue Perfusion R/T interruption of blood flow
• Risk for decreased cardiac output R/T damaged heart muscle

Normal <120/<80
Elevated 120-129/<80
HTN Stage 1 130-139/80-89
HTN Stage 2 140+/ 90+
HTN Crisis >180/>120

-Evidence-based: Healthy eating patterns and regular physical activity maintain good health and reduce chronic
disease. Follow a healthy eating pattern across the life span. Focus on variety, nutrient density, and amount.
Limit calories from added sugars and saturated fats and reduce sodium intake. Shift to healthier food and
beverage choices. Support healthy eating patterns for all

Chapter 22
1. Describe the structure and functions of blood vessels, including capillaries, & lymphatic circulation.

-Arteries- Deliver oxygen-rich blood to capillaries to tissues; Blood is propelled under pressure from the left
ventricle Heartbeat forces blood through arteries creating a surge, “arterial pulse” Artery walls are thick
and strong with elastic fibers Head and neck: Temporal & carotid; Arms: Brachial, radial, ulnar; Legs:
Femoral, popliteal, dorsalis pedis & posterior
-Veins- Blood vessels that carry deoxygenated, nutrient-depleted waste-laden blood from tissues back to the
heart; No force to propel forward blood flow; blood from legs must flow upward with no pumping action of
heart
- 3 mechanisms: 1. One-way valves prevent blood backflow, 2. Skeletal muscular contraction;
squeeze blood toward the heart, 3. Pressure gradient through breathing
If these mechanisms fail, venous return is impeded and venous stasis results
-Capillaries- Small blood vessels that allow the circulatory system to maintain equilibrium between the vascular
and interstitial spaces
-Hydrostatic force involved with interstitial fluid diffusing out of capillaries into tissue spaces
- Fluid re‐enters capillaries by osmotic pressure;
- Lymphatic capillaries remove excess fluid left
-Lymphatic System- Drains excess fluid and plasma proteins from bodily tissues and returns them to the venous
system; During circulation more fluid leaves the capillaries than veins can absorb; draining excess fluid
prevents edema. Fluids & proteins absorbed become lymph from lymph nodes where microorganisms, foreign
materials, dead blood cells and abnormal cells are trapped and destroyed. Nodes vary from small, nonpalpable
to 1‐2 cm.; grouped together; accessible for exam in neck, arms, and legs

2. Discuss risk factors for peripheral vascular disease across cultures and ways to reduce risks.
3. Describe an accurate nursing history of the peripheral vascular system.

-Subjective Data: Color, temperature or texture change in skin, Pain or cramping in the legs; with walking;
Intermittent claudication: weakness, cramping, aching, fatigue or pain in calves or thighs; relieved by rest; may
indicate peripheral arterial disease; Heaviness and aching sensation aggravated by standing or sitting for long
periods of time and relieved by rest associated with venous disease; Lack of pain may indicate neuropathy; Leg
veins rope‐like, bulging, contorted, Sores or open wounds in legs? Location? Pain? Swelling (edema) in legs or
feet? What time of day? Pain with swelling? Swollen lymph glands; Male clients: change in sexual activity
(may be RT erectile dysfunction); History of circulatory problems, blood clots, ulcers, poor healing; History of
heart or blood vessel surgeries or treatments; Family history of diabetes, HTN, CAD, claudication, elevated
lipid levels; Lifestyle practices – Smoking, exercise, contraceptives, support hose

4. Discuss an accurate peripheral vascular assessment.

-Assessment and Preparation PVD: Early detection of peripheral vascular disease- inspection, palpation and
auscultation; Compare arms and legs bilaterally ; includes groin exam (not for class); Position from sitting for
exam of arms; lying down for exam of legs/groin;

Assessment of Upper Extremity- Observe arm size & venous pattern; assess for edema – If an observable
difference in size, measure bilaterally, arm circumference at same location; Arms bilaterally symmetric without
edema, prominent venous patterning; Lymphedema/prominent venous patterning (may affect 1 extremity);
Palpate for temperature of fingers, hands and arms – Should be equal bilaterally; A cool extremity may be sign
of arterial insufficiency; or Raynaud’s; Inspect coloration of hands and arms – Should be equal bilaterally;
Palpate to assess capillary refill; normal is capillary beds refill less than 2
seconds – > 2 seconds may indicate vasoconstriction, decreased cardiac output or arterial occlusion; Palpate
radial pulses for elasticity and strength – Normal 2+/3+ and bilaterally strong; artery walls resilient; Ulnar
pulses not commonly palpated; if suspect arterial insufficiency, palpate brachial pulses; should be equally
strong; Assess nail angle; (should be approximately 160°); clubbing indicates chronic hypoxia; Palpate the
epitrochlear Nodes-Normally not palpable – Enlarged epitrochlear nodes may indicate an infection in the hand
or forearm , generalized lymphadenopathy or lesion

Assessment of Lower Extremity- With client supine, groin area draped, observe skin color, hair distribution &
for lesions/ulcers; Pink color for light-skinned clients is normal; pink or red tones visible under darker-
pigmented skin; Hair should be seen on legs and dorsal area of toes; legs are free of lesions or ulcerations;
Inspect for edema; measure if asymmetric- Normally identical size/shape without swelling or atrophy (Bilateral:
systemic problem, i.e. CHF; Unilateral with local problem (lymphedema or prolonged standing); Palpate for
edema to determine if pitting or nonpitting; press with tips of fingers; hold for a few seconds then release;
Pitting edema associated with systemic problems (CHF) or local cause (venous stasis) 1+ to 4+ scale (or
measure with tape); Assess temperature legs/feet, compare symmetrically – should be warm and equal
bilaterally; Feet may be slightly cooler but bilaterally equal; Generalized coolness in 1 leg or cooler down the
leg suggests arterial insufficiency; increased warmth may be RT thrombophlebitis; Palpate inguinal lymph
nodes -Normal is nontender, movable lymph nodes up to 1-2 cm. Nodes larger than 2 cm. with or without
tenderness may be from a local infection or generalized lymphadenopathy; Palpate femoral artery pulse; strong
& equal bilaterally; Popliteal pulse (difficult to localize) – Place thumbs on the knee, with fingers deep in the
bend of the knee, lateral to the medial tendon – Easier with pt. prone; Assessment of the pulses- Dorsalis pedis
pulse- Dorsiflex the foot & apply light pressure lateral to & along the side of the extensor tendon of the big toe;
Assess at the same time; 0- 3+ scale; Posterior tibial pulse- Palpate behind & just below the medial malleolus
(the groove between
the ankle & Achilles tendon) Assess same time; 0-3+ scale; Inspect for varicosities and thrombophlebitis- Ask
the client to stand to make any varicose veins more visible; as the client stands inspect for superficial vein
thrombophlebitis. Palpate for suspected thrombophlebitis. Normally veins are flat and barely seen; no redness or
discoloration is seen. Varicose veins appear as distended, bulging or tortuous; result from incompetent valves.
Blood flow is decreased; may see redness or swelling; with pt. complaint of
aching or cramping with walking

Neurovascular Assessment- Assessment of circulation, motor, sensation; Critical assessment if limb

injury/trauma, fracture, or cast/restrictive bandages
-Ps: – Pain – Paralysis (Movement) – Paresthesia (Sensation) – Pulses (or pulselessness) and
capillary refill – Pallor and Temperature (cold) – Some say pressure (able to detect pressure
applied)
 -ASSESS: Recognize and/or prevent Compartment Syndrome. Pressure within the muscles builds
to dangerous levels; decreasing blood flow, which prevents oxygen from reaching nerve and muscle
cells. Some causes: fracture, cast or tight bandage. Symptoms: pain, burning, tingling, full or tight
feeling. Medical or surgical emergency!

5. Differentiate between normal and abnormal findings of the peripheral vascular system.

- Venous stasis: Blood pooling in lower legs which increases pressure in the veins
Risk factors: long periods of standing still, sitting, or lying down; lack of muscular activity;
varicose veins (lead to incompetent valves)

-Raynaud’s disorder is a vascular disorder caused by vasoconstriction or vasospasm of fingers or toes with color
change

-PAD—Abnormal findings include pallor, rubor, cyanosis, rusty/brownish pigmentation; hair loss with thin
shiny skin, ulcers on toes or ankles
-Arterial Insufficiency- If pulses in the legs are weak, assess for arterial insufficiency; Client in supine position;
support the ankles & knees; raise legs about 12 inches above the heart level; ask client to pump feet up and
down for a minute to drain venous blood; Ask client to sit up and dangle off the exam table and note time for
color to return to both feet; Feet should be pink to slightly pale with elevation; pinkish color should return to
tips of toes in 10 sec. Marked pallor with legs elevated or return of color that takes > 10 seconds suggests
arterial insufficiency; Pain: Intermittent claudication to sharp, unrelenting, constant. Pulses: diminished or
absent. Skin Characteristics: – Dependent rubor – Dry, shiny skin – Cool to cold temperature – Loss of hair
over toes and foot – Nails thickened & ridged;
Ulcer Characteristics – Location: Tips of toes, toe webs, heel or other pressure areas if confined to
bed – Pain: Very painful – Depth of ulcer: Deep, often involving joint space – Shape: Circular – Ulcer base:
Pale black to dry & gangrene – Leg edema: Minimal unless extremity dependent pos.
-Venous Insufficiency- Pain: Aching, cramping; Pulses: Present but may be difficult to palpate through edema;
Skin Characteristics: – Pigmentation in medial & lateral malleolus – Skin
thickened & tough – May be reddish‐blue – Associated w/dermatitis
-Ulcer Characteristics: – Location: Medial malleolus or anterior tibial – Pain: If superficial,
minimal pain, but may be very painful – Depth of ulcer: superficial – Shape: Irregular border – Ulcer
base: Beefy red to yellow – Leg edema: Moderate to severe
-Peripheral Edema
-Lymphedema – Caused by abnormal or blocked lymph vessels – Nonpitting – Usually bilateral; may
be unilateral [Depends on etiology with mastectomy, node removal – unilateral] No skin ulceration or
pigmentation
-Chronic Venous Insufficiency – Caused by obstruction or insufficiency of deep veins – Pitting 1+ to
4+ – Usually unilateral; may be bilateral – Skin ulceration and pigmentation may be present

6. Describe findings frequently seen when assessing the peripheral vascular system in individuals across
the lifespan.
7.  Analyze data from the interview and physical assessment of the peripheral vascular system to formulate
nursing diagnoses, collaborative problems, and/or referrals.

-Allen Test evaluates patency of the radial or ulnar arteries; implemented when patency is questionable or
before procedures like radial artery puncture – Normal pink coloration returns to the palms within 3‐5 seconds –
With arterial insufficiency or occlusion of the artery, pallor persists
- Peripheral Arterial Disease: Disease increases with age; associated with diabetes; Major cause of impaired
ambulation, extremity wounds and amputations; Occurs with reduced blood flow to limbs, usually from
atherosclerosis; Calf pain is most common symptom – Others include numbness, weakness, coldness, sores on
toes, change in skin color of legs, hair loss, slow growth on legs, shiny skin, slow‐growing toenails, diminished
pulses in legs and feet and erectile dysfunction in men
- Risk Factors for lower‐ extremity PAD include: Ages younger than age 50, to 65 and older –
Atherosclerosis, carotid or renal artery disease – Smoking, diabetes, obesity, hypertension, high
cholesterol, family hx , heart disease
- Client Education – Stop smoking – Manage diabetes, if present – Regular exercise 30 minutes
3X/week per MD – Lower cholesterol and BP – Maintain healthy weight

Chapter 29
1. Describe the physiologic and anatomical changes that occur during pregnancy
2.  Describe an accurate nursing history of the pregnant client.
3. Discuss a physical assessment of the pregnant client using the correct techniques.
4.  Differentiate between normal and abnormal findings identified during pregnancy.
5. Analyze the data from the interview and physical assessment of the pregnant client to formulate valid
nursing diagnoses, collaborative problems, and/or referrals
6. Document and verbally report accurate assessment findings of the pregnant client.
Chapter 18
1. Describe the structure and functions of the mouth, throat, nose, and sinuses.

-Mouth: beginning of digestive tract & respiratory tract

-Oral cavity: Lips, cheeks, uvula, tongue; Hard palate (bone), Soft palate (muscle)
-Salivary glands: Parotid, Submandibular, Sublingual
-Uvula- extension of the soft palate
-Tongue- – Muscle connected to floor of mouth by frenulum; Assists with moving food, swallowing,
and speaking; contains taste buds
-Frenulum – Connects the tongue to the floor of the mouth
-Gums (gingiva)- covered by mucous membranes, hold 32 permanent teeth in adults
-Throat (Pharynx), located behind the mouth and nose; Muscular passage for food & air; Upper part:
Nasopharynx; Below the nasopharynx lies the oropharynx; Soft palate, anterior and posterior pillars, uvula
connect behind the tongue to form arches; Masses of lymphoid tissue/palatine tonsils on both
sides of oropharynx at the end of soft palate between the anterior/posterior tonsillar pillars; Lingual tonsils lie at
the base of the tongue; Pharyngeal tonsils (adenoids)-high in the nasopharynx
-Nose– External nose- bridge, tip and nares; Nasal septum separates cavity into 2 halves; Front of the septum
contains blood vessels- Kiesselbach’s area, common for bleeding; Nasal hairs filter large particles; blood supply
of the nose warms inspired air as it is moistened by mucous membrane
Sinuses: 4 pairs (frontal, maxillary, ethmoidal, and sphenoidal) located in skull; Air-filled cavities- resonance
chambers during speech; Lined with ciliated mucous membranes that trap debris and propels it toward the
outside; A primary site of infection because they easily become blocked

2. Discuss the risk factors for oral cancer  and ways to reduce one’s risks.

-Oral diseases are prevalent in poorer populations (dental caries, periodontal disease, oropharyngeal lesions &
cancers)

-Oropharyngeal Cancer
-RF: Tobacco products, Heavy alcohol use, Chewing betel nuts, Sunlight (lip cancer), Male, Fair
skin, Poor oral hygiene, Poor diet
 -Client education: Avoid tobacco, Avoid excess ETOH, Avoid betel nuts, Avoid HPV infection, Avoid
excess sun exposure, Healthy diet, Good oral hygiene

3. Describe an accurate nursing history of the mouth, throat, nose, and sinuses.
4. Discuss an accurate assessment of the mouth, throat, nose, and sinuses.

Subjective Data: Mouth, Tongue & Throat

-Mouth sores/lesions RT meds, stress, infection, trauma, malignancy, canker sores, herpes; Redness, swelling,
bleeding mouth/gums (Gingivitis, periodontitis), Hoarseness– Upper resp. infection/Laryngeal cancer;
Difficulty swallowing/Dysphagia- seen with tumors- Risk for aspiration Late sign of oral cancer; Sore throat-
Viral infections, mono, bacterial infections, dry heat, allergies, reflux, tumors, cancer
-Nose and Sinuses: • Pain-acute/chronic sinusitis; dental pain, Nosebleeds (epistaxis), Frequent clear/ mucous
drainage from nose (rhinorrhea), chronic allergy, or with head injury CSF leak mucous drainage with cold, or
sinus infection, Stuffy nose- sinus congestion, obstruction or deviated septum, Trauma- deviated septum,
obstruction, decreased smell with URI, smoking, cocaine, or
frontal lobe tumor
-Oral, nasal or sinus surgery, History of sinus infections, Use of nasal sprays – Frequent use may
cause nasal irritation, nosebleeds and rebound swelling, Dx with allergies (seasonal, drug, food),
Treatments for mouth, nose, throat conditions, Smoking/tobacco use/alcohol use Grinding teeth, Dental
care/braces

-Inspect the Mouth- Inspect the lips for consistency/color; Normal- smooth/moist w/o lesions or
swelling; Abnormal- Circumoral pallor with anemia and shock; cyanosis with cold or hypoxia; Abnormal- Red
lips with CO poisoning; ketoacidosis, and COPD with polycythemia
-Inspect Teeth & Gums-retract lips, cheeks; Normal 32 white teeth with smooth surfaces; may have dental
repairs, Gums pink, moist and firm w/tight margins; Abnormal- Discolored or missing teeth; poor occlusion;
red, swollen gums that bleed easily, receding gums or gingival hyperplasia
-Inspect Buccal Mucosa- Use penlight/tongue depressor to retract the lips & cheeks to check color and
consistency, Pink in light-skinned clients; increased pigmentation in dark-skinned clients, Tissue-smooth/moist
w/o lesions; w/o redness, swelling, pain or moistness in area; Abnormal-Leukoplakia may be seen in chronic
irritation and smoking, which is a precancerous lesion; Abnormal- Candidiasis (thrush) is whitish, curd-like
patches that scrape off over reddened mucosa and bleed easily; Abnormal- Canker sores, brown patches inside
cheeks; Abnormal- Koplik spots are early sign of measles
-Inspect & Palpate Tongue- Assess for color, size, texture, & moisture; Pink, moist & moderate size with
papillae; without lesions; assess ventral surface, frenulum, & under tongue– Smooth, shiny pink, or slightly pale
with visible veins and no lesions; Palpate if lesions seen or in clients > 50 with alcohol or tobacco use; Area
under tongue is common site of oral cancers
Inspect Tongue; Strength, Taste- Observe sides of tongue for ulcers, lesions, nodules; Abn. Canker sores on
sides of tongue; Abn. Leukoplakia, persistent lesions, ulcers or nodules with cancer; Check strength- Normally
strong resistance- Decreased with shortened frenulum, CN XII problem; Check taste on anterior tongue; client
should distinguish sweet & salty; Abn Loss of taste with CN VII deficit
-Inspect Hard & Soft Palate- Anterior hard palate- white with firm, transverse rugae (wrinkle-like folds) without
foul odor; Posterior soft palate- pink, movable, spongy & smooth; Abn. Candida infection with thick, white
plaques; Abn. purple lesions with Kaposi’s sarcoma, AIDS; Abn. yellow tint on hard palate with jaundice; Abn.
a cleft palate (opening on the hard palate)
-Assess the Uvula- Apply a tongue blade halfway between the tip and back of the tongue; shine a penlight; Ask
the client to say “ahhh” and watch for uvula and soft palate to move; No redness or exudate; midline elevation
and symmetric rise of palate
– Bifid uvula (looks like it is split in two)
– Abn. Loss of movement or asymmetric movement with CVA or paralysis of vagus nerve
-Inspect Tonsils- Inspect tonsils (present or absent); Pink, symmetric, may be enlarged to 1+ in healthy clients;
no exudate, swelling or lesions should be present; Abn. Tonsils are red, enlarged to 2+, 3+, 4+ and covered with
white or yellow exudate with tonsillitis; Inspect the posterior pharyngeal wall; normal- pink, without exudate or
lesions; Abn. A bright red throat with white or yellow exudate indicates pharyngitis; yellow mucus with
postnasal sinus drainage
-Tonsils 1+ Visible 2+ midway between tonsillar pillars and uvula 3+ touching the uvula
4+ touching each other
-Assess the Nose- Inspect and palpate the external nose for color, shape, consistency, & tenderness. Normal-
same color as face; nasal structures smooth & symmetric without tenderness; Abn. Tenderness accompanies
infection; Check patency of air flow; able to sniff through each nostril while other is occluded; Cannot sniff
through nostril nor blow through nostrils w/ swelling, rhinitis, or foreign object; A line across the tip is
common with chronic allergies
-Inspect the Inner Nose- Insert the otoscope/penlight into the nostril without touching the septum. Nasal mucosa
normally red, smooth, moist surface without discharge; Septum is intact, free of ulcers or perforation; deviated
septum can be normal finding if breathing is not obstructed; Turbinates dark pink without lesions
-Palpate Sinus Area- Palpate using thumb, Press over frontal sinuses to press up on the brow on each side of the
nose, Over maxillary sinuses below cheekbones, Normally nontender without crepitus; Abn. Tender with
chronic allergies and acute infection (sinusitis); may feel crepitus; Percuss normal nontender

5. Differentiate between normal and abnormal findings of the mouth, throat, nose, and sinuses.
6. Describe the cultural variations seen with assessment findings of the mouth, throat, nose, and sinuses.

-Sinusitis
-RF: – Nasal passage abnormalities, Aspirin sensitivity/respiratory symptoms; Medical conditions-
immunity disorders, Hay fever/allergies, Asthma, Exposure to pollutants
-Client education- Avoid colds or flu, Good hand hygiene, Flu vaccine, Avoid pollutants, Care for
asthma, Seek care for symptoms

-Abnormal Findings: Inner Nose- Swollen, pale pink or bluish gray mucosa with allergies; red & swollen with
URI; exudate watery, usually with allergies; yellow-green, purulent with sinusitis. Bleeding(epistaxis),crusting
with local irritation; Ulcers of mucosa or a perforated septum are seen with use of cocaine, trauma, chronic
infection or nose picking; Polyps (small round growths),chronic allergies

-Abnormal Findings Nose- Epistaxis: Local cause or underlying illness. Nose picking, foreign body, forceful
sneezing, or coagulation disorder; Perforated Septum: Hole in the septum; R/T snorting cocaine, chronic
infection, trauma from picking of crusts, or nasal surgery; Foreign body: Children put objects in nose; produces
unilateral, mucopurulent drainage, foul odor; Polyps: Pale, round, firm, overgrowths or masses on mucosa seen
with chronic allergies

-Abnormal Findings Mouth- Herpes Simplex 1,Cleft Lip, Angular Cheilitis (Cheilosis)

-Abnormal Findings Tongue – Smooth glossy tongue, Fissured tongue, Black hairy tongue, Enlarged tongue
(mental retardation, hypothyroidism, acromegaly), Dry mouth with dehydration; Ankyloglossia (tongue-tie)

-Abnormal Findings Gums: Gingival hyperplasia-Painless enlargement of gums, sometimes overreaching teeth.
Occurs w/ puberty, pregnancy, and leukemia, & long therapeutic use of Dilantin; Gingivitis – Gum margins red,
swollen &bleed easily. R/T poor dental hygiene, vitamin C deficiency, or during pregnancy and puberty with
changing hormone balance

-Abnormalities of Oropharynx: Koplik Spots (associated with measles)-Small blue-white spots with irregular
red halo scattered over mucosa opposite molars. An early sign of measles; Acute Tonsillitis and Pharyngitis-
Bright red throat, swollen tonsils, white or yellow exudate on tonsils & pharynx, Swollen uvula, Severe, sore
throat, fever > 101 and enlarged lymph nodes; Cleft palate– A congenital defect, failure of fusion of the
maxillary processes. Varies from upper lip only, palate only, uvula only, to cleft of nostril and palates.

7. Describe the findings frequently seen when assessing the mouth, throat, nose, and sinuses in individuals
across the lifespan.

-Bifid uvula – occurs in Native Americans & Asians

-Cleft lip & palate- Common in Asians & Native Americans

8. Analyze data from the interview and physical assessment of the nose, mouth, throat, and sinuses to form
nursing diagnoses, collaborative problems, and/or referrals.

+Ch 18: Mouth, Throat, Nose, and Sinuses

Structure and Function: know the location of frenulum (looking under the tongue for cancer), oral mucosa,
hard and soft palate, tonsils, uvula (CN9 and CN10), oral pharynx, pharynx,

Oropharynx, nasopharynx, (evaluate airway for NG tube)

Ethmoidal sinus, frontal sinus, maxillary sinus, nasal septum (know that deviated septum can obstruct airway)

Pg 360:

oropharyngeal cancer

Where to check: under the tongue inside of mouth

Who is at high risk: tobacco users, drink alcohol frequently, have had previous oral cancers, or have had heavy sun
exposure

What teaching to be done: avoid tobacco, avoid excessive alcohol use, avoid heavy sun exposure, practice
good oral hygiene
CN1 – sense of smell – sudden change could mean stroke

Pg 367: Objective assessment

Lips- should be pink and moist - Pallor around the lips (circumoral pallor) is seen in anemia and shock. Bluish
(cyanotic) lips may result from cold or hypoxia. Reddish lips are seen in clients with ketoacidosis, carbon monoxide
poisoning, and chronic obstructive pulmonary disease (COPD) with polycythemia.

Oral mucosa –
Know status of teeth such as carries and dentures. Patient should not be intubated with dentures in place.

Tongue - should be pink, moist, a moderate size with papillae (little protuberances) present.

Canker sores may be seen on the sides of the tongue in clients receiving certain kinds of chemotherapy.
Leukoplakia, persistent lesions, ulcers, or nodules may indicate cancer and should be further evaluated medically.
Induration increases the likelihood of cancer.

CN 12 (hypoglossal) – is the strength of the tongue. Decreased tongue strength may occur with a defect of the twelfth cranial
nerve

 Fasciculation (constant tongue movement) points to cranial nerve (hypoglossal, CN 12) damage.

Hard Palate: is pale or whitish with firm, transverse rugae (wrinkle-like folds) located right behind the front teeth. Due to the
rugae yeast is more common and happens in that area.

Short palate: should be pinkish, movable, spongy, and smooth.

Uvula: should rise symmetrically when saying ahhh - Asymmetric movement or loss of movement may occur after a
cerebrovascular accident (stroke). Palate fails to rise and uvula deviates to normal side with cranial nerve X (vagus) paralysis.

Tonsils and how they are graded:

Abnormal findings: bright red throat, drainage purulent, ulcers

Pg 377: know these!

Pg 379 Know abnormalities of the nares
Chapter 23 
1. Describe the structures and functions of the abdomen.

Abdomen- oval cavity extending from diaphragm to pelvis, Abdominal wall muscles-Protect internal organs;
Internal anatomy-Parietal peritoneum; thin, shiny serous membrane; protective covering for organs; Abdominal
Viscera: (Solid and hollow)
Internal Anatomy
- Solid viscera: Organs that maintain their shape consistently- Liver, pancreas, spleen,
kidneys, ovaries, uterus
-Hollow viscera: Organs that change shape depending on their contents Stomach, gallbladder,
intestines, colon, bladder
- Vascular structures- Aorta, Iliac arteries

2. Identify the organs located in each of the quadrants and the nine regions of the abdomen.
3. Discuss the incidence of peptic ulcer disease and ways to reduce one’s risks.
4. Describe the teaching opportunities to reduce the risks of peptic ulcer disease and to promote health.
5. Describe an accurate nursing history of the client’s abdomen and related functions.
6. Discuss a physical assessment of the abdomen using the correct techniques of inspection, auscultation,
palpation, and percussion.

Subjective Data: Indigestion-pyrosis/heartburn, GERD, peptic ulcer, stomach cancer; Nausea/vomiting-Liver,

pancreas, renal, dietary intolerances, morning sickness; Appetite- Women – LMP, Medications; Bowel
elimination-Change in pattern, color of stool, constipation, diarrhea; Yellowing of skin; Past History- UTI, GI
disorder, pancreatitis, gallbladder, hepatitis; Lifestyle/Health- ETOH, stress; Abdominal pain- Character (dull,
aching, knife-like, etc.), Onset: Onset of pain is a
diagnostic clue, whether sudden or gradual, Location: Area, radiation, Duration, Severity 0-10, Pattern: Timing
& relationship of events-clue to origin of pain, Precipitating factors: Alcohol, supine, stress, Alleviating factors:
Antacids, H2 blockers, Associated Factors: Tarry stools, abdominal cramping, nausea, vomiting, diarrhea,
weight loss, lack of energy

-Examination Sequence is different. Why?

1) Inspection
2) Auscultation
3) Percussion
4) Palpation

-Preparation- Good lighting + tangential lighting; drape breast & genitalia area; adjust bed height; explain
procedures; warm hands, Have client empty bladder first, Approach client from the RIGHT SIDE, Help
promote abdominal muscle relaxation, Overcome ticklishness. Position supine, head on pillow, knees slightly
flexed; arms at side OR hands resting on center of chest, DO NOT put arms above head, tenses abdominal
muscles, Examine painful areas last
-Inspect Skin- Observe coloration-May be paler RT not exposed to sun; Abn. Purple, yellow, pale &
taut, redness, bruises; Note vascularity-Scattered fine veins may be visible; Abn. Dilated veins seen with
cirrhosis, ascites, portal hypertension; Observe any striae-New striae are pink or bluish in color; older striae
silver, white, linear; Abn. Dark bluish pink with Cushing’s syndrome, May be RT ascites; Inspect for scars-
Document size/location and healing; Abn. nonhealing, keloids; Assess for lesions/rashes- Flat, brown moles
normal; no rashes; Abn.-Changes in mole; bleeding moles or petechiae; Inspect umbilicus, location, and
contour, Skin tones similar to surrounding skin or pinkish Midline, round, inverted; or small protruding; Abn.
deviated with mass, enlarged organs, fluid or scar tissue, Everted with abdominal distention or hernia, Cullen’s
sign (bluish-purple) from intra-abdominal bleeding; Inspect piercings for intactness; should be no redness or
discharge; Inspect Abdominal Contour-Sitting at the client’s side; look across the abdomen, slightly higher
level; Normal flat, rounded or scaphoid in thin adults, evenly rounded Abn. Generalized protuberant or
distended abdomen RT air, obesity, fluid, organ enlargement, full bladder, uterine enlargement, ovarian tumor
or cyst, fibroid tumors, (6 Fs of Abdominal Distention); Measure abdominal girth (Table 23-2)] Abn. Scaphoid
can be abnormal with severe weight loss; Assess abdominal symmetry- Abdomen is symmetric; Abn.
Asymmetry-organ enlargement, masses or bowel obstruction; If indicated, assess for hernias or mass, Ask client
to raise the head; normally no bulge; Abn. A hernia is seen as a bulging into the abdominal wall (Abn.
umbilical & incisional hernias); Inspect abdominal movement; respiratory movement may be seen in males;
Observe aortic pulsations- Slight pulsation from aorta, visible in the epigastrium; Abn. Vigorous, wide
exaggerated pulsation with abdominal aortic aneurysm, Best screening for aneurysm is ultrasound, Recommend
1-time screening men 65-75 with past hx of smoking, for abdominal aortic aneurysm; Observe for peristaltic
waves- Normal only in thin people; Abn. Intestinal obstruction; Demeanor should be relaxed; Abn. With pain-
restlessness v. extreme stillness v. knees and grimacing with pain

-Auscultation-Auscultate BEFORE percussing & palpating to Avoid increasing peristalsis/false interpretation of

bowel sounds; Use diaphragm, warmed; Begin in the RLQ – ileocecal valve then
proceed clockwise, all 4 quads; Apply light pressure on a tender abdomen; Normally you hear soft clicks/
gurgles (5-30X/min)
-Hyperactive sounds (borborygmus); loud sounds (stomach growling)
Abn. rapid motility in early bowel obstruction, GE, diarrhea
-Hypoactive- Abn. diminished motility, paralytic ileus, peritonitis or late bowel obstruction; listen
for 5 minutes before reporting no bowel sounds (absent)
Bowel sounds return gradually post-op; small intestines in 1st few hours; colon 3-5 days
Auscultate Vascular Sounds- Bell- listen for bruits over the abdominal aorta, renal, iliac &
femoral , esp. in clients with hypertension or arterial insufficiency- Normally no bruits; Abn. Turbulent blood
flow/obstruction with aneurysm or stenosis, Confirm w/ angiogram or ultrasound
-Abdominal Aorta and Aneurysm- A sac formed by dilation in the artery wall; Atherosclerosis-
weakens vessel walls; BP creates the balloon enlargement; Most below renal arteries, extending to
umbilicus; feels like a pulsating mass to left of midline (don’t palpate), Audible bruit; decreased femoral
pulses, Lower abdominal & lower back pain
-Percussion-Nurses may or may not typically perform; Indirect percussion- assess for tones & density of
abdominal contents, locate organs, screen for fluid or masses; Use same sequence as for
auscultation, clockwise; tympany -all 4 quads (air in intestines rises to surface when supine); Dullness (expected
sound over organ, i.e. liver or spleen, full colon); Abn. Dullness – over distended bladder (suprapubic
area),enlarged organ, masses or ascites (all abnormal)
Considerations for Palpating the Abdomen: Box 23-2: Tender/painful areas LAST, Light palpation
BEFORE deep palpation, Normal abdomen MAY be tender, Overcome ticklishness/
minimize voluntary guarding using client self-palpation and stethoscope, Promote
relaxation/minimize voluntary guarding, Pillow under the knees, Ask client to take slow, deep breaths
through the mouth, Apply light pressure on sternum to encourage relaxation of abdominal muscles

-Measuring Abdominal Girth: Assessment Guide 23-: Abdominal distention- measure abdominal girth, evaluate
progress or treatment of distention, Measure girth-same time of day, morning, just after voiding, or at
designated time for bedridden clients or those with catheters; Standing- ideal position; otherwise supine
position, head slightly elevated; same position for all measurements; Use disposable/cleaned tape measure;
measure at umbilicus, Record the distance in inches or centimeters, Take all future measurements from the same
location

-Light Palpation- Light palpation-to ID areas of tenderness, resistance, Use fingertips; palpate a nontender
quadrant; press to a depth of 1cm; Minimize voluntary guarding (Box 23-2) Avoid tender areas UNTIL LAST
Light palpation BEFORE deep palpation, Overcome ticklishness/voluntary guarding; client performs self-
palpation, Light pressure over sternum while palpating to relax abdominal muscles; Abdomen is nontender and
soft with no guarding; Abn. Involuntary reflex guarding often reflects peritoneal irritation; abdomen is rigid &
rectus muscle fails to relax; Right-sided guarding with cholecystitis

-Deep Palpation (not routinely performed)- Deeply palpate all quadrants to delineate abdominal organs and
detect subtle masses; Figure 23-20 Normally palpable structures, Use palmar surface of fingers; press 5-6 cm-
Normal mild tenderness possible; no masses present; Abn. Severe tenderness or pain- RT trauma, peritonitis,
infection, tumors, or enlarged or diseased organs, Masses may be due to tumor, cyst, enlarged organ, aneurysm
or adhesions

-Palpation-Palpate umbilicus/surrounding areas for bulges/masses; Normally free of swelling, bulges or masses;
Abn. A soft center can be a potential for herniation, A hard nodule- metastatic nodes from an occult GI cancer;
The aorta is not routinely palpated; in clients older than 50 with suspected aneurysm, may palpate width (wide,
bounding pulse may be aneurysm)
* DO NOT PALPATE A PULSATING MIDLINE MASS; a dissecting aneurysm rupture*
-Palpating the Liver- Liver not normally palpable but may be felt in thin client- should be firm, smooth & even
MILD tenderness may be normal; Abn. Hard, firm liver -cancer; nodularity with tumors, metastatic cancer,
cirrhosis or syphilis, A liver > 1-3 cm. below costal margin is enlarged
-Palpating the Spleen- Not commonly performed by staff nurses- Stand on pt. right side; reach left arm over the
abdomen; place your hand under the posterior lower ribs- Pull up gently; place your
right hand below the left costal margin with fingers pointing toward the head, Ask client to inhale and
press inward and upward as you provide support with other hand; be gentle; The spleen is seldom palpable at
the left costal margin. If palpated, should be soft, nontender; A palpable spleen suggests enlargement (up to 3
times normal size) resulting from infection, trauma, mono, chronic blood disorders and cancer
-Palpation of Kidneys-NOT COMMONLY PERFORMED; Left normally not palpable; Right
lower, may feel round, smooth
-Palpate the Urinary Bladder- Palpate for distended bladder when the client’s history or other findings warrant;
Begin at the symphysis pubis and move upward & outward; An empty bladder is not palpable NOR tender;
Abn. Distended bladder- smooth, round, and firm mass extending as far up as the umbilicus, May be dull to
percussion
-Inspect for Ascites- Inspect for fluid especially if suspect ascites; Ascites causes a fluid wave through the
abdomen
-Test for Appendicitis (Not routinely performed by nurses)- Assess for rebound tenderness; palpate deeply at
90 degrees into abdomen away from painful area; Sharp, stabbing pain with release of pressure (Blumberg’s
sign) suggests peritoneal irritation from appendicitis; Test for referred rebound tenderness—deep palpation in
LLQ. Pain in RLQ is (appendicitis).Avoid continued palpation RT danger of rupturing appendix; Assess for
psoas sign: Normally no pain; Pain in RLQ suggests inflamed appendix; Obturator sign- No abdominal pain;
Abn. Pain in RLQ suggests irritation
of obturator muscle due to appendicitis or perforated appendix

-Test for Cholecystitis- Assess the RUQ for tenderness; Press your fingertips under the liver border at the right
costal margin and ask the client to inhale deeply; No increase in pain is present Abn. Accentuated sharp pain
that causes the client to hold his breath (inspiratory arrest) is a positive Murphy’s sign, associated with
cholecystitis

-Acute Abdomen- Acute abdominal pain is a symptom of intra-abdominal disease- May be the sole indicator of
need for surgery; requires quick actionperforation may occur RT interruption of abdominal blood supply;
RED FLAGS are signs of shock (tachycardia, hypotension, diaphoresis,
confusion), signs of PERITONITIS, and abdominal distention along with pain

-Peritonitis: Inflammation of the peritoneum—bacterial or fungal infection; Primary (rare); Secondary-

infection enters peritoneum from the GI or biliary tract; May be RT a tear in GI or biliary tract, i.e. pancreatitis,
ruptured appendix, stomach ulcer, diverticulitis; Often caused by liver disease; build-up of fluid creates an
environment for bacterial growth; Symptoms: Swelling & abdominal
tenderness, pain ranging from dull ache to severe, sharp pain, Fever, chills, N/V, thirst,
low urine output

7. Differentiate between normal and abnormal findings of the abdomen.

-Peptic Ulcer Disease

-Risk Assessment- H. pylori in GI tract, Excessive ETOH, Use of NSAIDs, Smoking, Serious
illnesses, Uncontrolled stress as contributing factor
-Client Education- Effective handwashing, Eat foods cooked completely, Take pain meds as
directed (dose, with food, avoid drinking ETOH), Stop smoking, Take GI med per order

-Abn. Tenderness/sharp pain over the CVA suggests kidney infection (pyelonephritis), renal calculi, or
hydronephrosis (over 12th rib)

8. Describe the findings frequently seen when assessing the abdomen in individuals across the lifespan.

- Sources of Abdominal Pain

- Visceral pain: Organs distended/stretched, Poorly defined/localized and intermittently timed Dull,
aching, burning, cramping, colicky
- Parietal pain: Parietal peritoneum inflamed, Localized to source, severe and steady, Referred pain:
Distant sites; travels/refers; localized at distant site
*Know Box 23-1 Patterns of referred pain

9. Analyze the data from the interview and physical assessment of the abdomen to formulate valid nursing
diagnoses, collaborative problems, and/or referrals.

-Abnormal Findings
-Abdominal Distention, 23-1
- Abdominal Bulges, 23-2 Umbilical hernia & incisional hernia
 - Enlarged abdominal organs, 23-3- Enlarged liver, enlarged nodular liver, enlarged spleen,
enlarged gallbladder, aortic aneurysm

Chapter 16
1. Describe the structures and function of the eyes.

-External Structures of the Eye

– Eyelids, inner/outer canthus, palpebral fissure, eyelashes, conjunctiva, lacrimal apparatus,
puncta, extraocular muscles
- Internal Structures of the Eye
– Sclera, cornea, iris, pupil, lens, retina, optic disc, macula, anterior chamber, humors
- Visual Fields & Visual Pathways
– Visual field: what a person sees with 1 eye (nasal and temporal, upper/lower)
– Pathways: Light rays strike retina  optic nerve; cross at optic chiasma

2. Discuss the risk factors for cataracts and ways to reduce those risk factors.

-Glaucoma- Risk Assessment: Ethnicity, aging, Caucasian: > 60, Afr. American > 40, Family history, Diabetes,
Hypothyroidism, Eye injuries, tumors, Prolonged corticosteroid use, Nearsightedness
• Screening: Regular eye exams, comprehensive for all adults age 40+; every 3-5 years w/o r risk
factors; yearly screening after age 60
– Known risk, African American periodic eye exams age 20-39 & every 1-2 years after age 40

-Macular Degeneration-• Risk Assessment: Age 50; then 70+, Smoking, Light-eye color, Family history,
Gender (higher in female), Race (Caucasians higher), Prolonged sun exposure, Hypertension/CV disease
• Screening: Comprehensive eye exams every 1-2 years for age 65+ who have no risk factors
Annual eye exams age 61+, Eval/screening for ALL women 65+, Visual acuity tests
• Teaching Avoid smoking Regular exercise, keep BP normal; healthy weight

-Cataracts- Clouding of the usually clear lens of the eye, like looking through a frosty or foggy window; Most
cataracts develop slowly and are often found over 65 years of age; With age, the lens becomes less flexible,
thicker and less transparent as tissues break down or clump together, turning the lens yellow or brown
• Risk Assessment: Increasing age (often start developing at 30 years of age; most prevalent by age
75, Diabetes, Excessive alcohol use
• Screening: Conflicting evidence; Some recommend screening visual acuity in adults
older than 65

Distant Visual Acuity: Snellen Chart

• Stand 20 ft. away; chart at eye level; Cover one eye; remove reading glasses
• 20/20 normal--larger the denominator, poorer vision
– Abn. Myopia (impaired far vision); legally blind at 20/200 or less

• Presbyopia—loss of elasticity, accommodation

Perform Corneal Light Reflex (Hirschberg Test)- Symmetric light reflection in both corneas is expected
response Hold penlight 12 in from the client’s face. Shine the line toward the bridge of the nose while the client
stares straight ahead.

Confrontation Test
• Gross measure of peripheral vision, visual fields; Compares patients peripheral vision with yours
Eye level, 2 feet away; cover eye opposite pt. Test uncovered eye; use an object/your finger; extend
arm at midline; slowly advance upward from below, superiorly, temporally & nasally Should see object at same
time as examiner

Extraocular muscle function: Perform Cover Test

• Detects small degrees of deviation Cover 1 eye w/card; observe uncovered eye Normal: Steady, fixed gaze
Uncover/observe newly uncovered eye; repeat with other eye
Abn. W/ weakness, eye moves, attempt refocus – Phoria: mild weakness; – Strabismus: constant
malalignment – Tropia: specific esotropia or exotropia

Extraocular Muscle Function: Positions Test

Assess eye muscle strength & CN function in 6 cardinal fields of gaze
– Normal: smooth, symmetric movement through 6 fields; parallel tracking with no nystagmus
- CN III, IV, VI– Can tell specifically which muscle is weak; Six point star pattern, clockwise direction
- Abn: Nystagmus- oscillation Lid lag- white rim of sclera between

3. Describe an accurate nursing history of the eyes and vision.

Subjective Data-Vision difficulty/change, Difficulty seeing at night, Spots or floaters, Blind spots, Halos/rings,
Eye itching or pain, Photophobia, Redness or swelling, Watering/tearing/discharge, Surgery/treatments,
Glasses/contacts, Medications, Last eye exam, Glaucoma test, Family history, Lifestyle: Workplace exposures,
wear sunglasses, aids to visual loss, smoking,

4. Discuss a physical assessment of the eyes and visual acuity correctly using inspection and visual testing.

-Visual Reflexes
• Pupillary Light Reflex
– No conscious control; Sensory link (afferent) is CN 2 (Optic); Motor link (efferent) is CN 3 (Oculomotor);
Direct light reflex; Constriction of same-sided pupil exposed to light; Consensual (indirect) light reflex;
Exposure to light in 1 eye results in constriction of the pupil in the opposite eye
• Accommodation
– Reflex allowing eyes to focus on near objects, Curvature of the lens increases through
movement of the ciliary muscles, Observed through convergence (motion toward) axes of eyeballs/ pupillary
constriction

5. Differentiate between normal and abnormal findings of the eyes and visual acuity.

• Glaucoma- damages the eye's optic nerve when fluid builds up in anterior part of the eye
– Caused by eye injury, inflammation, tumor, advanced cataracts, or diabetes.
• Primary open angle glaucoma: Gradual loss of peripheral vision, usually in both eyes; tunnel vision in the
advanced; eye drainage canals clogged
stages.
• Acute angle closure glaucoma: Severe eye or eyebrow pain, severe headache, nausea/vomiting, sudden onset
of visual disturbances, blurred vision, rainbow halos around lights, reddening of the eye; Drain is functioning
properly but is blocked
• Macular degeneration: vision is affected in the central visual fields, impacts reading, driving, recognizing
faces
– Early symptom is blurred vision or straight lines appear crooked.

Inspect External Ocular Structures

• Eyelids & Lashes- Upper lid margin- between upper margin of iris & upper margin of pupil; lower lid rests on
lower border of iris
• Abn: Ptosis (drooping w/ CN III damage, myasthenia gravis; retracted lid margins with hyperthyroidism
- Palpebral fissures horizontal in non-Asians
– Upper and lower lids close easily and meet completely; Lower eyelid is upright with no inward or outward
turning
-Normal variation- xanthelasma—raised yellow plaque
• Abn: Entropion or ectropion- No redness, swelling, discharge, lesions
• Abn: seborrhea, blepharitis, staph infection, stye, periorbital edema

-Periorbital Edema: Puffy lids with local infections, crying; Systemic conditions: CHF, renal failure, Myxedema
-Ptosis: (Drooping Upper Lid) CN III damage (Oculomotor) Or with muscle weakness (myasthenia gravis)

6. Describe the findings frequently seen when assessing the older client’s eyes and visual acuity.
7. Analyze the data from the interview and physical assessment of the eyes and visual acuity to form
nursing diagnoses, collaborative problems, and/or referrals.
Chapter 20

1. Describe the structure and functions of the breast and major axillary lymph nodes.

-Glandular tissue- arranges in 15-20 lobes; only kind that produces milk, lobules & secreting alveoli; mammary
ducts- lactiferous ducts, nipple- lactiferous sinus (areas where milk is stored)
- Fibrous Tissue- suspends breast; cooper ligaments
-Fatty Tissue- adds bulk and shape to breast
-Axillary Lymph Nodes-anterior, posterior, lateral & central

2. Discuss the risk factors for breast cancer and ways to reduce one’s risks.

-Breast Cancer Classification- Type & Grade (1-3)

-Estrogen/Progesterone receptors positive or negative
-Heu2/neu positive or negative
-DNA & other gene expressions
-Ductal carcinoma in situ- well encapsulated
-Invasive ductal carcinoma- not well encapsulated
-Medullary Carcinoma
-Invasive Lobular Carcinoma
-Triple Negative Carcinoma
-Tubular Carcinoma etc.

-RF- female, age, BRCA1/BRCA2 genes, race, family history, personal history, breast consistency, early
menstruation/late menopause, radiation to chest, exposure to diethylstilbestrol
-Modifiable RF- no children or first child > age 30, recent oral contraceptive use, hormone replacement therapy,
no history of breast feeding, alcohol consumption, overweight, limited physical activity, second-hand smoke

3. Describe an accurate nursing history of the breast and axillary lymph region.

4. Discuss a physical assessment of the breast and lymphatic tissues using the correct techniques of
inspection, auscultation, palpation.
-HPI- lumps or swelling- related to menstrual cycle? in axillae? Redness, warmth, dimpling of breasts; rash on
breast/nipple/axillary area, change in size/firmness, pain in breasts—COLDSPA, discharge from nipples

-History- Prior breast disease, surgery or trauma; age of menarche/menopause; children/age of first child; 1st and
last day of menstrual cycle; history of breast cancer in family; hormone/contraceptive use; exposure to
radiation, benzene, asbestos; typical diet, alcohol/caffeine use; exercise * protective equipment; perform self-
breast exam? had a mammogram? and result

-Inspection- size, symmetry, color, texture, superficial venous pattern, retraction/dimpling palpate texture,
elasticity, tenderness, temperature; demonstration of BSE; Focused- palpate nipples for discharge/breasts for
mass, palpate mastectomy/lumpectomy site and inspect/palpate axillae
-Palpation- masses- location, size, shape, mobility, consistency, tenderness, consistency of skin, nipples- send
specimen of discharge, mastectomy/lumpectomy site, axillae, BSE demo
Benign Masses
-Fibroadenoma- 1-5 cm, round, nontender, mobile, solid, elastic
-Milk cysts
-Lipoma-soft fatty tissue
-Intraductal papilloma
-Male- may be enlarged with obesity; gynecomastia- smooth firm movable disc of glandular tissue may be seen
in puberty, hormonal imbalance, drug abuse, cirrhosis, leukemia, thyrotoxicosis
-irregular hard nodules occur in breast cancer

-Breast palpation- client lying with same side arm up, pillow or roll under breast being palpated, flat pads of
three fingers, palpate systemically, be sure to palpate every square inch including nipple & tail of spence,
bimanual technique for large breasts

5. Differentiate between normal and abnormal findings of the breasts and lymphatic system.

6. Explain how to teach clients how to perform breast self-examinations.

7. Describe the findings frequently seen when assessing the breasts and axillary lymph nodes in in
individuals across the lifespan.

8. Analyze data from the interview and physical assessment of the breasts and axillary lymph nodes to
form nursing diagnoses, collaborative problems, and/or referrals.

-readiness for enhances knowledge- requests information for SBE; risk for ineffective health maintenance r/t
lack of breast self-awareness, fear of breast cancer r/t increased risk factors; disturbed body image r/t
mastectomy; r/c mastitis, benign breast disease, breast cancer

Chapter 30

1. Complete a newborn history by reviewing prenatal records with parents.

2. Discuss an initial physical assessment of the newborn using correct techniques.

3. Discuss follow-up physical assessments of the newborn using correct techniques.

4. Differentiate between normal and abnormal assessment findings seen in the initial and subsequent
assessments of the newborn.

5. Analyze data from the interview and initial and subsequent physical assessments of the newborn to form
nursing diagnoses, collaborative problems, and/or referrals.

6. Differentiate between general routine screening versus skills needed for focused or specialty assessment
of the newborn.

7. Document and verbally report accurate assessment findings of the newborn.

Diagnostic Reasoning Process

 Step one - Identify abnormal data and strengths
 Step two - Cluster data (related abnormal findings)
 Step three - Draw inferences “hunches”
 Step four: Propose possible nursing diagnoses (actual, risk, promotion)
 Step five - Check for defining characteristics(use references i.e. NANDA)
 Step six - Confirm or rule out diagnosis (validate)
 Step seven - Document conclusions( nursing or risk diagnosis)
Part 1: The diagnosis (NANDA) Ineffective breathing pattern
Part 2: The cause (related to) Related to impaired chest wall expansion
Part 3: The evidence or symptoms As evidenced by RR 28, nasal flaring, tripod positio

Exam 3 Listen to office hours on the 21st

Module 8 Objectives
Chapter 17

1. Describe the functions and the structures of the ear.

 The ear is the sense organ of hearing & equilibrium

-External ear
• Auricle (Pinna)
• External auditory canal: S-shaped structure; Modified sweat glands secrete cerumen
• Tympanic membrane (eardrum): Translucent, pearly gray appearance; Separates the
auditory canal from the middle ear; Cone of light reflects otoscope light
- Middle ear: A small, air-filled chamber; 3 small bones- transmitting sound waves (malleus,
incus, stapes); Air pressure equalized on both sides of the tympanic membrane by eustachian
tube, connects the middle ear to the nasopharynx
-Inner ear: Contains the organ of Corti – sensory organ of hearing

 Conductive Hearing- transmission of sound waves through the external and middle ear
-Loss- dysfunction of external or middle ear
ex. (impacted ear wax; otitis media, foreign object, perforated eardrum, drainage of
middle ear, otosclerosis)
 Sensorineural (Perceptive) Hearing- transmission of sound waves in the inner ear
-Loss- dysfunction of the Organ of Corti, Cranial Nerve VIII, or temporal lobe

2. Discuss the risk factors for hearing loss and ways to reduce one’s risks.

3. Describe an accurate nursing history of the ears and hearing.

 Subjective
- Changes in Hearing- Hearing loss or sounds affected
-Drainage- Otorrhea
-Earache-Otalgia
-Swimmer’s Ear
-Nausea/Dizziness
-Tinnitus (Ringing/Roaring/Crackling in ears)
-Vertigo- Sensation of spinning or room spinning
-History of repeated Infection
-Lifestyle- Environmental Noise, Swimming, Hearing Loss, ADL’s, Socialization, Last
Hearing Exam, Hearing Aid, Ear Care/Cleaning

4. Discuss a physical assessment of the ears and hearing ability using the correct techniques.

-
6. Differentiate between normal and abnormal findings of the ear and hearing.

7. Describe the findings frequently seen when assessing the older client’s ears and hearing.

8. Analyze the data from the interview and physical assessment of the ears and hearing to form
nursing diagnoses, collaborative problems, and/or referrals.

• Air conduction v. bone conduction

-Ears and Kidneys Develop during 5th to 8th week of pregnancy—Genetic problem with coordinating
development during this time OR Non-Genetic problem like an infection may affect development of
both areas at the same time—IF HEARING PROBLEMS—ASSESS Kidneys.

Chapter 25

1. Describe the structures and function of the central and peripheral nervous system.

2. Discuss the risk factors for stroke (also known as cerebral vascular accident [CVA]) across cultures
and ways to reduce one’s risks.

3. Describe the teaching opportunities to reduce a client’s risk of stroke and to promote health.

4. Describe an accurate nursing history of a client’s neurologic system.

5. Discuss a physical assessment of the nervous system using the correct techniques of inspection,
auscultation, palpation, and percussion.

6. Differentiate between normal and abnormal findings of the nervous system.

7. Describe the findings frequently seen when assessing the older client’s nervous system.

8. Analyze the data from the interview and physical assessment of the nervous system to formulate
valid nursing diagnoses, collaborative problems, and/or referrals.

Chapter 31 Video NOT ON EXAM

2.  Interview children, adolescents, and their parents or caregivers as appropriate for an accurate
nursing history.

3.  Discuss a physical assessment of children/ adolescents using correct techniques.

4.  Differentiate between normal and abnormal findings of children and adolescents.
5.  Describe the findings frequently seen with assessing children and adolescents.

6.  Analyze the data from the interview and physical assessment of children and adolescents to form
nursing diagnoses, collaborative problems, and/or referrals.

7.  Communicate interview and assessment findings through clear concise documentation and verbal
reports.

Module 9 Objectives ?
Chapter 11

Chapter 12

Chapter 32 Video NOT ON EXAM

Module 10 Objectives
Chapter 26 Video

1. Describe structure and functions of the male genitalia, anus, rectum, prostate
2. Discuss incidence of prostate cancer and ways to promote health.
3. Discuss the incidence of testicular cancer across cultures and ways to promote health.
4. Describe accurate nursing history of male client’s genitalia, anus, rectum, prostate.
5. Discuss a physical assessment of the male genitalia, anus, rectum, and prostate using the
correct techniques of inspection, auscultation, and palpation.
6. Differentiate between normal and abnormal findings of the male genitalia, anus, rectum, and
prostate.
7. Describe the findings frequently seen when assessing the male genitalia, anus, rectum, and
prostate in individuals across the lifespan.
8. Analyze the data from the interview and physical assessment of the abdomen to formulate
valid nursing diagnoses, collaborative problems, and/or referrals.
 Chapter 27 Video

1. Describe the structure and functions of the female genitalia, anus, and rectum.
2. Discuss risk factors for cervical cancer and ways to reduce these risks.
3. Describe teaching opportunities to reduce risks of cervical cancer and ways to promote health.
4. Discuss risk factors for colorectal cancer and ways to reduce these risks.
5. Describe an accurate nursing history of the female client’s genitalia, anus, and rectum and
related functions.
6. Discuss a physical assessment of the female client’s genitalia, anus, and rectum using the
correct techniques of inspection and palpation.
7. Differentiate between normal and abnormal findings of the female client’s genitalia, anus, and
rectum.
8. Describe the findings frequently seen when assessing the genitalia, anus, and rectum in
individuals across the lifespan.
9. Analyze data from interview and physical assessment of client’s genitalia, anus, and rectum to
form nursing diagnoses, collaborative problems, and/or referrals

Module 11 Objectives
Chapter 28 Video

1. Explain how to prepare yourself and the client for a holistic nursing interview and head-to-toe
integrated physical examination.
2. List all the equipment needed for a total physical examination.
3. Describe the parts of the physical examination that can be integrated within assessment of
each of the body systems.
4. Correctly interview a client for an accurate holistic nursing history.
5. Correctly perform a total head-to-toe integrated physical examination, identifying normal and
abnormal findings.
6. Analyze data from a holistic nursing interview and head-to-toe integrated physical assessment
to formulate valid nursing diagnoses, collaborative problems, and/or referrals.

3320 Exam 3 Objectives 

Module 8 Objectives
Chapter 17
1. Describe the functions and the structures of the ear.

   The ear is the sense organ of hearing & equilibrium

-External ear
• Auricle (Pinna)
• External auditory canal: S-shaped structure; Modified sweat glands secrete cerumen
• Tympanic membrane (eardrum): Translucent, pearly gray appearance; Separates the  
auditory canal from the middle ear; Cone of light reflects otoscope light
- Middle ear: A small, air-filled chamber; 3 small bones- transmitting sound waves (malleus,
incus, stapes); Air pressure equalized on both sides of the tympanic membrane by eustachian
tube, connects the middle ear to the nasopharynx
-Inner ear: Contains the organ of Corti – sensory organ of hearing

    Conductive Hearing- transmission of sound waves through the external and middle   ear
    -Loss- dysfunction of external or middle ear
  ex. (impacted ear wax; otitis media, foreign object, perforated eardrum,   drainage of middle
ear, otosclerosis)
    Sensorineural (Perceptive) Hearing- transmission of sound waves in the inner ear
     -Loss- dysfunction of the Organ of Corti, Cranial Nerve VIII, or temporal lobe
 

2. Discuss the risk factors for hearing loss and ways to reduce one’s risks.
RISK Assessment: Premature birth/hypoxia, Rubella or infections, Neonatal Jaundice, Head Injury,
Wax/Foreign Bodies, Bottle-Fed, Poor Air Quality, Ethnicity, Aging, Heredity, Ototoxic Medication,
Illnesses especially w/high fevers, Noise exposure (Occupational/Recreational), Smoking, CV Risk
Factors
Risk Reduction: Childhood Immunizations, Avoid ototoxic drugs, avoid bottle feeding supine, treat ear
infections, NB hearing screen, avoid sound exposure louder than a washing machine, avoid
recreational risks involving loud sounds/risk of head or ear injury, wear hearing protection, take
breaks from environmental noise, avoid very loud music especially age 50+
 
3. Describe an accurate nursing history of the ears and hearing.
Subjective
 
 -Changes in Hearing- Hearing loss or sounds affected
 -Drainage- Otorrhea
 -Earache-Otalgia
 -Swimmer’s Ear
 -Nausea/Dizziness
 -Tinnitus (Ringing/Roaring/Crackling in ears)
 -Vertigo- Sensation of spinning or room spinning
 -History of repeated Infection
 -Lifestyle- Environmental Noise, Swimming, Hearing Loss, ADL’s,           Socialization, Last
Hearing Exam, Hearing Aid, Ear Care/Cleaning
 

4. Discuss a physical assessment of the ears and hearing ability using the correct techniques.
Objective
-Evaluate condition of external ear, Normally equal in size (4-10 cm) -
Patency of Ear Canal -Status of
Tympanic Membrane -Bone & Air
Conduction -Hearing Acuity
-Equilibrium
-Palpate auricle and mastoid process-
soft, nontender, movement should not produce pain
6. Differentiate between normal and abnormal findings of the ear and hearing.
-Abnormal: Ears smaller/larger than normal; Mal-aligned/Low Set Ears (genitourinary disorders or
chromosomal defects); Enlarged lymph nodes, tophi (gout), blocked sebaceous glands,
ulcerated/crusted/bleeding nodules (skin cancer), redness, swelling, scaling, itching (otitis externa),
pale/blue ear (frostbite) -Tophi: Hard nodules containing uric
acid crystals related to gout -Sebaceous Cyst- painful nodule
-Carcinoma-ulcerated nodule with clear borders
-Otitis externa or Postauricular Cyst- may have painful
auricle or tragus; Otitis externa may have foul smelling yellow discharge, redness, swollen
canal -Mastoiditis-may have tenderness over mastoid process
-Otitis Media- may have tenderness behind the ear, red building drum diminished
light reflex; Otitis Media with ruptured Tympanic Membrane may have bloody,
purulent discharge -Polyp
-Normal Variation: Darwin’s Tubercle (normal variation); 
-Normal: Smooth skin no lesions/nodules, color consistent with face color, no discharge
 
7. Describe the findings frequently seen when assessing the older client’s ears and hearing.
Eardrum may appear cloudy-atrophy of Tympanic Membrane. Inability to hear high frequency sounds
related to degeneration of hair cells. Coarser/Thicker hair in the external ear only abnormal if it
impairs hearing. Earlobes elongate with wrinkles. Cerumen decreased, dryer, harder, only abnormal if
it becomes impacted and impairs hearing.
 
8. Analyze the data from the interview and physical assessment of the ears and hearing to
form nursing diagnoses, collaborative problems, and/or referrals.
 
 
• Air conduction v. bone conduction
-Ears and Kidneys Develop during 5 to 8 week of pregnancy—Genetic problem with coordinating
th th

development during this time OR Non-Genetic problem like an infection may affect development of
both areas at the same time—IF HEARING PROBLEMS—ASSESS Kidneys.
 -Ear Care: Wax-Natural, self cleaning agent; NOT FOR REGULAR USE. Only remove it causing a
problem, soften with mineral oil. DON’T put anything into the ear canal -Candling/Coning-
place cone-shaped device in ear canal to extract earwax and other impurities; creates low-level
vacuum to draw out wax; risk of burns and perforation of the Tympanic Membrane.
 -Client Education: Use devices to improve hearing loss, Check hearing periodically after age 50
Chapter 18 Objectives
Describe the structure and functions of the mouth, throat, nose, and sinuses.
 
 The mouth and throat comprise the first part of the digestive system and are responsible for receiving
food (ingestion), tasting, preparing food for digestion, and aiding in speech. 
 Cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), and XII (hypoglossal) assist with some
of these functions
 The nose and paranasal sinuses constitute the first part of the respiratory system and are responsible
for receiving, filtering, warming, and moistening air to be transported to the lungs. Receptors of cranial
nerve I (olfactory) are also located in the nose. These receptors are related to the sense of smell.
 
 Structure and function of the mouth: 
 o The mouth is formed by the lips, cheeks, hard (bone)  and soft palate (muscle), uvula, the
tongue and its muscles.
o The mouth is the beginning of the digestive tract and serves as an airway for the respiratory
tract. 
o The upper and lower lips form the entrance to the mouth, serving as a protective gateway to the
digestive and respiratory tracts. 
o The roof of the oral cavity is formed by the anterior hard palate and the posterior soft palate. 
o An extension of the soft palate is the uvula, which hangs in the posterior midline of the
oropharynx. 
o The cheeks form the lateral walls of the mouth, whereas the tongue and its muscles form the
floor of the mouth. 
o The mandible (jaw bone) provides the structural support for the floor of the mouth.
o The tongue assists with moving food, swallowing, and speaking.
 Muscle connected to the floor of the mouth by the frenulum
o Frenulum: Connects the tongue to the floor of the mouth
o Gums: Also called gingiva. Covered by mucous membranes and hold 32 permanent adult teeth

 Structure of the throat:

o The throat (pharynx) is located behind the mouth and nose
o It is a muscular passage for air and food
o Upper part = nasopharynx
o Middle part = oropharynx
o Lower part = larynopharynx 
 Structure of the nose:
o External nose = bridge, tip, nares
o Nasal septum separates cavity into 2 halves
o Front of the septum contains blood vessels-Kiesselbach’s area, common for bleeding
o Nasal hairs filter large particles; blood supply of the nose warms inspired air as it is
moistened by mucous membranes

 Structure of the sinuses:

o 4 pairs = frontal, maxillary, ethmoidal, and sphenoidal which are located in the skill
o These air-filled cavities decrease the weight of the skull and act as resonance chambers
during speech
o The sinuses are often a primary site of infection because they can easily become
blocked. 
o The frontal sinuses (above the eyes) and the maxillary sinuses (in the upper jaw) are
accessible to examination by the nurse. 
o The ethmoidal and sphenoidal sinuses are smaller, located deeper in the skull, and are
not accessible for examination.
 o

 
 
 
Discuss the risk factors for oral cancer and ways to reduce one’s risks.
 
 Oral diseases are more prevalent in poorer populations (dental caries, periodontal disease,
oropharyngeal lesions, and cancers)
 Higher in men versus women 
 more than 90% of oral and oropharyngeal cancers are squamous cell carcinoma.
 
Risk factors for oropharyngeal cancer as listed by the ACS (2015b) are: Area under the tongue is a
common site of oral cancers
 Using tobacco products (including cigarettes, cigars, pipes, and smokeless and chewing
tobacco, with pipe smoking being a significant risk factor)
 Heavy alcohol use
 Drinking alcohol and smoking together
 Being infected with a certain types of human papillomavirus (HPV)
 Being exposed to sunlight (lip cancer only)
 Being male (twice as common in men versus women)
 Age over 55
 Fair skin
 Poor oral hygiene
 Poor diet/nutrition: low in fruits and vegetables
 Chewing betel quid (betel nuts and lime wrapped in betel leaves), or chewing gutka (a mixture
of betel quid and tobacco), both often used in South and Southeast Asia (CDC, 2016)
  Weakened immune system
 Graft-versus-host disease
 Genetic syndromes such as Fanconi anemia, dyskeratosis congenita
 Lichen planus (skin disease with an itchy rash, which can affect mouth and throat lining and is
most noted in older people)
 Two controversial potential risks are use of mouthwash with high alcohol content and irritation
from dentures
CLIENT EDUCATION
Teach Clients
 Avoid smoking cigarettes or using oral tobacco, or get assistance to stop smoking or chewing
currently.
 Avoid excessive alcohol use, especially if you smoke.
 Avoid chewing betel nuts.
 Avoid infection with HPV, which can be transmitted through oral sex or contact with others who
are infected, or seek medical assistance if infection suspected.
 Avoid excessive sun exposure (or tanning booth exposure) to lips. Use adequate sunscreen if
unable to avoid the sun.
 Eat a diet rich in fruits, vegetables, vitamin A, and generally well rounded.
 Practice regular oral hygiene, using a soft toothbrush, dental floss at least two times per day,
and have routine dental care.
 If you have a weakened immune system, take extra precautions to avoid risks for oral cancer.
 Avoid use of mouthwash with high alcohol content
 If wearing dentures, have them checked for good fit with no irritation to gums.
 
Describe an accurate nursing history of the mouth, throat, nose, and sinuses.
 COLDSPA OF TONGUE AND MOUTH: Exploring symptoms with coldspa can provide data to
determine if lesions are associated with medications, stress, infection, trauma, or malignancy 
o Do you experience tongue or mouth sores or lesions? If so, explore the symptoms using
COLDSPA.
o Characteristics: Describe the size and texture of the lesions.
o Onset: When did they first occur? Do you notice these more when you are under stress or taking
certain medications? Did they occur after any injury to your mouth?
o Locations: Describe exactly where these lesions are located in your mouth.
o Duration: How long have you had these lesions? Have you ever had these before and did they go
away?
o Severity: Do these lesions keep you from eating, talking, or swallowing?
o Palliative/relieving factors: What aggravates these lesions or makes them go away? What over-
the-counter remedies and past prescriptions have you used?
o Associated Factors: Do you have any other symptoms with these lesions such as stress, pain,
bleeding? Describe.
GATHER A FURTHER HISTORY BY:
o Do you experience redness, swelling, bleeding, or pain of the gums or mouth? How long has
this been happening? Do you have any toothache? Have you lost any permanent teeth?
 Gingivitis: Red, swollen gums that bleed easily occur in early gum disease 
 Periodontitis: Destruction of the gums with tooth loss occurs in more advanced gum
disease.
  Dental pain may occur with dental caries, abscesses, or sensitive teeth.
 Periodontal disease is highly correlated with cardiovascular disease.
 
  
o Do you have pain in your sinuses?
 Pain, tenderness, swelling, and pressure around the eyes, cheeks, nose, or forehead
are seen in acute sinusitis, which is an infection of the sinuses. In chronic sinusitis, the
sinuses become inflamed and swollen, but symptoms last 12 weeks or longer even with
treatment
 
o Do you have a sore throat? How long have you had it? Describe. How long have you had it?
How often do you get sore throats?
 Sore throat refers to pain, itchiness, or irritation of the throat. Hoarseness may be
present as well.
 Throat irritation and soreness are commonly seen with viral infections such as the flu,
colds, measles, chicken pox, whooping cough, croup, or infectious mononucleosis, with
bacterial infections such as streptococcus, and are often present with HIV.
 

 Do you experience hoarseness? For how long?

o Hoarseness is associated with upper respiratory infections, allergies, hypothyroidism,
overuse of the voice, smoking or inhaling other irritants, and cancer of the larynx. 
o If hoarseness lasts 2 weeks or longer, refer the client for further evaluation.

 Do you have difficulty swallowing?

o Dysphagia is seen with people who have tumors
o Causes a risk for aspiration
o Late sign of oral cancer 

Differentiate between normal and abnormal findings of the mouth, throat, nose, and sinuses.
 

 Cleft lip and palate: (seen most common in native americans and asians)
 Bifid uvula: The uvula is split at the bottom (most common in asians and native americans)

 Epistaxis: nose bleed

 Rhinorrhea: Frequent clear mucus drainage from the nose
 Stuffy nose: could be from sinus congestion, obstruction or deviated septum
 Trauma: could be from deviated septum or obstruction
 Decreased smell: could be from upper respiratory infection, smoking, cocaine, or frontal lobe
tumor
 Inspect the lips for consistency and color:
 o Abnormal = pallor with anemia and shock, cyanosis with cold or hypoxia
o Abnormal = red lips with CO poisoning, ketoacidosis, and COPD with polycythemia
 Inspect teeth and gums, retract lips and cheeks
o Normal = 32 teeth. Gums pink, and moist
o Abnormal = Discolored or missing teeth; poor occlusion; red swollen gums that bleed
easily; receding gums or gingival hyperplasia
 Inspect buccal mucosa:
o Use penlight to retract lips and cheeks to check for color and consistency
o Abnormal = leukoplakia (thickened white patches in the mouth) may be seen in chronic
irritation and smoking 
o Abnormal = Candidiasis (thrush) is whitish, curd like patches that scrape off over
reddened mucosa and bleed easily 
o Abnormal = Canker sores, brown patches inside the cheeks
o Abnormal = Koplik spots is an early sign of measles. Found especially on the inside of
the cheek.

(Look in powerpoint for a lot more abnormal situations)

 Tonsil sizes:
o 1+ is visible
o 2+ is midway between tonsillar pillars and uvula
o 3+ is touching the uvula
o 4+ is touching each other 

Chapter 25: Neurovascular

1. Describe the structures and function of the central and peripheral nervous system.
Anatomy Review
CNS: Brain and spinal cord.
 Covered by the meninges, which have three layers of connective tissues.
o Dura mater - touching the bone.
o Arachnoid - middle.
o Pia mater - touching the brain.
 Subarachnoid space surrounds the brain and spinal cord.
o Filled with cerebrospinal fluid (CSF).
 Formed in the ventricles of the brain and flows through the ventricles into space.
 Cushions the brain, nourishes CNS, removes waste materials.
 Electrical activity - neurons located throughout the sensory and motor neural pathways.
o CNS contains upper motor neurons that influence lower motor neurons, located mostly
in the peripheral nervous system.
 Brain
 Located in the cranial cavity.
 Four divisions: cerebrum, diencephalon, brain stem, and cerebellum.
 
 Cerebrum
 R and L cerebral hemispheres, joined by corpus callosum.
 Each hemisphere sends/receives impulses from the opposite sides of the body and consists of
four lobes
o Frontal, parietal, temporal, occipital.
 
 Each lobe composed of gray matter
o Mediates high-level functions like memory, perception, communication, and initiation of
voluntary movements.
o Rims the surfaces of the cerebral hemispheres, forming the cerebral cortex.
 
Diencephalon
 Beneath the cerebral hemispheres and consists of the thalamus and hypothalamus.
o Thalamus - most sensory impulses travel through the gray matter of the thalamus,
responsible for screening and directing the impulses to specific areas in the cerebral
cortex.
o Hypothalamus - autonomic nervous system, responsible for regulating water balance,
appetite, vital signs, sleep cycles, pain perception, and emotional status.
Brain Stem
 Located between the cerebral cortex and the spinal cord. Consists of mostly nerve fibers and
has three parts.
o Midbrain - relay center for ear and eye reflexes and relays impulses between the higher
cerebral centers and lower pons, medulla, cerebellum, and spinal cord.
o Pons - Links cerebellum to the cerebrum and the midbrain to the medulla. Responsible
for various reflex actions.
o Medulla oblongata - contains nuclei for cranial nerves and has centers that control and
regulate respiratory function, heart rate and force, and blood pressure.
Cerebellum
 Located behind the brainstem and under the cerebrum, has two hemispheres.
o Primary functions include coordination and smoothing voluntary movements,
maintenance of equilibrium, and maintenance of muscle tone.
 Spinal Cord
 Located in the vertebral canal and extends from the medulla oblongata to the first lumbar
vertebra.
 Conducts sensory impulses up ascending tracts to the brain, conducts motor impulses down
the descending tracts to neurons that stimulate glands and muscles throughout the body.
 Responsible for simple reflex activity, reflex arc, etc.
 
 
Neural Pathways
 Sensory (Afferent) - travel to the brain through two pathways:
o Spinothalamic tract
 Sensations of pain, temperature, and crude/light touch.
o Posterior columns
 Sensations of position, vibration, and fine touch.
 Stereognosis
 Graphesthesia
 
 
  Motor (Efferent) - conducted to the muscles by two descending neural pathways:
o Pyramidal (corticospinal)
 Skilled and purposeful movements - writing.
 Originate in the motor cortex and travel down to medulla, cross over, travel down
-> anterior horn of the spinal cord.
o Extrapyramidal tract
 Maintenance of muscle tone, body control.
 Originate in the motor cortex, basal ganglia, brain stem, and spinal cord
OUTSIDE the pyramidal tract.
 Travel from frontal lobe to the pons, cross over, down the spinal cord, connect
with lower motor neurons that conduct impulses to the muscles.

Peripheral Nervous System

 Consists of 12 pairs of cranial nerves and 31 pairs of spinal nerves. Categorized as two types.
o Somatic
 Carry CNS impulses to voluntary skeletal muscles.
 Mediates conscious, or voluntary, activities.
o Autonomic
 Carry CNS impulses to smooth, involuntary muscles (in the heart and glands).
 Mediates unconscious, or involuntary, activities.
 Spinal Nerves
o 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal nerve.
 o Named after the vertebrae below each one's exit point along the spinal cord.
o Sensory (afferent) - enters through dorsal roots of the cord.
o Motor (efferent) - exits through the ventral roots of the cord.
o Each spinal nerve innervates an area of the skin called a dermatome.

 Cranial Nerves **KNOW THESE!! NAMES OF NERVES AND TESTS INVOLVED!!**

o 12 pairs supply primarily the head and neck.
o Transmit motor or sensory messages.
o Enters and exits the brain.
o CN 10 (Vagus) is the "wanderer" - travels to the heart, respiratory muscles, stomach,
and gallbladder.
Autonomic Nervous System
 Impulses carried by both cranial and spinal nerves.
 Carried from the CNS to the involuntary, smooth muscles - heart and glands.
 Maintains internal homeostasis of the body, incorporates the sympathetic and parasympathetic
nervous system.
o Sympathetic - Fight-or-flight
 Activated during stress and elicits responses such as decreased gastric secretions,
bronchodilation, increased pulse rate, and pupil dilation.
 Sympathetic fibers arise from thoracolumbar level (T1 to L2).
o Parasympathetic - restore and maintain normal body functions.
 Decrease heart rate.
 Parasympathetic fibers arise from craniosacral regions (S1 to S4 and cranial nerves III, VI,
IX, and X).
 
2. Discuss the risk factors for stroke (also known as cerebral vascular accident [CVA]) across
cultures and ways to reduce one’s risks.
Risk Factors
CVA (Stoke) or Brain Attack
 Hypertension (main risk factor)
o At or above 140/90, or with diabetes/chronic kidney disease at or above 130/80.
 Diabetes mellitus
 Heart disease
o Coronary heart disease, cardiomyopathy, heart failure, afib.
 Smoking
o Also exposure to secondhand smoke.
 Age
o Risk increases with age. 
 Gender
o Men are more likely to have a stroke at a younger age.
o Women are more likely to die of a stroke.
o Women who take birth control pills have slightly higher risk.
 Race and ethnicity
o More strokes in African Americans, Native Americans, and Alaska natives.
 Personal or family history of stroke or TIA
 Brain aneurysms or arteriovenous malformations.
 Alcohol and drug use.
 Certain medical conditions, sickle cell, vasculitis, bleeding disorders.
 Lack of physical activity.
 Overweight and obesity.
 Stress and depression.
 Unhealthy cholesterol levels.
 Unhealthy diet.
 Use of NSAID medications, such as ibuprofen and naproxen (not aspirin).
 
3. Describe the teaching opportunities to reduce a client’s risk of stroke and to promote
health.
Client Education
Teach Clients:
 Do not smoke.
 Control cholesterol levels through diet, exercise, and medications.
 Control high blood pressure.
 Control diabetes.
 Exercise at least 30 minutes a day.
 Maintain a healthy weight by eating healthy foods, eat less, and join a weight loss program.
 Choose a diet rich in fruits, vegetables, and whole grains.
 Choose lean proteins such as chicken, fish, beans, and legumes.
 Choose low-fat dairy products such as 1% milk and other low-fat items.
 Avoid sodium and fats in fried foods, processed foods, and baked goods.
 Eat fewer animal products and foods that contain cheese, cream, or eggs.
 Read labels - avoid saturated and anything with hydrogenated fats.
 Limit your alcohol intake.
 Avoid cocaine and other illegal drugs.
 Talk to your doctor about the risk of taking birth control pills.
 Talk to your doctor about taking aspirin first.

Teach warning signs of a stroke:

 Sudden numbness/weakness of the face, arm, or leg. Especially on one side of the body.
 Sudden confusion, trouble speaking, or understanding speech.
 Sudden trouble seeing in 1 or both eyes.
 Sudden trouble walking, dizziness, loss of balance or coordination.
 Sudden, severe headache with no known cause.

4. Describe an accurate nursing history of a client’s neurologic system.

Subjective History
 Headaches
o COLDSPA
 Seizures
o What type?
o Medications?
 Dizziness
o Problems with balance/coordination?
o Any falls?
 Numbness/Tingling
o COLDSPA
 Sense - Think Cranial Nerves!
o Smell/Taste?
 o Tinnitus?
o Vision?
 Difficulty Speaking
o Comprehension
o Dysarthria
o Dysphasia
 Difficulty Swallowing
o Dysphagia
 Muscle Control
o Bladder control
o Muscle weakness
o Quivering, shaking, trembling.
 Memory Loss
o Recent memory is often impaired in amnesic disorders
 Korsakoff syndrome, delirium, dementia.
o Remote memory may be impaired in cerebral cortex disorders.
 
5. Discuss a physical assessment of the nervous system using the correct techniques of
inspection, auscultation, palpation, and percussion.
Physical Assessment
Complete Neuro Exam
 Neurological concerns
o Mental status
 Tests cerebral cortex function
 Intellect
 Communication
 Emotional behaviors
o Cranial nerves
 Provides information RT transmission of motor and sensory messages.
o Motor and cerebellar systems
 Function of pyramidal and EPS tracts.
 Level of balance and coordination.
o Sensory systems
 Information RT integrity of spinothalamic tract, posterior columns and parietal lobes.
o Reflexes.
 Integrity of deep and superficial reflexes
 Requires intact sensory nerve, functioning synapse, and intact motor nerve, plus
competent muscles. 
Speech
 Tone, clarity, and pace.
o Normal = moderate tone and pace, speech is clear.
o Abnormal = slow, repetitive speech with depression or Parkinson's; loud, rapid speech with
manic phase of bipolar disorder; dysarthria, dysphasia, or garbled speech with neuro deficit.
***Cranial Nerves***
 CN I (Olfactory)
o Smell impulses. 
o Identifies scents.
o Abnormal = inability to smell or correctly identify scent. May indicate lesion or tumor of frontal
lobe.
 Loss of smell may also be congenital = nasal or sinus problems.
 Injury to nerve tissue at the top of the nose due to viral URI.
 Smoking/cocaine use impairs sense of smell.
 CN II (Optic)
o Visual acuity (Chapter 16 for reference)
 Snellen chart
 Read paper
 Visual fields - confrontation test
 Red reflex.
o Abnormal = inability to read Snellen chart, presbyopia, loss of visual fields may indicate lesion of
optic nerve or lesion of parietal cortex, papilledema = increased intracranial pressure, optic
atrophy = brain tumor.
 CN III (Oculomotor)
o Elevates eyelids
o Constricts pupils
o CN III, IV, and VI tested together.
 Diagnostic Positions Test.
o Abnormal = Ptosis, Nystagmus, limited eye movement, paralytic strabismus = paralysis of the
oculomotor/trochlear/abducens nerve, dilated pupil 6-7mm, Argyll Robertson pupils,
constricted/fixed pupils, unilaterally dilated pupil unresponsive to light/accommodation,
constricted pupil unresponsive to light.
 CN IV (Trochlear)
o Contracts muscle to control inferomedial eye movement.
o Same testing as CN III (diagnostic positions).
 CN V (Trigeminal)
o Motor - clench teeth and strength of temporal and masseter muscles.
o Sensory - light touch on forehead, cheeks, and chin.
o Corneal REFLEX
o Abnormal = decrease contraction, asymmetric strength in jaw, pain when clenching teeth,
bilateral muscle weakness, unilateral muscle weakness, inability to feel and correctly identify
facial stimuli, absent corneal reflex.
 CN VI (Abducens)
o Controls lateral eye movement.
o Test same as III and IV (diagnostic positions)
 CN VII (Facial)
o Motor - smile, frown, wrinkle forehead, show teeth, puff cheeks, purse lips, raise eyebrows,
close eyes tightly to resistance.
o Abnormal = inability to do items listed above. Paralysis on lower one side  of face = Bell palsy,
paralysis of lower part on face opposite = sign of stroke.
o Sensory - Anterior 2/3 of tongue, taste salt, sugar, or lemon; tears from lacrimal gland.
o Abnormal = cannot identify flavor.
 CN VIII (Acoustic or Vestibulocochlear)
 o Sensory fibers for hearing and balance.
o Hearing - whispered voice (1-2ft away)
o Weber and Rinne tuning fork tests.
o Abnormal = vibratory sound lateralizes to good ear in sensorineural loss. Air conduction is
longer than bone conduction, but not twice as long.
 CN IX (Glossopharyngeal) - Tested with CN X
o Say "ahh", equal upward movement of soft palate and uvula.
o Gag reflex
o Posterior 2/3 of tongue - taste.
o Swallow ability and voice quality.
o Abnormal = soft palate does not rise, unilateral rising of soft palate, absent gag reflex,
dysphagia, hoarseness.
 CN X (Vagus)
o Swallowing, talking, production of digestive juices.
 CN XI (Spinal Accessory)
o Shrug shoulders against resistance
o Turn head against hand to resistance.
o Abnormal = asymmetric muscle contraction or drooping, atrophy.
 CN XII (Hypoglossal)
o Mobility and strength of the tongue; talking.
o Abnormal = atrophy, deviation to the affected side. 

Motor System
 Inspect muscles for size, symmetry
o Abnormal = atrophy, loss of motor function/strength.
 Assess strength and tone of all muscle groups.
o Normal = relaxed muscles contract voluntarily and show mild, smooth resistance to passive
movement. All muscles are equally strong against resistance.
o Abnormal = soft, limp, flaccid muscles with lower motor neuron problem, spastic tone, rigidity.
 Involuntary movements
o Normal = none should occur.
o Abnormal = fasciculation (rapid twitching), tic (twitch of the face/head/shoulder), tremor
(rhythmic, oscillating movements), chorea (brief, rapid, irregular, jerk movements), athetosis
(slow, twisting movements with spasticity).

Cerebellar Function
 Evaluate gait and balance.
o Tandem walking
o Heel and toe walking
o Romberg
o Bend knee, hop on 1 foot (not in the hospital).
o Abnormal = uneven/unsteady/uncoordinated gait. Positive Romberg test (patient
swaying/moving feet apart to prevent fall). Inability to hop on one foot.
 
 Coordination
o Finger to nose test (eyes open/closed).
o Abnormal = uncoordinated, jerky movements and inability to touch nose.
  Rapid alternating movements
o Touch each finger to thumb rapidly.
o Pat palms of hands on both legs.
o Heel to shin test.
o Abnormal = inability to perform rapid alternating movements. Uncoordinated/tremors.
Deviation of heel to one side or the other. If a patient is unconscious, note posture =
decorticate or decerebrate.

Light Touch, Pain, and Temperature

 Have patient close eyes; state what they feel/when/where.
o Scatter stimuli over distal and proximal parts of extremities and trunk (cover dermatomes).
o Light touch (cotton wisp), identify light touch.
o Pain sensation, identify sharp/blunt ends of paper clip, safety pin.
o Temperature (if pain sensation is normal).
 Abnormal = light touch is impaired with peripheral neuropathy, impaired pain
sensations. Anesthesia, hypesthesia.

Sensation
 Vibratory sensation
o Strike tuning fork to distal radius, forefinger tip, medial malleolus, tip of great toe.
 Report when vibrations starts and stops, distal locations first; compare right/left.
 Abnormal = loss of vibration sense, peripheral neuropathy.
 Sensitivity to Position
o Finger or toe moved up or down.
o Correctly identifies position.
o Abnormal = peripheral neuropathy.
 Point localization

Tactile Discrimination to Fine Touch

 Stereognosis
o Familiar object in hand.
 Graphesthesia
o Use a blunt instrument to "draw" a number on the hand - recognize the number.
 Two-point discrimination
o Use a paper clip or 2 cotton-tipped applicators.
o ID if feel 1 or 2 points.
 Abnormal = Inability to correctly identify objects (astereognosis). 
Deep Tendon Reflexes
 
 Reveals intactness of reflex are at specific spinal levels; relaxed limb, short, snappy blow.
o Triceps = C 6-8.

 Biceps = C5-6
 Brachioradialis = C5-6.

 Patellar = L2-4
 Achilles = S1-2

 Plantar = L4-S2

 Ankle clonus.
 
 Clonus
o Test when reflexes are hyperactive; a set of rapid, rhythmic contractions of the muscle.
 Hyperreflexia
o An exaggerated reflex, occurs with UPPER motor neuron lesions = STROKE.
 Hyporeflexia
o Absence of a reflex; LOWER motor neuron lesion = SPINAL CORD INJURY.

Tests for Meningeal Irritation

 Assess the client's neck mobility
o Normal = supple, full ROM.
o Abnormal = Pain and resistance to flexion seen with meningeal irritation, arthritis, or neck
injury.
 Brudzinski's sign
o Flex the neck and watch hips and knees.
 Normal = relaxed/motionless.
 Abnormal = movement with meningeal irritation.
 Kernig's sign
o Flex the leg at hip and knee, then straighten the knee.
 Normal = no pain.
 Abnormal = pain and increased resistance with meningeal irritation.

Change in LOC
 Earliest, most sensitive indicator of neurologic status or ICP
 o Wakefulness
o Awareness
o Fully alert when:
 Eyes open spontaneously
 Oriented to person, place, and time.
 Able to follow commands.
 Assessing LOC
o Glasgow coma scale
 15 point scale
 Best response to eye opening, motor response, and verbal response.
 Fully alert person = 15 points.
 Score 7 < = coma.
 
 
 
 
 
 
6. Differentiate between normal and abnormal findings of the nervous system.
Abnormal Findings

 
 
 
 
 

 
 
 
 
 
 
 
 
Stoke Assessment
 Ischemic vs. Hemorrhagic
 
 
 Right vs. Left
o Right
 Left hemiplegia
 Spatial/perceptual deficits
 Left-sided neglect may be RT visual field loss.
 Impulsivity
 Poor decision making, lack of insight.
 Short attention span and slowed learning.
 Confusion/memory loss.
o Left
 Right hemiplegia
 Speech deficits (Wernicke/Broca)
 Slow, cautious behavior style or movements.
 Memory loss.
 Apraxia - difficulty translating ideas or performing function into action.
 Cerebellar Stroke
o Abnormal reflexes of head and torso.
o Coordination and balance problems.
o Dizziness
 o Nausea/vomiting.
 Brain Stem Stroke
o "Life-support area"
o Respirations, BP, heart rate, eye movements, hearing, speech and swallowing.
7. Describe the findings frequently seen when assessing the older client’s nervous system.
8. Analyze the data from the interview and physical assessment of the nervous system to
formulate valid nursing diagnoses, collaborative problems, and/or referrals.
Analyze Data

 
  Collaborative problems that may be identified when assessing the neurologic system:
 

 
Referral to a primary care physician may be required after assessment for treatment options.
Chapter 31 Video NOT ON EXAM
2.  Interview children, adolescents, and their parents or caregivers as appropriate for an accurate
nursing history.
3.  Discuss a physical assessment of children/ adolescents using correct techniques.
4.  Differentiate between normal and abnormal findings of children and adolescents.
5.  Describe the findings frequently seen with assessing children and adolescents.
6.  Analyze the data from the interview and physical assessment of children and adolescents to form
nursing diagnoses, collaborative problems, and/or referrals.
7.  Communicate interview and assessment findings through clear concise documentation and verbal
reports.
Module 9 Objectives ?
Chapter 11 
Chapter 12 
Chapter 32 Video NOT ON EXAM
 
Module 10 Objectives
Chapter 26 Video

1.    Describe structure and functions of the male genitalia, anus, rectum, prostate
2.    Discuss incidence of prostate cancer and ways to promote health.
3.    Discuss the incidence of testicular cancer across cultures and ways to promote health.
4.    Describe accurate nursing history of male client’s genitalia, anus, rectum, prostate.
5.    Discuss a physical assessment of the male genitalia, anus, rectum, and prostate using the correct
techniques of inspection, auscultation, and palpation.
6.    Differentiate between normal and abnormal findings of the male genitalia, anus, rectum, and prostate.
7.    Describe the findings frequently seen when assessing the male genitalia, anus, rectum, and prostate in
individuals across the lifespan.
 8.    Analyze the data from the interview and physical assessment of the abdomen to formulate valid nursing
diagnoses, collaborative problems, and/or referrals.
 Chapter 27 Video

1.    Describe the structure and functions of the female genitalia, anus, and rectum.
2.    Discuss risk factors for cervical cancer and ways to reduce these risks.
3.    Describe teaching opportunities to reduce risks of cervical cancer and ways to promote health.
4.    Discuss risk factors for colorectal cancer and ways to reduce these risks.
5.    Describe an accurate nursing history of the female client’s genitalia, anus, and rectum and related
functions.
6.    Discuss a physical assessment of the female client’s genitalia, anus, and rectum using the correct
techniques of inspection and palpation.
7.    Differentiate between normal and abnormal findings of the female client’s genitalia, anus, and rectum.
8.    Describe the findings frequently seen when assessing the genitalia, anus, and rectum in individuals
across the lifespan.
9.    Analyze data from interview and physical assessment of client’s genitalia, anus, and rectum to form
nursing diagnoses, collaborative problems, and/or referrals

Module 11 Objectives
Chapter 28 Video

1.    Explain how to prepare yourself and the client for a holistic nursing interview and head-to-toe integrated
physical examination.
2.    List all the equipment needed for a total physical examination.
3.    Describe the parts of the physical examination that can be integrated within assessment of each of the
body systems.
4.    Correctly interview a client for an accurate holistic nursing history.
5.    Correctly perform a total head-to-toe integrated physical examination, identifying normal and abnormal
findings.
6.    Analyze data from a holistic nursing interview and head-to-toe integrated physical assessment to
formulate valid nursing diagnoses, collaborative problems, and/or referrals.

Chapter 15 (hannah)

Describe the structures and functions of the head and neck.

 
 Structures of the head (face and cranium)
o Cranium
 Frontal
 Parietal
 Temporal
 Occipital
 Ethmoid
 Sphenoid
o Face
 Maxilla
 Zygomatic (cheek)
 Inferior conchae
 Nasal
 Lacrimal
 Palatine
 Vomer
  Mandible (jaw) 
o In adults, cranial bones are joined together by immovable sutures: sagittal,
coronal, squamosal, lamboid
o All facial bones are immovable except for mandible
 Structures of the neck
o Composed of muscles, ligaments, and cervical vertebrae
o Sternomastoid and trapezius are two muscles that allow movement and provide
support
o 11th cranial nerve is responsible for muscle movement, permits shrugging of
shoulders
 Blood vessels
o Internal jugular veins and Carotid arteries
 Parallel and anterior to sternomastoid muscles
o External jugular veins lie diagonally over the surface of sternomastoid muscles
o Important to avoid bilateral compression => reduces blood supply to brain
 Thyroid gland
o Surrounded by trachea, hyoid bone, 
o Trachea composed of c-shaped hyaline cartilage rings
 Cricoid has a notch
 Below that is thyroid cartilage (adams apple)
o Consists of two lateral lobes that curve posteriorly on both sides of trachea and
esophagus
 2 lobes are connected nu an isthmus that covers 2nd and 3rd tracheal
rings 
 In about one third of population, there is a third lobe that extends up from
isthmus
 Lymph nodes
o Preauricular
o Postauricular
o Tonsillar
o Occipital
o Submandibular
o Submental
o Superficial cervical
o Posterior cervical
o Deep cervical
o Supraclavicular

Discuss the risk factors for head and neck disorders across cultures and ways to reduce one’s risks.
 
Describe an accurate nursing history of his/her head and neck.

 Neck pain and headaches

o COLDSPA
 Difficulty moving head or neck
 Lumps or lesions?
o Describe appearance
 Difficulty cough or swallowing?
  Dizzy, lightheaded, spinning, blurry vision, loss of consciousness?
 Change in texture of skin hair or nails?
 Change in sleep habits or energy level?
 Experienced any palpations?
 Weakness or numbness in face or extremities?
 Any previous head or neck injuries?
 
Describe a physical assessment of the head and neck using the correct techniques.

 General Routine Screening

o Inspect head for size, shape, and configuration
o Palpate temporal arteries; located between top of ear and eye
o Palpate temporomandibular joint for swelling, tenderness, or crepitation
 Place index finger over the front of each ear as patient opens mouth
o Inspect neck for movement, position, symmetry, lumps, or masses
o Palpate trachea for position
 Place fingers in sternal notch and palpate tracheal rings
o Palpate thyroid for enlargement, lumps, or masses
 Key landmarks
 Hyoid bone - arch shaped bone; high anterior neck
 Thyroid cartilage - under hyoid bone, adams apple
 Cricoid cartilage - smaller upper tracheal ring under thyroid
cartilage
o Palpate for any enlarged or tender lymph nodes
 Size and shape
 Delimitation
 Mobility
 Consistency
 Tenderness and location
o Auscultate for bruits over thyroid if enlarged
 Use bell over lateral lobes
 Focused Specialty Assessment
o Assess and determine type of headache client is experiencing
o Assess signs of thyroid dysfunction
o Assess signs of Bell palsy


 
Differentiate between normal and abnormal findings of the head and neck.

 Acromegaly - characterized by enlargement of the facial features (nose, ears) and the
hands and feet.
 Cushing syndrome - may present with a moon-shaped face with reddened cheeks and
increased facial hair.
 Hyperthyroidism - exophthalmos (bulging eyes)
 Scleroderma - tight, hard face with thinning facial skin
 Bell palsy - begins suddenly, reaches peak within 48 hours; s/s: twitching, weakness,
drooping, paralysis, facial distortion
 hypothyroidism/myxedema - dull puffy face; edema around eyes
  Cerebrovascular accident - results in neuro damage
 Parkinsons dz - mask like face, shuffling gait, rigid muscles, diminished reflexes
 
Describe the findings frequently seen when assessing the head and neck in individuals across the
lifespan.

 infants/toddlers
o Environmental risks
o Shaken baby syndrome
 children/teens
o Protective equipment in sports
o Safety practices while driving
 adults/older adults
o Impaired physical or mental stability
o Potential for maltreatment or domestic violence
 
Analyze the data from the interview and physical assessment of the head and neck to formulate valid
nursing diagnoses, collaborative problems, and/or referrals.

 Collaborative problems
o hyper/hypocalcemia
o Corneal abrasion
o Thyroid crisis/dysfunction
o Seizures
 Dx
o Constipation related to hyperthyroidism or hypothyroidism
o Chronic pain: sinus headache related to inflammation of sinuses secondary to
seasonal allergies.
o Disturbed Body Image related to head injury
o Impaired Swallowing related to mechanical obstruction of the head and neck
secondary to tissue swelling, tracheostomy, or abnormal growth
o Impaired Swallowing related to lack of gag reflex, paralysis of facial muscles, or
decreased cognition
o Ineffective Tissue Perfusion: Cerebral related to impaired circulation to brain
o Imbalanced Nutrition: Less Than Body Requirements related to increased
metabolism secondary to hyperthyroidism

Exam 4