HEALTH ASSESSMENT intro to PHYSICAL ASSESSMENT and IPPA 2021

HEALTH ASSESSMENT intro to PHYSICAL ASSESSMENT and IPPA 2021

1. Health Assessment   is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.

2. Physical Examination  is the process of evaluating objective anatomic findings through the use of observation/inspection, palpation, percussion, and auscultation.

3. Health assessment of patients falls under the purview of both physicians and nurses. Assessment of patients varies based on both role and setting.

4. As you progress through this course, keep in mind that exposure to a detailed health assessment may lead you to a more comprehensive and thorough exam. For instance, if you note a patient has leukoplakia (coated tongue) as you perform your general assessment, you may wonder about hygiene issues, underlying diseases, or medications that may cause this.

5. General Health Assessment The nursing health assessment is an incredibly valuable tool nurses have in their arsenal of skills. A thorough and skilled assessment allows you, the nurse, to obtain descriptions about your patient’s symptoms, how the symptoms developed, and a process to discover any associated physical findings that will aid in the development of differential diagnoses .

6. CASE ANALYSIS: WHAT ARE THE SIGN YOU CAN ASSESS FROM THIS CLIENT?

7. During the assessment period, you are given an opportunity to develop a rapport with your patient and their family. Remember the adage “first impressions are lasting impressions?” That adage is also very true in healthcare. You are often the first person your patient sees when admitted to your unit, returns from testing, or at the beginning of a new shift.

8. Nurses use physical assessment skills to: Obtain baseline data Enhance the nurse-patient relationship Find further problems of the patient D. all of the above

9. During the nursing assessment, which data represent information concerning health beliefs? A. Family role and relationship patterns B. Educational level and financial status C. Promotive , preventive, and restorative health practices. D. Use of prescribed and over-the-counter medications

10. Types of General Health Assessments In general, there are four fundamental types of assessments that nurses perform: • A comprehensive or complete health assessment • An interval or abbreviated assessment • A problem-focused assessment • An assessment for special populations Types of General Health Assessments

11. A comprehensive or complete health assessment usually begins with obtaining a thorough health history and physical exam . This type of assessment is usually performed in acute care settings upon admission , once your patient is stable, or when a new patient presents to an outpatient clinic. A COMPREHENSIVE OR COMPLETE HEALTH ASSESSMENT

12. If the patient has been under your care for some time , a complete health history is usually not indicated. Nurses perform an interval or abbreviated assessment at this time. These assessments are usually performed at subsequent visits in an outpatient setting , at change of shift , when returning from tests , or upon transfer to your unit from another in-house unit. interval or abbreviated assessment

13. The problem-focused assessment is usually indicated after a comprehensive assessment has identified a potential health problem. The problem-focused assessment is also indicated when an interval or abbreviated assessment shows a change in status from the most current previous assessment or report you received, when a new symptom emerges, or the patient develops any distress. PROBLEM-FOCUSED ASSESSMENT

14. The fourth type of assessment is the assessment for special populations, including: • Pregnant patients • Infants • Children • The elderly ASSESSMENT FOR SPECIAL POPULATIONS

15. What are the types of General Health Assessment? SATA • A comprehensive or complete health assessment • An interval or abbreviated assessment • A problem-focused assessment • An assessment for special populations

16. Nurse Carlo is acquiring information from a client in the emergency department. Which is an example of biographic information that may be obtained during a health history? A The chief complaint B Past health status C History immunizations D Location of an advance directive.

17. Assessment Techniques: Whether you are performing a comprehensive assessment or a focused assessment, you will use at least one of the following four basic techniques during your physical exam: -Inspection, -Auscultation, -Palpation, -Percussion, and unless you're performing an abdominal assessment.

18. INSPECTION is the most frequently used assessment technique . When you are using inspection, you are looking for conditions you can observe with your eyes, ears, or nose. Examples of things you may inspect are skin color, location of lesions, bruises or rash, symmetry, size of body parts and abnormal findings, sounds, and odors. Inspection can be an important technique as it leads to further investigation of findings

19. A Alert and oriented to date, time, and place B Buccal cyanosis and capillary refill greater than 3 seconds. C Clear breath sounds and nonproductive cough D Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3 Mang Centeno is a 73-year old patient diagnosed with pneumonia. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient?

20. Inspection has numerous use, for example inspecting the following:

21. Assessment Techniques: Auscultation AUSCULTATION is usually performed following inspection, especially with abdominal assessment. The abdomen should be auscultated before percussion or palpation to prevent production of false bowel sounds. When auscultating, ensure the exam room is quiet and auscultate over bare skin, listening to one sound at a time

22. Auscultation should never be performed over patient clothing or a gown, as it can produce false sounds or diminish true sounds. The bell or diaphragm of your stethoscope should be placed on your patient’s skin firmly enough to leave a slight ring on the skin when removed. Be aware that your patient’s hair may also interfere with true identification of certain sounds. Remember to clean your stethoscope between patients.

23. Assessment Techniques: Palpation PALPATION, another commonly used physical exam technique, requires you to touch your patient with different parts of your hand using different strength pressures.

24. During light palpation, you press the skin about ½ inch to ¾ inch with the pads of your fingers. When using deep palpation, use your finger pads and compress the skin approximately 1½ inches to 2 inches. Light palpation allows you to assess for texture, tenderness, temperature, moisture, pulsations, and masses. Deep palpation is performed to assess for masses and internal organs

25. A Breast B Integumentary C Ophthalmic D OraL Newly hired nurse Chynna is excited to perform her very first physical assessment with a 19-year-old client Mr. Rafael. Which assessment examination requires Chynna to wear gloves?

26. Assessment Techniques: Percussion When Percussing directly over suspected areas of tenderness, monitor the patient for signs of discomfort. Percussion requires skill and practice. the action of tapping a part of the body as part of a diagnosis.

27. The method of percussion is described as follows: Press the distal part of the middle finger of your nondominant hand firmly on the body part. Keep the rest of your hand off the body surface. Flex the wrist, but not the foreman, of your dominant hand. Using the middle finger of your dominant hand, tap quickly and directly over the point where your other middle finger contacts the patient’s skin, keeping the fingers perpendicular. Listen to the sounds produced

28. The most frequently used assessment technique is: Palpation Inspection Percussion Auscultation

29. A Auscultation immediately after inspection and then percussion and palpation. B Percussion, followed by inspection, auscultation, and palpation C Palpation of tender areas first and then inspection, percussion, and auscultation D Inspection and then palpation, percussion, and auscultatio Physical assessment is being performed to Keith by Nurse Globa . During the abdominal examination, Globa should perform the four physical examination techniques in which sequence?

30. Client’s physical appearance Mood and behavior Speech patterns and voice intonations Signs and symptoms of distress Vital signs Height and weight INITIAL OBSERVATIONS

31. The client interview Before assessment can begin the nurse must establish a professional and therapeutic mode of communication. This will also assure that the person will be as comfortable as possible when revealing personal information.

32. A common method of initiating therapeutic communication by the nurse is to have the nurse introduce herself or himself. The interview proceeds to asking the client how they wish to be addressed and the general nature of the topics that will be included in the interview.

33. The therapeutic communication methods of nursing assessment takes into account developmental stage (toddler vs. the elderely ), privacy, distractions, age-related impediments to communication such as sensory deficits and language, place, time, non-verbal cues. Therapeutic communication is also facilitated by avoiding the use of medical jargon and instead using common terms used by the patient, You have pneumonoultramicroscopicsilicovolcanoconiosis

34. Components of a Nursing Health History Biographic Data: includes all personal information of client (name, age, sex, religion, etc.) Chief Complaint: this answers the question “what brought you to the hospital?” History of present illness: when the symptoms started? How often the problem occurs? Location of the distress? Character of the illness? Factors that aggravate the Sx .? Activity before the illness?

35. Components of a Nursing Health History Past history: childhood illness? Immunization? Allergies? Accidents? Hospitalization? Medications? Family history of illness: diseases from family or relatives? Genetics or hereditary? Lifestyle: Personal habit? Diet? Sleep/rest pattern? ADL? Hobbies? Social data: family relationships/friends? Ethnic affiliations? Educational history? Occupational history? Economic status?

36. Components of a Nursing Health History Psychologic data: major stressors? Copping Pattern? Patterns of healthcare: family physician? Herbalist?

37. Health History The purpose of obtaining a health history is to provide you with a description of your patient’s symptoms and how they developed . A complete history will serve as a guide to help identify potential or underlying illnesses or disease states. In addition to obtaining data about the patient’s physical status, you will obtain information about many other factors that impact your patient’s physical status including spiritual needs, cultural idiosyncrasies, and functional living status.

38. The basic components of the complete health history (other than biographical information) include: • Chief complaint • Present health status • Past health history • Current lifestyle • Psychosocial status • Family history • Review of systems

39. Communication during the history and physical must be respectful and performed in a culturally-sensitive manner. Privacy is vital, and the healthcare professional needs to be aware of posture, body language, and tone of voice while interviewing the patient (Jarvis, 2012; Caple, 2011).

40. Chief Complaint In your patient’s own words , document the chief complaint. The chief complaint may be elicited by asking one of the following questions: • So, tell me why you have come here today? • Tell me what your biggest complaint is right now? • What is bothering you the most right now? • If we could fix any of your health problems right now, what would it be? • What is giving you the most problems right now?

41. Chief Complaint If your patient has more than one complaint, discuss which one is the most troublesome for them and document the complaints in order of importance as determined by the patient (Jarvis, 2012).

42. Present Health Status Obtaining information about a patient’s present health status allows the nurse to investigate current complaints. The mnemonic, PQRST, utilizes a structured format for information gathering, including evaluation of pain, and provides an efficient methodology to communicate with other healthcare providers. (Jarvis, 2012).

43. PQRST P = Provocative or Palliative • What makes the symptom(s) better or worse? Q = Quality • Describe the symptom(s). R = Region or Radiation • Where in the body does the symptom occur? Is there radiation or extension of the symptom(s) to another area of the body? S = Severity • On a scale of 1-10, (10 being the worst) how bad is the symptom(s)? Another visual scale may be appropriate for patients that are unable to identify with this scale. T = Timing • Does it occur in association with something else (i.e. eating, exertion, movement)

44. Past Health History It is important to ask questions about your patient’s past health history. The past health history should elicit information about the patient’s childhood illnesses and immunizations, accidents or traumatic injuries, hospitalizations, surgeries, psychiatric or mental illnesses, allergies, and chronic illnesses. For women, include history of menstrual cycle, how many pregnancies and how many births (Jarvis, 2012).

45. Past Health History Hospitalizations: Be sure to ask the reason for the hospitalization and the nature of the treatments received while in the hospital such as blood transfusions, surgeries and any follow-up treatments. Remember to include hospitalizations for childbirth (Jarvis, 2012). Surgeries: Many surgical procedures are performed on an outpatient basis. Questions regarding surgeries should also be asked in addition to hospitalizations, as patients may not discuss a surgery if there was no associated hospital stay (Jarvis, 2012).

46. Past Health History: Psychiatric or Mental Illnesses: If your patient has a past history of psychiatric or mental illnesses, ask what triggered the illness, if anything, and the course and the progression of the illness. This includes depression and anxiety, as well as diagnosed mental illness (Jarvis, 2012). Allergies: Identify what your patient is allergic to (both food and medication), as well as the reaction and response to treatment. It is important to ask about any environmental allergies or sensitivities (such as latex) also (Jarvis, 2012)

47. Family History Family history is important in identifying your patient’s risk for certain disease states. Chronic illnesses or known diseases with genetic components should also be screened for. Chronic illness or disease can include cancer, diabetes, autoimmune disorders, cholesterol, heart disease, hypertension, renal disease, and mental illness, among others (Jarvis, 2012).

48. Review of Systems and Physical Exam The physical examination can be performed in a “head-to-toe” fashion, starting with the head and ending with the toes. Although some healthcare professionals have varied tactics to performing this skill, the key to assessment is to ensure a consistent, methodical approach to avoid missing any vital assessment areas.

49. A Brief statement about what brought the client to the health care provider B Client complaints of chest pain, dyspnea, or abdominal pain. C Information about the client’s sexual performance and preference D The client’s name, address, age, and phone number Which assessment data should the nurse include when obtaining a review of body systems

50. OLDCART O nset of health concern or complaint L ocation of pain or other symptoms related to the area of the body involved D uration of health concern or complaint C haracteristics A ggravating factors or what makes the concern or complaint worse R elieving factors or what makes the concern or complaint better T reatments or what treatments were tried in the past or ongoing [ The patient history and interview is considered to be subjective but still of high importance when combined with objective measurements. 

51. Performing the examination Informing the client and explain the methods (ask for permission) Check the environment Provide privacy Provide safe equipment Positioning Draping

52. Supplies and Equipment Hospital gown Sheet or disposable paper drapes Bath blanket (to prevent chill) Tray with flashlight, gloves, lubricant normal saline, cotton- tipped applicators, and tissues Basin for soiled instruments Waste container for paper goods Scale with height measuring rod Gooseneck lamp or hospital light Gloves Thermometer (oral or rectal) Tape measure Tongue depressors Ophthalmoscope (for examining eyes) Otoscope (for examining ears) Tuning fork Blood pressure apparatus and stethoscope Percussion hammer (to check reflexes) Red and blue pencils (to mark skin) Small speculum (for nose examination) Head mirror (to reflect light into body orifice, such as the throat You may also need slides, blood tubes, a vaginal speculum, or other equipment; medications; and a surgical permit if a biopsy or other tests are to be done *BP apparatus, thermo , steth .

53. A “What brought you to the clinic today?” B “Would you describe your overall health as good?” C “Do you understand what is happening?” D “Is there anything else you would like to tell me?” Joyce has come to the nursing clinic for a comprehensive health assessment. Which statement would be the best way to end the history interview?

54. Integument Skin : The client’s skin is uniform in color, unblemished and no presence of any foul odor. He has a good skin turgor and skin’s temperature is within normal limit. Hair : The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair. There are also no signs of infection and infestation observed. Nails : The client has a light brown nails and has the shape of convex curve. It is smooth and is intact with the epidermis. When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds.

55. SKIN An extensive language has been developed to standardize the description of skin lesions,

56. Lesion types: Macules  are flat, nonpalpable lesions usually < 10 mm in diameter. Macules represent a change in color and are not raised or depressed compared to the skin surface. A patch is a large macule. Examples include freckles, flat moles, tattoos, and port-wine stains, and the rashes of  rickettsial infections, rubella, measles (can also have papules and plaques), and some allergic drug eruptions.

57. Papules  are elevated lesions usually < 10 mm in diameter that can be felt or palpated. Examples include nevi, warts, lichen planus, insect bites, seborrheic keratoses , actinic keratoses , some lesions of acne, and skin cancers.

58. Plaques  are palpable lesions > 10 mm in diameter that are elevated or depressed compared to the skin surface. Plaques may be flat topped or rounded. Lesions of psoriasis and granuloma annulare commonly form plaques.

59. Nodules  are firm papules or lesions that extend into the dermis or subcutaneous tissue. Examples include cysts, lipomas, and fibromas.

60. Vesicles   are small, clear, fluid-filled blisters < 10 mm in diameter. Vesicles are characteristic of herpes infections, acute allergic contact dermatitis, and some autoimmune blistering disorders ( eg , dermatitis herpetiformis).

61. Bullae  are clear fluid-filled blisters > 10 mm in diameter. These may be caused by burns, bites, irritant or allergic contact dermatitis, and drug reactions. Bullae also may occur in inherited disorders of skin fragility.

62. Pustules   are vesicles that contain pus. Pustules are common in bacterial infections and folliculitis and may arise in some inflammatory disorders including pustular psoriasis

63. Urticaria  (wheals or hives) is characterized by elevated lesions caused by localized edema. Wheals are pruritic and red. Wheals are a common manifestation of hypersensitivity to drugs, stings or bites, autoimmunity, and, less commonly, physical stimuli including temperature, pressure, and sunlight. The typical wheal lasts < 24 h.

64. Scale  is heaped-up accumulations of horny epithelium that occur in disorders such as psoriasis, seborrheic dermatitis, and fungal infections. 

65. rare genetic skin disease known as Ichthyosis, after the ancient Greek word for fish.

66. Crusts (scabs)  consist of dried serum, blood, or pus. Crusting can occur in inflammatory or infectious skin diseases ( eg , impetigo).

67. Erosions  are open areas of skin that result from loss of part or all of the epidermis. Erosions can be traumatic or can occur with various inflammatory or infectious skin diseases. An excoriation is a linear erosion caused by scratching, rubbing, or picking.

68. Ulcers  result from loss of the epidermis and at least part of the dermis. Causes include venous stasis dermatitis, physical trauma with or without vascular compromise ( eg , caused by decubitus ulcers or peripheral arterial disease), infections, and  vasculitis .

69. Petechiae  are nonblanchable punctate foci of hemorrhage. Causes include platelet abnormalities ( eg , thrombocytopenia, platelet dysfunction), vasculitis, and infections ( eg , meningococcemia, Rocky Mountain spotted fever, other rickettsioses).

70. Purpura  is a larger area of hemorrhage that may be palpable. Palpable purpura is considered the hallmark of leukocytoclastic vasculitis. Purpura may indicate a coagulopathy. Large areas of purpura may be called ecchymoses or, colloquially, bruises.

71. Atrophy  is thinning of the skin, which may appear dry and wrinkled, resembling cigarette paper. Atrophy may be caused by chronic sun exposure, aging, and some inflammatory and neoplastic skin diseases, including cutaneous T-cell lymphoma and  lupus erythematosus . Atrophy also may result from long-term use of potent topical corticosteroids.

72. Scars  are areas of fibrosis that replace normal skin after injury. Some scars become hypertrophic or thickened and raised.  Keloids  are hypertrophic scars that extend beyond the original wound margin.

73. Telangiectases  are foci of small, permanently dilated blood vessels that may occur in areas of sun damage, rosacea, systemic diseases.

74. Color Red skin  (erythema) can result from many different inflammatory or infectious diseases. Cutaneous tumors are often pink or red. Superficial vascular lesions such as port-wine stains may appear red. Orange skin  is most often seen in hypercarotenemia, a usually benign condition of carotene deposition after excess dietary ingestion of beta-carotene. Yellow skin  is typical of jaundice. Green fingernails  suggest  Pseudomonas aeruginosa  infection.

75. Violet skin  may result from cutaneous hemorrhage or vasculitis. Vascular lesions or tumors, such as Kaposi sarcoma and hemangiomas, can appear purple. Shades of blue, silver, and gray  can result from deposition of drugs or metals in the skin. Ischemic skin appears purple to gray in color. Deep dermal nevi appear blue (cyanosis)

76. Edema  is the medical term for swelling. Body parts swell from injury or inflammation. It can affect a small area or the entire body. Medications, infections, pregnancy, and many other medical problems can cause edema. Edema happens when your small blood vessels become "leaky" and release fluid into nearby tissues. That extra fluid builds up, which makes the tissue swell

77. Pitting Edema Measurement Scales S.B. O'Sullivan and T.J. Schmitz Physical rehabilitation: assessment and treatment M. Hogan Medical-Surgical Nursing 1+ Barely detectable impression when finger is pressed into skin. 2mm depression, barely detectable. Immediate rebound. 2+ Slight indentation. 15 seconds to rebound 4mm deep pit. A few seconds to rebound. 3+ Deeper indentation. 30 seconds to rebound. 6mm deep pit. 4+ > 30 seconds to rebound. 8mm: very deep pit.

78. Discussion will resume after the break References: Audrey Berman . . . [et al.]. – 9th ed. (2012) KOZIER & ERB’S Fundamentals of NURSING Concepts, Process, and Practice. Bickley, Lynn S. -11 TH ED. (2013) Bates’ guide to physical examination and history-taking.

79. Different types of open wounds There are five types of open wounds, which are classified depending on their cause. Abrasion An abrasion occurs when the skin rubs or scrapes against a rough or hard surface. Road rash is an example of an abrasion. There’s usually not a lot of bleeding, but the wound needs to be scrubbed and cleaned to avoid infection.

80. Incision A sharp object, such as a knife, shard of glass, or razor blade, causes an incision. Incisions bleed a lot and quickly. A deep incision can damage tendons, ligaments, and muscles.

81. Laceration A laceration is a deep cut or tearing of the skin. Accidents with knives, tools, and machinery are frequent causes of lacerations. The bleeding is rapid and extensive.

82. Puncture A puncture is a small hole caused by a long, pointy object, such as a nail, needle, or ice pick. Punctures may not bleed much, but these wounds can be deep enough to damage internal organs. If you have a puncture wound (even just a small one), visit your doctor to get a tetanus booster shot and prevent infection.

83. Avulsion An avulsion is a partial or complete tearing away of skin and tissue. Avulsions usually occur during violent accidents, such as body-crushing accidents, explosions, and gunshots. They bleed heavily and rapidly.

84. CASE ANALYSIS! WHY PAPER CUT HURTS SO MUCH?

85. HAIR AND SCALP Vellus hair  is short, thin, slight-colored, and barely noticeable thin  hair  that develops on most of a person's body during childhood. Exceptions include the lips, the back of the ear, the palm of the hand, the sole of the foot, some external genital areas, the navel, the forehead and scar tissue

86. Terminal hairs  are thick, long, and dark, as compared with vellus  hair . During puberty, the increase in androgenic hormone levels causes vellus  hair  to be replaced with terminal hair  in certain parts of the human body

87. Alopecia is the general medical term for hair loss. Male-pattern baldness is the most common type of hair loss, affecting around half of all men by 50 years of age. It usually starts around the late twenties or early thirties and most men have some degree of hair loss by their late thirties.

88. Alopecia areata Alopecia areata causes patches of baldness about the size of a large coin. They usually appear on the scalp but can occur anywhere on the body. It can occur at any age, but mostly affects teenagers and young adult. Alopecia areata is caused by a problem with the immune system (the body's natural defence against infection and illness).

89. Hirsutism  is excessive body hair in men and women on parts of the body where hair is normally absent or minimal, such as on the chin or chest in particular, or the face or body in general.

90. Case Analysis? What you see? Rapunzel syndrome   is an extremely rare intestinal condition in humans resulting from ingesting hair ( trichophagia ).

91. Pediculus Capitis Head lice infestation  (also known as  pediculosis capitis ,  nits , or  cooties ) is the infection of the head hair and scalp by the head louse ( Pediculus humanus capitis )

92. Pediculosis corporis  (also known as " Pediculosis vestimenti " and "Vagabond's disease") is a cutaneous condition caused by body lice (specifically  Pediculus corporis ) that lay their eggs in the seams of clothing.

93. Pediculosis pubis  (also known as " crabs " and " pubic lice ") is a disease caused by the pubic louse,  Pthirus pubis , a parasitic insect notorious for infesting human pubic hair. The species may also live on other areas with hair, including the eyelashes, causing pediculosis ciliaris . Infestation usually leads to intense itching in the pubic area.

94. CASE STUDY! ANYARE DITO? -_-

95. A patient asks Student Nurse Ana, SN ‘26, if it is possible to grow new skin. What is the nurses most appropriate response? A) Even if new skin growth is required, the melanocytes do not regenerate. B) The avascular epidermis sheds slowly and is replaced completely every 4 weeks.. C) The outer layer of skin remains the same over the lifetime except for repairing injuries. D) Epidermal regeneration is impossible because it is avascular.

96. Studen Nurse Jessa is assessing her patient with liver disease, she is expecting to find which manifestation during the examination? A) Yellowish color in the axilla and groin B) Yellow pigmentation in the sclera C) Very pale skin on the palms D) Ashen-gray color in the oral mucous membranes

97. Carlo, a dark-skinned patient who has a Liver Problem due to heavy consumption of alcohol. How does the nurse recognize if he has a jaundice? A) Inspect the conjunctiva for ashen-gray color. B) Inspect the nail beds for a deeper brown or purple skin tone. C) Inspect the palms and soles for yellowish-green color. D) Inspect the oral mucous membrane for yellow color.

98. Keith Charmaine, a new nurse in the ward is doing an assessment to her client. How can she inspect a client with a cyanosis on a dark colored patient? A) Ashen-gray color of the oral mucous membranes B) Blue color in the nail beds C) Ashen-blue color in the palms and soles D) Blue-gray color in the ear lobes and lips

99. Christian, a self proclaimed coffee lover has been admitted in the ER with a inapproriate enlargement of his lower extremities. He mentioned to the nurse “manas lang yan”. What is the best tool to measure and/or know if it is edema? A) Pitting Edema Scale B) Bristol Stool Chart C) Use a tape measure tool D) CT Scan

100. NAIL The primary purpose of the nail is protection. Abnormalities of the nail are often caused by skin disease and infection (most often fungal) but may also indicate more general medical conditions.

101. The patient's manicure can reveal state of health, nutritional status, past events, personality, occupation, and one's inner state. Systemic illness should show the nail changes in each of the nails on one hand. The thumb may reveal more extensive changes given its increased size. It is useful to follow the following sequence when examining the nails: Check the nail shape; Examine the nail color; Survey processes around the nails; Compare hands; and Note skin conditions.

102. Assessment Process Remove any nailpolish , shoes and socks first. Inspect all surfaces of the patient's nailbeds. Pay attention to " dryness , inflammation , or cracking"  Nails should be smooth, surrounding cuticles and tissues clear and normal in color. Look for  ingrown nails  that occur in either hands or feet. Assess capillary refill of finger nailbeds which should be two seconds or less. Circulation problems can change the nail integrity or increase chance of infection. Observe the patient's gait by having them walk to and from you. Note if the person experiences pain with ambulation. Types of shoes worn may predispose patients to nail problems such as "infection, areas of friction, ulcerations". Check if your patient wears nailpolish or artificial nails. Certain chemicals can cause the nailbeds to become dry and brittle. These patients are prone to nail ridges, redness and swelling beneath the polish or artificial nail.

103. Check for: Nail clubbing , also known as digital clubbing, is a deformity of the finger or toe nails associated with a number of diseases, mostly of the heart and lungs.

104.   Koilonychia , also known as spoon nails, is a nail disease that can be a sign of hypochromic anemia, especially iron-deficiency anemia.

105. Beau's lines .  Beau's lines  are deep grooved  lines that run from side to side on the fingernail or the toenail. They may look like indentations or  ridges  in the nail plate. ... This may be caused by an infection or problem in the nail fold, where the nail begins to form, or it may be caused by an injury to that area.

106. paronychia  is a nail disease that is an often-tender bacterial or fungal infection of the hand or foot where the nail and skin meet at the side or the base of a finger or toenail. The infection can start suddenly (acute paronychia) or gradually (chronic paronychia).

107. Nail Fungus (Onychomycosis) The term  fungal nails , medically known as onychomycosis, refers to a fungal infection of the toenails or fingernails. Fungal infection of the nails may cause changes in the nail itself and its appearance, including symptoms and signs

108. Head Head : The head of the client is rounded; normocephalic and symmetrical. Skull : There are no nodules or masses and depressions when palpated. Face : The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses.

109. HEAD Assess for history of headaches, migraines, trauma, vertigo, dizziness, syncope, lesions, or lumps.

110. Headache Basics What Are the Types of Headaches? Tension headaches:   Also called stress headaches, chronic daily headaches, or chronic non-progressive headaches, they are the most common type among adults and teens . They cause mild to moderate pain and come and go over time.

111. Migraines:   These headaches are often described as pounding, throbbing pain . They can last from 4 hours to 3 days and usually happen one to four times per month. Along with the pain, people have other symptoms, such as sensitivity to light, noise, or smells; nausea or  vomiting ; loss of appetite; and upset  stomach  or  belly pain . When a child has a migraine, she often looks pale, feels dizzy, and has blurry  vision , fever, and an upset stomach.

112. Cluster headaches:   This type is intense and feels like a burning or piercing pain behind the eyes, either throbbing or constant. It’s the least common but the most severe type of headache. The pain can be so bad that most people with  cluster headache s can’t sit still and will often pace during an attack. You might get them one to three times per day during a cluster period, which may last 2 weeks to 3 months. The headaches may disappear completely (go into "remission") for months or years, only to come back again.

113. Sinus headaches:   With these, you feel a deep and constant pain in your cheekbones, forehead, or bridge of your nose. They happen when cavities in your head, called sinuses, get inflamed. The pain usually comes along with other  sinus  symptoms, such as a runny nose, feeling of fullness in the ears, fever, and swelling in your face. Mixed headache syndrome:   Also called transformed migraines, this condition is a mix of migraine and tension headaches. Both adults and children can have it.

114. Hormone headaches:   Women can get headaches from changing hormone levels during  their  periods,  pregnancy , and  menopause . The hormone changes from  birth control pills  also trigger headaches in some women. Chronic progressive headaches:   Also called traction or inflammatory headaches, these get worse and happen more often over time. They make up less than 5% of all headaches in adults and less than 2% of all headaches in kids. They may be the result of an illness or disorder of the  brain  or skull.

115. Levels of consciousness Level Summary (Kruse) Description Conscious Normal Assessment of LOC involves checking  orientation : people who are able promptly and spontaneously to state their name, location, and the date or time are said to be oriented to self, place, and time, or "oriented X3". A normal  sleep  stage from which a person is easily awakened is also considered a normal level of consciousness. "Clouding of consciousness" is a term for a mild alteration of consciousness with alterations in attention and wakefulness.

116. Confused Disoriented; impaired thinking and responses People who do not respond quickly with information about their name, location, and the time are considered "obtuse" or " confused ". [8]   A confused person may be bewildered, disoriented, and have difficulty following instructions. [9]   The person may have slow thinking and possible memory time loss. This could be caused by sleep deprivation, malnutrition, allergies, environmental pollution, drugs (prescription and nonprescription), and infection.

117. Delirious Disoriented; restlessness, hallucinations, sometimes delusions Some scales have "delirious" below this level, in which a person may be restless or agitated and exhibit a marked deficit in  attention . [2] Somnolent Sleepy A  somnolent  person shows excessive  drowsiness  and responds to stimuli only with incoherent mumbles or disorganized movements. [8]

118. Obtunded Decreased alertness; slowed psychomotor responses In  obtundation , a person has a decreased interest in their surroundings, slowed responses, and sleepiness. [9] Stuporous Sleep-like state (not unconscious); little/no spontaneous activity People with an even lower level of consciousness, stupor, only respond by  grimacing  or drawing away from painful stimuli. [8] Comatose Cannot be aroused; no response to stimuli Comatose people do not even make this response to stimuli, have no  corneal  or  gag reflex , and they may have no  pupillary response  to light. [8]

119. Glasgow Coma Scale  ( GCS ) is a neurological scale which aims to give a reliable and objective way of recording the conscious state of a person for initial as well as subsequent assessment. Glasgow Coma Scale  [2] 1 2 3 4 5 6 Eye Does not open eyes Opens eyes in response to  painful stimuli Opens eyes in response to voice Opens eyes spontaneously N/A N/A Verbal Makes no sounds Incomprehensible sounds Utters incoherent words Confused, disoriented Oriented, converses normally N/A Motor Makes no movements Extension to painful stimuli ( decerebrate response ) Abnormal flexion to painful stimuli ( decorticate response ) Flexion / Withdrawal to painful stimuli Localizes painful stimuli Obeys commands

120. Interpretation: Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 02:35". Generally, brain injury is classified as: Severe, with GCS < 8–9 Moderate, GCS 8 or 9–12 (controversial) Minor, GCS ≥ 13.

121. HEAD Circumference Generally round, with prominences in the frontal and occipital area. ( Normocephalic ). No tenderness noted upon palpation.

122. Face Observe the face for shape. Inspect for Symmetry. Inspect for the palpebral fissure (distance between the eye lids); should be equal in both eyes. Ask the patient to smile, There should be bilateral Nasolabial fold (creases extending from the angle of the corner of the mouth). Slight asymmetry in the fold is normal. If both are met, then the Face is symmetrical

123. Eyes and Vision Eyebrows : Hair is evenly distributed. The client’s eyebrows are symmetrically aligned and showed equal movement when asked to raise and lower eyebrows. Eyelashes : Eyelashes appeared to be equally distributed and curled slightly outward. Eyelids : There were no presence of discharges, no discoloration and lids close symmetrically with involuntary blinks approximately 15-20 times per minute.

124. Eyes The Bulbar conjunctiva appeared transparent with few capillaries evident. The sclera appeared white. The palpebral conjunctiva appeared shiny, smooth and pink. There is no edema or tearing of the lacrimal gland. Cornea is transparent, smooth and shiny and the details of the iris are visible. The client blinks when the cornea was touched.

125. CASE STUDY Why eyes changes its pupil?

126. CASE STUDY WHY WE CHECK THE EYES OF CLIENT WHO HAD AN ACCIDENT?

127. CASE STUDY WHY WE CHECK THE EYES OF CLIENT WHO HAD AN ACCIDENT?

128. The pupils of the eyes are black and equal in size. The iris is flat and round. PERRLA (pupils equally round and respond to light accommodation), illuminated and non-illuminated pupils constricts. Pupils constrict when looking at near object and dilate at far object. Pupils converge when object is moved towards the nose. When testing for the Extraocular Muscle, both eyes of the client coordinately moved in unison with parallel alignment.

129. Myopia, also known as nearsightedness, is a common type of refractive error where close objects appear clearly, but distant objects appear blurry.

130. Hyperopia Far-sightedness, also known as long-sightedness and , is a condition of the eye in which light is focused behind, instead of on, the  retina. This causes close objects to be blurry, while far objects may appear normal

131. Presbyopia farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age

132. Astigmatism: a defect in the eye or in a lens caused by a deviation from spherical curvature, which results in distorted images, as light rays are prevented from meeting at a common focus.

133. Sty is a red, painful lump near the edge of your eyelid that may look like a boil or a pimple. Sties are often filled with pus. A sty usually forms on the outside of your eyelid. But sometimes it can form on the inner part of your eyelid.

134. Sore Eyes  — Sore eyes  is a broad term describing a range of possible sensations. ... One common cause of  sore eyes  is conjunctivitis (or pink  eye ), but the problem can also be caused by an infection, allergies, too much sun exposure,  eye  fatigue, or contact lens wear

135. Ears and Hearing Ears : The Auricles are symmetrical and has the same color with his facial skin. The auricles are aligned with the outer canthus of eye. When palpating for the texture, the auricles are mobile, firm and not tender. The pinna recoils when folded. During the assessment of Watch tick test, the client was able to hear ticking in both ears.

136. Ears Inspect the auricles of the ears for parallelism, size position, appearance and skin color. Palpate the auricles and the mastoid process for firmness of the cartilage of the auricles, tenderness when manipulating the auricles and the mastoid process. Inspect the auditory meatus or the ear canal for color, presence of cerumen, discharges, and foreign bodies. Perform otoscopic examination of the tympanic membrane, noting the color and landmarks

137. Normal Findings The ear lobes are bean shaped, parallel, and symmetrical. The upper connection of the ear lobe is parallel with the outer canthus of the eye. Skin is same in color as in the complexion. No lesions noted on inspection. The auricles are has a firm cartilage on palpation. The pinna recoils when folded. There is no pain or tenderness on the palpation of the auricles and mastoid process. The ear canal has normally some cerumen of inspection. No discharges or lesions noted at the ear canal. On otoscopic examination the tympanic membrane appears flat, translucent and pearly gray in color

138. Discussion will resume after the break References: Audrey Berman . . . [et al.]. – 9th ed. (2012) KOZIER & ERB’S Fundamentals of NURSING Concepts, Process, and Practice. Bickley, Lynn S. -11 TH ED. (2013) Bates’ guide to physical examination and history-taking.

139. THANK YOU 