Evidence-Based Nursing Assessment: Health, Interview, Substance Abuse, and Neuro System, Study Guides, Projects, Research of Nursing

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Health Assessment Kaplan Study Guide Evidence Based Assessment:

• first-level priority problems—emergent, life-threatening and immediate (establishing an airway, supporting breathing)
• second-level priority problems—next in urgency—requires prompt intervention to prevent further harm ( mental status change, acute pain, acute urinary elimination problems, abnormal lab values, risks of infection/safety)
• third-level priority problems—important to patient’s health but can be addressed at later time ( long term, treatment takes more time)
• collaborative problems—involves multiple disciplines
• four types of data collection: o complete—total health history o focused—problem-centered/ focuses on mainly one problem o follow-up—used to monitor progress of health problems o emergency—urgent, rapid collection of crucial information compiled concurrently with lifesaving measures
• Objective data—what the health professional can OBSERVE
• subjective data—what the patient says about himself/herself Cultural Competence:
• acculturation—process of social and psychological exchanges with encounters between people of different cultures resulting in changes in either group
• a nurse must be culturally competent—able to understand the cultural context of the patient’s situation
• cultural background can influence how a patient views his/her health problems—such as pain
• nurse must respect patient’s cultural background and how it influences the way they seek treatment The Interview:
• Process of communication: o sending—be aware of both verbal and nonverbal cues you could be sending o receiving—consider culture of receiver, context and gestures o internal factors-- 4 inner factors: ▪ liking others—keeping an optimistic view of others—client must believe he/she is accepted by the interviewer ▪ empathy— being able to view the world from the client’s perspective ▪ ability to listen—listening is ACTIVE; pay attention to nonverbal communication from patient o external factors—avoid interruptions and excessive notetaking; make physical environment comfortable; ensure privacy
• 3 interview phases:

o introduction phase—establish rapport o working phase—data-gathering phase o closing phase—summary of data gathered

• open ended questions—useful for beginning interview
• complete health history—provides insight into person’s past and present health — important to know patient’s perception of health
• mental status—a person’s emotional and cognitive functioning o a person’s mental status is inferred through their behaviors o assessment of mental status- 4 components: ▪ Appearance—posture, dress, grooming and hygiene ▪ Behavior—level of consciousness—awake, alert and aware, facial expression, speech, mood, affect ▪ Cognitive function—attention span, recent memory, new learning ( unrelated word test) ▪ thought processes/perceptions—logical, coherent, relevant, aware of reality, suicidal thoughts
• Substance Abuse: o alcohol—must used and abused psychoactive drug—presence of consumption in a patient’s history is a significant risk factor for development of comorbidities ▪ more than 150 meds interact with alcohol o assess for withdrawal symptoms Neurological System
• controls body function and is related to every other body system
• divided into 2 parts: o CNS—brain and spinal cord—collect and interpret voluntary and involuntary motor and sensory stimuli ▪ brain consists of:
• cerebrum
• brain stem—regulates automatic body functions ( heart rate, breathing and swallowing)
• cerebellum—controls ability to think and reason—divided into 4 lobes (frontal, parietal, temporal and occipital) and 2 hemispheres ( right hemisphere controls left side of body, left hemisphere controls right side of body)—helps maintain equilibrium ▪ spinal cord—primary pathway for messages traveling between the peripheral body and brain o PNS—12 pairs of cranial nerves, 31 pairs of spinal nerves and all their branches ▪ cranial nerves—enter/exit brain NOT spinal cord; 12 pairs; primarily supply head and neck, EXCEPT vagus nerve—travels to heart, respiratory muscles, stomach and gallbladder ▪ spinal nerves—31 pairs—arise from spinal cord

• frontal lobe—motor control of voluntary muscles, personality, problem solving
• temporal lobe—hearing
• parietal lobe—sensory, understanding speech and language
• occipital lobe—visual recognition
• sympathetic nervous system-=-controls fight or flight responses
• parasympathetic nervous system—maintains baseline body functions
• Infants: o neurologic system not completely developed at birth—movement directed primarily by primitive reflexes: ▪ rooting reflex ▪ grasping ▪ morro ▪ sucking o if these reflexes don’t go away with age, indicates CNS dysfunction
• aging adult: o atrophy with steady loss of neuron structure in brain/spinal cord ▪ loss of weight/volume ▪ reduced subcortical brain structures ▪ expansion of ventricles ▪ slower reaction time ▪ diminished sensation of touch, pain, taste, and smell ▪ muscle strength/agility decrease ▪ cerebral blood flow and O2 consumption decrease= dizziness/loss of balance
• 4 types of reflexes:
• dermatomes: o deep tendon reflexes—knee jerk o superficial—corneal reflex, abdominal reflex o visceral—pupillary response to light o pathologic (abnormal)—Babinski’s reflex/extensor plantar reflex o area of skin that’s inhabited by each sensory nerve o purpose—documenting sensory nerve function
• subjective data: o headache? o head injury? o dizziness? o seizures? o tremors? effect ADLs? o weakness? o incoordination? o numbness or tingling? o difficulty swallowing/speaking? o past history? o environmental/occupational hazards

o additional history for infants/children: ▪ problems during pregnancy/at birth? ▪ premature/full term? ▪ birth weight? ▪ birth trauma? did infant breathe immediately? ▪ Apgar scores? ▪ congenital defects? ▪ reflexes:

• sucking and swallowing seem coordinated? ▪ problem with balance? ▪ motor/developmental milestones? ▪ exposure to lead?—cause developmental delay/loss of newly acquired skill—can be asymptomatic o additional history for aging adult: ▪ dizziness—FALLS—affect ADLs? ▪ decrease in memory/change in mental function/confusion?
• memory loss/cognitive decline= early onset Alzheimer’s ▪ tremor in hands/face ▪ sudden vision change?
• Objective Data: o Prep: ▪ screening neurologic exam on well persons ▪ complete neuro exam on patients with neurologic concerns ▪ recheck exam on patients with deficits periodically o complete neurologic exam—highest level of neurological function to lowest) ▪ mental status:
• begins during health history
• level of consciousness—alert, lethargic, comatose
• appearance/behavior—personal hygiene
• speech—express themselves? clear? difficulty forming words? ▪ Cranial Nerves:
• Olfactory (CN 1)—smell
• Optic (CN 2)—visual acuity, visual fields, ocular fundi
• optic/oculomotor (CN 2, 3)—pupillary reactions
• oculomotor, trochlear, and abducens (CN 3, 4, 6)—extra- ocular movements, including opening of the eyes
• trigeminal (CN 5)—facial sensation, movements of jaw, corneal reflexes
• facial (CN 7)—facial movements
• Acoustic (CN 8)—hearing/balance
• Glossopharyngeal & Vagus (CN 9, 10)—swallowing, elevation of palate, gag reflex
• trigeminal, facial, vagus, & hypoglossal (CN 5, 7, 10, 12)—voice and speech
• spinal accessory (CN 11)—shrugging shoulders and turning head

• hypoglossal (CN 12)—movement and protrusion of tongue ▪ Inspect/palpate motor system—muscle tone, muscle strength, & cerebellum testing
• muscles: o size—compare right side with left—difference of 1 cm or less=not significant o strength—muscle groups of extremities, neck and trunk o tone—normal tension in relaxed muscles o involuntary movements—normally none occur ▪ cerebellar function:
• balance tests: o gait—smooth, rhythmic, and effortless—note any imbalances/abnormalities o Romberg test—feet together, arms at side, eyes closed —20 seconds Skin, Hair, and Nails Skin
• Skin in the first line of defense in the body’s immune system. o Adapts the body to heat & and cold
• 3 Layers of skin o Epidermis: tough, thin, avascular, produces melanin o Dermis: Consists mostly of connective tissue or collagen, contains nerves, sensory receptors, blood vessels, and lymphatics o Subcutaneous: made up of fat cells, provides for temperature control, stores fat for energy Hair
• 2 types o vellus: fine body hair o terminal: eyebrows, axillae, pubic area, beard & chest
• sebaceous (oil) glands: produce sebum, oils and lubricates the skin & hair and helps prevent water loss from skin. Found everywhere but palms and soles.

Sweat Glands

• Eccrine: odorless sweat, reduces body temperature
• Apocrine: active during puberty, produce musky odor
• Ceruminous: located in ear, produce lubricating cerumen Nails
• Hard plates of keratin on fingers and toes for protection
• Functions: o Prevents penetrations of microorganisms o Perception o Temperature regulation o Communication o Wound repair o Absorption & excretion o Production of vitamin D with sun exposure Infants
• Infants are at greater risk for fluid loss
• Skin can’t contract or shiver with cold temperatures
• Assess for turgor in the abdomen Skin Changes in aging adult
• Loss of collagen and protective cushioning of subcutaneous fat, increase for pressure ulcers
• Loss of elastic, loss of turgor (tenting) Pregnancy
• Increased pigmentation of abdomen (linea nigra)
• “stretch marks” (striae gravidarum) Inspection Subjective:
• Change in mole size or color
• Change in skin color pigment o Jaundice, pallor, cyanosis
• Excessive dryness (xerosis) or excessive moisture, oily, (seborrhea)
• Pruritus (itching)
• Rash or lesions
• Hair loss (alopecia) Inspection Color:
• Pigmentation should be normal for ethnicity o Abnormalities: vitiligo, freckles, moles, birthmarks
• Widespread color change: o Pallor, erythema (rubor), cyanosis, jaundice
• Look at color, consistency, and contour of nails o Look for clubbing (which present with congenital cyanotic heart disease, lung cancer, and pulmonary disease) Inspection Palpation

• Temperature o Hypothermia: o Hyperthermia:
• Moisture o Diaphoresis: Perfuse o Dehydration:
• Texture, Edema, Turgor
• Cap refill o Anything longer than 1-2 is sluggish Inspect Lesions:
• When a lesion develops on unaltered skin it is primary
• When a lesion changes over time or change due to scratching or infection it is secondary
• Asymmetry
• Border
• Color
• Diameter
• Elevation Hair
• Color, uniformity
• Texture
• Hair distribution
• Lesions Burns
• First degree superficial burn (sunburn o Skin remains intact, mild to moderate pain involved
• Second degree o Involves dermis & epidermis causing blisters causing blisters, extremely painful
• Third degree o Involves full thickness skin damage, burn often reaches dep muscles & bones causing extensive infections, not always painful due to damaged nerves.

Head, Face & Neck with Regional Lymphatics Head structure

• Cranial bones o Frontal, parietal, occipital, and temporal
• Sutures; adjacent cranial bones o Coronal suture, sagittal suture, and lambdoid suture Facial Structure Facial bones: articulate at sutures Facial muscles: mediated by cranial nerve VII the facial nerve and is symmetric and bilateral Salivary glands: o Parotid: in the cheeks over the mandible, anterior to and below the ear. Are the largest but not normally palpable o Submandibular: are beneath the mandible at the angle of the jaw. o Sublingual: lie in the floor of the mouth Temporal Artery: lies superior to the temporalis muscle: its pulsation is palpable anterior to the ear Structures and Function of the Neck
• Neck Muscles o Sternomastoid o Trapezius ▪ Both of these are innervated by cranial nerve XI the spinal accessory
• Anterior and posterior triangles: divided by the sternomastoid
• Hyoid bones Cricoid cartilage
• Trachea
• Carotid Arteries
• Jugular Veins Thyroid Gland
• Endocrine gland
• Rich blood supply
• Synthesizes and secretes thyroxine (T4) and triiodothyronine (T3) which stimulates the rate of cellular metabolism Lymphatics
• Detects and eliminates foreign substances from body Salivary Glands
• Parotid Glands (accessible for examination)
• Submandibular Glands (accessible for examination)
• Sublingual Glands Temporal artery
• Pulsation is palpable anterior to the ear Infants and Children
• Bones of the skull are separated by sutures and fontanels

• Head size is greater than chest circumference at birth. Pregnant Women
• Thyroid gland is slightly enlarged Aging Adult
• Facial bones appear more prominent
• Skin sags due to decreased elasticity and decreased fat
• Senile tremors may present o Benign o Head nodding and tongue protrusion Abnormal Findings
• Pediatric o Fetal alcohol syndrome o Congenital hypothyroidism o Down syndrome o Atopic (allergic) facies o Allergic salute and crease o Hydrocephalus
• Adult o Simple Diffuse Goiter o Hyperthyroidism o Hypothyroidism o Cushing Syndrome o Bell Palsy o Parkinson Syndrome Ears, Nose, Throat, and Eyes Ears: Ears are the sensory organs for hearing and maintaining equilibrium and have three parts.
• External ear - Cartilage, Auditory canal. The shape funnels sound waves into the opening of the ear which is the external auditory canal. The canal is lined with glands that secrete cerumen, a yellow, waxy material that lubricates and protects the ear.
• Middle ear - Air filled cavity. Its opening to the outer ear is covered by the tympanic membrane. It has 3 functions. Conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. It protects the inner ear by reducing the amplitude of loud sounds. It’s Eustachian tube allows equalization of air pressure on each side of the tympanic membrane so the membrane does not rupture.
• Inner ear - Cochlea (snail shell). The inner ear is embedded in bone. Contains the bony labyrinth, which holds the sensory organs for equilibrium and hearing. Hearing Loss: Anything that obstructs the transmission of sounds impairs hearing.

• Conductive hearing loss - involves a mechanical dysfunction of the external or middle ear. It is a partial hearing loss because the person can hear if the sound amplitude is increased enough.
• Sensorineural loss - loss signifies pathology of the inner ear, cranial nerve VIII, or the auditory areas of the cerebral cortex. May be caused by presbycusis, and by ototoxic drugs, which affect the hair cells in the cochlea.
• Mixed loss - a combination of conductive and sensorineural types in the same ear. Equilibrium: The 3 semicircular canals, or labyrinth, in the inner ear constantly feed information to your brain about the position of your body in space. Infants and children: The inner ear starts to develop early in the fifth week of gestation. In early development the ear is posteriorly rotated and low set; later it ascends to its normal placement around eye level. If maternal rubella information occurs during the first trimester, it can damage the organ of Corti and impair hearing. It is easier for pathogens from the nasopharynx to migrate through the middle ear because the Eustachian tube is shorter and wider and its position is more horizontal than the adults. Otosclerosis: A common cause of conductive hearing loss in young adults between the ages of 20 and 40 years. The aging adult: A person of living or working in a noise-polluted area has a greater risk for sensorineural hearing loss. Presbycusis is a type of hearing loss that occurs with 60% of those older than 65 years, even in people living in a quiet environment. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear that slowly progresses after the fifth decade. Otitis media - Middle ear infection, occurs because of obstruction of the Eustachian tube or passage of nasopharyngeal secretions into the middle ear. Most common in childhood. Nose: The first segment of the respiratory system. It warms, moistens, and filters the inhaled air, and it is the sensory organ for smell.
• The external nose contains cartilage and nares.
• The nasal cavity contains the septum, olfactory receptors, and turbinates.
• The paranasal sinuses: air-filled pockets within the cranium. They communicate with the nasal cavity and are lined with the same type of ciliated mucous membrane. Two pairs of sinuses that are accessible for examination: the frontal and maxillary sinuses. The ethmoid and sphenoid sinuses are deep within the skull in the sphenoid bone.
• Only the maxillary and ethmoid sinuses are present at birth.
• The maxillary sinuses reach full size after all permanent teeth have erupted.
• The frontal sinuses are absent at birth, and are fairly well developed between 7 and 8 years of age. They reach full size after puberty.

Throat: It is the area behind the mouth and nose.

- Oropharynx: separated from the mouth by a fold of tissue on each side, the anterior tonsillar pillar. - Tonsils: Behind the folds, each a mass of lymphoid tissue. The same color as the surrounding mucous membrane. Tonsillar tissue enlarges during childhood until puberty and then involutes. - Nasopharynx: continuous with the oropharynx, although it is above the oropharynx and behind the nasal cavity. - The oral cavity and throat have a rich lymphatic network. Eyes: The sensory organ of vision.

• More than half of the neocortex is involved with processing visual information.
• The outer layer: Sclera
• Middle layer: Choroid, ciliary body and iris, pupil, lens, anterior chamber.
• Inner layer: Retina, optic disc, retinal vessels, macula Visual reflexes
• Pupillary light reflexes: the normal constriction of the pupils when bright light shines on the retina.
• Fixation: a reflex direction of the eye toward an object attracting our attention.
• Accommodation: adaptation of the eye for near vision. It is accomplished by increasing the curvature of the lens through the muscles of the ciliary body. Infants and children
• At birth eye function is limited
• At 3 months, infants can fixate on objects. Most babies are born farsighted; this gradually decreases after 7 to 8 years of age. The aging adult
• Cataract formation : a clouding of the crystalline lens from a clumping of proteins. Age is the primary risk factor. Curable with lens replacement surgery.
• Glaucoma : an optic nerve neuropathy characterized by loss of peripheral vision, caused by increased intraocular pressure. Age is the primary risk factor. Newer evidence shows a higher risk for women.
• Macular degeneration : a loss of central vision caused by yellow deposits and neovascularity in the macula. Culturally based variability exists in the color of the iris and retinal pigmentation, with darker irides having darker retinas behind them. Individuals with light retinas generally have better night vision but can have pain in an environment that has too much light. Cataracts occur at a higher prevalence among whites. Abnormal findings
• Strabismus: disorder in which the eyes don’t look in exactly the same direction at the same time
• Esotropia: a form of strabismus in which one or both eyes turn inward. Can be constant or occur intermittently and could give a cross eyed appearance.

• Exotropia: a form of strabismus in which one or both eyes turn outward. It is opposite of crossed eyes.
• Presbyopia: the decrease in power of accommodation with aging.

Health Assessment Kaplan Exam

Chapter 7: Domestic and Family Violence

Focus on intimate partner violence, dating violence, child abuse, and elder abuse

Four types of IPV (pg.103)

-Physical Violence: use of force

-Sexual violence: force someone to engage in sex against there will or someone who is

unable to consent

-Threats of physical or sexual violence

-Psychological/emotional abuse and/or coercive tactics: name calling, public

embarrassment or humiliation, stalking, and harassment

Child Abuse and Neglect (pg.103)

-The Child Abuse and Prevention Treatment Act (2010) dictates the minimum

definitions that must be incorporated into state defined standards

-Neglect: failure to provide child’s basic needs (physical, educational, medical, and

emotional)

-Physical abuse: Caused by punching, beating, kicking, biting, burning, shaking, or

otherwise harming a child

-Sexual abuse

-Emotional abuse: any pattern that of behavior that harms a child’s emotional

development or sense of self-worth

Adolescent Relationship abuse (pg.103)

-Physical, sexual, or psychological/emotional violence within a dating relationship,

and includes stalking

- Abuse may occur electronically

Elder abuse and neglect (pg. 103-104)

-Physical abuse: intentionally injured

-Sexual abuse or abusive sexual contact: Peron who is forced, does not understand the

act and is unable to consent

-Psychological abuse or emotionally abuse: when an elder experiences trauma after

exposure to threats or coercive tactics—humiliation, embarrassment, controlling,

behavior, social isolation, and damaging/destroying property

-Financial abuse or exploitation: Improper use of the elder’s resources for monetary or

personal benefit, profit, or gain such as forgery, theft, or improper use of guardianship

and power of attorney

- Blunt force injury is the most common form of IPV (Pg.104)

- Laceration : skin tears

- cut or incision : when a sharp instrument (knife, razor, scapel, glass) slices through the tissue

- Strangulation : manually or with cordlike

-Abused women have been found to have significantly more chronic health problems,

including more neurologic, gastro intestinal, and gynecologic symptoms and chronic pain, they

usual visit health care professionals more often than women not battered.

-Women also have more depression, suicidality, PTSD symptoms, and substance abuse problems

-Ask women every time they come in for a checkup about domestic violence screening (pg.105)

-The Abuse Assessment Screen (AAS) is the tool used to screen (pg. 106)

You only need a yes from one of these answers to ask for a follow

up

-For the elderly use the Elder Abuse Suspicion Index (EASI)

Child abuse and neglect (pg.108)

-When assessing a child make sure to observe for present and reported injuries and determine

the child’s age and developmental level. Could the child have suffered this injury because of his

or her developmental period? Ask the caregivers if the child crawls, walks, pulling or standing?

-If the child is verbal ask open ended questions

-a child who is 11 or older can be expected to provide a history like most adults

Table 7-1 Forensic terminology

-When documenting IPV, adolescent relationship violence, and elder abuse must include

detailed, nonbiased progress notes, and the use of injury maps, and photographic documentation

in the health record.

-need to be verbatim but within reason

-However it is still critical to report exceptionally poignant statements made by the victim to

identify the reported perpetrator

-always use the exact terms of the abused patient may use to describe the sexual organs, or

sexually assaultive behaviors

-YOU DON’T NEED PROOF OF DOMESTIC VIOLENCE TO FURTHER ASSESS AND

REPORT

Culture and Genetics (pg. 112)

Chapter 8 Assessment Techniques and Safety in the clinical setting

(pg. 115) and (pg.5-7 on Kaplan)

-Inspection: watching, close careful scrutiny, first of the individual as a whole then the

whole body

-Palpation- Fingertips: best used for fine tactile discrimination as of skin texture,

swelling, pulsation, and determining presence of lumps

Grasping action of fingers and thumbs: to detect position, shape, and consistency of an

organ or mass

Dorsa (back) of hands and fingers: best for determining temperature because the skin

here is thinner than on the palms

Base of fingers: or ulnar surface of the hand-best for vibration

-Percussion: able to map out the location and size of an organ by exploring where the

percussion note changes, between the borders of an organ and its neighbors. Signiling

density (air, fluid, solid), detecting an abnormal mass. Eliciting a deep tendon reflex

using the percussion hammer

-and auscultation: Listening to sounds produced by the body such as the heart and the

blood vessels, and the lungs and the abdomen

- be sure to eliminate any extra noise, keep the examination room warm (if it’s too cold a

person may start shivering and cause involuntary muscle contractions), clean the

stethoscope with an alcohol pad wipe and warm the stethoscope. If a man is hairy it can

cause a cracking sound so be sure to wet the hair before auscultating. Never listen

through a gown. Avoid also breathing on the stethoscope.

-Performed one at a time and in this order, except when doing an abdominal assessment

-Abdominal is: Inspection, auscultation, percussion and palpation

- Examination room should be warm and comfortable, quiet, private, and well lit, Avoid

distractions. Natural daylight is the best. The table should be at a height where you can stand

without stooping and should be equipped to raise the persons head up 45 degrees.

- Equipment (Pg118-119)

-A clean field put trash where it belongs and clean your stethoscope!

-HAND HYGIENE!!! Before and after every physical patient encounter, after contact with

bodily fluids, blood, and excretions. After contact with contaminated equipment, and after

removing gloves.

- The infant: (pg 122) -parent should always be present

-have the parent remove clothing, and leave diaper on

-make sure stethoscope is warm

-Use a soft voice

-lock eyed from time to time

-smile

-keep movement slow and deliberate

- use a pacifier

-offer toys

-let and older baby touch the stethoscope

-SEIZE THE OPPUTINUTY WITH A SLEEPING BABY TO LISTNEN TO THE

HEART, LUNGS, AND ABSOMIAL SOUNDS FIRST

-Leave the eye, ear, nose and throat until last

The toddler: (pg. 123) -Should be sitting up in the parents lap

-Ask the parents for help

-greet the child

-collect objective data

-begin with games such as the Denver II or cranial nerve testing

-be assertive children like to say “no”

-start with non-threating areas

Preschool child: (pg.123) -parent also has to be present

- use simple short explanations

- talk to the child

- use games

-a preschool likes to help

-complement the child in his/her cooperation’s

School aged child: (124) – sitting or lying in the examination table

-child should undress himself

-demonstrate equipment

-comment on the body and how it works

The adolescent (pg125): -sitting on the examination table

-keep clothes on as much as possible

-body is changing, they need feedback on healthy and developing normally

-communicate with care

-positive attitude!

Aging adult (125): -older adults may look supine when sitting

-allow as few positions as possible

-allow rest periods

-adjust examination pace

-us physical touch

Chapter 9: General Survey, Measurement, and Vital Signs

General Survey (pg. 8 Kaplan)

-Apparent Age

- Sex

-Racial and ethnic groups

-apparent state of mind

-Height and weight

-posture

-gait. Movement, and range of motion

-suitable clothing

-Hygiene

-body and breath order

-skin color, condition

-Presence of assistive devices, hearing aid, glasses

General Behavior

-Signs of distress

-LOC, oriented x3, mood, speech, thought process appropriate

-Level of cooperation, eye contact (culture must be considered)

Vital Signs

Temperature

-Infants –performed axillary

-Intra-auricular probe allows rapid, non-invasive reading when appropriate

-Tympanic membrane sensors—positioning is crucial, ear canal must be straightened

Pulse

-Rate: look for medications that may affect it. Tachycardia or bradycardia

-and rhythm-Sinus arrhythmia is common in in children

Force

-on a scale of 0-3, 0 meaning absent, 1+ weak, and 2+ normal, 3+ full, bounding

Respirations (rate, pattern, depth)

-adult-costal (chest movement) regular, expiration slower than inspiration, rate 12-

respirations per minute

-neonates- diagpgramatic breathing (abdominal breathing), irrguklar, 30-

respirations/min

Respirations (look for def. in Kaplan pg.8-9)

-abdominal respirations—irregular, 30-60 respirations/min

-Apnea—temporary cessation of breathing

-Cheyne stokes respirations—periodic breathing characterized by rhythmic waxing and

waning of the depth of respirations

-Dyspnea—difficult, labored, or painful breathing

-Hyperpnea—abnormally deep breathing

-Hyperventilation—abnormally rapid, deep and prolonged breathing

-Hypoventilation—reduced ventilator efficiency—produces respiratory acidosis due to

elevation in CO

-Kussmaul’s respirations—marked increase in depth and rate

-Orthopnea—inability to breathe except when trunk is in an upright position

-paradoxical respirations—breathing pattern in which a lung deflates during inspiration

-periodic breathing—rate, depth, or tidal volume changes markedly from one interval to

the next

-Cyanosis—skin appears blue because of an excessive accumulation of unoxygenated

hemoglobin in the blood

-Stridor—harsh, high-pitched sound associated with airway obstruction near larynx

-cough—normal reflex to remove foreign material from lungs—NORMALLY ABSENT

IN NEWBORNS

Cranial Nerves: saying to remember cranial nerves (thanks to Christine for sharing at clinicals) “Oh, Oh, to touch and feel a girl’s vagina, so heavenly”