Download NR509 Mid Term Exam: Basic and Advanced Interviewing Techniques and more Exams Nursing in PDF only on Docsity! NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. ● Chapter 1 Basic and Advanced Interviewing Techniques Basic maximize patient's comfort, avoid unnecessary changes in position, enhance clinical efficiency, move head to toe, examine the patient from their right side Active listening, empathic responses, guided questioning, nonverbal communication, validation, reassurance, partnering, summarization, transitions, empowering the patient Active Listening- closely attending to what the patient is communicating, connecting to the patient’s emotional state and using verbal and nonverbal skills to encourage the patient to expand on his or her feelings and concerns. Empathic Responses-the capacity to identify with the patient and feel the patient’s pain as your own, then respond in a supportive manner. Guided Questioning- show your sustained interest in the patient’s feelings and deepest disclosures and allows the interviewer to facilitate full communication, in the patient’s own words, without interruption. Non-verbal- includes eye contact, facial expression, posture, head position and movement such as shaking or nodding, interpersonal distance, and placement of the arms or legs-crossed, neutral, or open. Validation- helps to affirm the legitimacy of the patient’s emotional experience. Reassurance- an appropriate way to help the patient feel that problems have been fully understood and are being addressed. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. Reliability- Varies according to the patient’s memory, trust, and mood. Chief Complaint Chief Complaint- Make every attempt to quote the patient’s own words. Present Illness Complete, clear and chronological description of the problem prompting the patient visit Onset, setting in which it occurred, manifestations and any treatments Should include 7 attributes of a symptom: ● Location ● Quality ● Quantity or severity ● Timing, onset, duration, frequency ● Setting in which it occurs ● Aggravating or relieving factors ● Associated manifestations -Differential diagnosis is derived from the “pertinent positives” and “pertinent negatives” when doing Review of Systems that are relevant to the chief complaint. A list of potential causes for the patients problems. -Present illness should reveal patient’s responses to his or her symptoms and what effect this has on their life. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. -Each symptom needs its own paragraph and a full description. -Medication should be documented, name, dose, route, and frequency. Home remedies, non- prescriptions drugs, vitamins, minerals or herbal supplements, oral contraceptives, or borrowed medications. -Allergies-foods, insects, or environmental, including specific reaction Tobacco use, including the type. If someone has quit, note for how long -Alcohol and drug use should always be investigated and is often pertinent to the Presenting Illness. Past history -Childhood Illness: measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever, and polio. Also include any chronic childhood illness -Adult illnesses: Provide information in each of the 4 areas: ● Medical: diabetes, hypertension, hepatitis, asthma and HIV; hospitalizations; number and gender of sexual partners; and risk taking sexual practices. ● Surgical: dates, indications, and types of operations ● Obstetric/gynecologic: Obstetric history, menstrual history, methods of contraception, and sexual function. ● Psychiatric: Illness and time frame, diagnoses, NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. hospitalizations, and treatments. -Health Maintenance: Find out if they are up to date on immunizations and screening tests. Review Tb tests, pap smears, mammograms, stool tests for occult blood, colonoscopy, cholesterol levels etc.. Family history Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents Documents presence or absence of specific illnesses in family, such as hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, and symptoms reported by patient. Ask about history of breast, ovarian, colon, or prostate cancer Ask about Genetically transmitted diseases Personal or social history Describes educational level, occupation, family of origin, current household, personal interests, and lifestyle NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. itching, hay fever, nosebleeds, sinus trouble. Throat (or mouth and pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness. Neck: “Swollen glands,” goiter, lumps, pain, or stiffness in the neck. Breasts: Lumps, pain, or discomfort, nipple discharge, self-examination practices. Respiratory: Cough, sputum (color, quantity; presence of blood or hemoptysis), shortness of breath (dyspnea), wheezing, pain with a deep breath (pleuritic pain), last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis. Cardiovascular: “Heart Trouble”; high blood pressure; rheumatic fever; heart murmurs; chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea breathing (paroxysmal nocturnal dyspnea); swelling in the hands, ankles, or feet (edema); results of past electrocardiograms or other cardiovascular tests. Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea. Bowel move-ments, stool color and size, change in bowel habits, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble; hepatitis. Peripheral vascular: Intermittent leg pain with exertion (claudication); leg cramps; varicose veins; past clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness. Urinary: Frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling. Genital Male: Hernias, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infections and their treatments. Sexual habits, NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. interest, function, satisfaction, birth control methods, condom use, and problems. Concerns about HIV infection. Female: Age at menarche, regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual tension. Age at menopause, menopausal symptoms, postmenopausal bleeding. If the patient was born before 1971, exposure to diethylstilbestrol (DES) from maternal use during pregnancy (linked to cervical carcinoma). Vaginal discharge, itching, sores, lumps, sexually transmitted infections and treatments. Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced), complications of pregnancy, birth-control methods. Sexual preference, interest, function, satisfaction, any problems, including dyspareunia. Concerns about HIV infection. Musculoskeletal: Muscle or joint pain, stiffness, arthritis, gout, backache. If present, describe the location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness. Psychiatric: Nervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts. Past counseling, psycho-therapy, or psychiatric admissions. Neurologic: Changes in mood, attention, or speech; changes in orientation, memory, insight, or NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. judgment; headache, dizziness, vertigo, fainting, black-outs; weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles”. Subjective vs Objective Data Subjective- symptoms or what the patient tells you. Apparent only to the person affected; includes client’s perceptions, feelings, thoughts, and expectations. Cannot be directly observed and can be discovered only asking questions. Examples: low back pain, fatigue, immunizations, weight gain, stomach cramps. Objective- signs or what you observe. Detectable by an observer or can be tested against acceptable standard; tangible; observable facts; includes observation of client behavior, medical records, lab and diagnostic tests, data collected by physical exam. Examples: blood pressure, heart rate, wound appearance, lung sounds, ambulation description. Subjective Data (symptoms) Objective Data (signs) What the patient tells you What is observed during physical examination Patients history, from Chief Complaint through Review of Systems Laboratory information, test data NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care. Critical thinking when developed in the practitioner includes adherence to intellectual standards, proficiency in using reasoning, a commitment to develop and maintain intellectual traits of the mind and habits of thought and the competent use of thinking skills and abilities for sound clinical judgments and safe decision- making. Differential Diagnoses (obtained from book and week 1 review) - A list with potential causes of patient specific problem/CC -A chief complaint must be identified first. -Includes all medical diseases that may possibly explain problem/ CC. -The differential diagnosis list should begin with the most likely explanation or etiology for the problem/CC. EX: C/O vomiting blood: 1. Peptic ulcer 2.Cirrhosis with bleeding esophageal varices 3. Acute hemorrhagic gastritis -Differential diagnostic procedures are used by clinicians to diagnose the specific disease in a patient, or, at least, to eliminate any imminently life-threatening conditions. The differential diagnosis list is similar to, but different from, the problem list. -The differential diagnosis includes all of the medical diseases that may possibly explain the patient’s chief complaint or principal problem -A differential diagnosis list is focused on providing an explanation for a specific complaint. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. -In order to develop a differential list versus a problem list, you must first identify the chief complaint. Each differential diagnosis should offer an explanation or etiology for the same chief complaint. Pathological and Physiological Processes Pathologic Process- patient complaints often stem from a pathologic process involving diseases of a body system or structure. Common Classified: congenital, inflammatory or infectious, immunologic, neoplastic, metabolic, nutritional, degenerative, vascular, traumatic, and toxic. Example: Possible pathological causes of a headache include- sinus infection, concussion from trauma, subarachnoid hemorrhage, or brain tumor. Problem List -After you complete the clinical record, it is good clinical practice to generate a problem list that summarizes the patient’s problems that can be placed in the front of the office or hospital chart. -List the most active and serious problems first and record their date of onset. - Helps to individualize the patient’s care. On follow-up visits, provides a quick summary of the patient’s clinical history and a reminder to review the status of problems the patient may not mention. -An accurate Problem List allows better population management of patients, by using EHRs to track patients with specific problems, recall patients who are behind on appointments, and follow up on specific issues. -Allows other members of the health care team to learn about the patient’s health status at a glance. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. For example, in a patient who is vomiting blood and is known to have migraines and to be diabetic, the problem list might read: 1. Hematemesis 2. Diabetes Mellitus 3. Migraine 4. Recent divorce 5. Poverty Prioritization Generate problem list with all problems noted, differential diagnoses should cover all possible causes of chief complaint. Prioritize which complaints/problems are highest priority (urgent) for this visit. (i.e., Tina has diabetes, htn, and a slew of other issues, but utmost importance is her foot wound and ankle pain) Chapter 3 **Interpretation and Analysis (Area is lacking information) Heather and Stacy NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. computer. Face the patient directly as you elicit the patient’s story, observing non-verbal behaviors. Look up from the computer as often as possible, readjusting your position as needed. 3. Establishing the Agenda=chief complaint Once you have established rapport, you are ready to pursue the patient’s reason for seeking care, traditionally called the chief complaint. In the ambulatory setting, where there are often three or four reasons for the visit, the phrase presenting problem(s) may be preferable. One benefit to this phrase is that it does not characterize the patient as a complainer. Begin with open-ended questions that allow full freedom of response: “What are your special concerns today?”, “How can I help you?”, or “Are there specific concerns that prompted your appointment today?” These questions encourage the patient to talk about any kinds of concerns, not just clinical ones. Note that the first problem the patient mentions may not be the one that is most important. Often, patients give one reason for the visit to the nurse and another to you. For some visits, patients do not have a specific concern and only “want a check-up”. Identifying all concerns allows you and the patient to decide which ones are most pressing and which can be postponed to another visit. Using questions such as, “Is there anything else?”, “Have we got everything?”, or “Is there anything we missed?”, can help to uncover the patient’s full agenda and “the real reason” for the visit. Identifying the full agenda protects time for the most important issues. Even negotiating the agenda at the outset doesn’t avert “oh by the way” concerns that suddenly emerge at the end of the visit. 4. Inviting the Patient’s story Once you have prioritized the agenda, invite the patient’s story by asking about the foremost concern, “Tell me more about...” Encourage patients to tell their stories in their own words, using an open-ended approach. Avoid biasing the patient’s story—do not inject new information or interrupt. Instead, use active listening skills: lean forward as you listen; add continuers such as nodding your head and phrases NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. like “uh huh,” “go on,” or “I see.” Train yourself to follow the patient’s leads. If you ask specific questions prematurely, you risk suppressing details in the patient’s own words. Studies show that clinicians wait only 18 seconds before they interrupt.28 Once interrupted, patients usually do not resume their stories. After the patient’s initial description, explore the patient’s story in more depth. Ask, “How would you describe the pain?”, “What happened next?”, or “What else did you notice?” so that the patient enriches important details. 5. Exploring the Patient’s perspective The disease/illness distinction model helps elucidate the different yet complementary perspectives of the clinician and the patient. Disease is the explanation that the clinician uses to organize the symptoms that leads to a clinical diagnosis. Illness is a construct that explains how the patient experiences the disease, including its effects on relationships , function , and sense of well-being. FIFE The Patient’s Feelings, including fears or concerns, about the problem The patients Ideas about the nature and cause of the problem The effect of the problem on the patients’ life and Function The patient’s Expectations of the disease, of the clinician, or of health care, often based on prior personal or family experiences. 6. Identifying and Responding to the Patient’s emotional Cues. Illness is often accompanied by emotional distress; 30% to 40% of patients have anxiety and depression in primary care practices. Visits tend to be longer when clinicians miss emotional clues. Clues to the patients’ perspective on illness NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. Direct statement by the patient of explanations, emotions, expectations, and effects of the illness Expression of feelings about the illness without naming the illness Attempts to explain or understand symptoms Speech clues (e.g., repetition, prolonged reflective pauses) Sharing a personal story Behavioral clues indicative of unidentified concerns, dissatisfaction, or unmet needs such as reluctance to accept recommendations, seeking a second opinion, or early return appointment Learn to respond attentively to emotional cues using techniques like reflection, feedback, and “continuers” that convey support. A mnemonic for responding to emotional cues is NURSE: Name- “that sounds like a scary experience for you”; Understand or legitimize- “It’s understandable that you feel that way”; Respect- “you’ve done better than most people would with this”; Support- “I will continue to work with you on this”; and Explore- “How else were you feeling about it”. 7. Generating and Testing Diagnostic Hypotheses As you gain experience listening to patient concerns, you will deepen your skills of clinical reasoning. You will generate and test diagnostic hypotheses about which disease process might be present. Identifying all the features of each symptom is fundamental to recognizing patterns of disease and to generate the differential diagnosis. It is important to fully flesh out the patient’s story. This avoids the common trap of premature closure, or shutting down the patient’s story too quickly, which can lead to errors in diagnosis. It is helpful to visualize the process of evoking a full description of each symptom as “the cone” First, open-ended questions to hear “the story of the symptom” in the patient’s own words Then more specific questions to elicit “the seven features of every symptom” Finally, the yes-no questions or “pertinent positives and negatives” from the relevant section of the NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. example would be: “Could you please tell me what you understand is our plan of care?” The patient should have a chance to ask any final questions, but the last few minutes are not a good time to bring up new topics. If this happens and the concern is not life threatening, simply assure the patient of your interest and make plans to address the problem at a future time. “That knee pain sounds concerning. Why don’t you make an appointment for next week so we can dis- cuss it?” Reaffirming your ongoing commitment to the patient’s health shows your involvement and esteem. 12. Taking Time for Self-Reflection The role of self-reflection, or mindfulness, in developing clinical empathy cannot be overemphasized. Mindfulness refers to the state of being “purposefully and nonjudgmentally attentive to [one’s] own experience, thoughts, and feelings.”44 As you encounter people of diverse ages, gender identities, social class, race, and ethnicity, being consistently respectful and open to individual differences is an ongoing challenge of clinical care. Because we bring our own values, assumptions, and biases to every encounter, we must look inward to see how our own expectations and reactions affect what we hear and how we behave. Self-reflection is a continual part of professional development in clinical work. It brings a deepening personal awareness to our work with patients. This personal awareness is one of the most rewarding aspects of patient care. Associated Symptoms OLD CARTS Seven Attributes of a Symptom 1.Location 2.Quality 3.Quantity or severity 4.Timing, including onset, duration, and frequency 5.The setting in which it occurs 6.Factors that have aggravated or relieved the symptoms 7. Associated manifestations NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. Adaptive Questioning Guided Questioning: 1.Moving from open-ended to focused questions 2.Using questioning that elicits a graded response 3.Asking a series of questions, one at a time 4. Offering multiple choices for answers 5. Clarifying what the patient means 6.Encouraging with continuers 7.Using echoing Challenging Patients -Silent -Blind -Confusing -With impaired capacity -Talkative -Angry or disruptive -With a language barrier -With low literacy or low health literacy -With hearing impairment -With limited intelligence -Seeking personal advice -Seductive Chapter 4 NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. General Approach to the Physical Examination Use open-ended questions-helps to encourage the patient to describe what they are experiencing Listen and ask common-sense questions Follow a thorough and systematic sequence to history taking and physical examination Keep an open mind toward both the patient and the clinical data Always include "the worst-case scenario" in your list of possible explanations of the patient's problem, and make sure it can be safely eliminated Analyze any mistakes in data collection or interpretation Confer with colleagues and review the pertinent clinical literature to clarify uncertainties Apply the principles of evaluating clinical evidence to patient information and testing As you talk with and examine the patient, heighten your focus on the patient’s mood, build, and behavior ○ 1. Reflect on your approach to the patient: When greeting the patient identify yourself as a student, beginners spend more time in certain areas and that is ok but just warn the patient that you may want to listen to their heart a little longer but that does not mean anything is wrong ■ Avoid interpreting your findings, you are not the patients primary care provider ■ Avoid negative reactions or showing distaste when finding abnormalities NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. Blood Pressure pg 124 Ambulatory and Home blood pressure monitoring are more predictive of cardiovascular disease and end organ damage than manual and automated measurements in the office Reference standard for confirming elevated office blood pressures- Measure blood pressure at preset intervals over 24 to 48 hours, usually every 15-20 minutes during the day and 30 to 60 minutes during the night. Gold Standard: Ambulatory blood pressure monitoring: automated. Provides 24 hour average blood pressures. Shows nocturnal blood pressure “dips” (normal) or stays elevated (Cardiovascular disease risk factor). Expensive and may not be covered by insurance. Types of hypertension: 1. White coat hypertension (isolated clinic hypertension) > 140/90 in medical settings and mean awake ambulatory readings <135/85 2. Masked hypertension office blood pressure <140/90, but elevated daytime blood pressure >135/85. 3.Nocturnal hypertension- “dipping occurs” in most patients at night as they shift from wakefulness to sleep. Selecting the Correct Size Cuff: Cuff too small= readings HIGH. Cuff too large= readings LOW Brachial Artery: brachial artery below heart= BP readings HIGHER. Brachial artery above heart level= BP readings LOW. Definitions of Hypertension ● Make sure patients understand all the steps needed to ensure accurate readings at home, as detailed in this section. Office manual or automated blood pressure based on the average of two readings on two separate occasions: ≥140/90 Classification of Hypertension Normal <120 systolic <80 diastolic NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. Prehypertension 120-139 systolic 80-89 diastolic Stage 1 ages 18-60; diabetes or renal disease 140-159 systolic 90-99 diastolic Ages > 60 years 150-159 systolic >100 Stage 2 >160 systolic >100 diastolic Steps to Ensure Accurate Blood Pressure Measurement 1. The patient should avoid smoking, caffeine, or exercise for 30 minutes prior to measurement. 2. The examining room should be quiet and comfortably warm. 3. The patient should sit quietly for 5 minutes in a chair with feet on the floor, rather than on the examining table. 4. The arm selected should be free of clothing, fistulas for dialysis, scars from brachial artery cutdowns, or lymphedema from axillary node dissection or radiation therapy. 5. Palpate the brachial artery to confirm a viable pulse and position the arm so that the brachial artery, at the antecubital crease, is at heart level—roughly level with the fourth interspace at its junction with the sternum. 6. If the patient is seated, rest the arm on a table a little above the patient’s waist; if standing, try to support the patient’s arm at the mid-chest level Estimate the Systolic Pressure and Add 30 mm Hg : To decide how high to raise the cuff pressure, first estimate the systolic pressure by palpation. As you palpate the radial artery with the fingers of one hand, rapidly inflate the cuff until the radial pulse disappears. Read this pressure on the manometer and add 30 mm Hg. Using this sum for subsequent inflations prevents discomfort from unnecessarily high cuff pressures. It also avoids the occasional error NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. caused by an auscultatory gap—a silent interval that may be present between the systolic and diastolic pressures (Fig. 4-5). Deflate the cuff promptly and completely and wait for 15 to 30 second Identify the Systolic Blood Pressure Inflate the cuff again rapidly to the target level, and then deflate the cuff slowly at a rate of about 2 to 3 mm Hg per second. Note the level when you hear the sounds of at least two consecutive beats. Identify the Diastolic Blood Pressure Continue to deflate the cuff slowly until the sounds become muffled and disappear. To confirm the disappearance point, listen as the pressure falls another 10 to 20 mm Hg. Then deflate the cuff rapidly to zero. The disappearance point, which is usually only a few mm Hg below the muffling point, provides the best estimate of diastolic pressure Average Two or More Readings Read both the systolic and diastolic levels to the nearest 2 mm Hg. Wait 2 or more minutes and repeat. Average your readings. If the first two readings differ by more than 5 mm Hg, take additional readings. When using an aneroid instrument, hold the dial so that it faces you directly. Avoid slow or repetitive inflations of the cuff because the resulting venous congestion can cause false readings Measure Blood Pressure in Both Arms At Least Once. Normally, there may be a difference in pressure of 5 mm Hg and sometimes up to 10 mm Hg. Subsequent readings should be made on the arm with the higher pressure. **A pressure difference of more than 10 to 15 mm Hg occurs in subclavian steal syndrome, supravalvular aortic stenosis, and aortic dissection, and should be NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. , but are about -Reducing weight by 5 to 10 %= improvement in blood pressure, lipids, and glucose tolerance, and reduce the risk for diabetes or hypertension -Oral and rectal temperature measurements remain common. Oral temperatures are generally lower than the core body temperature. They are also lower than rectal temperatures by an average of 0.4 to 0.5°C (0.7 to 0.9°F), and higher than axillary temperatures by approximately 1°. Axillary temperatures take 5 to 10 minutes to register and are considered less accurate than other measurements. -Tympanic membrane temperatures can be more variable than oral or rectal temperatures. Studies vary in methodology, but suggest that in adults, oral and temporal artery temperatures correlate more closely with the pulmonary artery temperature 0.5°C lower.54–56 Oral Temperatures. -For glass thermometers, shake the thermometer down to 35°C (96°F) or below, insert it under the tongue, instruct the patient to close both lips, and wait for 3 to 5 minutes. Then read the thermometer, reinsert it for a minute, and read it again. If the temperature is still rising, repeat this procedure until the reading remains stable. Note that hot or cold liquids, and even smoking, can alter the temperature reading. In these situations, delay taking the temperature for 10 to 15 minutes. -Rectal Temperatures. For a rectal temperature, ask the patient to lie on one side with the hip flexed. Select a rectal thermometer with a stubby tip, lubricate it, and insert it about 3 cm to 4 NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. The chief cause of hypothermia -Temporal Artery Temperature Tympanic Membrane Temperatures cm (1.5 inches) into the anal canal, in a direction pointing to the umbilicus. Remove it after 3 minutes, then read. Alternatively, use an electronic thermometer after lubricating the probe cover. Wait about 10 seconds for the digital temperature recording to appear - . The tympanic membrane shares the same blood supply as the hypothalamus, where temperature regulation occurs in the brain. Accurate temperature readings require access to the tympanic membrane. Make sure the external auditory canal is free of cerumen, which can lower temperature readings. Position the probe in the canal so that the infrared beam is aimed at the tympanic membrane, or otherwise the measurement will be invalid. Wait for 2 to 3 seconds until the digital temperature reading appears. s This method takes advantage of the location of the temporal artery, which branches off the external carotid artery and lies within a millimeter of the skin surface of the forehead, cheek, and behind the ear lobes. Place the probe against the center of the forehead, depress the infrared scanning button, and brush the device across the forehead, down the cheek, and behind an earlobe. Read the display, which records the highest measure temperature. Industry information suggests that combined forehead and behind-the-ear contact is more accurate than scanning only the forehead is exposure to cold. Other causes include reduced movement as in paralysis, interference with vasoconstriction from sepsis or excess alcohol, starvation, hypothyroidism, and hypoglycemia. Older adults are especially susceptible to hypothermia and also less likely to develop fever. -Unable to Korotkoff sounds= use alternative methods using a doppler probe or direct arterial pressure tracings. Chapter 6 NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. Integumentary Assessment and Modification for Age Dermoscopy- office practice for determining lesion benign vs malignant Normal VS. Abnormal Findings and Interpretation Melanoma pg 176 - Least common skin cancer but most lethal - Melanoma risk tool: 5 year risk of developing melanoma based on geographic location, gender, race, age, history of blistering sunburns, complexion, number of size of moles, freckling, and sun damage. - Risk factors: family history, > 50 common moles, Atypical/large moles, Red or light hair, Solar lentingines (acquired brown macules on sun-exposed areas), Freckles, UV radiation from heavy sun exposure, light eye or skin color, severe blistering sunburns in childhood, HIV or chemo, personal history of nonmelanoma skin cancer -Signs of sun damage: solar lentigines, solar elastosis, cutis rhomboidails, actinic purpa -Prevention: regular use of sunscreen at least SPF 30 -Full body examinations for patients over 50 -At least half of melanomas arise de novo form isolated melanocytes rather than pre- existing NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. There are many shades of tan and brown, but start with tan, light brown, and Dark brown if you are having trouble. Use "skin-colored" to describe a lesion that is the same shade as the patient’s skin. For red lesions or rashes, blanch the lesion by pressing it firmly with your finger or a glass slide to see if the redness temporarily lightens then refills. Texture: Palpate the lesion to see if it is smooth, fleshy, verrucous or warty, or scaly (fine, keratotic, or greasy scale). Location: Be as specific as possible. For single lesions, measure their distance from other landmarks (e.g., 1 cm lateral to left oral commissure). Configuration: Although not always necessary, describing patterns is often very helpful. Psoriasis pg 192 Table 6-1 If raised spot is small (<1 cm)= papule If raised spot is larger (>1 cm)=plaque -Guttate Psoriasis (papules raised, small)- scattered erythematous round drop-like, flat topped well circumscribed scaling papules and plaques on the trunk NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. -Plaque psoriasis :Plaques (raised, large)- scattered erythematous to bright pink well- circumscribed flat-topped plaques on extensor knees and elbows, with overlying silvery scale -Tinea versicolor: multiple 2-5 mm hypopigmented, hyperpigmented, or tan round to oval macules on upper neck and back, upper chest, and arms with slight inducible scale on scraping NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. -Tinea Cruris: bilateral erythematous, geographic patches with peripheral scaling, on the inner thighs bilaterally, sparing the scrotum “jock itch” Pityriasis Rosea pg 193 looks like ringworm NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. 1. Preauricular—in front of the ear NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. 2. Posterior auricular—superficial to the mastoid process 3.Occipital—at the base of the skull posteriorly 4.Tonsillar—at the angle of the mandible 5. Submandibular—midway between the angle and the tip of the mandible. These nodes are usually smaller and smoother than the lobulated submandibular gland against which they lie. 6. Submental—in the midline a few centimeters behind the tip of the mandible. 7.Superficial cervical—superficial to the sternocleidomastoid. 8. Posterior cervical—along the anterior edge of the trapezius. 9. Deep cervical chain—deep to the sternocleidomastoid and often inaccessible to examination. Hook your thumb and fingers around either side of the sternocleidomastoid muscle to find them. 10. Supraclavicular—deep in the angle formed by the clavicle and the sternocleidomastoid. Note lymph nodes size, shape, delimitation (discrete or matted together), mobility, consistency, and any tenderness. Small, mobile, discrete, nontender nodes, sometimes termed “shotty,” are frequently found in normal people. Describe enlarged nodes in two dimensions, maximal length and width, for example, 1 NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. Towering IV Trochlear Motor Money Tops V Trigeminal Both But A VI Abduscens Motor My Frenchman VII Facial Both Brother And VIII Acoustic Sensory Says NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. German IX Glossopharyngeal Both Big Viewed X Vagus Both Brains Some XI Spinal Accessory Motor Matter Hops XII Hypoglossal Motor Most NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. HEENT Assessment and Modification for Age/Normal vs Abnormal Findings and Interpretation HEENT Assessment and Modifications for Age. Normal and Abnormal Findings HEAD 1. Hair and scalp…Note its quantity, distribution, texture, and any pattern of loss. You may see loose flakes of dandruff. Part the hair in several places and look for scaliness, lumps, nevi, or other lesions. Fine hair is seen in hyperthyroidism, coarse NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. more than half the letters. Record the visual acuity designated at the side of this line, along with use of glasses, if any. Testing near vision with a hand-held card can help identify the need for reading glasses or bifocals in patients older than 45 years. If patients cannot read even the largest letters, test their ability to count your upraised fingers and distinguish light (such as your flashlight) from dark. a. Myopia (nearsightedness) causes focusing problems for distance vision. b. Presbyopia(farsighted) causes focusing problems for near vision, found in middle-aged and older adults. A presbyopic person often sees better when the card is farther away. c. legally blind when vision in the better eye, corrected by glasses, is 20/200 or less. Legal blindness also results from a constricted field of vision: 20° or less in the better eye. d. Vision of 20/200 means that at 20 feet the patient can read print that a person with normal vision could read at 200 feet. The larger the second number, the worse the vision. “20/40 corrected” means the patient could read the 20/40 line with glasses (a correction). Visual fields Recent studies recommend combining two tests to achieve the best results: the static finger wiggle test and the kinetic red target test. Static finger wiggle test: Position yourself about an arm’s length away from the patient. Close one eye and have the patient cover the opposite eye while staring at your NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. open eye. So, for example, when the patient covers the left eye, to test the visual field of the patient’s right eye you should cover your right eye to mimic the patent’s field of view. Place your hands about 2 feet apart out of the patient’s view, roughly lateral to the patient’s ears. While in this position, wiggle your fingers and slowly bring your moving fingers forward into the patient’s center of view. Ask the patient to tell you as soon as he or she sees your finger movement. Test each clock hour, or at least each quadrant. Test each eye individually and record the extent of visits in each area. Note any abnormal “field cuts” Kinetic Red Target Test. Facing the patient, move a 5-mm red-topped pin inward from beyond the boundary of each quadrant along a line bisecting the horizontal and vertical meridians. Ask the patient when the pin first appears to be red. -An enlarged blind spot occurs in conditions affecting the optic nerve such as glaucoma, optic neuritis, and papilledema. -Graves disease or ocular tumors: Abnormalities include esotropia (inward deviation) or exotropia (out-ward deviation) of the eyes and also abnormal protrusion NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. -Seborrheic dermatitis scaliness, lateral sparseness in hypothyroidism. -Down Syndrome Upslanting palpebral fissures. - Blepharitis- Red inflamed lid margins, often with crusting. Position and Alignment of the Eyes. Stand in front of the patient and survey the eyes for position and alignment. If one or both eyes seem to protrude, assess them from above (see p. 264). Eyebrows. Inspect the eyebrows, noting their fullness, hair distribution, and any scaliness of the underlying skin. Eyelids. Note the position of the lids in relation to the eyeballs. Inspect for the following: ■ Width of the palpebral fissures ■ Edema of the lids ■ Color of the lids ■ Lesions ■ Condition and direction of the eyelashes NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. showing black circles of varying sizes, and test the light reaction. Note if the pupils are large (>5 mm), small (<3 mm), or unequal. -Miosis refers to constriction of the pupils -Mydriasis to dilation. c. Pupillary sizes. Simple anisocoria, or a difference in pupillary diameter of 0.4 mm or greater without a known pathologic cause, is visible in approximately 35% of healthy people, and rarely exceeds 1 mm. -Simple anisocoria is considered benign if it is equal in dim and bright light, and there is brisk pupillary constriction to light (the light reaction). d. The Light Reaction. In dim light, test the pupillary reaction to light. Ask the patient to look into the distance, and shine a bright light obliquely into each pupil in turn. Both the distant gaze and the oblique lighting help to prevent a near reaction. Extraocular muscles The normal conjugate movements of the eyes in each direction. Note any deviation from normal, or dysconjugate gaze. ■ Nystagmus: a fine rhythmic oscillation of the eyes. A few beats of nystagmus on extreme lateral gaze are normal. If you see this, bring your finger in to within the field of binocular vision and look again. ■ Lid lag as the eyes move from up to down Test the Six EOMs (Extraocular Muscles): CN 3,4,6 Ask the patient to follow your finger NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. or pencil as you sweep through the six cardinal directions of gaze. Making a wide H in the air, lead the patient’s gaze (Fig. 7-25): 1. to the patient’s extreme right, 2. to the right and upward, and 3. down on the right; then 4. without pausing in the middle, to the extreme left, 5. to the left and upward, and 6. down on the left. Pause during upward and lateral gaze to detect nystagmus. Move your finger or pencil at a comfortable distance from the patient. *Because middle-aged or older adults may have difficulty focusing on near objects, increase this distance. Some patients move their heads to follow your finger. If necessary, hold the head in the proper midline position. If you suspect lid lag or hyperthyroidism, ask the patient to follow your finger again as you move it slowly from up to down in the midline. The upper eyelid should overlap the iris slightly throughout this movement. The Optic Disk Inspect the optic disc. Note the following features: ● The sharpness or clarity of the disc outline. The nasal portion of the disc mar-gin may be somewhat blurred, a normal finding. ● The color of the disc, normally yellowish orange to creamy pink. White or pigmented crescents may ring the disc, a normal finding. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. ● The size of the central physiologic cup, if present. It is usually yellowish white. The horizontal diameter is usually less than half the horizontal diameter of the disc. ● The comparative symmetry of the eyes and findings in the fundi FINDINGS: In a refractive error, light rays from a distance do not focus on the retina -In myopia, they focus anterior to the retina -hyperopia, posterior to it -Retinal structures in a myopic eye look larger than normal -An enlarged cup suggests chronic open-angle glaucoma Detecting Papilledema Swelling of the optic disc and anterior bulging of the physiologic cup suggest papilledema= increased intracranial pressure. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. wet exudative, or neovascular. Cellular debris, called drusen, may be hard and sharply defined or soft and confluent with altered pigmentation. Vitreous floaters are dark specks or strands seen between the fundus and the lens. Cataracts are densities in the lens NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. EARS The Ear Anatomy and Physiology. The ear has three compartments: the external ear, NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. Ménière disease, noise exposure, ototoxic drug exposure, and acoustic neuroma. b. Air conduction (AC) describes the normal first phase in the hearing pathway. An alternative pathway, known as bone conduction (BC), bypasses the external and middle ear and is used for testing purposes. A vibrating tuning fork, placed on the head, sets the bone of the skull into vibration and stimulates the cochlea directly. In those with normal hearing, AC is more sensitive than BC (AC > BC). c. Equilibrium. The labyrinth of three semicircular canals in the inner ear senses the position and movements of the head and helps maintain balance. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. EAR ASSESSMENT 1. The Auricle. Inspect the auricle and surrounding tissue for deformities, lumps, or skin lesions. 2. Ear Canal and Drum. To see the ear canal and drum, use an otoscope with the largest ear speculum that inserts easily into the canal. Position the patient’s head so that you can see comfortably through the otoscope. To straighten the ear canal, grasp NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. the auricle firmly but gently and pull it upward, backward, and slightly away from the head. Movement of the auricle and tragus (the “tug test”) is painful in acute otitis externa (inflammation of the ear canal), but not in otitis media (inflammation of the middle ear). Tenderness behind the ear occurs in otitis media. -Exostoses Nontender nodular swellings covered by normal skin deep in the ear canals suggest exostoses (nonmalignant overgrowths which may obscure the eardrums). Inspect the ear canal, noting any discharge, foreign bodies, redness of the skin, or swelling. -Cerumen which varies in color and consistency from yellow and flaky to brown and sticky or even to dark and hard, may wholly or partly obscure your view. Inspect the eardrum, noting its color and contour -The cone of light—usually easy to see—helps to orient you. -In chronic otitis externa, the skin of the canal is often thickened, red, and itchy. -Acute purulent otitis media- red bulging drum and amber drum of a serous effusion. Testing Auditory Acuity—Whispered Voice Test. To begin screening, ask the patient “Do you feel you have a hearing loss or difficulty hearing?” If the patient reports hearing loss, proceed to the whispered voice test. The whispered voice test is a reliable screening test for hearing loss if the examiner uses a standard method of testing and exhales before whispering. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. hears a vibration. Here, the “U” of the fork should face forward, which maximizes sound transmission for the patient. Normally, the sound is heard longer through air than through bone (AC > BC) In unilateral sensorineural hearing loss= sound is heard in the good ear In conductive hearing loss= sound is heard through bone as long as or longer than it is through air (BC = AC or BC > AC). In sensorineural hearing loss=sound is heard longer through air (AC > BC). NOSE Techniques of Examination. Inspect the anterior and inferior surfaces of the nose. Gentle pressure on the tip of the nose with your thumb usually widens the nostrils. Use a penlight or otoscope light to obtain a partial view of each nasal vestibule. If the nasal tip is tender, be gentle and manipulate the nose as little as possible. Note any asymmetry or deformity of the nose. -Tenderness of the nasal tip or alae suggests local infection such as a furuncle, particularly if there is a small erythematous and swollen area. -Test for nasal obstruction, if indicated, by pressing on each alnasi in turn and asking the patient to breathe in. Inspect the inside of the nares with an otoscope and the largest available ear speculum.* Tilt the patient’s head back a bit and insert the speculum gently into the vestibule of each nostril, avoiding contact with the sensitive nasal septum. By directing the speculum posteriorly, then upward in small steps, try to see the inferior and middle NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. turbinates, the nasal septum, and the narrow nasal passage between them. Some asymmetry of the two sides is normal. Inferior and middle turbinates. Inspect the nasal mucosa, the nasal septum, and any abnormalities. Inspect: ■ The nasal mucosa that covers the septum and turbinates. Note its color and any swelling, bleeding, or exudate. If exudate is present, note its character: clear, mucopurulent, or purulent. The nasal mucosa is normally somewhat redder than the oral mucosa. ■ The nasal septum. Note any deviation, inflammation, or perforation of the septum. The lower anterior portion of the septum (where the patient’s finger can reach) is a common source of epistaxis (nosebleed). -In viral rhinitis, the mucosa is reddened and swollen -allergic rhinitis, it may be pale, bluish, or red. Fresh blood or crusting may be seen. -Causes of septal perforation include trauma, surgery, and intranasal use of cocaine or amphetamines, which also cause septal ulceration. Palpate for sinus tenderness. Press up on the frontal sinuses from under the bony brows, avoiding pressure on the eyes. Then press up on the maxillary sinuses. -Local tenderness, together with symptoms such as facial pain, pressure or fullness, purulent nasal discharge, nasal obstructions, and smell disorder, especially NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. when present for >7 days, suggest acute bacterial rhinosinusitis involving the frontal or maxillary sinuses. THROAT Techniques of Examination. If you detect any suspicious ulcers or nodules, put on a glove and palpate any lesions, noting any thickening or infiltration of the tissues that might suggest malignancy. Inspect the following: -The Lips. Observe their color and moisture, and note any lumps, ulcers, cracking, or scaliness. -The Oral Mucosa. Look into the patient’s mouth and, with a good light and the help of a tongue blade, inspect the oral mucosa for color, ulcers, white patches, and nodules. In this patient the wavy white line on the adjacent buccal mucosa developed where the upper and lower teeth meet, related to irritation from sucking or chewing. -The Gums and Teeth. Note the color of the gums, which are normally pink. Brown patches may be present, especially but not exclusively in dark-skinned individuals. Inspect the gum margins and the interdental papillae for swelling or ulceration. Inspect the teeth. Are any of them missing, discolored, misshapen, or abnormally positioned? To assess tooth, jaw, or facial pain, palpate the teeth for looseness and the gums with your gloved thumb and index finger. -The Roof of the Mouth. Inspect the color and architecture of the hard palate. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. examining the lungs. Stridor is an ominous, high-pitched musical sound from severe subglottic or tracheal obstruction that signals a respiratory emergency. -Causes include epiglottitis, foreign body, goiter, and stenosis from placement of an artificial airway. -Inspect the neck for the thyroid gland. Tip the patient’s head slightly back. Using tangential lighting directed downward from the tip of the patient’s chin, inspect the region below the cricoid cartilage to identify the contours of the gland. Confirm your visual observations by palpating the gland outlines as you stand facing the patient. This helps prepare you for the more systematic palpation to follow. - Palpate the thyroid gland. Find your landmarks—the notched thyroid cartilage and the cricoid cartilage below it Locate the thyroid isthmus, usually overlying the second, third, and fourth tracheal rings. Palpate the thyroid gland. If the lower pole of the thyroid gland is not palpable, suspect a retrosternal location. If the thyroid gland is retrosternal, below the suprasternal notch, it is often not palpable. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. Steps for Palpating the Thyroid Gland (Posterior Approach) ● Ask the patient to flex the neck slightly forward to relax the sternocleidomastoid muscles. ● Place the fingers of both hands on the patient’s neck so that your index fingers are just below the cricoid cartilage. ● Ask the patient to sip and swallow water as before. Feel for the thyroid rising up under your finger pads. It is often, but not always, palpable. ● Displace the trachea to the right with the fingers of the left hand; with the right-hand fingers, palpate laterally for the right lobe of the thyroid in the space between the displaced trachea and the relaxed sternocleidomastoid. Find the lateral margin. In a similar fashion, examine the left lobe. The lobes are somewhat harder to feel than the isthmus, so practice is needed. The anterior surface of a lateral lobe is approximately the size of the distal phalanx of the thumb and feels somewhat rubbery. ● Note the size, shape, and consistency (soft, firm, or hard) of the gland and identify any nodules or tenderness. In general, benign (or colloid) nodules tend to be more uniform, ovoid structures and are not fixed to surrounding tissue. ● If the thyroid gland is enlarged, listen over the lateral lobes with a stethoscope to detect a bruit, a sound similar to a cardiac murmur but of not of cardiac origin. -When the thyroid gland is retrosternal, below the suprasternal notch, it is often not palpable. Retrosternal goiters can cause hoarseness, shortness of breath, stridor, or NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. - Retina is found in the optic fundus - follow vessels peripherally in each direction (size and characteristics), ID any lesions: measured in terms of "disc diameters" - Fovea is the tiny bright reflection at the center: shimmering light reflections are common - look for opacities in the vitreous or lens (vitreous floaters are dark specs/strands send between fundus and lens) Cottonwood PATCHES: irregular patches= DM & HTN “Think of Tina” HARD DRUSSEN: Lipids and proteins/ older population, can lead to macular- NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. degeneration. Citreous floaters are dark specs/strands between fundus and lens -A light beam shining onto one retina causes pupillary constriction in both that eye Chapter 8 - Lung/thorax assessment and modification for age Begin with inspection, then palpate, percuss, and auscultate o With patient sitting: examine posterior thorax and lungs. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. Arms should be folded across chest with hands resting on opposite shoulders if possible. This position increases access to lung fields. The ask pt to lie down. o With patient supine: Examine anterior thorax and lungs. This position allows breast to be gently displaced. It is acceptable to examine posterior and anterior chest with patient sitting. o EXAMINE POSTERIOR CHEST Inspection (shape of chest and how chest moves) · Assess for deformities or asymmetry of chest expansion o Asymmetric expansion occurs in large pleural effusions · Abnormal muscle retraction of the intercostal space during inspirations, most visible in the lower intercoastal spaces o Retraction occurs in severe asthma, COPD, or upper airway obstruction. · Impaired respiratory movement on one of both sides of a unilateral lag (or delay) in movement o Unilateral impairment or lagging suggests pleural disease from asbestosis or silicosis; it is also seen in phrenic nerve damage or trauma. Palpation (focus on areas of tenderness or bruising, respiratory expansion, and fremitus) NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. Percussion: o Asymmetric increased fremitus occurs in unilateral pneumonia which increases transmission through consolidated tissue. · Percussion sets the chest wall and underlying tissues in motion, producing audible sound and palpable vibrations. Percussion helps you establish whether the underlying tissues are air-filled, fluid-filled, or consolidated. · Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. Examples include: lobar pneumonia, in which the NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. alveoli are filled with fluid and blood cells; and pleural accumulations of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor. Dullness makes pneumonic and pleural effusion three to four times more likely, respectively · Generalized hyperresonance is common over the hyperinflated lungs of COPD or asthma. Unilateral hyperresonance suggests a large pneumothorax or an air-filled bulla. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. · Assess chest expansion. · Tactile fremitus Normally decreased or absent over precordium · The dullness of right middle lobe pneumonia typically occurs behind the right breast. Unless you displace the breast, you may miss the abnormal percussion note. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. - Normal VS abnormal findings and interpretation o Abnormalities in rate and rhythm of breathing (When observing respiratory patterns, note rate, depth, and regularity of patient’s breathing.) (p. 335) Normal: Adults – 14-20 per minute; infants – up to 44 per minute Slow breathing (bradypnea) - Slow breathing with or without an increase in tidal volume that maintains alveolar ventilation. Abnormal alveolar hypoventilation without increased tidal volume can arise from uremia, drug-induced respiratory depression, and increased intracranial pressure. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. NR509_ Mid Term Exam 2021. NR509_ Mid Term Exam BEST EXAM SOLUTION LATEST 2021/2022 GRADEDA+. · Sighing Respiration- Breathing punctuated by frequent sighs suggests hyperventilation syndrome—a common cause of dyspnea and dizziness. Occasional sighs are normal. Rapid Shallow Breathing (Tachypnea)- Rapid shallow breathing has numerous causes, including salicylate intoxication, restrictive lung disease, pleuritic chest pain, and an elevated diaphragm Cheyne–Stokes Breathing - Periods of deep breathing alternate with periods of apnea (no breathing). This pattern is normal in children and older adults during sleep. Causes include heart failure, uremia, drug-induced respiratory depression, and brain injury (typically bihemispheric). Obstructive Breathing - In obstructive lung disease, expiration is prolonged due to narrowed airways increase the resistance to air flow. Causes include asthma, chronic bronchitis, and COPD. Rapid Deep Breathing (Hyperpnea, Hyperventilation) – In hyperpnea, rapid deep breathing occurs in response to metabolic demand from causes such as exercise, high altitude, sepsis, and anemia.