Florida University : NUR 3125 Health Assessment Exam 2 /Chapter 9-17,100% CORRECT

Florida University : NUR 3125 Health Assessment Exam 2 /Chapter 9-17 Chapter 9: General Survey and Measurement General Survey: the study of the whole person, covering the general health state and any physical characteristics; begins when you meet a person ● Components ○ Physical Appearance ■ Age: the person appears his or her age ● Some people may appear older because of chronic illness or chronic alcoholism ■ Sex: sexual development is appropriate for their age ● If the individual is transgender, note the stage of transformation ● Some individuals experience delayed or precocious puberty ■ Level of Consciousness: alert and oriented to person, place, time, and situation, responds appropriately to questions ● Some may be confused, drowsy, lethargic due to illness ■ Skin Color: tone should be even, appropriate to genetic background; skin is intact, no obvious lesions ● Note any tattoos or piercings, stage of healing ● Note deviations such as pallor, cyanosis, jaundice, erythema ■ Facial features: symmetric with movement ● Abnormal findings include immobile, asymmetric, masklike, drooping ■ Overall appearance: no signs of acute distress ● Cardiac or respiratory signs (diaphoresis, SOB, wheezing, pain signs like clutching chest, grimacing) ○ Body Structure ■ Stature: normal range for age and genetic heritage ● Abnormally short or tall, abnormal proportions ● Table 9.2 abnormalities in body height and proportion ○ Hypopituitary dwarfism: deficiency in growth hormone results: in growth below 3rd percentile; delayed puberty onset; hypothyroidism; adrenal insufficiency ○ Achondroplastic dwarfism: genetic disorder resulting in cartilage becoming bone, results in: normal trunk size, short arms and legs, large head with frontal bossing, midface hypoplasia; sometimes thoracic kyphosis, lumbar lordosis, and abdominal protrusion; men around 4’4” and women around 4’1” ○ Acromegaly: excessive growth hormone secretion in adults after normal body growth, causes overgrowth of bone in face, head, hands, and feet with no change in height; internal organs can enlarge (cardiomegaly example), metabolic disorders can be present ○ Anorexia nervosa ○ Endogenous Obesity: excessive ACTH stimulates secretion of cortisol or administration of adrenocorticotropin; cervical obesity, moon face (round, fat); weight gain in central trunk, cervical obesity, muscle wasting, weakness, think extremities, reduced height, thin fragile skin with purple abdominal striae, bruising, and acne ○ Gigantism: excessive secretion of growth hormone during childhood, results of overgrowth of entire body; when it occurs before cone epiphyses close it causes increased height, weight, and delayed sexual development ○ Marfan syndrome: inherited connective tissue disorder characterized by tall, thin stature (>95%), arachnodactyly, hyperextending joints, arm span greater than height, flat feet (pes planus), sternal deformity such as pectus excavatum, narrow face, high-arched and narrow palate, and more; cardiovascular complications can cause early morbidity and mortality ■ Symmetry: body parts look equal bilaterally and are in relative proportion to each other ● Asymmetry or unilateral hypertrophy/atrophy ■ Nutrition: normal weight and height, body fat evenly distributed ● Cushing's obesity is different than normal obesity ■ Posture: person sits comfortably with arms relaxed at sides and head turned to the examiner ● Tripod: leaning forward with arms braced on chair arms, occurs with chronic pulmonary disease, asthma ● Sitting up straight and resisting lying down- heart failure ● Fetal position- pain, usually abdominal ■ Body build and contour ● Proportions: arm span = height; crown to pubis = pubis to sole (roughly) ● Elongated arms could be from marfans, hypogonadism ■ Obvious physical deformities: not any congenital or acquired defects such as missing extremities, webbed digits, shortened limb ○ Mobility ■ Gait: smooth walk, no assistance, symmetry, feet about shoulder width apart ● Propulsion- difficulty stopping ■ Range of motion: rom for each joint and movements are deliberate, accurate, smooth, and coordinated ■ Involuntary movements: tics, tremors, seizures, abnormal muscle movements ○ Behavior ■ Facial expression: culturally appropriate eye contact, expressions appropriate to situation, note face at rest and while talking ● Anxiety is common in ill people, some people smile when they are anxious ● Abnormalities can include flat, depressed, angry, sad, anxious, etc ■ Mood and affect: comfortable and cooperative ■ Speech: articulation is clear and understandable ■ Speech pattern: fluent, even pace, word choice is appropriate, conveys ideas clearly, communicates easily on their own or with interpreter ■ Dress: appropriate, clean, fits properly ■ Personal hygiene: clean, well groomed, “normal” ○ Measurements ■ Weight: remove heavy outer clothing and shoes, aim for weighing at same day with same type of clothing, record in kg and lbs; before breakfast, after void ● Look for weight loss and gain ● Example: patient with initial weight in undergarments and gown should be repeated in gown ● Unexplained loss: from short term or chronic illness (malignancy, endocrine disease, depression, anorexia, bulimia) ○ Person treated for pneumonia for several weeks may have some weight loss ● Unexplained gain: fluid retention ■ Height: measured with a wall-mounted device or pole on balance scale; align extended headpiece with top of head, person should be shoeless, standing straight and looking straight ahead, slight traction under jaw; feet, shoulders, butt should be in contact with the wall or measuring pole ■ BMI: there are two tables, one for inches, and one for meters. Look at it ● BMI is a practical marker for optimal healthy weight for height, indication of obesity or malnutrition. Should be used with other measures such as weight circumference ● Review the classifications. You should already know them ● Formula: Weight (kg) divided by height^2 (m^2) OR [(lbs)/(in^2)]*703 ■ Waist circumference: should be <40in men, <35in women, measured at iliac crest; larger increases risk for T2D, heart disease, dyslipidemia, CVD, hypertension, etc ○ Developmental competence ■ Infants and children ● Length/height: should be measured on horizontal board until 2 years of age, not by tape measure, may need to momentarily extend legs, stretch spine and hold head against plate; repeat to ensure accuracy ● Chest circumference: tape is encircled around chest at nipple height or an infant ● Head circumference ○ Newborns: 32-38cm, 34 avg; measure at eyebrows ■ Will be about 2cm larger than chest; will reach same size some time between 6 months and 2 years because chest grows faster, after 2 years chest will be bigger than the head ● Weight: to the nearest 10g (½ oz) for infants and 100g (¼ lb) for toddlers ○ Platform-type scales for infants ● Physical growth is the best indicator of a child’s general health. Recording height and weight will help determine growth patterns. Consider genetic background in the small-for-age child, but the most important factors are economic, nutrition, and environmental ■ The aging adult ● Postural changes: general flexion occurs by 8th or 9th decade ○ Kyphosis (humpback) common in very old and those with osteoporosis, slight flexion in knees and hips ● Decreased body weight: muscle shrinkage (more evident weight loss because of greater muscle shrinkage in men), decrease in subcutaneous fat from face and periphery, and additional fat deposited in abdomen and hips ○ More prominent body landmarks ● Changes in overall proportions: shorter trunk, longer extremities (long bones don't shorten with age) ● Measuring vitals and observing specific body systems while performing a physical assessment are not part of a general survey but are part of a physical examination Documentation (pg 135) ● Subjective: appears healthy and of stated age. Alert, oriented, and cooperative during health history ● Objective: Skin tone is even with senile lentigines on dorsa of hands and forearms bilaterally. Gait smooth; feet slightly wider than shoulders. No obvious physical deformities. Intention tremor noted when completing history form. Speech appropriate, clear, and understandable. Kempt appearance. Height 152 in (5 ft 10 in), weight 75 kg (165 lb). BMI 23 (healthy). Waist circumference 30 in. ● Another example: Mrs Jones, a 28 year old obese African American single woman, who presents for complete physical examination and evaluation for right for injury, is alert and oriented, seated upright on exam table. She is in no apparent distress. She is well nourished, well developed, and dressed appropriately with good hygiene. Be sure to practice documented general surveys in clinicals! Chapter 10: Vital Signs Vital signs are performed often and can be delegated to the nursing assistant personnel depending on the patient’s situation. Even if taking vitals is delegated when the patient is stable, interpretation is the responsibility of the nurse. You must interpret the findings based on the patient’s condition. Always follow provider’s orders for vital signs range and understand each patient is different. Vital signs are composed of ● Temperature: balance between heat production and heat loss; the body maintains a steady temp through a feedback mechanism regulated by the hypothalamus which regulates heat production from metabolism, exercise, food digestion, and other external factors ○ Oral (sublingual): most convenient and accurate ■ Need to wait 15 minutes before taking temperature if patient has ingested hot or cold liquids, 2 minutes if patient smoked ■ Normal Oral temps ● Avg 98.6 F ● Range of 35.8 C to 37.3 C (96.4 F to 99.1 F) ■ Methods: ● Glass thermometer: infrequently used but still available ○ Should be left in place for 3-4 minutes is the patient is afebrile ○ Should be left up to 8 minutes if the patient is febrile ○ Before use, shake down to 35.5 C, place at base of tongue ■ Should not be used in persons who cannot follow commands or are unable to close their mouths ● Electronic: swift and accurate ■ Blue probe = oral ○ Rectal: taken when other routes are impractical ■ Ex: patients are comatose or confused because they are unable to follow directions for oral temp; patients who are in shock or those who cannot close mouth because of oxygen tubes, wired mandible, or other facial dysfunctions ■ Normal temps ● About .4-.5 C (.7-1 F) higher than oral ■ How to: ● Blunt tip should be lubricated and inserted only 2-3 cm (about an inch); left in place for 2.5 minutes if using glass thermometers; hold and support it; ½ inch for infants less than 6 months ■ Red probe = rectal ■ Cigarette smoking does not affect ○ Tympanic membrane temperature: useful for young children who do not cooperate with oral temp and fear rectal temp, toddlers who squirm with rectal route ■ Use in newborn infants and young children is conflicting because it is not as accurate as other devices ■ Shares vascular supply that perfuses thalamus so it is an accurate measurement of core body temp ○ Temporal artery thermometer: uses infrared, newest measurement, takes multiple readings and provides avg; more accurate that TMT but still some concerns on accuracy ○ Axillary: questionable accuracy and reliability ○ Factors that influence ■ Diurnal cycle: 1-1.5 F with trough occuring in the early morning hours and peak in the late afternoon or early evening ■ Exercise: moderate to hard exercise increases temp ■ Hormones ● Menstrual cycle: progesterone w/ ovulation at mid-cycle causes a .5-1 F rise until menses ○ Reason why they use basal body temperature as a method of contraception (change in temp) ■ Age ● Older adults: lower temperatures with a mean of 36.2 C (97.2 F) by oral route ● Children: wider normal variations in infants and young children because of less effective heat control mechanisms ■ Mechanisms of heat loss ● Radiation ● Evaporation of sweat ● Convection ● Conduction ● Pulse ○ Rate: ■ Measuring 30 sec x2 is more efficient when HR is normal or rapid and when rhythm is regular compared to 15s by 4 because any one beat in the later measurement would result in an error of 4 beats per minute ■ If rhythm is irregular count for one full minute ■ Bradycardia: HR under 50 mins ● HR in 50s or lower normally occurs in well-trained athletes since heart muscles develop with skeletal muscles ■ Tachycardia: over 100 ● Can increase with anxiety and exercise to match body’s demand for increased metabolism ■ Normal: 50-95 BPM; traditional limits 60-100BPM; both used in adults ■ Table 10.1 Normal Rates in Infants and Children ● Newborn ○ Awake: 100-180 ○ Asleep: 80-160 ○ Exercise/fever: Up to 220 ● 1wk-3mo ○ Awake: 100-220 ○ Asleep: 80-200 ○ Exercise/fever: Up to 220 ● 3mo-2yr ○ Awake: 80-150 ○ Asleep: 70-120 ○ Exercise/fever: Up to 220 ● 2-10yr ○ Awake: 70-100 ○ Asleep: 60-90 ○ Exercise/fever: 195-215 ● 10-20yr ○ Awake: 55-95 ○ Asleep: 50-90 ○ Exercise/fever: 195-215 ■ Apical rate ● Auscultate for 1 min in infants and toddlers, then assess for irregularities such as sinus dysrhythmia ■ Stroke volume: about 70ml in adults into aorta; flares arterial walls and generates a pressure rate which is felt in the peripheral pulse ● Peripheral pulse examples ○ Radial ○ Brachial ○ Dorsalis Pedis ○ Posterior tibial ○ Rhythm ■ Respiratory sinus arrhythmia: heart rate varies with respiratory cycle, speeding up at peak of inspiration and slowing to normal with expiration; common in children and young adults. ● Inspiration momentarily causes a decreased stroke volume from left side and to compensate HR decreases ■ Is not assessed by dynamo ○ Force: ■ Scale: usually 0-3 but some agencies use a four point scale ● 3: full, bounding ● 2: normal ● 1: weak, thready ● 0: absent ■ Is not assessed by dynamo ■ Judging between 2-3 is somewhat subjective, experience helps ■ In older people there is an increase in the rigidity of the arterial walls which makes palpation easier ● Respiratory rate ○ Rate: how many times a full cycle occurs (one inhalation and one expiration) ■ Infants assess through abdomen because their respirations are more diaphragmatic ■ Elderly: decreased vital capacity, decreased inspiratory reserve volume ● Observer may notice a shallower inspiratory phase and an increased rate attributed the aging process ■ There’s a table for rates she didn’t mention. It’s on page 245 of the PDF. May be worth looking at or you can just ignore until Peds next semester ○ Depth: ■ Shallow ■ Normal ■ Deep ○ Rhythm: ■ Regular: count for 30 seconds ■ Irregular: if suspected, count for one full minute, maintain position as if taking pulse and count to make sure patient is not aware ■ Place hand on upper chest of abdomen if you are having trouble to help you feel them ● Blood pressure: force of blood pushing on the vessel walls ○ Five determining factors: from table on pg 145 physical book, 246 PDF ■ Cardiac output ● Increase: exercise to meet body demand for increased metabolism ● Decrease: with pump failure (weak pumping action after MI or in shock) ■ Peripheral vascular resistance ● Increase: with vasoconstriction ● Decreases with vasodilation ■ Volume of circulating blood ● Decrease: hemorrhage, dehydration ● Increase: increased Na and H2O retention, IV fluid overload ■ Viscosity ● Increases: increased hematocrit and polycythemia ■ Elasticity of vessel walls ● Increase: rigidity and hardening such as in arteriosclerosis as heart is pumping against greater resistance ○ Influencing factors ■ Age: normal rise through childhood into adult years ■ Hormones/Sex: after menopause, in women, BP is higher than in men; after puberty females are lower ■ Obesity: BP is higher in obese people than in people of normal weight of the same age, including adolescents ■ Ethnicity/Race: in the US african american adults BP is higher than non-hispanic white adults of the same age, incidence of hypertension is twice as high as well. Full reasoning unknown, but genetic profile and environmental factors involved. ■ Emotions: temp rise with fear, anger, pain thanks to SNS ■ Stress: elevated ■ Diurnal rhythm: high in late afternoon and early evening, low in early morning ■ Exercise: elevated ○ Assessing BP ■ Systolic: numerator, maximum pressure felt on artery during left ventricular contractions or systole; Phase 1 Korotkoff Sound that is best indicator of systolic BP ■ Diastolic: denominator, elastic recoil or resting pressure that the blood constantly exerts between contractions; pressure in vessels when the heart is at rest; in adults the last audible sound best indicates diastolic pressure ● When variance is greater than 10-12mm between Phases 4 and 5 both phases should be recorded with diastolic reading ○ Ex: First Korotkoff sound at 142, at 98 you are hearing sounds, at level 80mm you hear the last sounds. Record 142 over 98/80 ○ Disappearance of Phase 5 can be used as diastolic reading in both children and adults ■ MAP: the pressure forcing blood into the tissues averaged over the cardiac cycle, perfusing organs ● [Systolic +( Diastolic*2)] / 3 ● Diastolic + ⅓ Pulse pressure ● ⅓ systolic + ⅔ diastolic ● Given my dinamap and some of the wifi-based vital monitors ● At least 60mm to perfuse vital organs ■ Children BP guidelines based on age, sex, height of child ● Children younger than 3 make hearing korotkoff sounds with stethoscope difficult because of small vessel; nurse can use electronic BP device with oscillometry or doppler ultrasound to amplify the sound ■ Pulse pressure: difference between diastolic and systolic pressures, reflects stroke volume as well ● Systolic minus diastolic = Pulse Pressure ● In older adults the pulse pressure is widened ■ Palpated BP: done before auscultating to detect presence of auscultatory gap ● Palpate radial artery or brachial and inflate; note number that you notice the pulse disappears, inflate 20-30mm more; “to detect presence of auscultatory gap inflate 20-30mm more than when the pulse disappears” ○ Ex: Palpated pulse and inflated cuff, pulsation of radial artery stops at 100, add 20-30; so 120-130 ● Auscultatory gap: period in when the korotkoff sounds disappears during auscultation ○ occurs in 5% of population, most often in those with hypertension because of non-compliant arterial period ○ If it is not detected the systolic may be falsely low or the diastolic may be falsely high ○ Ideally done every time. In the clinical area you look at the trend in patients BP, however palpated BP is done before auscultated ■ Auscultated BP ■ Technique ● Position: comfortable, relaxed position yields accurate BP; nurse should allow at least 5 minutes rest before measuring BP because patients may be anxious or a person may have walked from the end of the parking lot, person may have been running from being afraid of being late ● Cuff sizing ○ A narrow cuff yields a falsely high pressure because it takes extra pressure to compress the artery ○ The width of the rubber bladder should equal 40% of the circumference of the arm ○ The length should be equal to 80% of the width of the bladder ● Table 10.4 Common Errors in BP measurement, pg 249 pdf, 149 book ○ Falsely high ■ Narrow/tight cuff, loose cuff ■ Crossed legs ■ Person supports arm - high diastolic ■ Arm is below level of heart ■ Emotional responses, exercise ■ Too quick - high diastolic ■ Too slow - high diastolic ■ Failure to wait before repeat - high diastolic ■ Halting descent and reinflating - high diastolic ○ False lows ■ Arm above heart ■ Cuff narrow, loose, or uneven; balloon out of wrap ■ Inflation not high enough - low systolic ■ Stethoscope too much pressure - low diastolic ■ Too quick - low systolic ● Orthostatic hypotension ● Coarctation of the aorta: obstructs blood flow to lower portion of body ○ When measurement is excessively high in adolescents or young adults, compare with thigh pressure to check for coarctation of the aorta (congenital form of narrowing); normally thigh pressure is 10-40mm higher systolic and diastolic is the same as the arm but if the arm is higher there is a problem ● Oxygen Saturation Sequence ● Adults: Temp, pulse, RR, BP ● Infants: RR, pulse, temp ○ Rectal temp may cause infants to cry which will raise the other rates Temp-> pulse -> resp -> BP Children Resp->Pulse->Temp-> BP Chapter 11: Pain Assessment Nociceptive Pain: develops when functioning and intact nerve fibers in the periphery and CNS are stimulated ● Triggered by events outside the nervous system from actual or potential tissue damage ● Four phases ○ Transduction: neurotransmitters released and transmit pain message along afferent sensory fibers to spinal cord ○ Transmission: pain message moves from spinal cord to brain ○ Perception: indicates conscious awareness of painful sensation; sensation recognized by higher cortical structures and identified as pain ○ Modulation: pain message is inhibited by neurotransmitters neurons release ● Descriptors: ○ Somatic: Dull, aching, well localized, nocturnal ○ Visceral: deep, squeezing pressure, local tenderness and referred, poorly localized ● Associated disorders ○ Somatic: Post-op pain, bone metastasis, arthritis, sports injury, mechanical back pain ○ Visceral: liver metastases, pancreatic cancer ● Treatment: underlying cause; NSAIDs, Opioids, muscle relaxant, corticosteroids, biphosphate Neuropathic Pain: implies an abnormal processing of a papin message; due to lesion or disease in somatosensory nervous system; does not adhere to typical and predictable phases of nociception; somatosensory nervous system ● Examples of conditions that can cause ○ Diabetes mellitus ○ Herpes zoster virus (shingles) ○ HIV/Aids ○ Sciatica ○ Trigeminal Neuralgia ○ Chemo ○ Phantom Limb pain ○ CNS alterations: stroke, MS, tumors ● Minor stimuli can cause significant pain ● Descriptors: constant dull ache, burning, stabbing, viselike, electric shock, numbness, tingling, allodynia, hyperalgesia, hyperpathia ● Associated disorders: distal polyneuropathy (diabetes, HIV), central poststroke pain, herpes zoster, trigeminal neuralgia, neuropathic back pain, complex regional pain syndrome ● Treatment: TCAs, anticonvulsants, antidepressants, anti neuroleptics, local anesthetics, bisphosphonate, corticosteroids, opioids, interventional techniques ● Peripheral neuropathy: symmetric damage to peripheral nerves resulting in pain without stimulation of nerves; numbness, tingling, interspersed shooting or lancinating pain ○ Etiologies: diabetic neuropathy that may relate to demyelination of larger nerves and increase in smaller nerves, ischemic damage, hyperglycemia; burning pain bilaterally that is worse at night ● Chemotherapy induced peripheral neuropathy: after chemo, increases with number of agents used, dose, pre-existing neuropathy, older age ○ Symptoms: numbness, burning, shooting pain in a glove and stocking distribution ○ Address new onsets of pain to rule out recurrence of cancer Sources of pain ● Visceral: originates from larger internal organs; described as dull, deep, squeezing, cramping ○ Ex: pain from cholecystitis, ureteral colic, appendicitis, ulcer pain ● Somatic: pain from musculoskeletal tissues or body surface ○ Deep somatic: tendons, joints muscles, bone, blood vessels ■ Described as aching or throbbing ○ Cutaneous: pain derived from skin surface and subcutaneous tissues ■ Superficial, sharp, burning ○ Usually well localized and easy to pinpoint ● Referred: pain that is felt at a particular site but originated in another location ○ Shared nerve Types of pain ● Duration ○ Acute: short term and self limiting, follows a predictable trajectory, dissipates after injury healths ■ Ex: surgery, trauma, kidney stones ■ Self-protective purpose ■ In cases where cause of acute pain is uncertain establishing the diagnosis is a priority but symptomatic treatment of pain should be given while investigation is proceeding ■ Rarely justified not to give analgesia until diagnosis is made; exception in initial exam of patient with an acute abdomen ○ Chronic: pain for 6 months or longer; malignant vs nonmalignant pain ○ Breakthrough pain Patients with poorly controlled pain respond with tachycardia, elevated BP, and hypoventilation A comfortable patient is able to cooperate with diagnostic procedures. Developmental Competence ● Infants and pain: infants feel pain just like adults; evidence suggests that repetitive and poorly controlled pain in infants can lead to changes in CNS that cause hypersensitivity ● Older adults and pain: no evidence suggests that pain perception is reduced with aging ○ Pain indicated a pathological incident or injury, should never be considered something an older adult should expect or tolerate ● Patients with dementia: become less able to identify and describe pain over time even though pain is still present ○ Patients may say no when asked about the existence of pain when there actually is a problem. Words seem to have lost their meaning ○ Communicate through behavior: agitation, pacing, repetitive yelling ■ May indicate pain and not worsening dementia Gender: women have greater pain sensitivity than men Culture- review Pain: a subjective experience, self report is the most reliable indicator of pain; physical exam can lend support but the nurse cannot exclusively diagnose pain on physical assessment findings, vital signs, or diagnostic results such as cat scans Pain Assessment tools: let patient describe pain in his or her own words ● OPQRST ○ Onset ■ What were you doing when it started? ○ Provocative/palliation: alleviating or aggravating factors ■ What makes the pain better or worse ○ Quality: nurse should refrain from providing descriptions, can help determining nociceptive vs neuropathic pain ■ What does the pain feel like ○ Region/Radiation: localized or multiple sites ■ Where is your pain? ○ Severity: assess intensity, multiple scales available ■ How much pain do you have? ○ Timing ■ When did it start? How long did it last? How often is it happening? ○ U: Quality impairment ■ How does the pain limit your function? What does it mean to you? ● Initial Pain Assessment: location, intensity, quality, onset, duration, variation, rhythms, manner of expressing pain, relief and causes; effects on: sleep, appetite, physical activity, relationship/emotional impact, concentration, symptoms; other comments; plan ● Brief Pain inventory: asks the patient to rate the pain within the last 24 hours using 0-10 scales with respect to its impact on mood, walking ability, and sleep ● Short form McGill Pain Questionnaire:: ask patient to rank list of descriptors in terms of their intensity and to give and overall intensity rating to the pain ● PAINAD for dementia patients: breathing, negative vocalization, facial expression, body language, consolability ● Pain Rating Scales: can be introduced at the age of 4-5 years ○ Numeric rating: 0-10, easy and consistent ○ Verbal descriptor: words to describe patient’s feelings and meaning of the pain for the person ○ Visual analogue scale: lets patient make a mark along 10cm horizontal line from no pain to worse pain imaginable ● Tools for infants and children: children do not have the ability to rate pain accurately on a numerical scale because a numerical scale is abstract ○ Faces pain scale - revised (FPS-R): six drawing of faces that show pain intensity, avoids smiles or tears so that children will not confuse pain intensity with happiness or sadness; asks child to choose face that shows how much hurt or pain they have now ○ CRIES neonatal post-op pain measurement ■ Crying ■ O2 requirement ■ Increased vitals ■ Expression ■ Sleepless ○ FLACC: nonverbal tool for infants and children under 3 ■ Facial expression ■ Leg movement ■ Activity level ■ Cry ■ consolability Table 11.5 pg 284 - Reflexive Sympathetic Dystrophy ● A key feature of this condition is that a typically innocuous stimulus creates a severe, intensely painful response. Affected extremity becomes less functional over time Chapter 12: Nutritional Assessment Nutritional status: the balance between nutrient intake and nutrient requirements ● Affected by physiologic, psychosocial, developmental, cultural, and economic factors Optimal nutritional status: achieved when sufficient nutrients are consumed to support day-to day body needs and any increased metabolic demands caused by growth, pregnancy, or illness ● People who achieve this are more active, have fewer physical illnesses, and live longer than people who are malnourished Undernutrition: occurs when nutritional reserves are depleted and/or when nutrient intake in inadequate to meet day-today needs or added metabolic demands ● Vulnerable groups: infants, children, pregnant women, recent immigrants, people with low incomes, hospitalized people, aging adults ○ At risk for impaired growth and development, lowered resistance to infection and disease, delayed wound healing, longer hospital stays, higher healthcare costs Overnutrition: caused by the consumption of nutrients, especially calories, sodium, and fat, in excess of body needs ● Can lead to obesity ○ BMI: calculated by using height/weight; practical marker of optimal weight for height and an indicator for obesity ○ Risk factor for many diseases Developmental competence ● Infants and children: a great deal of growth in the first four years of life in regards to weight, height, length, and brain development; need to maintain adequate fat and caloric intake ○ Fats which are calories and fatty acids are required for proper growth and development ○ Breastfeeding: recommended for full-term infants for the first year of life because breast milk is ideally formulated to promote normal infant growth and development and natural immunity through IgA antibodies ■ Other advantages ● Fewer food allergies and intolerances ● Reduced likelihood of overfeeding ● Less cost ● Increased mother-infant time ○ Cow’s milk not recommended until 1 year of age; children under 2 should not drink skim milk or low fat milk or be placed on low fat diets ○ Small portions, finger foods, simple meals, and nutritious snacks help improve dietary intake of young children ○ Avoid foods that can be easily aspirated or cause choking such as hot dogs, nuts, grapes, round candies, or popcorn ● Adolescence: after a period of slow growth in late childhood, adolescence is characterized by rapid growth and endocrine and hormonal changes; caloric and protein requirements increase to meet demand ○ Because of bone growth and increasing muscle mass, and in girls the onset of menarche, calcium and iron requirements also increase ○ Increased body awareness and self consciousness which can cause eating disorders such as anorexia nervosa and bulimia; perceived body image does not favorably compare with an ideal body image ● Pregnancy and lactation: in particular, iron, folate, and zinc are essential for fetal growth and vitamin and mineral supplements are often required ○ The National Academy of Sciences recommends a weight gain of 25-35lbs during pregnancy for women of normal weight ■ Women who are underweight should gain between 28 and 40 lbs ■ Overweight women should gain 15-25 lbs ■ Obese women should gain 11-20 lbs ● Adulthood: important time for education to preserve health and/or delay onset of chronic illness ○ Metabolic syndromes carry increased cardiac risks; diagnosed when a person has ⅗ biomarkers: elevated BP, increased fasting plasma glucose, elevated triglycerides, increased waist circumference, low high-density lipoproteins ■ Table 12.5 ● BP: >130 sys, or >85 dia, or drugs for hypertension ● TG >150 or drug treatment ● HDL <40 in men <50 in women, or drug treatment ● Glucose >99 or drug treatment ● Waist measurements >39 men >34 women ■ People with elevated cholesterol should be taught about planning a healthy diet that limits the intake of foods high in saturated fats. Reducing dietary fats is part of the treatment for this condition ● The aging adult: socioeconomic conditions frequently affect the nutritional status of the aging adult ○ Physical limitations, income, and social isolation are frequent problems that interfere with the acquisition of a balanced diet ○ Physiologic changes that occur in aging such as decrease in taste and smell, slowed or decreased GI motility and absorption, decreased saliva production, decreased visual acuity, and poor dentition can directly impact nutrition status ○ If a person reports changes in appetite, taste, smell, chewing, and swallowing should ask about the type of change and when the change happened or occurred. These problems interfere with adequate nutrient intake ○ Dysphagia or impaired swallowing: interferes with adequate nutrient or food intake ○ Asking about medications: assesses the potential interactions with foods or nutrients ■ Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and oral contraceptives are drugs that can interact with nutrients affecting their digestion, absorption, metabolism, or use. ○ Important nutritional features ■ Decreased energy requirements from loss of lean body mass which is the most metabolic active tissue ● Sarcopenia is the age related loss of muscle mass; sarcopenic obesity is characterized by low muscle mass with excess fat and can be attributed to low levels of physical activity and poor diet ■ Increased fat mass means less energy calorie foods Culture and genetics ● Immigrants from underdeveloped countries in general have poor nutrition ○ Hypertension, diarrhea, lactose intolerance, osteomalacia, scurvy, dental caries are among the more common nutrition related problems of new immigrants from developing countries ● Dietary practices/restrictions of selected cultural groups - Table 12.1 ○ Buddhism: Will vary depending on the Buddhist sect; All meat (some sects); Alcohol; Pungent spices (garlic, onion, scallions, chives, leeks) ○ Catholicism: Meat by some denominations on Ash Wednesday, Good Friday, and other holy days; Alcoholic beverages by some denominations ○ Hinduism: Lacto-vegetarianism often favored; Alcohol and intoxicating substances; Garlic, onion, and spicy foods by some; Fasting on some holy days ○ Islam: All pork and pork products; Meat not slaughtered according to ritual; Alcoholic beverages and alcohol products (e.g., vanilla extract), coffee, and tea; Food and beverages before sunset during Ramadan ○ The Church of Jesus Christ of Latter-Day Saints: Alcoholic beverages; Hot beverages, specifically coffee and tea; Food and beverages for 2 consecutive meals on fast Sunday ○ Orthodox Judaism: All pork and pork products; Meat not slaughtered according to ritual; All shellfish (e.g., crab, lobster, shrimp, oysters); Dairy products and meat at the same meal; Leavened bread and cake during Passover; Food and beverages on Yom Kippur ○ Seventh-Day Adventist: All pork and pork products; Shellfish; Meat, dairy products, and eggs by some; Alcoholic beverages, coffee, and tea Types of Nutrition Assessment ● Nutrition screening: first step in assessing nutritional status, based on easily obtained data; a quick and easy way to identify individuals at nutritional risk ○ Parameters used ■ Weight and height history ■ Conditions associated with increased risk ■ Dietary info ■ Routine laboratory data ● Example: albumin level, a person who is on a low protein diet for a period of time may have a serum albumin of less than 3.5 g/dL ● Methods of collecting current dietary intake information ○ Food frequency questionnaire: information is collected on how many times per day, week, or month the individual eats a particular food which provides and estimate of usual intake ■ This is used to assess how many times a person eats a specific food ○ Food diary: asks individuals to write down everything consumed for a certain period of time ■ Can be sued for a person with irritated food patterns ○ Calorie count: calculates calories of all foods consumed for a period of time; often performed for hospitalized clients ○ 24 hour recall: interview or questionnaire that asks person to recall everything they ate within the last 24 hours ○ Direct observation of feeding and eating process can detect problems that are not easily identified through standard nutrition interviews ● Individuals identified at risk should undergo a comprehensive nutritional assessment which includes dietary history and clinical info, physical examination for clinical signs, anthropometric measures, and laboratory tests ● Objective data ○ Anthropometric measures ■ Height ■ Weight ● Unintentional loss of >5% over one month, 7.5% over 3 months, or 10% over 6 months is clinically significant ● Current weight at 85-95% of usual indicates mild malnutrition; 75-84% indicates moderate malnutrition, and <75% indicates severe malnutrition ■ BMI ■ Waist to hip ■ Arm span or total arm length ● Subjective data ○ Eating patterns ○ Usual weight ○ Changes in appetite, tast, smell, chewing, swallowing ○ Recent surgery, illness, trauma, burns ○ Chronic illness ○ GI patterns ○ Allergies or intolerances ○ Meds and supplements ○ Alcohol or drug use ○ Exercise and activity patterns ○ Family history ● Abnormal findings: ○ Marasmus (PCM): protein calorie malnutrition, starved appearance ○ Kwashiorkor: high in calories but no protein, appear well nourished or even obese ○ Scorbutic (scurvy gums) gums: swollen, ulverated, bleeding gums because of vitamin C induced defects ○ Bitot spots: foamy plaques on cornea and accumulation of keratin are a sign or vitamin A deficiency; can result in conjunctival xerosis, corneal ulceration, keratomalacia (destruction of eye) ○ Magenta tongue: riboflavin deficiency ○ Pellagra: niacin deficiency ○ Follicular hyperkeratosis: deficiency in linoleic acid ○ Ricketts, osteomalacia: vitamin d deficiencies, bent bones ○ Table 12.2 Clinical signs of malnutrition Chapter 13: Hair, Skin, and Nails Skin: the largest organ system of the body; first line of defense against environmental stresses; adapts to environmental stressors ● Holds information about the body’s circulation, nutritional status, and signs of systemic disease as well as palpable data ● Two layers ○ Epidermis: highly differentiated, thin but tough ■ Inner basal layer forms new skin cells ■ Keratin: a fibrous protein and the major ingredient of skin ■ Melanocytes: same number in all people but the amount they produce varies with genetic, hormonal, and environmental influences ○ Dermis: supportive layer mostly made of connective tissue or collagen, which is a tough fibrous protein that enables the skin to prevent tearing ■ Nerve sensory receptors, blood vessels, and lymphatic vessels lie in the dermis ■ Hair follicles, sebaceous glands, and sweat glands are all embedded in the dermis ○ Subcutaneous: composed of adipose tissues which is made up of lobules of fat cells ■ Stores fat for energy, provides insulation, and aids in protection ● Two types of sweat glands ○ Eccrine glands (sweat glands): coiled tubules that open directly onto skin surface and produce saling solution called sweat ■ Widely distributed throughout the body and are mature in a two month old infant ○ Apocrine glands: produce thick, milky secretion that open into hair follicles ■ Located in axilla, niples, navel, ano-genital areas ■ Vestigial in humans ■ Active in puberty and secretion occurs with emotional and sexual stimulation ■ Bacteria + apocrine sweat produces musky body odor ■ Function decreases with age ● Sebaceous glands: produce lipid sebum that protects skin from water loss Hair: threads of keratin; cyclical growth with active and resting phases ● Two types ○ Vellus hair: fine and faint hair that covers most of the body ○ Terminal hair: thicker hair that grows on other parts of the body Nails: hard plates of keratin on dorsal edges of fingers and toes Developmental competence ● Infants and children ○ Skin: newborn skin is similar to adults but many of the functions are not fully developed; newborn skin is smooth, elastic, and more permeable than adults placing them at greater risk for fluid loss and dehydration ○ Lanugo hair in newborns, disappears and is replaced by vellus hair ○ Vernix caseosa on newborns skin ● Aging adult ○ Skin: increased loss of elastin and decrease of subcutaneous fat that leads to wrinkled, thin and dry skin ■ Factors for skin disease and breakdown ● Thinning of skin ● Decrease in vascularity and nutrients ● Loss of protective cushioning of the subcutaneous layer ● Lifetime of environmental trauma to skin ● Social changes of aging ○ Increased sedentary lifestyle ○ Chance of immobility ■ Xerosis: excessive dryness of skin ○ Hair: hair becomes grey or white and begins to feel thin and fine due to decreased function of melanocytes ■ Male patterned alding ○ Nail growth slows ● Pregnant women ○ Skin changes ■ Linea nigra ■ Striae ■ Chloasma: brown patches of hyperpigmentation ■ Vascular spiders ● Culture and genetics: ○ Conditions more common in african americans ■ Keloids: benign and excess scars that grow beyond normal boundaries of the wound with very compact collagen below; more common in African Americans, hispanics, asians ● Caused by: surgery, ance, ear piercings, tattoos, infections, burns ● Looks smooth, rubbery, shiny, claw like, is smooth and firm ● Found in earlobes, back of neck, scalp, chest, and back ● May occur months to years after initial trauma ■ Hyper and hypopigmentation ■ pseudofolliculitis : razor bumps and ingrown hairs ■ Melasma: mask of pregnancy ○ Melanoma: higher in white people ■ Common locations: trunk and back, legs in women, palms and soles of feet and nails in african americans ■ Incidence ● Melanoma is most common cancer in women ages 25-29 years old, second most common after breast cancer in women 30-34, more common in women vs men under 50 but men double women after age 65 ■ Risk factors: UV radiation from sun exposure, indoor tanning, family history Subjective data ● Past history of skin disease: allergies, hives, psoriasis, eczema; how it was treated ● Change in pigmentation ● ABCDEs of moles ● Excessive dryness or moisture ● Pruritus: itching skin ● Excessive bruising ● Rash or lesions ● Medications ○ Increase sunlight sensitivity and give burn response ■ Sulfonamides ■ Oral hypoglycemics ■ Tetracyclines ■ Thiazide diuretics (diuril brand) ○ Cause hyperpigmentation ■ Antimalarials ■ Anticancer ■ Hormones ■ Metals ■ tetracyclines ● Hair loss ● Changes in nails ● Environmental and occupational hazards Objective data for skin, abnormal conditions ● Color ○ Jaundice: exhibited by a yellow color of the skin and mucous membranes, which indicates rising levels of bilirubin in the blood. It is first noticed in the junction of the hand and soft palette of the mouth, and sclera. ■ True jaundice – yellow sclera of jaundice extends up to the edge of the iris. ○ Pallor: attributable to shock, with decreased perfusion and vasoconstriction ■ In black-skinned people will cause the skin to appear ashen, gray, or dull ■ It occurs when the red-pink tones from oxygenated hemoglobin are lost and the skin takes on the color of the connective tissue (or collagen) which is mostly white. ○ Cyanosis: is a bluish-gray color of the skin ○ Erythema: is an intense redness of the skin caused by excess blood (or hyperemia) in the dilated superficial capillaries. ○ ● Pigmentation ○ Freckles ○ Moles ■ Asymmetry ■ Border irregularity ■ Color variation ■ Diameter ■ Evolution ■ And any other symptoms such as change in size, itching, bleeding, or new pigmented lesions raise the suggestion of melanoma and warrant immediate referral. ○ Cutis marmorata: transient mottling in the trunk and extremities in response to cooler room temperatures; forms reticulated red or blue patterns over skin ■ ○ Vitiligo: complete absence of melanin pigment in patchy areas of white, or light skin on face, neck, hands, feet, body folds, and around orfices ○ Senile lentigines: “liver spots” - clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure ● Temperature ● Moisture ● Thickness ● Edema ● Mobility and turgor ○ Test over abdomen in infant ○ Adults: under clavicle, forearm, anterior chest ○ Mobility: ease of skin to rise ○ Turgor: returns to place promptly ■ Poor turgor indicates dehydration or malnutrition ○ Represents elasticity ● Vascularity or bruising ○ Cherry angiomas ○ Bruises change color as time progressive ■ Reddish initially ■ Purple or blew ■ Greenish ■ Yellow ● Lesions ○ Acne: 90% of males 80% of females will develop acne. Caused by increased sebum production and epithelial cells that do not desquamate normally ○ Primary lesions ■ Nodule: solid, elevated, hard or soft growth that is larger than 1 cm ■ Papule: something one can geel, soliv, elevated, circumscribed, less that 1 cm in diameter and is due to superficial thickening of the epidermis ■ Vesicle: friction blister <.5cm ■ Bulla: larger than 1 cm, thin walled, superficial, blister >.5 cm ○ Vascular lesions ■ Erythema Migrans of Lyme Disease: bull’s eye rash in 50% of cases, fades in 4 weeks; caused by spirochete bacterium carried by black or dark brown deer tick which is common in northeast and upper midwest with cases in people who spend time outdoors in may through september ■ Petechiae: tiny, round purple spots due to bleeding under the skin. This may be in a small area due to minor trauma or widespread due to blood clotting disorder. ■ Purpura: rash of purple spots due to small blood vessels leaking blood into the skin, joints, intestines, or organs. ● Causes can be due to underlying disease or other factors ○ Bruising from trauma ○ Aging ○ Medication ○ Drawing blood ■ Impetigo: moist, thin-roofed vesicle with a thin erythematous base and is a contagious bacterial infection of the skin. Most common found in infants and children. (Measles – highly contagious) ● ■ Measles – or rubeola, the examiner assesses a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears, spreads over the face, and then over the neck, trunk, arms, and legs. The rash appears coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik spot ● ■ Psoriasis – hereditary, chronic inflammatory disease with inflammatory triggers. ● Plaque psoriasis: raised, scaly, erythematous patch with silvery scALES, often pruritic and painful, can occur on scalp, extensor surfaces of knees and elbows, lower back; accompanied by nail pitting or onycholysis ○ ■ Basal Cell Carcinoma - usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly. ● ■ Squamous Cell Carcinoma ● Arise from actinic keratosis or de novo. ● Erythematous scaly patch with sharp margins, 1 cm or more ● Develops central ulcer and surrounding erythema. ● Usually on hands or head, areas exposed to UV radiation ● Less common than basal cell carcinoma but grows rapidly ● ■ Pressure Injuries: ● Stage I: closed injury ● Stage 2: partial thickness skin erosion with a loss of epidermis or also the dermis; open blisters have a red-pink wound bed ● Stage 3: extends into subcutaneous tissue ● Stage 4: extends into muscle or bone ■ Keratosis ● Seborrheic keratosis - appear like dark, greasy, stuck-on lesions that primarily develop on the trunk. These lesions do not become cancerous ○ ● Actinic (senile or solar) keratosis: lesions that are red-tan scaly plaques that increase over the years to become raised and roughened ○ May have a silvery-white scale adherent to the plaque. ○ Occur on sun-exposed surfaces and are directly related to sun exposure ○ Premalignant and may develop into squamous cell carcinoma ○ ■ Acrochordons: skin tags ■ Sebaceous hyperplasia: raised yellow papules with central depression, common in older men and occur over forehead, nose, and cheeks, have a plebby look ● Abnormal conditions of the Hair ○ Kaposi Sarcoma: vascular tumor that, in the early stages, appears as multiple, patch-like, faint pink lesions over the patient’s temple and beard areas. ■ ○ Tinea Capitis: rounded patchy hair loss on the scalp, that leaves broken-off hairs, pustules, and scales on the skin are present, and is caused by a fungal infection. Lesions are fluorescent under a wood light and are usually observed in children and farmers. Tinea capitis is highly contagious. ■ ● Abnormal conditions of the nails ○ Clubbing of the nails: occurs with congenital cyanotic heart conditions/diseases and with other pulmonary diseases. Often seen in patients with cystic fibrosis. Health Promotion and Patient teaching: focus on teaching patients how to asses skin, which also includes hair and scalp Chapter 14: Head, Face, Neck, and Regional Lymphatics Head ● Infants ○ During the fetal period head growth predominates ○ Head size is greater than the chest circumference at birth ○ Reaches 90% of its final size when a child is 6 ○ At 2 years old the head circumference and chest circumference are the same ○ Chest circumference grows to excess head circumference by 5-7 cm ○ Fontanelles: membrane covered soft spots that allow for growth of the brain during the first year ■ Should be firm and concave in an infant ■ Will gradually ossify ■ Types ● Anterior: diamond shape; closes between 9 years - 2 months ● Posterior: triangular, closes by 1-2 months ■ Depressed fontanelle occur with dehydration or malnutrition ● No tears, dry membranes, no urine ■ Increased ICP will cause tense/pulsating fontanelles, appear convex or bulge ○ Head control is achieved by 4 months old ■ Defined by holding head erect and steady when pulled in a vertical position ● Cervical 7, C7 vertebra has a long spinous process called the vertebral prominence which is palpable when the head is flexed ● Cranial nerve 7 mediates facial muscles ○ Damage to this nerve will result in asymmetry of the palpebral fissures as in the case of bell’s palsy ● Cranial nerve 5 is the trigeminal nerve, mediates facial sensation of pain and touch, face symmetry such as eyebrows, palpebral fissures, nasolabial folds, and corners of the mouth ● In aging adults: ○ Facial bones and orbits appear more prominent and facial skin sags ■ Attributed to decreased elasticity, decreased subcutaneous fat, decreased moisture in skin ● Salivary glands ○ Parotid glands: in cheeks over mandible, anterior to and below the ear ■ Largest but normally non-palpable; become swollen with onset of mumps; swelling is most evident below the angle of the jaw and is most visible when the head is extended ■ Enlargement has been found in people with HIV ■ Stensen duct ○ Submandibular glands: beneath the mandible at the angle of the jaw ■ Warden’s fuct ○ Sublingual: below tongue in floor of mouth ● Temporo-mandibular joint: located just below the temporal artery and anterior to the tragus ● Temporal bruits: common in skull of children under 4 or 5 years of age and in children with anemia ○ Systolic or continuous and hurt over the temporal area ● Temporal arteritis: artery appears more torturous and feels sharpened and tender ○ s/s: sharp localized pain over a tender, nodular, temporal artery; fever, malaise, anorexia, weight loss, polymyalgia, ischemic jaw, face pain ○ Headaches and blindness are the major dangers ■ Left untreated blindness may may occur in both eyes, not reversible ○ An emergency, refer to ER ● Cranial nerve 12: innervates muscles of the tongue; involved in speech and swallowing The Neck and Lymphatics ● Cranial nerve 11 (spinal accessory nerve): innervates sternomastoid and trapezius muscle ○ Assists with head rotation, flexion, extension, and turning; movement of shoulders ○ Assess function: ask patient to shrug against resistance, place hand on face and ask patient to push to side ● Thyroid gland: highly vascular endocrine gland that secretes T3 and T4, two lobes ○ Hormones stimulate the rate of cellular metabolism ○ Elevated levels (hyperthyroidism): tachycardia with an enlarged thyroid gland (goiter), or nodular lump ■ If enlarged assess for bruit ● Bruit: soft, pushing, flowing sound heard best with the bell side of the stethoscope- occurs with accelerated or turbulent blood flow ● If heart blood vessels are compressed ○ Pregnancy enlarges it slightly because of hyperplasia of the tissues and increased vascularity ○ Examination ■ Posterior approach ■ Anterior approach: tip head forward and to right, then left ■ Choose approach based on culture ● Trachea ○ Displaced to unaffected side with tumor, pneumothorax, unilateral thyroid lobe enlargement ○ Displaced to affected side: pleural adhesions, fibrosis, large atelectasis ○ Tracheal tug: downward pull that is synchronous with systole and occurs with aortic aneurysm ● Lymphatics ○ Lymph nodes: located all throughout the body but only accessible in four areas, assess with 1-3 fingers ■ Head and neck ■ Arms ■ Axilla ■ Inguinal area ■ Specific nodes: ● Preauricular, in front of the ear ● Posterior auricular (mastoid), superficial to the mastoid process ● Occipital, at the base of the skull ● Submental, midline, behind the tip of the mandible ● Submandibular, halfway between the angle and the tip of the mandible ● Jugulodigastric (tonsillar), under the angle of the mandible ● Superficial cervical, overlying the sternomastoid muscle ● Deep cervical, deep under the sternomastoid muscle ● Posterior cervical, in the posterior triangle along the edge of the trapezius muscle ● Supraclavicular, just above and behind the clavicle, at the sternomastoid muscle ■ ○ Normal nodes feel moveable, discrete, soft, and nontender; may be up to 1cm in size in cervical and inguinal areas ○ Palpable lymph nodes ■ Normal in children until puberty (10-11 years) when lymph node tissue begins to atrophy after growing past adult size from ages 6-10 ■ Palpability decreases with age, most are non-palpable in adults ■ When enlarged, check area which they drain for source of problem ● Problem is proximal or upstream to location of abnormal nodes ● Acutely infected lymph nodes bilaterally: enlarges, warm, tender, firm, freely moveable ■ Unilaterally enlarged nodes that are firm, non-tender, and may indicate cancer ■ Use gentle pressure because using strong pressure can push nodes into neck muscle ● Palpate with both hands in a gentle, circular motion ● Palpate in a systematic and thorough manner Headaches: Table 14.1 ● Migraines: supraorbital, retro-orbital, or frontotemporal with throbbing qualities ○ Can be relieved by lying down, dark spaces, eyeshades, sleep, take NSAIDs early, avoid opioids if possible ○ Associated with family history, hormones, foods, hunger, letdown after stress, sleep deprivation, changes in weather, sensory stimuli, and physical activity ○ Aura, photosensitivity, n/v, phonophobia, abd pain, prodrome ○ Chronic migraine: more prevalent among whites and hispanics; >14 days/month ○ Maybe caused by stimulation of cranial nerve 5 (trigeminal) with neurotransmitter changes in CNS and changes in vessel tone ○ Rapid onset, peaks 1-2hr, lasts 4-72 hours ○ Throbbing and pulsating ● Cluster headaches: produced pain around eyes, temples, forehead and cheek ○ Unilateral, usually on the same side of the head, excruciating with ANS signs (nasal congestion, runny nose, watery or reddened eyes, eyelid drooping, miosis, agitation) ○ Treatment/relief: need to move, pacing floor ○ Continuous, burning, piercing, excruciating, severe, stabbing pain ○ Abrupt onset, peaks in minutes, last 45-90 minutes; exacerbated by alcohol, stress, daytime napping, wind or heat exposure ○ Can occur multiple times in day, in clusters, lasting weeks ○ Excruciating, can occur once or twice per day and can last .5-2 hours ● Tension headaches: both sides, across frontal, temporal, and occipital region of head (forehead, sides, back of head); musculoskeletal in origin ○ Bandlike, ciselike, non throbbing, non pulsatile; diffuse and dull aching pain ○ Lasts 30 minutes to days ○ Rest, NSAIDS, massage muscles Developmental competence ● Infants and children ○ Skull ■ Caput succedaneum: edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma ● Usually causes skull to look markedly asymmetric ● Gradually resolves within first few days of life and needs no treatment ■ Cephalhematoma: subperiosteal hemorrhage from birth trauma ● Soft, fluctuant, and well defined over one cranial bone because the periosteum holds the bleeding in place ● Appears several hours after birth, gradually increasing in size ● Will be reabsorbed during first few weeks of life without treatment ● No discoloration, but looks bizarre; reassure parents ■ Hydrocephalus: obstruction of drainage of CSF which results in excessive accumulation, increasing ICP, and enlargement of head ● Face looks small compared with enlarged cranium ● ICP produces dilated scalp veins, frontal bossing, setting sun eyes ● Cranial bones thin, sutures separate and percussion yields cracked pot sound (macewen sign) ■ Down syndrome: most common chromosomal abnormality ● Head and face: upslanting eyes with inner epicanthal folds, flat nasal bridge, small, broad, flat nose; protruding thick tongue; ear dysplasia; short broad neck with webbing ■ Craniosynostosis: severe deformity of the head with marked asymmetry caused by premature closure of the sutures ● Hypoplasia of the face can result ■ Microcephaly: abnormally small head ■ Plagiocephaly: positional deformity; asymmetry of cranium when seen from top; can be mitigated by tummy time ● Physical therapy and corrective headbands ■ Atopic facies (allergic facies): in children with chronic allergies you may see exhausted face, blue shadows below eyes (allergic shiners) from sluggish venous return, a double or single crease on lower eyelids, central facial pallor, and opened mouth breathing (leads to malocclusion of teeth and malformed jaw) ■ Meningeal irritation: characterized by acute onset of neck stiffening (nuchal rigidity) and pain along with headache, fever; can lead to a severe headache in adults or children who have never had it before (red flag) ● Projectile vomiting ■ Fetal alcohol spectrum disorders: severe cognitive and psychosocial impairment, changes in face and brain structure ● Facial characteristics: short palpebral fissures, flat midface, short nose, indistinct philtrum, thin upper lip, epicanthal folds, low nasal bridge, minor ear abnormalities, micrognathia ● Smaller head circumference, decreased birth weight, feeding problems, irritability, neurologic and behavior defects including intrusive talking, inattention, poor abstract reasoning, problems with IADLs ● Leading preventable cause of intellectual disability, learning disability, and birth defects ■ Sutures no longer palpable at 5-6 months ■ Positional molding: from sleeping, flattened cranial bone and occiput ■ Note head posture and head control ○ Face: symmetry, wrinkling, swelling ○ Neck: looks short until 3-4 years, check ROM ● Pregnant women: chloasma on face, increased thyroid ● Aging adult ○ Temporal arteries may look twisted and prominent ○ Mild tremor may be normal ○ Isolated tremors and benign and include head nodding, tongue protrusion ○ Kyphosis w/ increased anterior curve on head extension ○ Slower ROMs ○ Prolapse of submandibular glands can be mistaken for tumors, should be soft and present bilaterally ○ Low lying thyroids that are non-palpable Head and neck ● Multinodular Goiter: multiple nodules usually indicate inflammation ○ Any painless, rapidly growing nodules, especially a single nodule in a young person should be suspected for cancer; usually hard and fixed to surrounding structure ■ Increased cancer risk for females, past history of goiter or nodules, size >4cm ● Grave’s disease: hyperthyroidism, autoimmune; increased metabolic rate manifested by goiter, eyelid retraction, exophthalmos (bulging eyes) ○ Symptoms: nervousness, fatigue, weight loss, muscle cramps, heat intolerance ○ Signs: forceful tachycardia, SOB, excessive sweating, thin silky hair, warm and moist skin, fine muscle tremor, infrequent blinking, staring appearance, brisk ankle jerks ● Hypothyroidism: reduces metabolic rate and when severe causes non pitting edema (myxedema) ○ Usual cause is Hashimoto Thyroiditis ○ Symptoms include fatigue and cold intolerance ○ Signs include puffy, edematous face, especially around eyes (periorbital edema); puffy hands and feet; coarse facial features; cool, dry skin; dry, coarse hair and eyebrows; slow reflexes; and sometimes thick speech. ● Congenital torticollis ● Simple diffuse goiter: lack of iodine ● Pilar cyst: contains sebum and keratin, overlying skin is shiny and hairless, benign ● Acromegaly: abnormal excessive secretion of growth hormone from pituitary gland after puberty, creates and enlarged skill and thickened cranial bones, massive face, overgrowth of nose and lower jaw, heavy eyebrow ridge, coarse facial features ● Cushin’s syndrome: excess ACTH and chronic steroid use; rounded moonlike face, prominent jowls, red cheeks, hirsutism on upper lick, lower cheeks, and chin, acneiform rash on chest ● Bell’s palsy: lower motor neuron lesion producing rapid onset of cranial nerve 7 paralysis of facial muscles, almost always unilateral ○ Reactivation of HSV1 latent since childhood ○ Paralysis of one side of face: smooth forehead, wide palpebral fissure, flat nasolabial fold, drooling, pain behind ear ○ Greatly improved if corticosteroids and antivirals given within 72 hours of onset ● Stroke: upper motor neuron lesion; BEFAST ● Parkinsons: deficiency in dopamine and degeneration of substantia nigra in basal ganglia; face looks flat, expressionless, masklike, elevated eyebrows, staring gaze, oily skin, drooling ● Cachetic appearance: accompanies chronic wasting diseases; sunken eyes, hollow cheeks, exhausted and defeated expression Chapter 15: Eyes External anatomy: ● Palpebral fissure: elliptical space the opens between the eyelids ○ Closes when lids close, normal finding ● Other anatomy ○ Extraocular muscles ● 3 Cranial nerves involved in movement of eye ○ Cranial nerve 3 ■ Superior rectus ■ Inferior oblique ■ Medial rectus ■ Inferior rectus ○ Cranial nerve 6 ■ Lateral rectus ○ Cranial nerve 4 ■ Superior oblique ● Oculus dexter: left eye ● Oculus sinister: right eye Internal anatomy ● 3 concentric coats ○ Cornea and sclera ■ Sclera: coat of the eye ■ Cornea: sensitive to touch ○ Choroid ■ Center layer, dark pigmentation to prevent light from reflecting and is highly vascularized to deliver blood to retin