A stethoscope is a medical device for listening to sounds inside the body. The initial stethoscope was invented in the early 19th century by French physician Ren� Laennec, but was actually trying to achieve a rather different end: doctor-patient distance....
Nursing diagnosis for decreased cardiac output may be related to altered myocardial contractility, inotropic changes; alterations in rate, rhythm, electrical conduction; or structural changes, such as valvular defects and ventricular aneurysm. ...
The electrocardiogram (ECG) is a graphic recording ofelectric potentials generated by the heart.The signals are detected by means of metal electrodes attached to the extremities and chest wall and are then amplified and recorded by the electrocardiograph. ECG leads actually display the instantaneous differences in potential between these electrodes. ...
Cranial
|
Test for function
|
|---|---|
I Olfactory (S)
|
|
Olfactory nerve, mucous membrane of nasal passages and turbinates |
With eyes closed child is asked to identify familiar odors such as peanut butter, orange, and peppermint. Test each nostril separately |
II Optic (S)
|
|
Optic nerve, retinal rods and cones |
Check visual acuity, peripheral vision, color vision, perception of light in infants, fundoscopic examination for normal optic disk |
III Oculomotor (M)
|
|
Muscles of the eyes (superior rectus, inferior rectus, medial rectus, inferior oblique) |
Have child follow an object or light with the eyes (EOM) while head remains stationary. Check symmetry of corneal light reflex. Check for nystagamus (direction elicited, vertical, horizontal, rotary). Check cover-uncover test. |
Muscles of iris and ciliary body |
Reaction of pupils so light, both direct and consensual, accommodation |
Levator palpebral muscle |
Check for symmetric movement of upper eyelids. Note ptosis |
IV Trochlear (M)
|
|
Muscles of eye (superior oblique) |
Check the range of motion of the eyes downward (EOM). Check for nystagmus |
V Trigeminal (M, S)
|
|
Muscles of mastication (M) |
Palpate the child’s jaws, jaw muscles, and temporal muscles for strength and symmetry. Ask child to move lower jaw from side to side against resistance of the examiner’s hand |
Sensory innervation of face (S) |
Test child for sensation using a wisp of cotton, warm and cold water in test tubes, and a sharp object on the forehead, cheeks, and jaw. Check corneal reflex by touching a wisp of cotton to each cornea. The normal response is blink |
VI Abducens (M)
|
|
Muscles of eye (lateral rectus) |
Have child look to each side (EOM) |
VII Facial (M, S)
|
|
Muscles for facial expression |
Have child make faces: look at the ceiling, frown, wrinkle forehead, blow out cheeks, smile. Check for strength, asymmetry, paralysis |
Sense of taste on anterior two-thirds of tongue. Sensation of external ear canal, lachrymal, submaxillary, and sublingual glands |
Have a child identify salt, sugar, bitter (flavoring extract), and sour substances by placing substance on anterior sides of tongue. Keep tongue out until substance is identified. Rinse mouth between substances |
VIII Acoustic (S)
|
|
Equilibrium (vestibular nerve) |
Note equilibrium or presence of vertigo (Romberg sign) |
Auditory acuity (cochlear nerve) |
Test hearing. Use a tuning fork for the Weber and Rinne tests. Test by whispering and use of a watch |
IX Glossopharyngeal (M, S)
|
|
Pharynx, tongue (M) |
Check elevation of palate with “ah” or crying. Check for movement and symmetry. Stimulate posterior pharynx for gag reflex |
Sense of taste posterior third of the tongue |
Test sense of taste on posterior portion of tongue |
X Vagus (M, S)
|
|
Mucous membrane of pharynx, larynx, bronchi, lungs, heart, esophagus, stomach, and kidneys Posterior surface of external ear and external auditory meatus |
Note same as for glossopharyngeal. Note any hoarseness or stridor. Check uvula for midline position and movement with phonation. Stimulate uvula on each side with tongue depressor – should rise and deviate to stimulated side. Check gag reflex. Observe ability to swallow |
XI Accessory (M)
|
|
Sternocleidomastoid and upper trapezius muscles |
Have child shrug shoulders against mild resistance. Have child turn head to one side against resistance of examiner’s hand. Repeat on the other side. Inspect and palpate muscle strength, symmetry for both maneuvers |
XII Hypoglossal (M)
|
|
Muscle of tongue |
Have child move the tongue in all directions, then stick out tongue as far as possible: check for tremors or deviations. Test strength by having child push tongue against inside cheek against resistance on outer cheek. Note strength, movement, symmetry |
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Assessment requires the use of the skills needed for interviewing, conducting a physical examination, and observing patients. As with the nursing process itself, these skills are not used one at a time. While you are interviewing the patient, you are also observing and determining physical areas that require a detailed physical assessment. While completing a physical assessment, you are asking questions (interviewing) and observing the patient’s physical appearance as well as the patient’s response to the physical examination.
Interviewing generally starts with gathering data for the nursing history. In this interview, you ask for general demographic information such as name, address, date of last hospitalization, age, allergies, current medications, and the reason the patient was admitted. Depending on the agency’s admission form, you may then progress to other specific questions or a physical assessment.
The physical assessment calls for four skills: inspection, palpation, percussion, and auscultation. Inspection means careful and systematic observation throughout the physical examination, such as observation for and recording of any skin lesions. Palpation is assessment by feeling and touching the patient. Assessing the differences in temperature between a patient’s upper and lower arm would be an example of palpation. Another common example of palpation is breast self-examination. Percussion involves touching, tapping, and listening. Percussion allows determination of the size, density, locations, and boundaries of the organs. Percussion is usually performed by placing the index or middle finger of one hand firmly on the skin and striking with the middle finger of the other hand. The resultant sound is dull if the body is solid under the fingers (such as at the location of the liver) and hollow if there is a body cavity under the finger (such as at the location of the abdominal cavity). Auscultation involves listening with a stethoscope and is used to help assess respiratory, circulatory, and gastrointestinal status.
The physical assessment may be performed using a head-to-toe approach, a body system approach, or a functional health pattern approach. In the head-to-toe approach, you begin with the patient’s general appearance and vital signs. You then progress, as the name indicates, from the head to the extremities.
The body system approach to physical assessment focuses on the major body systems. As the nurse is conducting the nursing history interview, she or he will get a firm idea of which body systems need detailed examination. An example is a cardiovascular examination, where the apical and radial pulses, blood pressure (BP), point of maximum intensity (PMI), heart sounds, and peripheral pulses are examined.
The functional health pattern approach is based on Gordon’s Functional Health Patterns typology and allows the collection of all types of data according to each pattern. This is the approach used by this book and leads to three levels of assessment. First is the overall admission assessment, where each pattern is assessed through the collection of objective and subjective data. This assessment indicates patterns that need further attention, which requires implementation of the second level of pattern assessment. The second level of pattern assessment indicates which nursing diagnoses within the pattern might be pertinent to this patient, which leads to the third level of assessment, the defining characteristics for each individual nursing diagnosis. Having a three-tiered assessment might seem complicated, but each assessment is so closely related that completion of the assessment is easy. A primary advantage in using this type of assessment is the validation it gives to the nurse that the resulting nursing diagnosis is the most correct diagnosis. Another benefit to using this type of assessment is that grouping of data is already accomplished and does not have to be a separate step.
