Cultural Considerations: Beliefs

A patient's belief system can be an important source of emotional support during illness. The nurse should ask whether the patient belongs to a church, religious organization, or spiritual group that could serve as a resource. When assessing patients from other cultures, inquire about stressors and available support systems, and understand who influences the patient's health care decisions — some cultures use collective decision-making (all members have input), while others defer to an elder whose decision the whole family upholds.

Diet & Nutrition: Culture significantly affects food choices and preparation. Some cultures prefer vegan diets; others avoid beef or pork; some prohibit mixing certain foods or have special requirements during illness. In cultures like Singapore, food plays a central role in palliative care — family mealtime traditions may be considered as important as medical treatment itself.

Sensitive information: When asking about heritage, ethnic group, sexual orientation, or socioeconomic status, the nurse must handle questions carefully to avoid offending the patient. It is also important to assess a patient's literacy level to create an effective teaching plan.

Cultural Considerations: Personal Space & Eye Contact

Eye contact preferences vary by culture:

• Patients from some Asian, Arabic, Native American, and Hispanic cultures may avoid eye contact — it may be seen as insulting or is reserved for close family
• Some groups see persistent eye contact as aggressive and avoid it as a sign of respect for authority

Personal space preferences also vary:

• Patients from Hispanic and Middle Eastern cultures may prefer less personal space and sitting side-by-side in close proximity
• If a patient moves closer, the nurse should not move away, as it may offend them
• Other cultures prefer greater distance during the interview

Cultural Considerations: Language

The nurse should determine the patient's language preference. If the patient speaks an unfamiliar language:

• Use a professional medical interpreter — family members as interpreters are not preferred, as patients may be unwilling to share embarrassing or alarming information with family, and family members lack the necessary medical terminology
• When working with an interpreter: speak clearly and plainly, pause after every 1–2 sentences, and allow time for the interpreter to relay information

Key Points (Section Summary)

• Nurses should understand patient preferences related to nutrition, personal space, and eye contact
• Cultural beliefs may restrict food choices or require specific food preparation methods
• Some cultures prefer close personal space; others prefer more distance
• Direct eye contact can be disrespectful or aggressive in some cultures; in others it signals respect
• When language barriers exist, always enlist a medical interpreter

Focused Patient History: Interview Techniques

The patient interview is the first step in patient assessment. Its goal is to gather information leading to the correct diagnosis and plan of care. Key principles:

• Begin by introducing yourself and addressing the patient appropriately
• Build rapport through courteous interactions, culturally appropriate eye contact, and personal space
• Be mindful not to exhaust the patient; ask questions in a nonjudgmental and empathetic manner
• Be flexible — patient needs may change the course of the interview

Important interview factors:

Focused Patient History: Components of an Effective Health History

The patient history gathers information about the patient's immediate needs and acute problem. It includes five components:

• Chief complaint — Reason for seeking care ("Tell me what brings you to see us today.")
• History of present illness — Symptoms and events surrounding the current problem ("When did the symptoms begin?" / "How does this affect your routine?")
• Medical history — Previous medical and surgical information ("What chronic diseases have you been diagnosed with in the past?")
• Family history — Family members' medical conditions ("What illnesses run in your family?")
• Personal and social history — Activities and behaviors ("How many cigarettes do you smoke per day?")

Key Points (Section Summary)

• The patient interview is essential to identify pertinent information related to both acute and chronic problems
• During the interview, the nurse should identify: chief complaint, history of present illness, medical history, family history, and personal and social history

Components of a Comprehensive Health History

A comprehensive history is usually obtained the first time a nurse sees a patient. It includes more data than a focused history and covers both current and past information. Components include: chief complaint, review of systems, history of present illness, family history, and social history.

The review of systems is a systematic assessment of all body systems for abnormalities — it can identify signs and symptoms related to the chief complaint as well as unrelated problems.

Medical and Family History

Medical & Surgical History gathers data on: past medications, allergies (drug, environmental, and food), past blood transfusions and reactions, recent screenings/tests, chronic medical conditions, past diagnoses (childhood and adult), immunizations, past surgical procedures, and serious injuries or functional limitations.

Family History gathers data on: illnesses similar to the patient's, history of major diseases, familial disease and cancer history (genetic illnesses, chronic diseases like diabetes and heart disease, types of cancer), age at onset and outcome of illness, ethnic and racial background, and creation of a pedigree diagram (noting disorders across the past three generations).

Personal and Social History

Requires careful, nonjudgmental questioning due to sensitive topics. Key components include:

• Marital status & support — identify emergency contacts; also assess for potential abuse
• Habits — use of illicit drugs, alcohol, and tobacco; eating and exercise habits
• Self-care — physical and emotional health
• Sexual history — potential risks including number of partners and contraceptive use
• Home conditions — living situation; homelessness increases risk for several diseases
• Occupation — type of work (manual labor, desk job, seasonal, etc.); clues about workplace hazards and financial access to care
• Religious preference — shapes health attitudes/behaviors; may indicate a support system
• Additional: past military service, access to health care

Factors That Affect the Nurse's Ability to Obtain a Comprehensive Health History

Several barriers may prevent a complete history. The nurse should establish clear communication, ensure patient comfort, and modify the assessment accordingly.

Key Points (Section Summary)

• Comprehensive history covers both current health and past events
• Ask about chronic condition diagnoses and family medical history
• Personal and social history reveals habits and behaviors affecting health
• Address any communication barriers quickly to prevent poor data collection — common barriers include cognitive ability, anxiety/depression, excessive crying, and emotional intimacy

Infants and Children

When taking history from a child, assess the child's ability to communicate. If very young or unable to communicate well, direct questions to the parent or caregiver, but pay equal attention to both the child and the adult — this reveals family dynamics and can signal potential abuse. Playing with the child builds trust and provides valuable information.

When speaking with the accompanying adult, explore:

• Mother's gestational, pregnancy, and birth history (including complications and whether full-term)
• Mother's exposure to environmental and occupational hazards (toxic chemicals, bacterial agents, etc.)
• Child's neonatal history, feeding ability/preferences, and achievement of developmental milestones; diet history and feeding schedule
• Child's adjustment to school and social situations, habits, and living conditions — ask the child directly about friends and concerns
• A review of systems specific to the child's condition (head-to-toe assessment)

Adolescents

Adolescents may look like adults but are still minors — the parent/accompanying adult should still be interviewed. Key principles:

• Respect the adolescent's autonomy and need for confidentiality
• Build trust and establish an alliance; do not force the conversation
• Stay flexible — self-esteem, peer pressure, and tension with parents can affect willingness to share information

Use these mnemonics to ensure complete assessment:

Older Adults

Age-related changes to consider include sensory loss, visual impairment, cognitive decline, and memory loss — these may hinder the patient's ability to understand or respond to questions. Key considerations:

• Leverage the older adult's life experience and perspective on health concerns
• Be aware of multiple comorbidities and chronic symptoms
• Medication history is extremely important due to the likelihood of polypharmacy
• Assess level of function

Age-Specific Elements Summary

Key Points (Section Summary)

• Adjust interview techniques and focus based on the patient's age and condition
• For children/infants: pay equal attention to the child and the accompanying adult
• For adolescents: consider self-esteem, peer pressure, and parent tension — all affect willingness to participate
• For older adults: age-related physical changes may decrease function and ability to respond
• With all patients: remain flexible and willing to change the course of the interview based on needs

Adaptive Techniques for Cognitively Impaired Patients

Cognitive impairment may make it difficult for patients to comprehend or respond to questions. Key principles:

• Mild impairment: Patient can speak for themselves and contribute to the history
• Severe impairment: A family member or caregiver should be interviewed instead
• Ensure the environment is quiet, private, and comfortable — loud noises can cause overstimulation and confusion
• Obtain simple, basic information directly from the patient when possible; identify the most appropriate caregiver to assist

Adaptive Techniques for Hearing-Impaired Patients

• Use a medical interpreter if the patient communicates primarily through sign language
• For lip readers: sit facing the patient, speak slowly, and clearly articulate each word; use gestures or pantomime if appropriate (note: some cultures find certain gestures offensive)
• For unilateral hearing loss: sit closest to the patient's hearing ear
• Ensure hearing aids are in place and functional
• For older patients with presbycusis (loss of high-pitch sounds): lower voice rather than increasing volume
• If the patient can read and write: use questionnaires, printed forms, a notepad, or whiteboard

Adaptive Techniques for Visually Impaired Patients

• Be careful not to startle the patient when approaching
• Use a normal tone, moderate speed, and clear enunciation
• Use subtle gestures to reorient the patient to their location and surroundings
• Written materials and questionnaires are not an option — use audio or braille educational materials instead

Key Points (Section Summary)

• Adapt interview techniques based on the patient's condition and immediate needs
• For hearing-impaired patients who use sign language: obtain an interpreter; if they can hear partially or read lips: speak slowly and enunciate clearly
• Visually impaired patients should be frequently reoriented to their surroundings
• For cognitively impaired patients: carefully assess ability to understand and respond; use a family member to relay information for severe impairments

Patient History for Sensitive Issues: Alcohol

Alcohol use is a sensitive topic and may not always produce truthful answers with direct questioning. The patient's perception of "excessive" drinking may differ greatly from the nurse's. Objective screening tools are the best approach. Common tools include CAGE, TACE, and CRAFFT. Screening tools identify whether a problem exists but must be followed up with a full assessment.

CAGE (general adult population)

• C — "Have you been told you need to Cut down on your drinking?"
• A — "Have you ever been Annoyed by someone's criticism of your drinking?"
• G — "Do you ever feel Guilty after drinking?"
• E — "Have you ever had a drink first thing in the morning (Eye opener)?"

TACE (similar to CAGE, often used in pregnancy screening)

• T — "How many drinks does it Take to make you feel high?"
• A — "Have people Annoyed you by criticizing your drinking?"
• C — "Have you felt you ought to Cut down on your drinking?"
• E — "Have you ever had an Eye-opener drink first thing in the morning?"

CRAFFT (adolescent population)

• C — Ridden in a Car driven by someone (including yourself) who had been using alcohol?
• R — Use alcohol to Relax or feel better about yourself?
• A — Use alcohol while Alone?
• F — Ever Forget things you did while using alcohol?
• F — Do Family or Friends tell you to cut down?
• T — Ever gotten into Trouble while using alcohol?

Patient History for Sensitive Issues: Domestic Violence

Domestic violence transcends every ethnic, socioeconomic, and age group. The nurse should screen every patient in a calm, safe environment — interviewed apart from their significant other. The nurse should ask:

• "Have you been hit, kicked, punched, or otherwise hurt by someone within the past year?"
• "Do you feel safe in your current relationship?"
• "Is there a partner from a previous relationship who is making you feel unsafe?"

Domestic violence is not just physical — also encourage reporting of verbal and emotional abuse.

HITS screening tool (partner violence) — "In the last year, how often has your partner…"

• H — Hurt you physically?
• I — Insulted or talked down to you?
• T — Threatened you with physical harm?
• S — Screamed or cursed at you?

Patient History for Sensitive Issues: Spirituality

Many patients find comfort in spirituality, while others consider it deeply personal. Use the FICA acronym:

• F — Faith, belief, meaning — Ask about spiritual heritage, important writings, and how beliefs help cope with stress
• I — Importance and influence — Ask how beliefs influence handling of stress and to what extent
• C — Community — Ask if they belong to a formal spiritual or religious community
• A — Address/action in care — Ask how religious beliefs affect health care decisions and how the nurse can support them

Patient History for Sensitive Issues: Sexuality

The nurse needs to know the patient's sexual orientation to ensure continuity of care — not all patients are heterosexual. Build trust by asking gender-neutral, nonjudgmental questions such as:

• "Tell me about your living situation."
• "Are you sexually active and in what way?"

These questions reassure patients they are in a safe, judgment-free space to give honest answers.

Key Points (Section Summary)

• Some history topics are difficult for patients to discuss, but the nurse must gather this information to develop an effective plan of care
• When assessing for alcoholism, domestic violence, spiritual preference, and sexuality, questions must be carefully phrased — not offensive, judgmental, or leading
• Screening tools like CAGE and HITS identify whether a problem exists, but the nurse must follow up with a complete assessment

Growth by Organ System

Each organ system has its own individual period of rapid growth marked by rapid cell differentiation. Growth timelines may vary between individuals, but sequential growth patterns are consistent. Weight is closely tied to growth in stature and organ development, and adequate nutrition influences the number and size of fat cells.

The four types of growth:

• General growth — body as a whole; includes respiratory, circulatory, digestive, renal, and musculoskeletal systems
• Lymphoid growth — thymus, lymph nodes, and intestinal lymph masses
• Neural growth — brain, dura, spinal cord, optic apparatus, and head dimensions
• Genital growth — reproductive organ growth

Peak growth periods by organ/tissue:

Developmental Changes in Weight & Body Composition

• Fetus — weight influenced by mother's pre-pregnancy weight, weight gain during pregnancy, placental function, and complications (e.g., gestational diabetes); weight increases most in the third trimester
• Infant — trunk growth predominates; weight gain is initially rapid then slows by 1 year of age
• Child — weight gained steadily until age 7; a prepubertal increase in fat occurs around age 7 before the true growth spurt
• Adolescent — approximately 50% of ideal body weight is gained; organ systems double in size; males gain lean body mass (~90%); females gain body fat with slight decrease in lean mass (~75%)
• Pregnant woman — expected weight gain; slow gain in first trimester, faster in second and third
• Older adult (60+) — ~5% body weight loss over several years with increased body fat due to loss of skeletal muscle

Skeletal Growth

• Peaks during fetal development, infancy, and adolescence
• Fetal — head is the fastest growing skeletal portion
• Infancy — trunk is the main area of skeletal growth
• Childhood — legs are the fastest growing body part
• Adolescence — trunk and legs lengthen; skeletal mass doubles; males develop broader shoulders, females develop a wider pelvic outlet
• Growth is complete when the epiphyses of the long bones fuse (later in puberty)
• Around age 50, height begins to decrease as intervertebral discs thin and kyphosis develops
• Older adults — skeletal muscle decreases due to reduced exercise and steroid production

Key Points (Section Summary)

• Each organ system has its own individual period of rapid growth
• Organs have periods of accelerated growth influenced by age
• Skeletal growth peaks during fetal development, infancy, and adolescence

Neuroendocrine Function

Many hormones must be in balance for normal growth and development. The hypothalamic-pituitary axis (part of the neuroendocrine system) consists of two glands — the hypothalamus and the pituitary gland — located in the brain. The system influences growth through direct interactions and negative feedback.

• Hypothalamus — regulates storage and secretion of hormones from the pituitary gland
• Anterior pituitary lobe — controls hormone synthesis and secretion, especially growth hormone
• Growth hormone-releasing hormone (GHRH) — stimulates the pituitary to release growth hormone
• Growth hormone is released in pulses, with 70% released during sleep
• Somatostatin — inhibits secretion of both GHRH and thyroid-stimulating hormone, preventing uncontrolled growth and maintaining homeostasis

Hormones and Growth

Key hormones influencing growth and their functions:

Hormone Effects on Target Organs

Additional hormones affecting growth:

Growth at puberty depends on the interaction between GH, IGF-1, and testosterone/estrogen. The gonads secrete estrogen and testosterone to achieve maturation of genitalia and promote bone maturation and epiphyseal fusion.

Key Points (Section Summary)

• Homeostasis is maintained in part through hormonal release
• Hormone secretion increases and decreases vary by age
• Growth at puberty depends on the interaction between multiple hormones
• GH, GHRH, and IGF-1 regulate growth
• Estrogen and testosterone regulate sexual development
• Ghrelin controls food intake
• Interleukin-6 regulates bone formation
• Leptin regulates body fat and may trigger puberty
• Luteinizing hormone stimulates the release of sex hormones

Growth and Development History: Modifiable Elements (Personal History)

Modifiable elements are things the patient can change to influence growth. The nurse should ask targeted questions to identify these factors:

Modifiable Elements of History of Present Illness

For growth-related concerns (weight loss, weight gain, changes in body proportions), the nurse should ask about:

Modifiable Elements of Personal and Social History

Focus on social habits that can affect growth. Key areas to assess:

• Activity and exercise pattern — ask about exercise consistency, what activity the patient enjoys, or if they exercise in a group
• Weight — ask how much the patient typically weighs
• Alcohol use — ask how many alcoholic beverages the patient drinks in a typical day
• Recreational drug use — ask if the patient has ever or currently uses recreational drugs, what type, and how often
• Dietary habits/conditions — asking if a patient craves ice, laundry starch, or clay can identify pica (an abnormal condition)

Age-appropriate questions are essential:

• Adolescent: "Do you participate in a team sport?" (evaluates activity/exercise)
• Infant: Assess for parental attachment as part of social history related to growth

Key Points (Section Summary)

• Modifiable elements affecting growth include exercise, alcohol/drug use, nutrition, stress, obesity, and exposure to toxins
• History of present illness related to growth centers on weight loss/gain or changes in body proportions
• Personal and social history modifiable elements include usual height/weight, activity/exercise pattern, and alcohol/drug use
• Always ask age-appropriate questions when gathering personal and social history related to growth

Growth and Development History: Nonmodifiable Elements

Nonmodifiable elements are things that cannot be changed — they are fixed or happened in the past. They include food allergies, genetic conditions, medical conditions, family history, and personal/social history. Although they can't be changed, identifying them helps recognize their influence on current illness and guides health education. Categories include medical history, family history, and personal/social history.

Age-specific nonmodifiable factors to consider:

• Infants — gestational age at birth, length and weight at birth, congenital anomalies, feeding intolerance
• Children & adolescents — short or tall stature, initiation or delay of sexual maturation, chronic diseases (e.g., cystic fibrosis)
• Pregnant women — last menstrual period, pre-pregnancy weight, eating disorders, difficulty with digestion
• Older adults — chronic debilitating illness, problems chewing, denture usage

Nonmodifiable Elements of Medical History

Questions to ask about present illness and past medical history:

• "Have you experienced an undesired weight loss or weight gain?"
• "Do you have a change in appetite, vomiting or diarrhea, difficulty swallowing, excessive thirst, or frequent urination?"
• "Can you tell me about your past medication usage, such as chemotherapy, diuretics, insulin, fluoxetine, diet pills, oral contraceptives, or steroids?"
• "Have you noticed any changes in fat distribution or body proportions, such as coarsening facial features or enlarging hands or feet?"
• "Do you have food allergies?"
• "Do you have a chronic illness, such as cancer, HIV infection, kidney problems, or heart problems?"
• "Would you tell me about your previous efforts with weight loss or weight gain?"
• "What is your maximum body weight — the most you have ever weighed?"

Nonmodifiable Elements of Family History

Focus on obesity, genetic disorders, metabolic disorders, constitutionally short or tall stature, and early or delayed puberty:

• "Are other family members overweight or obese?"
• "Has anyone in the family been diagnosed with a metabolic or genetic disorder, such as diabetes or cystic fibrosis?"
• "How tall are your parents and siblings?"
• "When did your parents or siblings go through puberty?"

Nonmodifiable Elements of Personal and Social History

These are past behaviors or exposures that can no longer be changed:

• Usual weight and height — compare to current findings
• Past drug or tobacco use — history of drug use or smoking, type, and duration
• Past exposure to toxins — secondhand smoke, occupational exposures to chemicals, pesticides, lead, or paints

Key Points (Section Summary)

• Nonmodifiable elements are things that cannot be changed or happened in the past
• Include food allergies, genetic conditions, medical conditions, family history, and personal/social history
• Always consider age- and condition-specific questions related to nonmodifiable factors influencing growth

Measurements Related to Growth

Steps to measure weight:

• Ask patient to remove excess clothing and shoes
• Have patient stand in the middle of the scale platform; note digital reading
• If using a balance scale: move the largest weight to the last 50-lb/10-kg increment under patient's weight, then adjust the smaller weight to balance; read to the nearest 0.1 kg or ¼ lb
• Measure at the same time each day when tracking daily weight (variations occur with body fluid and intestinal contents)
• For bed scales: subtract the weight of sheets, blankets, and pads

Steps to measure height:

• Ask patient to remove shoes
• Have patient stand erect with back to the stature-measuring device, arms at sides
• Pull up the height attachment and position the headpiece on top of the head, parallel to the floor
• Read to the nearest centimeter or ½ inch
• For infants/children 0–24 months: place supine on a measuring device; read to the nearest 0.5 cm or ¼ inch

Body Mass Index (BMI)

BMI is the most common method to assess total body fat and nutritional status.

Formulas:

• Standard (lb/in): (Weight in lbs ÷ [height in inches]²) × 703
• Metric (kg/m): Weight in kg ÷ (height in meters)²

Example: 130 lb / 64 inches → BMI = 22.3 (standard) or 22.2 (metric)

Infant Measurements Related to Growth

Head circumference (measure until age 2–3):

• Wrap measuring tape snugly around the head at the occipital protuberance and supraorbital prominence (largest circumference)
• Record to the nearest 0.5 cm or ¼ inch

Chest circumference (generally at birth; then as condition warrants):

• Wrap tape around chest at the nipple line, snugly but without indentation
• Record to the nearest 0.5 cm or ¼ inch

Size for gestational age — use an intrauterine growth curve to plot birth weight, length, and head circumference:

• Appropriate for gestational age (AGA): 10th–90th weight percentile
• Small for gestational age (SGA): less than 10th weight percentile
• Large for gestational age (LGA): greater than 90th weight percentile

Equipment Used for Measuring Growth

Correct positioning for stature measurement in children: back against device, looking straight ahead; outer canthus of the eye on the same horizontal plane as the auditory canal. Read to nearest 0.5 cm or ¼ inch.

Key Points (Section Summary)

• Growth measurements include weight and height
• BMI is the most common method to assess total body fat
• Infants require head circumference, chest circumference, and size for gestational age
• Equipment needed varies by age: scale, stature-measuring device, and measuring tape

Physical Growth and Sexual Maturation

Assessing growth in older children and adolescents includes evaluating sexual maturation. Key considerations:

• Secondary sexual characteristic development is associated with the height growth spurt
• Physiologic milestones: menarche in females and nocturnal emission in males
• Females: breast and pubic hair development assessed using Tanner stages
• Males: genital and pubic hair development assessed using Tanner stages
• Sexual maturity rating = average of the female's pubic hair + breast stage, OR male's pubic hair + genital stage
• Onset of sexual maturation varies among individuals; delayed puberty is often a normal variation

Tanner Stages: Females — Breast Development

Onset of puberty = reaching breast Tanner stage 2 or pubic hair Tanner stage 2, whichever comes first. Most females develop breasts before pubic hair. Breast development typically occurs ages 9–12; breasts often appear asymmetric. Menarche typically follows breast development, average age 12–13 years. Higher weight/BMI is associated with earlier sexual maturation.

Tanner Stages: Females — Pubic Hair Development

Tanner Stages: Males — Genital (Penis & Scrotum) Development

Growth of external genitalia usually occurs before pubic hair development in males.

Tanner Stages: Males — Pubic Hair Development

Key Points (Section Summary)

• Secondary sexual characteristic development is associated with the height growth spurt
• Onset of sexual maturation varies among individuals
• Females: breast development precedes pubic hair
• Males: genital development precedes pubic hair

Infant Weight, Length, and Head Circumference

Accurate measurement of weight, length, and head/chest circumference is essential for assessing infant growth:

• Measure length in recumbent position; weigh without clothing or diapers
• Measurements are retained and compared at each subsequent visit to track growth patterns
• Head circumference: measured at every visit until age 2–3 years; normal full-term newborn range = 32.5–37.5 cm; by age 2 = approximately two-thirds adult size
• Chest circumference: measured until age 2 years
• Failure to thrive is diagnosed when infants fall below the 3rd–5th percentile on the growth chart
• Newborns classified as AGA (10th–90th percentile), SGA (<10th), or **LGA** (>90th)

Developmental Assessment and Milestones

Developmental milestones represent activities, behaviors, and expressive language a child should be capable of based on psychosocial development. The nurse should:

• Assess the infant carefully and interview the parents with strategic questions to determine if milestones are met by the expected age
• Example: for a 3-month-old, assess ability to maintain eye contact

Height, BMI, and Obesity in Children & Adolescents

Children able to stand unassisted and walk well (usually by 24 months) use a standing scale. Remove shoes and heavy clothing for accuracy.

BMI classifications (adult scale — same formula used for children):

Pediatric BMI — plotted on age- and gender-specific growth charts:

The nurse should also note the child's upper-to-lower segment ratio and arm span — a higher upper-to-lower ratio may indicate certain growth disorders.

Growth Curve and Velocity

At each visit, the nurse compares the child's current growth to prior assessments and plots weight/height on an age- and gender-specific growth chart. The growth curve is developed based on national average weights and heights. Plotting weight and height shows the child's percentile compared to other children. Children's body proportions change in a predictable pattern.

Puberty and Sexual Maturity

Most girls begin puberty between ages 9–12, with breast enlargement occurring before menarche. The nurse assesses sex characteristics and notes the child's Tanner stage. Areas assessed:

• Females: breast size and pubic hair (using Tanner stages 1–5 for breasts; 1–6 for pubic hair)
• Males: scrotum/penis development and pubic hair (Tanner stages 1–5 for genitalia; 1–6 for pubic hair)

Key Points (Section Summary)

• Infant growth assessment includes length, weight, head circumference, and chest circumference
• For children and adolescents: note BMI and assess Tanner stage of sexual maturity
• Tanner staging is based on breast size (females), pubic hair (both), and scrotum/penis development (males)
• Height, weight, and BMI should all be plotted on a growth curve and compared to peers: below 5th, 5th–90th, or greater than 90th percentile

Growth Assessment: Older Adult

Measurement procedures for older adults are the same as for the general adult population. The nurse should:

• Measure height and weight to calculate BMI, then chart and classify as underweight, overweight, or obese
• Measure triceps skinfold thickness, charted and classified using age- and gender-specific data

Expected age-related changes to assess for:

• Loss of height and decline in stature (height loss typically begins at age 50)
• Decreased muscle mass and bone density
• 60% of adults over age 65 are overweight (a natural result of aging changes)
• The nurse may assess bone mass and body composition to determine the extent of muscle and bone loss

Growth Assessment: Older Adult — Additional Considerations

As part of the older adult growth assessment, the nurse should determine:

• Patient's functional ability — can they prepare their own meals and access healthy foods?
• Ability to chew, swallow, and self-feed
• Need for dentures and any problems with digestion

Key Points (Section Summary)

• The older adult growth assessment is very similar to that of the general adult population
• Complete height, weight, and BMI calculations to classify as underweight, overweight, or obese
• Pay special attention to the patient's ability to access healthy foods and their ability to chew, swallow, and digest nutrients

Expected Findings: Weight and Height

Weight and height are objective measures of patient growth. For accuracy: remove shoes and heavy clothing; stand in the middle of the scale platform. Weight variations are normal throughout the day and from day to day (body fluid, intestinal contents).

Expected findings for infants and children: height and weight should fall between the 5th and 95th percentile and should follow the expected growth curve. Length/height and weight should fall in approximately the same percentile on the growth chart.

Expected Findings: Body Mass Index

• Pediatric patients (ages 2–20): BMI plotted on a BMI-for-age percentile chart; expected between the 5th and 95th percentile, following an expected growth curve
• Adult patients: BMI expected between 18.5 and 24.9

Age-Related Expected Growth Findings

Key Points (Section Summary)

• Measure weight and height for all patients
• For patients under 20: plot on a growth chart; expect between 5th and 95th percentile
• Use height and weight to calculate BMI
  • Ages 2–20: BMI percentile should be between 5th and 95th
  • Adults: BMI expected between 18.5 and 24.9
• Infant head circumference should also be plotted; expected 5th–95th percentile
• Older adults: expect decreased stature, increased fat content, and decreased bone and muscle mass

Abnormal Findings: Growth Assessment

The nurse should recognize abnormal growth findings early. Unexpected findings include:

• Weight loss ≥ 1–2% per week, 5% in 1 month, 7.5% in 3 months, or 10% in 6 months
• BMI < 18.5 (underweight); 30–39.9 (obesity); > 40 (extreme obesity)
• Waist circumference > 40 inches in men or > 35 inches in women
• Waist-to-hip ratio > 1.0 in men or > 0.85 in women
• Triceps skinfold thickness < 10th or > 95th percentile
• Upper-to-lower segment ratio > 1.0 (normal: 1.7 for neonates, 1.3 for toddlers)

Acromegaly

Caused by hypersecretion of growth hormone and IGF-1 after epiphyseal closure → excessive growth with distorted proportions.

Cushing's Syndrome

Caused by prolonged, excessively high exposure to glucocorticoids.

Turner's Syndrome

Genetic disorder in females with partial or complete absence of a second X chromosome.

Hydrocephalus

Excess volume of CSF in the brain → enlarged head circumference.

Growth Hormone Deficiency

Caused by inadequate GH secretion from the anterior pituitary.

Precocious Puberty

Onset of sexual characteristics before the expected time (typically before age 7), with progressive sexual maturation. Normal puberty begins ages 9–12.

Key Points (Section Summary)

• Evaluate weight loss, BMI, waist circumference, waist-to-hip ratio, and triceps skinfold as part of a thorough growth assessment
• Key conditions and their hallmarks:
  • Acromegaly: excessive growth, skin thickening, oily/sweaty skin, excessive snoring
  • Cushing's syndrome: buffalo hump, moon facies, proximal muscle weakness, hirsutism, weight gain with slow height velocity
  • Turner's syndrome: short stature, webbed neck, poor height growth, amenorrhea
  • Hydrocephalus: enlarged head circumference, prominent distended scalp veins, severe headache, diplopia
  • Growth hormone deficiency: short stature, cherubism
  • Precocious puberty: secondary sexual characteristics before age 7

Growth and Measurement: History of Present Illness

The nurse must accurately document the current symptoms, associated symptoms, aggravating and alleviating factors, onset and duration of symptoms, and prior treatments. Growth-related HPI documentation focuses on:

Weight Loss or Weight Gain — document patient reports of:

• Undesired weight loss
• Anorexia (decreased appetite)
• Vomiting or diarrhea
• Difficulty swallowing
• Excessive thirst / frequent urination
• Use of weight-affecting medications (laxatives, chemotherapy, diuretics, insulin, steroids)

Changes in Body Proportion — document patient reports of:

• Coarsening facial features
• Enlarging hands/feet
• Moon facies
• Change in fat distribution
• Use of steroids

Growth and Measurement: Medical History

Chronic illnesses that affect growth assessment should be documented. These include:

• GI: acid reflux, irritable bowel disease, celiac disease
• Renal: chronic or acute renal failure
• Pulmonary: asthma, COPD
• Cardiac: congestive heart failure, hypertension
• Cancer
• HIV or other infections
• Allergies (particularly food allergies)

Growth and Measurement: Family History

Document any family history of conditions that may relate to the patient's growth:

• Obesity
• Short or tall stature of family members
• Genetic or metabolic disorders (e.g., cystic fibrosis, dwarfism)
• Other systemic disorders that could affect growth

Growth and Measurement: Personal and Social History

Tobacco, alcohol, and recreational drug use can affect ability to eat or digest nutrients. The nurse should also document:

• Activity and exercise patterns
• Usual weight and height

All information should be thoroughly documented to aid diagnosis and treatment planning.

Key Points (Section Summary)

• Accurately document HPI: onset and duration of symptoms, associated symptoms, aggravating and alleviating factors
• Ask for family history, medical/surgical history, and personal/social history related to growth
• Specifically assess for and document: GI disorders (affecting digestion), familial disorders such as obesity, and drug or alcohol use

Objective Growth Assessment: Weight and Height

The nurse completes a thorough physical examination and documents weight and height — especially for pediatric patients — on growth charts to determine weight percentile. The nurse should also document the patient's frame size to assess appropriateness of weight for age, height, and gender. The child's length (not height) should be documented on the growth chart until 2 years of age.

Objective Growth Assessment: Body Mass Index

BMI is calculated from height and weight and documented with the patient's classification:

Formulas:

• Standard: (Weight in lbs ÷ [height in inches]²) × 703
• Metric: Weight in kg ÷ (height in meters)²

Objective Growth Assessment: Head Circumference

For infants and children, the nurse should document head circumference until the child reaches 2 years of age. The result is plotted on the head circumference percentile chart and the percentile is documented in the medical record, allowing comparison to other children of the same age group.

Key Points (Section Summary)

• Document height, weight, and frame size for all patients
• Calculate and document BMI to classify as underweight, appropriate weight, overweight, obese, or extremely obese
• For infants under 2 years: document length (not height) and head circumference

Interviewing Basics — Establishing Rapport

Good Patient Rapport: Definition

• The first step in the assessment process is typically the history and interview
• As the interview begins, the nurse must build rapport with the patient
• Rapport = a positive relationship that facilitates communication
• Helps ensure the nurse obtains information necessary to develop an effective plan of care

Good Patient Rapport: Importance

• Establishing rapport builds trust and openness in the nurse-patient relationship
• Patients who trust their nurse are:
  • More amenable to nurses' input
  • More likely to ask questions and offer pertinent information
• A previously established rapport helps diffuse situations when a patient becomes upset or frustrated
• Redirects the patient toward a more positive expression of emotions
• The positive relationship should be reinforced with each encounter

Factors Involved in Achieving Good Patient Rapport

The 5 C's — Required for a positive nurse-patient relationship:

Practical techniques to promote rapport:

• Provide privacy during the interview
• Maintain a calm, low voice
• Ensure a comfortable room temperature
• Address the patient's immediate needs (toileting, thirst, etc.)
• Sit down to interview the patient — less intimidating, shows the nurse values their time
• Keep appropriate social distance (several feet away) — professional yet positive tone
• Maintain eye contact — keeps focus on the patient and their needs

HIPAA considerations:

• Must maintain patient privacy during AND after medical contact
• May not share health information with anyone without the patient's consent

Benefits of good rapport:

• Patients are more likely to cooperate with the treatment plan
• Patients play an active role in their own plan of care

Key Points

• Developing good rapport is the first step to effective communication
• The nurse must provide comfort, be courteous, and consider the patient's immediate needs at the start of the interview
• Careful attention to physical and psychological comfort prevents intimidation and shows the patient the nurse cares
• This opens lines of communication and makes for a more thorough and complete patient history assessment

Interviewing Basics — Effective Communication

Overview: Question Styles

• Every interaction should build trust and elicit information to develop the plan of care
• The nurse must formulate questions that:
  • Allow the patient to answer fully
  • Ask for specific information
  • Encourage truthful disclosure
  • Discourage answers given only because the patient thinks it's what the nurse wants to hear

Three basic question styles:

Enhancing the Patient's Response During an Interview

• Be aware of the patient's comfort level
• Use appropriate body language
• Maintain eye contact to keep focus on the patient
• Phrase questions so they are not judgmental
• Give the patient opportunity to fully describe symptoms without interruption
• Actively listen — interrupt only to seek clarification
• Take notes but limit note-taking to maintain eye contact; explain why the laptop/notebook is being used
• Avoid asking several yes/no questions in succession — confusing and discourages elaboration

Therapeutic Communication Principles (Effective Techniques)

Ineffective Communication Techniques (Avoid)

Key Points

• Effective communication is key to ensuring accurate, thorough information is obtained during the patient interview
• The nurse must use therapeutic communication principles and phrase questions that are open-ended and nonjudgmental
• If there is miscommunication, the nurse should remember to: Facilitate, Reflect, Clarify, Empathize, Confront, Interpret
• Ineffective communication hinders the assessment process and limits the information the nurse receives
• When effective communication is achieved, the nurse is better able to meet the patient's needs

📋 Inspection — Course Notes

Course: Examination Techniques / Inspection (Sherpath)

1. Inspection: Overview

Definition: Inspection is the process of observation, beginning with the initial meeting of the patient and continuing through the history and physical examination.

Two Parts of Inspection:

• General inspection — observing the patient from front to back and from each side; checks for symmetry of body parts, obvious injuries or abnormalities, and overall appearance.
• Systematic inspection — inspecting each body region from head-to-toe (also called a head-to-toe assessment).

Routine visits: Begin with general inspection → then systematic (head-to-toe) inspection. Example: inspect chest for shape/symmetry, then assess abdomen for shape and contour.

Focused inspection: If a patient presents with an illness, perform general inspection first, then a focused inspection of only the affected body system. Example: for a respiratory illness, inspect chest and airway — do not continue head-to-toe.

2. Inspection Guidelines

Guidelines for inspection include:

1. Having adequate lighting — daylight or artificial

   • Sunlight or artificial lighting is acceptable as long as it reveals color, texture, and mobility without casting shadows.
   • Also have indirect/tangential lighting (e.g., a lamp) available to observe contour and variations in the body surface.

2. Conducting unhurried and careful inspection

   • Perform inspection carefully, giving adequate time to observe findings.

3. Exposing what you want to inspect

   • Expose the area to be inspected for accurate results, but inform the patient before exposing areas of the body.

4. Validating findings with patient

   • Be willing to validate your inspection findings with the patient.

5. Ensuring appropriate equipment is available

   • Ensure equipment is ready before beginning — such as a penlight, and possibly an ophthalmoscope and otoscope.

3. Inspection Guidelines, Cont'd

Inspection is an ongoing process — begins at the initial meeting and continues throughout the physical examination. Continue observing until a complete picture is formed. General inspection can be performed in seconds and influences the rest of the exam.

What to observe:

• Gait & stance — observe how the patient walks and how easily/difficultly they get onto the examination table → provides information about neurologic and musculoskeletal status.
• Eye contact, demeanor, clothing — observe for good eye contact, appropriate demeanor, and appropriate clothing for the weather → provides information about emotional and mental status.
• Skin & odors — take time to observe the color and moisture of the skin, and any unusual odors.
• Verbal statements & body language — observe throughout the entire examination to determine the patient's perception of the encounter.

📋 Palpation — Course Notes

Course: Examination Techniques / Palpation (Sherpath)

1. Palpation Guidelines

Definition: Palpation involves using the hands and fingers to gather assessment data through touch. It is used to gather information about skin temperature, pulsations or vibrations, size of organs, and tenderness of internal structures.

Guidelines for palpation:

• Keep fingernails short to avoid hurting the patient.
• Have warm hands and be gentle to help the patient relax for more accurate data.
• Use the correct palpation depth and the appropriate part of the hand to identify findings without causing unnecessary discomfort.

2. Palpation Considerations

• Palpation usually follows inspection, but not always. The key exception: when assessing the abdomen, always perform palpation after inspection and auscultation — palpation can increase intestinal activity, causing misleading auscultation findings (e.g., increased bowel sounds).
• Wear gloves when palpating areas with possible contact with body fluids (genitalia, wounds) or mucous membranes.
• Touch has cultural significance — each culture has its own understanding of touch. The nurse should:
  • Ask the patient's permission before touching.
  • Explain the purpose of the touch (e.g., "I am going to press in on your abdomen to feel your liver.").
  • Honor the patient's cultural beliefs — if touch is unacceptable in certain areas, gather as much data as possible without touching that area.

3. Palpation: Using Areas of the Hand

Different areas of the hand are used to detect specific findings:

4. Types of Palpation

Palpation is classified as light or deep based on the amount of pressure applied. Light palpation is always performed before deep palpation — deep palpation can cause tenderness or disrupt fluid, altering light palpation findings. Deep palpation is often reserved for advanced practice due to injury risk.

Light Palpation

• Press down approximately 1 cm
• Assesses: moisture, texture, temperature, pulsations, tenderness, superficial masses and lesions

Deep Palpation

• Press down approximately 4 cm with one or two hands
• Used to determine: organ size and contour, especially the liver

Bimanual Palpation

• Can be used for light or deep palpation
• Uses both hands to entrap a mass or organ (e.g., uterus, kidney, or large breasts) between fingertips
• Assesses: size and shape

📋 Percussion — Course Notes

Course: Examination Techniques / Percussion (Sherpath)

1. Overview

Definition: Percussion uses sound waves to gather information about the density of tissue. It can be direct or indirect and is used to evaluate the size and borders of internal organs. It can also provide information about tenderness or the amount of fluid within a body cavity.

Percussion principles:

• One object striking against another produces vibrations and sound waves.
• The tapping of the nurse's finger causes vibrations by impact on underlying tissues.
• Sound waves arise from vibrations and produce percussion tones.
• The tone heard is related to the density of the underlying tissue.

2. Percussion Tones

Tones vary based on the density of the object the sound waves travel through — the denser the object, the quieter the tone. Flat (over bone/muscle) is the quietest; tympanic (over stomach/gastric bubble) is the loudest.

(Two videos on this page demonstrated percussion tones for various areas of the chest and the anterior chest.)

3. Guidelines for Distinguishing Percussion Tones

• Percussion tones are easier to distinguish by listening to the change in tone when moving from one area to another.
• It is easier to hear the change by percussing from resonance to dullness (not dullness to resonance).
• Example: Because resonance is heard over the lungs and dullness over the liver, start percussing over the chest and percuss down to the abdomen.

4. Percussion Techniques

There are three types of percussion:

5. Percussion Techniques, Cont'd — Tips for Accuracy

• The downward tap should originate from the wrist, not the forearm.
• Tap sharply and rapidly to help identify tones.
• After tapping, snap the wrist back and quickly lift the finger to prevent dampening the sound.
• Use the tip (not the pad) of the tapping finger — short fingernails are important.
• Percuss one location several times to help interpret the tone.
• For mediate percussion, avoid striking the interphalangeal joint (knuckle) — this will dampen the sound.

(A video on this page demonstrated percussion of the posterior chest using these techniques.)

📋 Auscultation — Course Notes

Course: Examination Techniques / Auscultation (Sherpath)

1. Overview

Definition: Auscultation involves listening for sounds produced by the body or organs within the body — usually the heart, lungs, intestines, and blood vessels. Sounds are produced by heart valves closing or by movement of air and fluid through internal organs. Most sounds require a stethoscope to amplify them for identification.

Important order note: When assessing the abdomen, auscultation occurs first, followed by percussion (same rule as with palpation — to avoid altering findings).

2. Auscultation Guidelines

When performing auscultation, follow these guidelines to identify sounds correctly:

• Angle the stethoscope earpieces in the ear correctly to hear sounds.
• Ensure a quiet environment free from distracting noises.
• Place the stethoscope on naked skin — listening through clothing can obscure or alter sounds.
• Listen for the presence and characteristics of the sound.
• Isolate the sound from sounds produced by other organs — this is called selective listening.
• Take time to identify characteristics of the sound: intensity, duration, pitch, and quality.
• Do not anticipate the next sound or try to predict what you will hear next.

3. Auscultation Considerations

Issues that may impede accuracy or impact patient safety:

• Close eyes and block out environmental noise to help identify sounds — listen to one sound at a time and distinguish it from other body sounds.
• Warm the stethoscope headpiece before placing it on the patient's skin — a cold stethoscope can cause shivering, and the involuntary muscle contractions from shivering could alter sounds or make listening difficult.
• Body hair friction — friction from body hair rubbing against the stethoscope diaphragm could be mistaken for adventitious lung sounds (crackles).
• Clean the stethoscope between patients to avoid transmitting infection.

4. Distinguishing Auscultation Sounds

Take time to identify the four characteristics of each sound:

• Intensity — the loudness of a sound; described as soft, loud, or medium.
• Pitch — the frequency of sound waves per second; high frequencies = high-pitched, low frequencies = low-pitched.
• Duration — the length the sound is heard; can be short, medium, or long.
• Quality — the description of the sound; examples include murmur or crackle.

Practical tip for distinguishing heart from lung sounds: Start by identifying the heartbeat, then assess its intensity (loud or soft?), then pitch (heart = low pitch; lungs = high pitch), then duration (normal heart sounds are usually shorter than lung sounds), then quality.

📋 Stethoscope — Course Notes

Course: Examination Equipment / Stethoscope (Sherpath)

1. Purpose of the Stethoscope

A stethoscope channels body sounds so they are audible to the examiner. There are four types:

• Acoustic — transmits sound waves from the body through a closed cylinder to the ear, blocking out extra sounds; does not magnify sound; most commonly used by nurses during physical assessment.
• Stereophonic — a type of acoustic stethoscope that uses a two-channel design with a divided bell and diaphragm to differentiate between right and left auscultatory sounds.
• Magnetic — contains an iron disk and a permanent magnet that picks up different frequency sounds.
• Electronic — sensitive to vibrations transmitted to the body surface; converts them to electrical impulses that are reconverted to sound via a speaker.

2. Stethoscope Design

The acoustic stethoscope has four parts:

• Earpieces — may be hard or soft; should fit snugly, completely filling the ear canal. If too small, they will slip in and be painful.
• Binaurals — metal tubes connecting the earpieces to the tubing; angled and positioned so earpieces direct toward the nose, channeling sound toward the tympanic membrane.
• Tubing — thick, stiff material; should be 12–18 inches long. Longer than 18 inches may distort sound.
• Head — consists of the diaphragm (larger, flat surface, rigid ring edge) and the bell (smaller, concave shape, plastic ring around edges).

3. Sounds Auscultated by the Head of the Stethoscope

The head has a closure valve — only the diaphragm or bell can be activated at one time. Turn the head in one direction to activate the diaphragm, the other direction for the bell. Lightly tap the head to confirm which component is active.

Diaphragm:

• Used to hear high-pitched sounds
• Examples: lung sounds, bowel sounds, normal heart sounds
• Must be held firmly on the skin during use

Bell:

• Used to hear soft, low-pitched sounds
• Examples: extra heart sounds, heart murmurs, vascular sounds (bruits)
• Must be placed lightly on the skin with just enough pressure to create a seal
• If pressed too firmly, the concave structure fills with skin, functions as a diaphragm, and damps the vibrations

4. Proper Technique for Using a Stethoscope

• Hold the head between the 2nd and 3rd fingers to stabilize the endpiece — prevents extra sounds.
• Do not touch the tubing with hands during use — produces false sounds.
• Do not allow tubing to rub against any surface — friction produces false sounds.
• Do not place the head over material (gown or clothing) — fabric friction produces false sounds.
• Do not talk during stethoscope use — voice produces false sounds.

📋 Pulse Oximeter — Course Notes

Course: Examination Equipment / Pulse Oximeter (Sherpath)

1. Purpose of Pulse Oximeter

Definition: A pulse oximeter measures the percentage of hemoglobin saturated with oxygen (oxyhemoglobin). Oxygen saturation measures how much oxygen the blood is carrying as a percentage of its maximum capacity.

How it works: The device measures the ratio of oxyhemoglobin to deoxyhemoglobin. The difference between those two values gives the fraction of oxyhemoglobin in the blood, reported as a percentage of hemoglobin saturated with oxygen.

2. Pulse Oximeter Probes and Placement

• A sensor probe is placed on a body site that is reasonably translucent and has good blood flow.
• A pulse oximeter also measures pulse rate.

Key points during use:

• Align the photodetectors in the probe before placing it on the body site. The cutaneous sensor probe emits red and infrared light, measuring how much light passes through the capillaries and recognizing the amount of color absorbed by arterial blood — this calculates the oxygen saturation level.
• Place the probe at a site that is highly vascular with capillaries near the skin surface. Adequate sites include: a nail bed (finger or toe), an earlobe, or the bridge of the nose.
• Alternate sensor probe sites if using the pulse oximeter for continuous measurements — this promotes patient comfort.

3. Preventing Potential Errors in Measurements

To prevent errors:

• Remove nail polish completely if a nail bed is the sensor site — nail polish can cause an inaccurate reading.
• Instruct the patient to lie still during measurement — movement can cause an inaccurate reading.
• Correlate the patient's radial pulse with the pulse value on the pulse oximeter display once the probe is placed — this confirms proper equipment function and ensures an accurate reading.

If an inaccurate measurement is suspected:

• Ensure the patient's body site under the probe is warm.
• Encourage the patient to take deep breaths and recheck to see if the reading improves.
• If the patient has an order for supplemental oxygen, ensure delivery equipment is properly functioning.

📋 Blood Pressure Equipment — Course Notes

Course: Examination Equipment / Blood Pressure Equipment (Sherpath)

1. How to Measure Blood Pressure

Blood pressure is measured using either a manual sphygmomanometer + stethoscope or an automated electronic device.

• The electronic sphygmomanometer senses vibrations converted to electrical impulses — does not require a stethoscope. Also measures pulse rate.
• Both types measure systolic and diastolic blood pressure.

Manual sphygmomanometer components:

• Cuff with inflatable bladder
• Pressure manometer (gauge to measure BP reading)
• Rubber hand bulb with pressure control valve (inflates/deflates bladder)

Electronic automated sphygmomanometer components:

• Cuff with inflatable bladder
• Device with digital display

2. Selecting Proper Blood Pressure Cuff Size

Accurate BP measurement depends on selecting the appropriate cuff size for the patient's limb.

Parameters:

• Inflatable rubber bladder should be 40% as wide as the patient's arm circumference and encircle at least 80% of the limb.
• Most adults use a cuff 12–14 cm wide.
• Check the range lines on the cuff — the cuff edge should lie between them if sized correctly.

Available sizes:

• Adult — standard cuff (adequate for most adults)
• Adult — oversized cuff (used for large/obese adults; if the arm is extremely obese, the oversized cuff is used on the thigh)
• Child — many different sizes available

3. Special Considerations When Obtaining Blood Pressure

Medical contraindications — avoid using an arm that has:

• An arteriovenous (AV) shunt → risk for vascular-related injury from cuff pressure
• Been on the same side as a radical mastectomy → risk for lymph system-related issues from cuff pressure

Cuff size errors:

• Too narrow a cuff → falsely high reading
• Too wide a cuff → falsely low reading

Cuff application: Wrap smoothly and tightly; uneven or loose cuff → falsely high reading

Cuff deflation: Deflate at 2–3 mm Hg/sec

• Too slowly → falsely high diastolic pressure
• Too quickly → falsely low systolic and/or falsely high diastolic pressure

Limb position: Support the limb at heart level

• Unsupported limb → falsely high reading
• Limb above heart level → falsely high reading
• Limb below heart level → falsely low reading

Repeat measurement: Wait 1–2 minutes before repeating

• Immediately repeating → falsely high systolic and falsely low diastolic reading

Automatic electronic device: Compare automatic reading with a manual reading when the patient has an irregular heartbeat — an automatic cuff may not obtain accurate results in this situation.

📋 Ophthalmoscope and Otoscope — Course Notes

Course: Examination Equipment / Ophthalmoscope and Otoscope (Sherpath)

1. Purpose of the Ophthalmoscope

Definition: The ophthalmoscope uses a system of lenses and mirrors to visualize the interior structures of the eye. It has a light source that projects through different apertures — changing the aperture changes the shape and/or color of the light, enabling assessment of different eye conditions.

Aperture settings and their uses:

2. Preparing the Ophthalmoscope and Patient for the Eye Exam

Assembly steps:

1. Seat the ophthalmoscope in the handle
2. Push downward
3. Turn the head in a clockwise direction
4. Lock the two pieces into place
5. Depress the on/off switch
6. Turn the rheostat control clockwise to desired light intensity

Lens settings: Zero diopter is the starting lens. Adjust as needed:

• Positive settings (0 to +40) — focus on near objects within the patient's eye
• Negative settings (0 to –20) — focus on objects further away within the patient's eye

Corrective lenses — patients:

• Patients should remove glasses before the exam — glasses obstruct proper entry into the pupil
• Patients can leave contact lenses in — contacts do not obstruct visualization

Corrective lenses — examiners:

• Examiners should remove glasses when using the ophthalmoscope — the plus/minus lenses on the device correct for myopia or hyperopia
• Examiners can leave contact lenses in — contacts do not interfere with exam technique

3. Purpose of the Otoscope

Definition: The otoscope allows inspection of the external ear canal and tympanic membrane. It has two main parts: the head and the handle. Assembled using the same procedure as the ophthalmoscope.

Parts:

• Handle — contains the power source; gripped during use
• Head — consists of magnification lens, light source, and speculum
• Speculum — funnel-shaped cone that attaches to the head; directs beam of light down the ear canal
• Pneumatic bulb attachment — rubber bulb and tubing that attaches to the head; evaluates fluctuation of the tympanic membrane (squeezing the bulb puffs air over the membrane, causing it to move)

Some newer models have an adjustable focus for greater magnification and field of view.

4. Selection of Otoscope Speculum

• Specula come in various sizes — choose the largest speculum that fits into the patient's ear canal.
• The otoscope can also be used to examine the nares of the nose — use the shortest, widest speculum and insert gently into the nostrils.

5. Holding the Otoscope for Examination

Proper technique:

• Assemble the otoscope and attach the proper size speculum.
• Hold the otoscope firmly with the handle pointing upward and head pointing downward.
• Tilt the patient's head slightly toward the opposite ear.
• Adults and children ≥2 years: Pull the pinna up and back to straighten the ear canal.
• Infants: Pull the pinna down and back to straighten the ear canal.
• Maintain hand contact with the patient's head throughout.
• Gently insert the speculum into the ear canal.

📋 Percussion (Reflex) Hammer — Course Notes

Course: Examination Equipment / Percussion (Reflex) Hammer (Sherpath)

1. Purpose of the Percussion (Reflex) Hammer

• Also known as the reflex hammer
• Used to test deep tendon reflexes (DTRs)
• Consists of a metal handle with a triangular rubber component on the end
• Has either a flat or pointed surface to elicit a reflex response:
  • Flat surface — more commonly used; strikes the tendon directly; more comfortable for the patient
  • Pointed surface — strikes the tendon directly, or strikes the nurse's finger placed on the tendon; useful in small areas

Alternative: The examiner's finger can act as a percussion hammer:

• Used in very young children
• Less threatening than the hammer

2. Proper Technique for Use of the Percussion Hammer

Steps for using the hammer:

1. Hold the hammer loosely between the thumb and index finger
2. Use a rapid downward snap of the wrist
3. Tap the tendon quickly and firmly
4. Snap the wrist back, removing the hammer from the tendon immediately

Steps for positioning the extremity:

• Position the patient's extremity so the tendon is slightly stretched
• Manipulate the patient's joint being tested away from you — this helps stretch the tendon being tested and makes it more accessible with the strike of the hammer

📋 Visual Acuity Charts — Course Notes

Course: Examination Equipment / Visual Acuity Charts (Sherpath)

1. Types of Visual Acuity Charts

A variety of visual acuity charts exist for assessing far vision, near vision, and macular degeneration. One eye is assessed at a time with the appropriate chart.

2. Assessing Visual Acuity and Field Perception Using the Snellen Chart

Visual acuity testing:

• Patient stands 20 feet from the chart and reads the smallest line possible with one eye at a time
• Visual acuity is recorded as a fraction:
  • Numerator = distance from the chart (20 feet)
  • Denominator = distance from which a person with normal vision can read the lettering (20 feet = 20/20 is normal)
• If the patient can read only some letters from the next smallest line, indicate this by adding the number of letters read correctly

📋 Tuning Fork — Course Notes

Course: Examination Equipment / Tuning Fork (Sherpath)

1. Purpose of the Tuning Fork

The tuning fork is used in physical assessment for two purposes:

1. Auditory assessment — uses a high-pitched tuning fork with a frequency of 500–1000 Hz
2. Assessment of vibratory sensation (part of the neurologic exam) — uses a low-pitched tuning fork with a frequency of 100–400 Hz

2. Auditory Evaluation — Activation & Use

To activate (for auditory evaluation):

• Hold the tuning fork by the stem
• Gently squeeze and stroke the prongs, OR
• Very gently tap the prongs against the heel of the hand so they ring softly

Cautions:

• Do not hold by the base of the prongs — this damps the sound by interfering with the vibration
• Do not vigorously hit the prongs against the hand — causes a loud, high pitch and could lead to inaccurate results

Placement during use:

• Activated tuning fork is held by the external ear
• Activated tuning fork is placed on the top of the head in the middle of the skull

3. Assessment of Vibratory Sensation — Activation & Use

To activate (for vibratory sensation):

• Hold the tuning fork by the stem
• Very gently tap the prongs against the heel of the hand

Cautions:

• Do not hold by the base of the prongs — damps the sound
• Do not squeeze the prongs together — this is not proper technique for the vibratory sensation tuning fork

Placement during use:

• Hold the activated tuning fork on a bony prominence
• Start evaluating at the most distal bony prominence
• If the patient does not feel vibration, move the fork proximally until vibration is felt

📋 Structures of Skin, Hair, and Nails — Course Notes

Course: Anatomy and Physiology: Skin, Hair, and Nails (Sherpath)

1. Structures of the Skin

The skin is separated into three layers, with the epidermis folding downward into the dermis to form appendages.

Epidermis

• The outermost layer of skin
• Avascular — no blood vessels; receives nutrients from the dermis beneath
• Has two layers: the stratum corneum and the cellular stratum
• The basement membrane lies beneath the cellular stratum and connects the epidermis to the dermis

Dermis

• Highly vascular — rich blood supply
• Separates the epidermis from the cutaneous adipose (fatty) tissue
• Has three components: elastin, collagen, and reticulin fibers; sensory nerve fibers; autonomic motor nerves

Hypodermis

• Connects the dermis to the underlying organs
• Contains a subcutaneous layer filled with fatty cells

Appendages (formed by epidermis folding into the dermis):

• Eccrine sweat glands
• Apocrine sweat glands
• Sebaceous glands
• Hair
• Nails

2. Structures of the Hair

• Hair is formed from epidermal cells that migrate into the dermal layer
• Hair has three parts: the follicle, shaft, and papilla
• The hair shaft contains melanocytes — cells that provide color
• Males and females have approximately the same number of hair follicles, but hair grows at different rates based on hormonal differences (particularly growth hormone)

Two types of adult hair:

• Vellus hair — short, fine, soft, and nonpigmented
• Terminal hair — coarser, longer, thicker, and usually pigmented

3. Structures of the Nails

• Nails are epidermal cells converted into hard plates of keratin
• Below the nail lies a vascular nail bed — this vascularity gives nails their pink appearance
• Cuticle (eponychium) — the stratum corneum of the skin that covers the nail root
• Paronychium — the soft tissue surrounding the nail border

📋 Functions of Skin, Hair, and Nails — Course Notes

Course: Anatomy and Physiology: Skin, Hair, and Nails (Sherpath)

1. Functions of the Skin (Overview)

The skin is the body's first line of defense against infection and injury. Its primary functions include:

• Protects underlying structures against microbial and foreign substance invasion and minor physical trauma
• Acts as a physical barrier against fluid loss
• Regulates body temperature through radiation, conduction, convection, and evaporation
• Sensory perception via free nerve endings and specialized sensory receptors
• Production of vitamin D
• Blood pressure regulation through constriction of skin blood vessels
• Repair of surface wounds by exaggerating normal cell replacement processes
• Excretion of sweat, urea, and lactic acid
• Expressing emotions — e.g., during stress or embarrassment, the skin reacts with sweat and warmth

2. Functions of the Skin: Epidermis, Dermis, and Hypodermis

Epidermis:

• Stratum corneum — protects against harmful environmental substances and restricts water loss
• Cellular stratum — synthesizes keratin

Dermis:

• Elastin, collagen, reticulin fibers — provide resilience, strength, and stability
• Sensory nerve fibers — provide sensations of pain, touch, and temperature
• Autonomic motor nerves — innervate blood vessels, glands, and muscles of the skin

Hypodermis:

• Generates heat
• Provides insulation
• Provides shock absorption
• Provides calorie reserve

3. Functions of the Skin: Sweat Glands and Sebaceous Glands

Sweat Glands:

• Eccrine sweat glands — regulate body temperature through secretion of water
• Apocrine sweat glands — emotional sweat response

Sebaceous Glands:

• Secrete sebum, a lipid-rich substance that keeps skin and hair from drying out

📋 History of Present Illness: Skin, Hair, and Nails — Course Notes

Course: Patient History: Skin, Hair, and Nails (Sherpath)

1. History of Present Illness: Skin

When patients present with skin concerns, the nurse should inquire about: onset and severity of symptoms, treatments and home remedies used prior to arrival, associated symptoms, changes in symptoms, aggravating and alleviating factors, and current medications. Additionally ask about changes to moles, unusual odors, excessive perspiration, and chronically irritated lesions.

2. History of Present Illness: Hair

When the chief complaint involves hair, the nurse should ask about changes in texture, color, or distribution, hair growth changes, recent exposures, attempted treatments, and associated symptoms. Also take a diet history — nutritional changes can affect hair, skin, and nails. Ask about current medications, as some affect hair growth and distribution.

Potential questions:

• "What changes have you noticed in the color and distribution of your hair?"
• "When did your current symptoms begin?"
• "What other symptoms are you currently experiencing?"
• "Have you recently been exposed to any chemicals?"
• "Have you been exposed to someone with similar symptoms?"
• "Describe your current diet."
• "What have you used to treat the problem and what was your response to that treatment?"

3. History of Present Illness: Nails

When a patient has nail concerns, gather information about: changes in nail color and texture, associated symptoms (pain or drainage), onset and duration of symptoms, recent exposures, and previous treatments.

Potential questions:

• "What changes have you noticed in the color and texture of your nails?"
• "What other symptoms are you currently experiencing?"
• "When did this problem start?"
• "Have you noticed that the symptoms are constant or do they come and go?"
• "Have you recently been exposed to any chemicals or infectious agents, such as fungus?"
• "What treatments have you tried, and what was the response?"

📋 Focused History: Skin, Hair, and Nails — Course Notes

Course: Patient History: Skin, Hair, and Nails (Sherpath)

1. Hair, Skin, and Nails: Pertinent Medical/Surgical History

During the patient interview, the nurse should inquire about past medical history to gain insight into possible causes of symptoms. The nurse should also ask about previous surgeries, especially those affecting the nails, scalp, or skin long-term.

2. Hair, Skin, and Nails: Pertinent Family History

Pertinent family history to gather during the assessment of a patient with hair, skin, or nail problems includes:

• Current or past dermatologic diseases or disorders in blood relatives — including melanoma, psoriasis, allergic skin disorders, infestations, and bacterial, fungal, or viral infections
• Allergic hereditary diseases, such as asthma or hay fever
• Familial hair loss or pigmentation patterns, such as alopecia

3. Hair, Skin, and Nails: Pertinent Personal/Social History

During the personal/social history assessment, the nurse inquires about personal care habits, exposure to occupational or environmental hazards, recent physical or psychologic stress, alcohol and tobacco use, sexual history and sexually transmitted infections (including HIV and syphilis), and use of recreational drugs.

📋 Inspecting Skin, Hair, and Nails — Course Notes

Course: Assessing Skin, Hair, and Nails (Sherpath)

1. Elements to Inspect: Skin

A thorough skin inspection entails evaluating the entire body. Key preparation and inspection points:

• Tattoos, ear piercings, and scars should be assessed for redness and swelling (suggesting infection)
• Skin folds should be assessed for moisture, excoriation, and yeast infection
• Lighting: Daylight provides the best illumination for color changes, especially jaundice; tangential lighting is useful for assessing contour
• Room temperature should be comfortable to prevent sweating or constriction of skin vessels (allows accurate assessment of temperature, texture, and moisture)
• During inspection, assess for: uniformity of skin color, localized areas of discoloration, skin thickness, symmetry, odor, and hygiene
• Note the presence of any nevi (moles) or skin lesions

2. Elements to Inspect: Hair

• In the healthy adult, fine vellus hair covers the body; coarser terminal hair is found on the scalp, pubic region, axillae, and arms and legs; also found in beards and mustaches in male patients
• Note hair color (varies from blond to black or gray) and any alterations from rinses, dyes, relaxers, or permanents
• Assess hair quantity and distribution for symmetry
• Note the presence of lice or nits

3. Elements to Inspect: Nails

Inspect nails and nail beds for:

• Color, configuration, symmetry, length, and changes in shape
• Nail edges for smoothness
• Proximal and lateral nail folds and cuticles for swelling, color changes, drainage, warts, or cysts
• Nail plate shape and nail base angle

4. Nevi Features

Nevi (moles) are normal variations in skin pattern and should be assessed thoroughly. They may be flat, slightly raised, dome-shaped, smooth, rough, or hairy. Color ranges from pink, tan, and gray to shades of brown and black.

What to inspect when assessing nevi:

• Size — diameter should be <6 mm
• Number — healthy adults may have up to 40 nevi throughout the body
• Color/degree of pigmentation
• Location — can be on all body surfaces; rarely found on scalp, breasts, and buttocks
• Shape
• Surface
• Symmetry
• Border — regular vs. irregular

📋 Palpating Skin, Hair, and Nails — Course Notes

Course: Assessing Skin, Hair, and Nails (Sherpath)

1. Elements to Palpate: Skin

During palpation, the nurse uses the hand and fingers to feel skin, hair, and nail characteristics.

• Palpate for temperature, texture, moisture, and mobility of the skin
• Use the thumb and forefinger to assess skin turgor — the skin is pinched and should quickly return to its original position (indicates hydration status)
• Assess skin temperature using the dorsal surface of the hand

2. Elements to Palpate: Hair and Nails

Hair:

• Feel the texture of the hair and scalp for dryness and brittleness
• Feel the hair shafts to note any broken or absent areas

Nails:

• Palpate for smoothness and uniform thickness
• Test adhesion to the nail bed by gently squeezing the nail between thumb and forefinger
• Assess the angle of the nail base — should be approximately 160 degrees

3. Assessment of Skin Lesion Features

Skin lesions are abnormalities that should be carefully assessed, as they may indicate localized or systemic conditions. The nurse should note:

• Size — height, width, and diameter
• Shape
• Color
• Texture
• Elevation or depression
• Attachment at the base — pedunculated (stalk-like attachment)
• Exudate or drainage — color, odor, amount, consistency
• Configuration — annular/ring-shaped, grouped, linear, arciform/bow-shaped, diffuse
• Location and distribution — generalized or localized, body region, patterns, discrete or confluent

📋 Normal Findings for Skin, Hair, and Nails — Course Notes

Course: Findings for Skin, Hair, and Nails (Sherpath)

1. Inspection Findings: Skin

During inspection of the skin, the nurse examines color, uniformity of appearance, thickness, symmetry, and hygiene.

• Color: Ranges from dark brown to light tan with pink or yellow overtones depending on ethnicity; should be uniform throughout but may be sun-darkened in exposed areas and darker on knees, knuckles, and elbows
• May note calluses on hands and feet (may appear yellow)
• Other normal color variations: nevi, nonpigmented striae (stretch marks), freckles, birthmarks
• Palms and soles may be lighter than the rest of the body; hyperpigmented macules are commonly found on the soles
• In darker-skinned patients: a bluish hue of the lips and yellowish-brown or brown pigment to the sclera may be common
• Thickness: Varies depending on body area
• Wounds: No open wounds or bleeding expected
• Symmetry: Expected on both sides of the body
• Hygiene: Good hygiene; no signs of foul odor

2. Inspection Findings: Hair and Nails

Expected Findings for Hair Inspection:

• Color: Varies from very light blond to black or gray; may show changes based on rinses, dyes, relaxers, or permanents
• Quantity and distribution: Coarse terminal hair normally on scalp, pubis, axillae, and male beard; fine vellus hair on other body surfaces

Expected Findings for Nail Inspection:

• Color: Nail bed should be pink; nurse may note pigment deposits in the nail bed; nails appear opaque with some white spots possible
• Nail plate: Should appear smooth and flat or slightly convex; longitudinal ridging and beading are common variations; curvature of toenail may be noted (usually related to shoe compression)
• Nail base angle: Should be 160 degrees — assessed by placing a ruler across the nail and dorsal surface of the finger and examining the angle formed by the proximal nail fold and nail plate

3. Palpation Findings: Skin

4. Palpation Findings: Hair and Nails

Hair: Coarse or fine, curly or straight; should be smooth, shiny, and resilient. Fine vellus hair on body; coarse terminal hair on scalp, pubis, axillae, and male beard.

Nails: Should feel hard and smooth with uniform thickness; nail should firmly adhere to nail bed. Proximal and lateral nail folds should show no swelling, discoloration, or tenderness.

📋 Age-Related Variations in the Skin, Hair, and Nails — Course Notes

Course: Findings for Skin, Hair, and Nails (Sherpath)

1. Age-Related Skin Findings: Infants

• For the first few hours after birth, infant skin may appear red; during infancy it becomes a gentle pink
• Dark-skinned newborns may not show the effects of melanocytes until 2–3 months of age
• Jaundice may be present in newborns (yellow tinge)
• Newborn hands and feet should have flexion creases — number of creases can indicate gestational age
• Vernix caseosa — white, moist, cheese-like substance often covering the skin of newborns
• Newborn skin may appear puffy for the first 2–3 days after birth
• Lanugo — fine, silky hairs covering the newborn's body, particularly over the back and shoulders; infants do not have terminal hair
• On palpation: milia (small, whitish, discrete papules on the face) may be noted in first 2–3 months of life
• Infant should have good skin turgor and resiliency
• Apocrine glands are not active in infants → less oily skin texture, non-odorous perspiration

Other Expected Newborn Color Changes:

2. Age-Related Skin Findings: Older Adults

As adults age:

• Skin becomes more transparent and pale; pigment deposits, increased freckling, and hypopigmented patches give a less uniform appearance
• Flaking or scaling is an expected finding as skin dries with aging
• Decreased subcutaneous tissue and muscle tone → looser, thinner skin with parchment-like appearance and texture, and poor turgor
• Increased wrinkling on expressive areas of the face and sun-exposed areas
• Sagging and drooping more evident under the chin, beneath the eyes, in the ear lobes, breasts, and scrotum

Common Lesions in Healthy Older Adults:

3. Age-Related Hair and Nail Findings: Older Adults

• Hormonal changes → decreased hair production in pubic and axillary regions
• Decreased functioning melanocytes → hair color changes to gray
• Nails become thicker and more brittle; grow at a slower rate due to decreased peripheral circulation

📋 Abnormal Findings for Skin, Hair, and Nails — Course Notes

Course: Findings for Skin, Hair, and Nails (Sherpath)

1. Abnormal Skin Findings: Primary Skin Lesions

Primary lesions are the skin's initial, spontaneous response to a pathologic process (disease, trauma, or injury).

2. Abnormal Skin Findings: Secondary Skin Lesions

Secondary lesions result from later evolution of or external trauma to a primary lesion.

3. Abnormal Hair and Nail Findings

Hair:

• Dryness or brittleness in hair/scalp is abnormal
• Hair loss may be normal in adult males — note onset and pattern; asymmetrical hair loss may indicate pathology
• Male-pattern alopecia — gradual loss of hair from the central scalp
• Alopecia areata — sudden, rapid, patchy hair loss from scalp and face
• Hirsutism (in female patients) — presence of terminal hairs on lower face, body, and pubic area; caused by hormonal changes

Abnormal Nail Findings:

📋 Documentation of Subjective Data for the Skin, Hair, and Nails — Course Notes

Course: Documenting Assessment of Skin, Hair, and Nails (Sherpath)

1. Documentation of Subjective Data Relating to the Skin Assessment

When interviewing a patient with a skin-related complaint, the nurse should document information about the onset, duration, and severity of symptoms. Important elements of the history of present illness to include in documentation:

• Changes in skin
• Temporal sequence (onset, duration, constant or intermittent)
• Symptoms (e.g., burning sensation may indicate the presence of herpes zoster)
• Location
• Apparent cause
• Travel history
• Treatment response
• Adjustment to problem
• Medications used

2. Documentation of Subjective Data Relating to the Hair and Nail Assessment

3. Documentation of Family History Relating to the Skin, Hair, and Nail Assessment

• Document current and past dermatologic diseases in family members
• Document allergic hereditary diseases such as asthma, hay fever, or eczema
• Document family history of hair loss or coloration patterns (hair loss may have familial connections)

4. Documentation of Personal/Social History Relating to the Skin, Hair, and Nail Assessment

Document the following from the personal/social history:

• Skin care habits — cleansing routine; soaps, oils, and lotions; cosmetics; home remedies; sunscreens
• Whether the patient conducts skin self-examinations (e.g., screening for abnormal nevi)
• Nail care habits
• Exposure to environmental or occupational hazards (e.g., frequent moisture exposure that may lead to paronychia)
• Psychologic or physical stress the patient is experiencing and coping strategies
• Recent trauma to the nails (e.g., puncture wounds)
• Use of alcohol, tobacco, or recreational drugs

📋 Documentation of Objective Data for the Skin, Hair, and Nails — Course Notes

Course: Documenting Assessment of Skin, Hair, and Nails (Sherpath)

1. Documentation of Objective Data Relating to the Skin Assessment

From inspection, the nurse should document:

• Skin color and whether uniformity in color and thickness was noted
• Whether the skin is symmetrical
• Whether the patient appears clean or unkempt
• Number and location of nevi and whether any nevi display abnormalities that could indicate melanoma

From palpation, the nurse should document:

• Temperature and texture of the skin
• Whether the skin is minimally or excessively moist or oily
• Whether the skin has good turgor (good resiliency and mobility, indicating the patient is well hydrated)
• Presence of any lesions — characterized by size, shape, color, texture, elevation/depression, and attachment at the base
  • Example: A macular or papular lesion may be indicative of Kaposi sarcoma

2. Documentation of Objective Data Relating to Hair Assessment

When documenting hair assessment findings, the nurse should include:

• Texture and color of the hair and scalp
• Any distinct abnormalities in growth pattern (e.g., hair loss on the scalp in women)
• Presence of vellus hair on the pubis, scalp, or beard, or male-pattern hair growth in a female patient
• Objective findings related to color, distribution, texture, and quantity of the hair

3. Documentation of Objective Data Relating to the Nail Assessment

The nurse should document findings to indicate potential physical or psychosocial problems:

• Condition of nails, nail beds, and nail edges
• Presence of redness, swelling, exudate, or abnormal growth
  • Exudate under the cuticle may suggest acute paronychia
• Angle of the nail base and presence of any discoloration
• Whether the nail is attached to the nail bed
  • A white nail plate that has separated from the nail bed is suggestive of onychomycosis