Nursing Jarvis Study Guide Essay

1. Identify the most common physical health problems that result from intimate partner violence.

2. Differentiate abuse from neglect.

3. Describe the tonic neck reflex in the infant.

4. List the condition (s) associated with parotid gland enlargement.

5. Describe the characteristics of lymph nodes often associated with: acute infection, chronic infection, cancer.Nursing Jarvis Study Guide Essay

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6. List the facial structures that should appear symmetric when inspecting the head.

7. The major neck muscles are the:

8. Describe the characteristics of normal cervical lymph nodes during childhood.

Please answer the above questions in correct APA format. No reply to peers are necessary.

Jon Teegardin
A thorough assessment of a patients head, eyes, ears, neck, and throat can reveal a wealth of objective information that is useful in developing nursing diagnoses. Careful attention to the patient’s subjective information and objective information obtained during the assessment will contribute to positive outcomes. This paper will address two presentations, a pediatric patient with ear pain, and an adult with thyroid related problems.

Patient 1

The first patient is a 2 year old female that presents with her mother. The mother reports the patient is fussy, unwilling to eat, has nasal drainage, and is tugging at her right ear.Nursing Jarvis Study Guide Essay

After introducing myself, the mother identifies the patient using two identifiers, name and birthdate. The information provided by the mother is verified against the chart and an identifying wristband is applied to the patient. A wristband is applied to the mother as well, to aid staff in identifying the mother as well as the patient. The mother reports that over the past three days, the patient has become increasingly irritable, is not eating well, and is tugging at her right ear. The mother further states that the patient was sent home from daycare because of a low grade fever and nasal congestion. The mother states she has tried giving the patient Benadryl and children’s Tylenol, but it hasn’t helped.

I continue with my interview by asking about the child’s health history and medication allergies. The mother states the child has no allergies and takes no prescription medications. She reports that the child has been healthy, and was a full term, normal birth with no complications.Nursing Jarvis Study Guide Essay

After obtaining subjective data from the mother, the physical assessment begins. The patient is allowed to sit on the mothers lap. To avoid undue stress to the patient, a focused assessment is performed. The patients vital signs are as follows: heart rate 128 beats per minute, respirations 22 per minute, even and unlabored, 100% oxygen saturation, oral temperature of 99.6, and a weight of 28 pounds or 12.7 kilograms. The patient is observed tugging at her right ear during the assessment. The right ear is examined using an otoscope. The otoscope exam is performed on a child by gently pulling the auricle of the ear downward and backward (Jarvis, 2012). This process will move the acoustic meatus in line with the canal. The otoscope is held like a pen/pencil and the little finger is used as a fulcrum. This prevents injury should the patient turn suddenly. The tympanic membrane erythematous, lacks luster, and is bulging. The cone of light is distorted. The manubrium, and short process of the malleus are difficult to visualize. The left ear is examined and reveals a glistening, translucent non-erythematous tympanic membrane with light reflex extending anteriorly/inferiorly from the umbo. Nursing Jarvis Study Guide EssayThe manubrium and short process of the malleus are well identified. No drainage is noted from either ear. Continuing the assessment, the eyes are clear with no redness or conjunctiva. The pupils are equal and reactive to light. The nares are bilaterally obstructed with clear sinus drainage. The patient has good dentition. Her lips, tongue, oral mucosa, and uvula are unremarkable. The patient’s lungs are auscultated and her respirations are even and unlabored. An apical heart rate of 129 beats per minute is auscultated, with a normal S1 and S2. At this time the patient becomes agitated and the physical assessment is completed.

Summary of findings

The patient has acute otitis media in her right ear, along with sinusitis. Children, especially those ages one to six years are at particular risk for acute otitis media because they have very narrow Eustachian tubes (Jarvis, 2012). Children in daycare are highly prone to getting upper respiratory tract infections, so they tend to get more ear infections as well (Baylor College of Medicine, 2014).

SOAP note

S: The patient’s mother reports irritability, decreased appetite, and tugging at the right ear.Nursing Jarvis Study Guide Essay

O: The patient is a nontoxic appearing white female child of approximately 2 years of age. The patient is slightly febrile (99.6), sinus drainage is noted from both nares. The right ear shows a tympanic membrane that is erythematous and bulging. The left ear appears healthy. The nares are occluded bilaterally with clear sinus drainage. The mouth and dentition are unremarkable. PERRLA at 3mm noted. Regular apical rate with S1 and S2, no S3 or S4 noted. Respirations are even and unlabored. Lungs are clear to auscultation bilaterally.

A: The patient appears to be suffering from acute otitis media and sinusitis. Because of the child’s age, an RSV (respiratory syncytial virus) specimen is obtained from the nares and sent to the lab. A normal result would be negative. Positive would indicate a viral infection. The lab results are negative for RSV.Nursing Jarvis Study Guide Essay

P: The patient will be treated with amoxicillin suspension at twenty five milligrams per kilogram divided into two doses per day (Medscape, 2014). This amounts to one hundred fifty eight milligrams every twelve hours, for five days. Children’s ibuprofen is also prescribed at a rate of ten milligrams per kilogram every 4-6 hours as needed for fever (Medscape, 2014). Ibuprofen is prescribed rather than Tylenol to minimize stomach upset for the patient. The mother will be instructed to keep the child hydrated with fluids and to return to ER if the child’s fever exceeds 102.5, the child begins vomiting, or if a reaction to the amoxicillin is noted, such as rash, itching, or any difficulty breathing.Nursing Jarvis Study Guide Essay

Patient 2

Patient two is a 51 year old female that reports fatigue, difficulty swallowing, increased sensitivity to cold, weight gain of twelve pounds in two months, and weakness over the past four months.

The patient is escorted to an exam room, I introduce myself and properly identify and apply a wristband to the patient. The patient is asked about allergies and medication. She reports that she has no allergies, and currently takes a blood pressure medicine. She also reports she has been to a dermatologist because her skin has been dry and she was instructed to use over the counter moisturizers that aren’t working very well.Nursing Jarvis Study Guide Essay

After interviewing the patient, the physical assessment begins. Vital signs are obtained: Blood pressure 118/82, heart rate 51 beats per minute, 16 respirations per minute, temperature 98.5 degrees, weight of 184 pounds.

The patient has short hair that is clean and well groomed. She denies any hearing problems, visual problems, congestion or cough. No drainage is noted from her ears, the eyes are clear with no redness or conjunctiva. Pupils are equal and reactive to light. Nares are clear bilaterally without swelling. The patient has good dentition. The lips, tongue, oral mucosa, and uvula are unremarkable. Facial symmetry is good with no drooping. The patient’s neck is supple with full range of motion and the trachea is midline. The thyroid is examined closely based upon the patient’s subjective information. The patient is seated and asked to slightly extend her neck. A portable light is used to provide cross lighting for the initial visual examination. The patient is asked to swallow and no appreciable difference is noted with the light applied from the right or left side. After completing anterior inspection of the thyroid, the neck is observed in profile. A smooth, straight contour is visualized from the cricoid cartilage to the suprasternal notch. An anterior palpation is done next. First the thyroid isthmus is located by palpating between the cricoid cartilage and the suprasternal notch. One hand is used to move the sternocleidomastoid muscle and the other hand is used to palpate the thyroid (Jarvis, 2012). The patient is asked to swallow and the upward movement of the thyroid gland is felt. To palpate the other side, the procedure is reversed. The left lobe of the patient’s thyroid feels fuller and moves slightly less than the right side. The patient reports pain on the left side during palpation.Nursing Jarvis Study Guide Essay

Alternatively, a posterior approach to examination of the thyroid can be performed (Jarvis, 2012). Standing behind the patient, locate the thyroid isthmus by palpating between the cricoid cartilage and the suprasternal notch. Once this landmark has been located, the hands are moved laterally to feel under the sternocleidomastoids for the thyroid. The patient is asked to swallow, and upward movement of the thyroid gland is felt.

Respirations are clear and even bilaterally. The heart is auscultated and is strong and even at 52 beats per minute. Normal S1 and S2 are present. The patient denies any pain or mass in the breasts and reports that she self-examines monthly and her last mammogram was within the last twelve months. Hand grips are strong and equal, radial pulses are strong and equal bilaterally. The abdomen is soft and non-tender to palpation. Bowel sounds are present in all four quadrants. Foot strength equal bilaterally, with strong bilateral pedal pulses. The patient’s mood and affect are appropriate for her age and the current situation. The skin is somewhat dry and flaky, despite the patient’s report of applying moisturizing lotion. Her speech is clear.Nursing Jarvis Study Guide Essay

Summary of findings

The patient has a palpable abnormality in her thyroid gland. Additionally, she has non-symptomatic bradycardia with an apical heart rate of 52 beats per minute. Her skin is dry.

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SOAP note

S: The patient reports reports fatigue, difficulty swallowing, increased sensitivity to cold, weight gain of twelve pounds in two months, and weakness over the past four months.

O: Nontoxic appearing white female that appears consistent with her stated age of 61 years old. PERRLA at 3mm. Facial symmetry equal with no facial droop noted. The neck is supple and trachea is midline. The left thyroid is enlarged and tender to palpation. Bradycardic apical rate of 52 beats per minute with S1 and S2. No S3 or S4 noted. Hand grips strong and equal bilaterally. Radial pulses strong and equal bilaterally. Respirations are even and unlabored. Lungs clear to auscultation bilaterally. The abdomen is soft and non-tender. Bowel sounds present in all four quadrants. Skin is dry and flaking. Leg strength strong and equal bilaterally. Ambulates without difficulty or assistance. Pedal pulses present with no edema noted in lower extremities.Nursing Jarvis Study Guide Essay

A: The patient may be suffering from hypothyroidism. Blood tests of thyroid stimulating hormone (TSH) and thyroxine (T4) levels are ordered. Normal values for TSH are 0.5-6 uU/ml, and normal T4 levels are 4.6-12 ug/dl (American Thyroid Association, 2012). Results show a high TSH level of 6.2 uU/ml and a low T4 level of 1.4 ug/dl. This indicates that the pituitary gland is releasing thyroid stimulating hormone, but the thyroid is not releasing thyroxine, which confirms that the thyroid gland is not functioning properly (American Thyroid Association, 2012).

P: This patient will most likely be referred to an endocrinologist for further testing, including a radioactive iodine uptake test and needle aspiration biopsy of the thyroid to rule out a malignant source of these symptoms. In the absence of a malignancy, she will probably be prescribed levothyroxine to increase her metabolism to counteract the decreased output of her thyroid. She should be instructed to self-check her pulse and seek medical attention if her bradycardia becomes symptomatic.Nursing Jarvis Study Guide Essay

Although these patients do not exist, their symptoms and diagnoses are relatively common. Close attention to both subjective and objective data can assist the nurse in providing the proper care and teaching to promote favorable outcomes in either case.

Nursing Assessment
1. Part of Nursing Process
2. Nurses use physical assessment skills to:
a) Obtain baseline data and expand the data base from which subsequent phases of the
nursing process can evolve
b) To identify and manage a variety of patient problems (actual and potential)
c) Evaluate the effectiveness of nursing care
d) Enhance the nurse-patient relationship
e) Make clinical judgments
Gathering Data
Subjective data – Said by the client (S)
Objective data – Observed by the nurse (O)
Document: SOAPIER
Assessment Techniques:Nursing Jarvis Study Guide Essay
The order of techniques is as follows (Inspect – Palpation – Percussion – Auscultation) except for the
abdomen which is Inspect – Auscultation – Percuss – Palpate.
A. Inspection – critical observation *always first*
1. Take time to “observe” with eyes, ears, nose (all senses)
2. Use good lighting
3. Look at color, shape, symmetry, position
4. Observe for odors from skin, breath, wound
5. Develop and use nursing instincts
6. Inspection is done alone and in combination with other assessment techniques
B. Palpation – light and deep touch
1. Back of hand (dorsal aspect) to assess skin temperature
2. Fingers to assess texture, moisture, areas of tenderness
3. Assess size, shape, and consistency of lesions and organs
4. Deep = 5-8 cm (2-3”) deep; Light = 1 cm deep
C. Percussion – sounds produced by striking body surface
1. Produces different notes depending on underlying mass (dull, resonant, flat, tympanic)
2. Used to determine size and shape of underlying structures by establishing their borders and
indicates if tissue is air-filled, fluid-filled, or solid
3. Action is performed in the wrist.
D. Auscultation – listening to sounds produced by the body
1. Direct auscultation – sounds are audible without stethoscope
2. Indirect auscultation – uses stethoscope
3. Know how to use stethoscope properly [practice skill]
4. Fine-tune your ears to pick up subtle changes [practice skill]
5. Describe sound characteristics (frequency, pitch intensity, duration, quality) [practice skill]
6. Flat diaphragm picks up high-pitched respiratory sounds best.
7. Bell picks up low pitched sounds such as heart murmurs.
8. Practice using BOTH diaphragms
PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Page 2 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
General Assessment Nursing Jarvis Study Guide Essay
A general survey is an overall review or first impression a nurse has of a person’s well being. This is
done head to toe, or cephalo-caudal, lateral to lateral, proximal to distal, and front to back. General
surveying is visual observation and encompasses the following.
Appearance appears to be reported age;
sexual development appropriate;
alert & oriented;
facial features symmetric;
no signs of acute distress
Body structure/mobility weight and height within normal range (refer to Center for Disease Control
and Prevention (CDC) Body Mass Index (BMI) [adult] or BMI-for-age and
gender forms [children]);
body parts equal bilaterally;
stands erect,
sits comfortably;
gait is coordinated;
walk is smooth and well balanced;
full mobility of joints
Behavior maintains eye contact with appropriate expressions;
comfortable and cooperative;
speech clear;
clothing appropriate to climate;
looks clean and fit;
appears clean and well-groomed
Deviations from what would generally be considered to be normal or expected should be documented
and may require further evaluation or action, including a report and/or referral.
Standardized and routine screening such as audiometric screening, scoliosis and vision screening
using the Snellen Test are usually discussed in General Survey areas.
***************************************************************************************************
Health History
A patient history should be done as indicated by the age specific prevention guidelines, usually set forth
by Center for Disease Control and Prevention (CDC), American Medical Association, American
Association of Pediatrics, and National Association of Pediatric Nurse Practitioners. The Healthy
People website (www.healthypeople.gov) provides an excellent source to determine benchmarks for
healthy living across the life span.
A comprehensive history, including chief complaint or reason for the visit, a complete review of
systems, and a complete past family and/or social history should be obtained on the first encounter with
a patient, regardless of setting and by a registered nurse. The history should be age and sex
appropriate and include all the necessary questions to enable an adequate delivery of services
according to prevention guidelines, scope of practice, patient need, visit requirement, and/or request.
Usually, completing a provider based Health History and Physical Examination Form will assist in the
assessment of the patient’s past and current health and behavior risk status. Certain health problems,
which may be identified on a health history, are more common in specific age groups and gender.
PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Page 3 of 35  Nursing Jarvis Study Guide Essay
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
An interval history (including an update of complaints, reason for visit, review of systems and past
family and/or social history) should be done. Usually family health histories are completed across three
generations looking specifically for patterns in genetic issues that negatively impact quality of life.
The health history gives picture of the patient’s current health and behavior risk status. Additional
information than what is on a form may be required depending on the specialized service(s) to be
provided or if the person presents with special needs or conditions. So a health history maybe may be
problem focused, expanded problem focused, detailed, or comprehensive. Regardless, documentation
must be completed for each visit and/or assessment.
Mental status evaluation may be done while doing health history (see neuro review).
***********************************************************************************************
Physical Examination
A comprehensive physical examination should be performed according to age specific preventive
health guidelines. American Medical Association clinical practice guidelines recognize the following
body areas and organ systems for purpose of the examination:
◊ Body Areas: Head (including the face); Neck; Chest (including breasts and axillae); Abdomen;Nursing Jarvis Study Guide Essay
genitalia, groin, buttocks; Back (including spine); and each extremity.
◊ Organ Systems: Constitutional (vital signs, general appearance), Eyes, Ear, Nose, Throat;
Cardiovascular; Gastrointestinal; Genitourinary; Musculoskeletal; Dermatological; Neurological;
Psychiatric; Hematological/lymphatic/immunological
◊ Integumentary: Both overall body and organ systems should have skin assessments integrated
into them. Integument includes skin, hair and nails.
Normal and abnormal findings should be recorded on a health history and physical examination form.
***********************************************************************************
Measurements
Body measurements include length or height, weight, and head circumference for children from birth to
36 months of age. Thereafter, body measurements include height and weight. The assessment of
hearing, speech and vision are also measurements of an individual’s function in these areas. The
Denver Development Screening Test measures an infant’s and young child’s gross motor, language,
fine motor-adaptive and personal-social development milestones. If developmental delay is suspected
based on an assessment of a parent’s development/behavior concern or if delays are suspected after a
screening of development benchmarks, a written referral is to a physician or pediatric nurse practitioner
is imperative.
A patient’s measurements can be compared with a standard, expected, or predictable measurement for
age and gender. Deviation from standards helps identify significant conditions requiring close
monitoring or referral to a physician or pediatric nurse practitioner.
The significance of measurements and actions to take when they deviate from normal expectations are
age-specific.
PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Page 4 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
How to measure Height:Nursing Jarvis Study Guide Essay
1. Obtain height by measuring the recumbent length of children less than 2 years of age and
children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary
headboard and a sliding vertical foot piece is ideal, but a tape measure can also be used.
a) Lay the child flat against the center of the board. The head should be held against the
headboard by the parent or an assistant and the knees held so that the hips and knees are
extended. The foot piece is moved until it is firmly against the child’s heels. Read and
record the measurement to the nearest 1/8 inch.
b) A modified technique in home settings is to lay the child flat and straight where the head
should be held by the parent and the knees held so that the hips and knees are extended,
mark the flat surface at the top of the head and tip of the heels. Move child and measure
the distance between the marks with a tape measure. Read and record the measurement
to the nearest 1/8 inch.
2. When a recumbent length is obtained for a two year old, it should be plotted on the birth to 36
months growth chart. When a standing height is obtained for a two year old, plot the finding on
the 2 year to 18 year chart. After plotting measurements for children on age and gender
specific growth charts, evaluate, educate and refer according to findings.
3. Obtain a standing height on children greater than 2 to 3 years of age, adolescents, and adults,
using a portable stadiometer. The patient is to be wearing only socks or be bare foot. Have
the patient stand with head, shoulder blades, buttocks, and heels touching the wall. The knees
are to be straight and feet flat on the floor, and the patient is asked to look straight ahead. The
flat surface of the stadiometer is lowered until it touches the crown of the head, compress the
hair. A measuring rod attached to a weight scale should not be used.
Measuring weight:
1. Balance beam or digital scales should be used to weigh patients of all ages. Spring type
scales are not acceptable. CDC recommends that all scales should be zero balanced and
calibrated. Scales must be checked for accuracy on an annual basis and calibrated in
accordance with manufacturer’s instructions.
2. Prior to obtaining weight measurements, make sure the scale is “zeroed”.
3. Weigh infants wearing only a dry diaper or light undergarments. Weigh children after removing
outer clothing and shoes. Weigh adolescents and adults with the patient wearing minimal
clothing.Nursing Jarvis Study Guide Essay
4. Place the patient in the middle of the scale. Read the measurement and record results
immediately. Plot measurements on age and gender specific growth charts and evaluate
accordingly
Measuring Body Mass Index.
1. The Body Mass Index (BMI) is a measure that can help determine if a person is at risk for a
weight-related illness.
2. Instructions for obtaining the BMI are included within the chart in this section for adults. To
calculate BMI for children, see BMI Tables for Children and Adolescents for guidance.
Measuring Head and Chest Circumference.

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1. Obtain head circumference measurement on children from birth to 36 months of age by
extending a non-stretchable measuring tape around the broadest part of the child’s head.
For greatest accuracy, the tape is placed three times, with a reading taken at the right side, at
the left side, and at the mid-forehead, and the greatest circumference is plotted. The tape
should be pulled to adequately compress the hair.
2. Head circumference should be measured each visit.
3. Chest: This is measured at the nipple line.
4. In a newborn, the head circumference will be about 2 cm larger than the chest circumference. As
the child ages, the chest circumference becomes larger than the head circumference.
PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Page 5 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
Vital Signs
Vital signs, generally described as the measurement of temperature, pulse, respirations and blood
pressure, give an immediate picture of a person’s current state of health and well being. Normal and
abnormal ranges with management guidelines follow for children and adults.
Equipment Needed
1. Stethoscope
2. Blood Pressure Cuff
3. Watch Displaying Seconds  Nursing Jarvis Study Guide Essay
4. Thermometer
General Considerations
1. The patient should not have had alcohol, tobacco, caffeine, or performed vigorous exercise
within 30 minutes of the exam.
2. Ideally the patient should be sitting with feet on the floor and their back supported. The
examination room should be quiet and the patient comfortable.
3. History of hypertension, slow or rapid pulse, and current medications should always be
obtained.
A. Temperature
1. Temperature can be measured is several different ways:
a) Oral with a glass, paper, or electronic thermometer (normal 98.6F/37C)
b) Axillary with a glass or electronic thermometer (normal 97.6F/36.3C)
c) Rectal or “core” with a glass or electronic thermometer (normal 99.6F/37.7C)
d) Aural (the ear) with an electronic thermometer (normal 99.6F/37.7C)
2. Of these, axillary is the least and rectal is the most accurate.
3. Use back of hand (dorsal aspect) to assess skin temperature
B. Respiration
1. Best done immediately after taking the patient’s pulse. Do not announce that you are measuring
respirations
2. Without letting go of the patients wrist begin to observe the patient’s breathing. Is it normal or
labored?
3. Count breaths for 15 seconds and multiply this number by 4 to yield the breaths per minute.
4. In adults, normal resting respiratory rate is between 14-20 breaths/minute.
5. Rapid respiration is called tachypnea.Nursing Jarvis Study Guide Essay
C. Pulse – see also Cardiovascular Exam
1. Sit or stand facing your patient.
2. Grasp the patient’s wrist with your free (non-watch bearing) hand (patient’s right with your right
or patient’s left with your left). There is no reason for the patient’s arm to be in an awkward
position, just imagine you’re shaking hands.
3. Compress the radial artery with your index and middle fingers.
4. Count the pulse for 15 seconds and multiply by 4.
5. Always count for a full minute if the pulse is irregular.
6. Record the rate and rhythm
Note whether the pulse is regular or irregular:
Regular – evenly spaced beats, may vary slightly with respiration
Regularly Irregular – regular pattern overall with “skipped” beats
Irregularly Irregular – chaotic, no real pattern, very difficult to measure rate accurately
PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Page 6 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
Interpretation
1. A normal adult heart rate is between 60 and 100 beats per minute (see below for children).
2. A pulse greater than 100 beats/minute is defined to be tachycardia. A pulse less than 60
beats/minute is defined to be bradycardia.
3. Tachycardia and bradycardia are not necessarily abnormal. Athletes tend to be bradycardic at
rest (superior conditioning). Tachycardia is a normal response to stress or exercise.
D. Blood Pressure – see also Cardiovascular Exam
Blood pressure (BP) is the pressure by circulating blood on the walls of blood vessels. Arterial refers
systemic circulation. During each heartbeat, blood pressure varies between a maximum systolic and a
minimum diastolic pressure. The blood pressure in the circulation is principally due to the pumping
action of the heart. Differences in mean blood pressure are responsible for blood flow from one location  Nursing Jarvis Study Guide Essay
to another during circulation. The rate of mean blood flow depends on the resistance to flow presented
by the blood vessels. Mean blood pressure decreases as the circulating blood moves away from the
heart through arteries, capillaries and veins due to viscous losses of energy. Mean blood pressure
drops over the whole circulation, although most of the fall occurs along the small arteries and arterioles.
Gravity affects blood pressure via hydrostatic forces (e.g., during standing) and valves in veins,
breathing, and pumping from contraction of skeletal muscles also influence blood pressure in veins.
The measurement blood pressure without further specification usually refers to the systemic arterial
pressure measured at a person’s upper arm and is a measure of the pressure in the brachial artery,
major artery in the upper arm. A person’s blood pressure is usually expressed in terms of the systolic
pressure over diastolic pressure and is measured in millimeters of mercury (mmHg).
To measure Blood Pressure
The patient should not have eaten, smoked, taken caffeine, or engaged in vigorous exercise within
the last 30 minutes. The room should be quiet and the patient comfortable.
1. Position the patient’s arm so the antecubital fold is level with the heart.
2. Center the bladder of the cuff over the brachial artery approximately 2 cm above the antecubital
fold. Proper cuff size is essential to obtain an accurate reading. Be sure the index line falls
between the size marks when you apply the cuff. Position the patient’s arm so it is slightly flexed
at the elbow.
3. Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough estimate
of the systolic pressure.
4. Place the stethoscope over the brachial artery.
5. Inflate the cuff 20 to 30 mmHg above the estimated systolic pressure.
6. Release the pressure slowly, no greater than 5 mmHg per second.
7. The level at which you consistently hear beats is the systolic pressure
8. Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic
pressure.
9. Record the blood pressure as systolic over diastolic (120/70).
Interpretation
1. Higher blood pressures are normal during exertion or other stress. Systolic blood pressures
below 80 may be a sign of serious illness or shock.Nursing Jarvis Study Guide Essay
2. Blood pressure should be taken in both arms on the first encounter. If there is more than 10
mmHg difference between the two arms, use the arm with the higher reading for subsequent
measurements.
3. Always recheck “unexpected” blood pressures yourself.
4. It is frequently helpful to retake the blood pressure near the end of the visit. Earlier pressures
may be higher due to the “white coat” effect.
PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Page 7 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
In children, pulse and blood pressure vary with the age. The following table should serve as a rough
guide:
Average Pulse and Blood Pressure in Normal Children
Age Birth 6mo 1yr 2yr 6yr 8yr 10yr
Pulse 140 130 115 110 103 100 95
Systolic BP 70 90 90 92 95 100 105
Blood Pressure Classification in Adults
Category Systolic Diastolic
Normal <130 <85
High Normal 130-139 85-89
Mild Hypertension 140-159 90-99
Moderate Hypertension 160-179 100-109
Severe Hypertension 180-209 110-119
Crisis Hypertension >210 >120
******************************************************************************************************
PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Page 8 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.Nursing Jarvis Study Guide Essay
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
The Physical Exam
A. Skin
B. Head and Neck Exam; Lymphatic Exam
C. Eye Exam
D. Chest and Lung Exam
E. Cardiovascular Exam and Peripheral vascular System
F. Abdominal Exam
G. Musculoskeletal Exam
H. Neurologic Exam
I. Genito-Urinary
A. Examination of Skin
1. Inspect: skin color and uniformity of color, moisture, hair pattern, rashes, lesions, pallor, edema
2. Palpate: temperature, turgor, lesions, edema, texture
3. Percussion and auscultation: rarely used on skin
4. Terminology: pallor, cyanosis, edema, ecchymosis, macule, papule, cyanosis, jaundice, types
of edema, vitiligo, hirsutism, alopecia, etc.
5. Pale, cool, moist skin can be indicative of heat stroke, shock or other cardiac complications.
6. There are abnormal and normal skin findings (such as nevus)
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B. Examination of the Head and Neck
Equipment Needed
1. Otoscope
2. Tongue blades
3. Cotton tipped applicators
4. Non-latex exam gloves
General Considerations
The head and neck exam is not a single, fixed sequence. The assessment varies depending on the
examiner and the situation.
Head
1. Look for scars, lumps, rashes, hair loss, or other lesions.
2. Look for facial asymmetry, involuntary movements, or edema.
3. Palpate to identify any areas of tenderness or deformity.
Fontanels in a newborn – toddler:Nursing Jarvis Study Guide Essay
1. Posterior fontanel – triangle shaped; closes 1-2 months
2. Anterior fontanel – diamond shaped; closes at 9 months – 2 years
PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Page 9 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
Ears – See also notes under Cranial Nerves for other assessments related to ears and hearing
1. Inspect the auricles and move them around gently. Ask the patient if this is painful.
2. Palpate the mastoid process for tenderness or deformity.
3. Assess ears using otoscope:
a) Hold the otoscope upside down with your thumb and fingers so that the ulnar aspect of your
hand makes contact with the patient.
b) For adults, pull the ear upwards and backwards to straighten the canal.
c) PEDIATRICS: For children pull the ear down and back.
d) Use the largest speculum that will fit comfortably.
e) Inspect the ear canal and middle ear structures noting any redness, drainage, or deformity.
f) Insufflate the ear and watch for movement of the tympanic membrane.
g) Repeat for the other ear.
4. Normal color of eardrum: shiny translucent, pearly gray.
5. Abnormal findings:
a) erythema – suppurative Otitis Media. purulent drainage.
b) Dull, nontransparent gray – serous otitis media with effusion
6. Conductive hearing loss is due to mechanical dysfunction of inner or middle ear.
7. Sensory-neural loss is due to pathological problem of inner ear, CNS or cerebral cortex.
8. In older adults, there may be some normal high-tone hearing loss.
Nose and sinuses
It is often convenient to examine the nose immediately after the ears using the same speculum.
1. Tilt the patient’s head back slightly. Ask them to hold their breath for the next few seconds.Nursing Jarvis Study Guide Essay
2. Insert the otoscope into the nostril, avoiding contact with the septum.
3. Inspect the visible nasal structures and note any swelling, redness, drainage, or deformity.
4. Repeat for the other side.
5. Turbinates should be pink and moist
6. Frontal sinuses are below eyebrows
7. Maxillary sinuses are below zygomatic arch  Nursing Jarvis Study Guide Essay