chapter 6
cognitive abilities orientation
Assesses awareness of person, place, time, and situation. (Knows their name, where they are, the date, why they’re being assessed or hospitalized.)
Documented as A&O ×1 to ×4
temperature
Normal oral: 35.9°C to 37.5°C (96.6°F to 99.5°F)
Tympanic: 36.7°C to 38.3°C (98.0°F to 100.9°F)
Axillary: 35.4°C to 37.0°C (95.6°F to 98.5°F)
Temporal and rectal: 36.3°C to 37.9°C (97.4°F to 100.3°F)
Hypothermia: <36.5°C (96.0°F)
Hyperthermia: >38.0°C (100.4°F)
Physiologic Responses to Pain
Pain activates the sympathetic nervous system, causing physical and emotional stress responses.
–Anxiety, fear, hopelessness, sleeplessness, crying, moaning, facial grimacing, verbal pain reports, decreased cognitive function, confusion, altered mood, dilated pupils, increased heart rate and blood pressure, increased respiratory rate, sputum retention → risk of infection or atelectasis
– Decreased gastric and intestinal motility
– Decreased urinary output → fluid retention
– Suppressed immune function
– Hormonal changes: ↑ antidiuretic hormone, epinephrine, norepinephrine, aldosterone, glucagon; ↓ insulin, testosterone
– Hyperglycemia, glucose intolerance, protein breakdown
– Muscle spasms → limited mobility, sweating
primary skin lesions
– Macule: Flat, well-defined color change, <1 cm (e.g., freckle, petechiae)
– Papule: Small, raised, firm bump, <1 cm (e.g., wart, mole)
– Nodule: Elevated, firm, deeper than papule, >0.5 cm (e.g., lipoma)
– Cyst: Fluid- or semisolid-filled bump under the skin, movable (e.g., sebaceous cyst)
– Plaque: Raised, flat-topped lesion >1 cm (e.g., psoriasis)
– Wheal: Raised, irregular, swollen area from fluid; transient (e.g., hives, insect bite)
– Vesicle: Small, clear fluid-filled blister <1 cm (e.g., herpes, chickenpox)
– Bulla: Large fluid-filled blister >1 cm (e.g., burn blister)
– Pustule: Elevated bump filled with pus (e.g., acne, impetigo)
neck structure and landmarks
–Composed of muscles, ligaments, and cervical vertebrae (C1–C7)
–Key structures: hyoid bone, thyroid cartilage (Adam’s apple), cricoid cartilage, trachea, thyroid gland
– Sternomastoid muscle: rotates and flexes the head
– Trapezius muscle: extends the head and moves the shoulders
– Muscles form anterior and posterior triangles, used as landmarks in assessments
– Cranial nerve XI (spinal accessory) controls shrugging and head rotation
– C7 (vertebra prominens) is an important landmark felt when neck is flexed
– Carotid arteries and jugular veins lie anterior to the sternomastoid
– Thyroid gland: largest endocrine gland; has two lobes connected by an isthmus overlying the 2nd–3rd tracheal rings
– Lymph nodes: clustered in neck regions, filter lymph and help with immune defense
cognitive abilities remote memory
Tests long-term memory (events from the distant past)
Ask questions like:
– “Where did you grow up?”
– “What high school did you attend?”
– “What’s your mother’s maiden name?”
Impairment suggests possible dementia, Alzheimer’s disease, or brain injury
pulse
Normal: 60–100 bpm
Assess rate, rhythm, amplitude, and contour
Most common site: radial artery
Amplitude scale:
0 = absent
1+ = weak/diminished (easy to obliterate)
2+ = normal (obliterate with moderate pressure)
3+ = bounding (unable to obliterate or requires firm pressure)
Elasticity: artery feels straight, resilient, and springy
objective data normal findings
– Calm facial expression
– Normal vital signs (HR, BP, RR)
– No guarding or wincing with movement or palpation
– Relaxed posture and clear speech
– No signs of distress or discomfort
secondary skin lesions
– Scale: Flaky skin from heaped-up keratin (e.g., dandruff, psoriasis)
– Crust: Dried serum, blood, or pus on surface (e.g., scab)
– Fissure: Crack through the skin (e.g., athlete’s foot)
– Ulcer: Deep open sore with loss into dermis (e.g., pressure ulcer)
– Scar: Fibrotic tissue replacing normal skin after injury
– Atrophy: Thinning or shrinking of the skin (e.g., stretch marks)
– Excoriation: Linear scratch or abrasion
– Lichenification: Thickened, rough skin with exaggerated markings from repeated rubbing (e.g., eczema)
normal objective data
– Neck is symmetric with smooth movement
– Trachea is midline
– Thyroid not visible, but may be palpable and smooth
– No swelling or tenderness
– Lymph nodes not palpable, or feel like small, soft, movable beads
– Full range of motion without pain
– Cranial nerve XI intact: patient can shrug shoulders and turn head against resistance
glascow coma scale eyes
4 – Spontaneous
3 – To verbal command
2 – To pain
1 – No eye opening
respirations
Normal: 12–20 breaths/min
Older adult: 15–22 breaths/min
Observe rate, rhythm, and depth without making client aware
Oxygen saturation (SpO₂): 92% to 99% in healthy individual
Acceptable levels for those with chronic lung disease: 85% to 89%
objective data abnormal findings
– Facial grimacing, guarding, crying, moaning
– Increased heart rate, BP, and respiratory rate
– Restlessness, agitation, clenched fists
– Diaphoresis (sweating)
– Decreased appetite, inability to sleep or focus
– Reduced activity or unwillingness to move
skin cancer education
– Avoid sun exposure; seek shade when outdoors
– Use sunscreen with SPF 15 or higher daily
– Wear protective clothing and wide-brimmed hats
– Avoid tanning beds and sunburns
– Perform monthly skin self-exams in a well-lit area
– Get routine professional skin checks, especially if at risk
abnormal objective data
– Asymmetry, enlarged lymph nodes, tracheal deviation
– Goiter or nodules in thyroid
– Pain or limited motion with neck movement
– Lymph nodes: hard, fixed = cancer; tender, mobile = infection
– Enlarged thyroid or visible masses may indicate thyroid disorder
– Weakness with shoulder shrug or head rotation suggests cranial nerve XI dysfunction
Glascow coma scale motor and verbal
Verbal Response (5 points)
5 – Oriented (knows name, place, time)
4 – Confused conversation
3 – Inappropriate words
2 – Incomprehensible sounds
1 – No verbal response
Motor Response (6)
6- Obeys commands
5 – Localizes pain
4 – Withdraws from pain
3 – Abnormal flexion (decorticate)
blood pressure
Normal: <120/80 mmHg
Elevated: 120–129 / <80 mmHg
Stage 1 Hypertension: 130–139 / 80–89 mmHg
Stage 2 Hypertension: ≥140 / ≥90 mmHg
Hypertensive crisis: >180 / >120 mmHg
Older adult: As people age, their arteries become less elastic, causing the systolic blood pressure to rise. When the systolic pressure is above 130 mmHg but the diastolic pressure remains below 80 mmHg, it is called isolated systolic hypertension. This condition, along with a widened pulse pressure (a larger gap between systolic and diastolic readings), is common in older adults.
Orthostatic hypotension: drop of ≥20 mmHg from sitting to standing.
chapter 14 objective data normal findings
– Skin: Even color, intact, warm, dry, no lesions
– Hair: Clean, evenly distributed, no pests
– Nails: Pink, smooth, no ridges or discoloration, capillary refill <2 seconds
skin cancer ABCDE mnemonic
– A – Asymmetry: One half of the mole doesn’t match the other
– B – Border: Edges are irregular, ragged, or blurred
– C – Color: Uneven color or multiple shades
– D – Diameter: Larger than 6 mm (about the size of a pencil eraser)
– E – Evolving: Any change in size, shape, color, or symptoms like itching or bleeding
stroke signs and symptoms (FAST)
Sudden numbness or weakness (especially one side of the body), confusion, difficulty speaking or understanding speech, vision changes, dizziness, loss of balance, severe headache with no known cause
Face drooping
Arm weakness
Speech difficulty
Time to call 911 (Requires immediate medical attention)
signs of alzheimers
– Repeating the same questions or statements
– Forgetting recently learned information
– Difficulty performing familiar tasks (e.g., managing money, cooking)
– Misplacing items and being unable to retrace steps
– Disorientation to time/place
– Trouble with words, naming, or following a conversation
– Changes in mood, behavior, or personality
– Poor judgment and decision-making
– Withdrawal from work or social activities
older adult considerations
Temp may range from 35.0–36.4°C (95.0–97.5°F)
Pulse may feel more rigid, hard, and bent
Respirations may increase to 15–22 bpm
BP may rise due to less elastic arteries
Gait changes:
Men – wider stance, arms out, shorter steps
Women – narrow base, waddle, shorter steps
Kyphosis is common and is an excessive outward curve of the upper spine, causing a hunched or rounded back.
chapter 14 objective data abnormal findings
– Skin: Pallor, cyanosis, jaundice, lesions, bruising, poor turgor, edema
– Hair: Patchy loss, brittle texture, lice or nits present
– Nails: Clubbing, spooning, yellowing, thickened, slow cap refill
subjective data
– Any changes in skin, hair, or nails (e.g., rashes, itching, hair loss, nail discoloration)
– Past or family history of skin conditions (e.g., eczema, psoriasis, skin cancer)
– Lifestyle factors such as sun exposure, chemical exposure, hygiene practices, medications, supplements, and stress levels
Rationale: Helps identify risk factors, underlying conditions, and potential causes of current symptoms
Cushing Syndrome
– Rounded “moon face”
– Facial redness, acne
– Hirsutism (excess facial hair in women)
– Fat deposits around face and upper back
Scleroderma
– Tight, hardened facial skin
– Thin, pursed lips; shiny appearance
– Reduced facial mobility
Bell Palsy
– Sudden, unilateral facial paralysis (upper and lower face)
– Inability to close eye, smile, or wrinkle forehead on affected side
– May include drooling, tearing, taste changes
– Caused by inflammation of cranial nerve VII
Parkinson’s Disease
– “Mask-like” expression: fixed facial features, reduced blinking
– Muscle rigidity, shuffling gait
– Resting tremor
– Difficulty initiating movement
– Soft, monotone voice