Exam #2 Flashcards
How does the nurse perform an abdominal assessment?
Inspection is followed by auscultation for bowel sounds before percussion and palpation
What would the nurse find upon inspection of the abdomen (5)?
- abdomen should be flat and symmetric.
- no scars, striae, or varicosity.
- skin should be even toned, and the umbilicus should be midline with no noted hernias.
- there should be no distention, visible pulsations, or peristaltic waves noted.
- respirations should be even, and no evidence of the use of accessory muscles.
How would the nurse perform auscultation of the abdomen (3)?
- auscultate all 4 quadrants for bowel sounds.
- recommend to start at the point of the ileocecal valve (slightly right and below the umbilicus;RLQ) and proceed clockwise (RLQ, LLQ, LUQ, RUQ).
- listen to each quadrant for a full minute.
What is the purpose of percussion during an abdominal assessment (3)?
- percuss all 4 quadrants, listening for tympany or dullness.
- used to determine organ size and tenderness.
- also detects any fluid, air, or masses in the abdominal cavity.
What is the purpose of palpation during an abdominal assessment (2)?
- light palpation in all 4 quadrants.
- observe for nonverbal signs of pain.
Describe the 2 methods used to map the location of abdominal findings:
1) 4 Quadrants: RUQ, RLQ, LLQ, LUQ
2) 9 regions: R-hypochondriac, epigastric, L-hypochondriac, R-ight lumbar, umbilical, L-lumbar, R-inguinal, hypogastric, L-inguinal
Identify the location of the major organs in the abdomen:
1) locations in quadrants
2) locations in regions
high-pitched gurgles or clicks that last from 1 to several seconds
- there are 5-30 gurgles per minute or one sound every 5-15 seconds in the average adult
bowel sounds
increased bowel sounds that occur with diarrhea and early intestinal obstruction
borborygmi
decreased bowel sounds that occur with a dynamic ileus, peritonitis, and post-anesthesia
- occur more than 30 gurgles per minute.
hypoactive bowel sounds
Vascular bowel sounds include (3):
1) Bruits
2) Venous hums
3) Friction rubs
- swishing sounds that indicate turbulent blood flow resulting from constriction or dilation of a tortuous vessel.
- in the hepatic area, indicate liver cancer or alcoholic hepatitis.
- over the aorta or renal arteries indicate partial obstruction of the aorta or renal artery.
bruits
- soft-pitched humming noises with systolic and diastolic components.
- they indicate partial obstruction of an artery and reduced blood flow to the organ (best heard in the epigastric region, near the liver & over the umbilicus).
venous hums
grating sounds that increase with inspiration and occur with liver tumors, splenic infarction, or peritoneal inflammation (auscultate over liver & spleen)
friction rubs
What is the purpose of the lymphatic system (4)?
- approximately 80 lymph nodes are in the head & neck region, serving as part of the immune system.
- the vessels filter potential pathogens from the body.
- they drain fluid that has moved outside the circulation back into the vessels.
- they drain fluid along a path in a chain and have a particular direction of flow; an enlarged node indicates inflammation that is “upstream” from it.
What are the names & locations of the lymph nodes of the head and neck?
- Preauricular
- Posterior auricular
- Occipital
- Tonsillar
- Posterior cervical
- Submaxillary
- Submental
- Anterior or deep cervical chain
- Supraclavicular
Very common in Pts older than 60yrs and steadily increases with age (older adults often lack classic S&S seen in younger Pts).
- has subtler onset in older adults and the typical S&S (cold intolerance, constipation, fatigue, weakness, reduced appetite, hair loss, dry skin) can easily be missed when attributed to aging or chronic disease.
- psychiatric symptoms (i.e., depression) can also be presenting symptoms in the older adult.
- more common in females assigned at birth, especially older females.
- consider that Pt has a thyroid difficulty when several symptoms are “clustered together”: metabolism is slow, hoarse/slow speech, cool/dry/coarse skin, bradycardia, delayed reflexes.
HYPOthyroidism
- May present as an emergency known as a “thyroid storm” or “thyroid crisis” with S&S of hypermetabolism in many systems.
- more common in females assigned at birth.
- females are more likely to have a goiter than males (greatest prevalence is in premenopausal people).
- an overactive thyroid gland increases the metabolic rate: eyelid retraction, eyelid lag, fine-finger tremor, moist/warm skin, brisk reflexes, tachycardia.
HYPERthyroidism
an autoimmune disorder that is an inflammation of the thyroid gland; can cause a goiter
Hashimoto’s thyroiditis
thyroid nodules and adenomas, small, noncancerous growths (start in cell layer that lines inner surface of thyroid gland); may secrete thyroid hormone and may cause hyperthyroidism
thyroid tumors
papillary thyroid cancer, follicular thyroid cancer, anaplastic thyroid cancer, and medullary thyroid cancer
thyroid cancer
What is the responsibility of the tongue (4)?
- manipulates solids & liquids in chewing and swallowing.
- involved in speech production and taste.
- anterior 2/3 of tongue surface contain taste buds (vallate papillae) which identify sweet, sour, salty, and bitter tastes.
- one of the body’s most vascular muscles; its blood supply includes the lingual, exterior maxillary, and ascending pharyngeal arteries.
What is the responsibility of the nose (2)?
- primary organ for smell.
- air within the nasal roof stimulates the olfactory receptors of cranial nerve I (CN I).
Describe the grading scale of tonsils:
1+: tonsil obstructs 0-25% to midline
2+: tonsil obstructs 25-50% to midline
3+: tonsil obstructs 50-75% to midline
4+: tonsil obstructs 75-100% to midline
- another name for the nasal septum
- anterior midline wall, divides the oval nares (nostrils), which are openings that lead into the internal nose and are lined with skin and ciliated mucosa.
- the ciliated mucosa beginning in the nose warms, filters, humidifies inspired air at nearly 100% humidity by the time it reaches the lungs.
columella
- also known as oral candidiasis, it is a fungal (yeast) infection that can grow in your mouth/throat
- may develop white, raised, cottage cheese-like lesions on the tongue and cheeks.
- can be seen in babies, toddlers, adults over 65, and people with weakened immune systems.
- meds such as corticosteroids & antibiotics can cause this.
thrush
decreases the angle between bones or brings bones together
flexion
bending the ankle so that the toes move toward the head
dorsiflexion
moving the foot so that the toes move away from the head
plantar flexion
increases the angle to a straight line or zero degrees
extension
extension beyond the neutral position
hyperextension
movement of a part away from the center of the body
abduction
movement of a part toward the center of the body
adduction
turning of the joint around a longitudinal axis
rotation
rotating an extremity medially along its axis
internal rotation
rotating an extremity laterally along its axis
external rotation
turning the forearm so the palm is down
pronation
turning the forearm so the palm is up
supination
a circular motion that combines flexion, extension, abduction, and adduction
circumduction
turning the sole of the foot inward
inversion
turning the sole of the foot outward
eversion
moving a body part forward and parallel to the ground
protraction
moving a body part backward and parallel to the ground
retraction
moving a body part upward
elevation
moving a body part downward
depression
moving the thumb to touch the little finger
opposition
Grading scale for muscle strength:
- 5/5 (100%) = normal: complete ROM against gravity and full resistance.
- 4/5 (75%) = good: complete ROM against gravity and moderate resistance.
- 3/5 (50%) = fair: complete ROM against gravity.
- 2/5 (25%) = poor: complete ROM with the joint supported; cannot perform ROM against gravity.
- 1/5 (10%) = trace: muscle contraction detectable, but no movement of the joint.
- 0/5 (0%) = zero: no visible muscle contraction.
to remember cranial nerves in order
to remember cranial nerve functions (S = sensory; M = motor; B = both)
Some Say Marry Money, But My Brother Says Big Brains Matter More
S&S of Cerebral Vascular Accident (CVA) [5]
- sudden numbness or weakness in the face, arm, or leg, especially on one side of the body.
- sudden confusion, trouble speaking, or difficulty understanding speech.
- sudden trouble seeing in one or both eyes.
- sudden trouble walking, dizziness, loss of balance, or lack of coordination.
- severe headache with no known cause.
Grading Scale of Reflexes
4+: very brisk, hyperactive responses
3+: brisker than average
2+: average, normal
1+: diminished, low normal
0: no response
- used to assess LOC
- scores eye opening, verbal response, and motor function
Glasgow coma scale
What is assessed with level of consciousness (LOC)?
- People visibly express through the degree of response to stimulus, with the highest level being spontaneous alertness
- eye opening response
- best verbal response
- best motor response
(1) enter room and observe normal arousal
spontaneous
(2) state Pts name; ask them to open eyes
normal voice
(3) use loud voice as no response to normal voice
loud voice
(4) touch Pt’s shoulder or arm lightly
tactile (touch)
(5) apply nail bed pressure to elicit pain response, telling Pt that you will be applying pressure
noxious stimulation (pain)
Pt appreciates the environment and responds quickly to stimuli
alert wakefulness
- Pt is disoriented to time, place, or person
- has shortened attention span
- shows poor memory
- has difficulty following commands
confusion
- Pt responds to stimuli appropriately but with delay & slowness
- may respond to some, but not all (also described as lethargy or obtunded state)
drowsiness
Pt is unresponsive and can be aroused only briefly by vigorous, repeated stimulation
stupor
Pt is unresponsive and generally cannot be aroused
coma
What is the difference between sensory & motor innervation?
- Sensory = involves the senses such as smell, hearing, & touch
- Motor = involves movement & function of muscles or glands
Consists of 3 components of the brain (cerebrum, cerebellum, & brainstem) as well as the spinal cord.
- protected by the blood-brain barrier, skull, and vertebrae.
Central Nervous System (CNS)
- left hemisphere has more control over language & analytical abilities, including math & logic
- right hemisphere is more involved with visual-spatial skills, emotion, intuition, and musical & artistic abilities
- part of CNS
- cerebral cortex, which forms outside of this, contributes to motor and sensory function, intellect, and language.
cerebrum
- afferent (sensory) stimuli travel through this to the cerebral cortex
- efferent (motor) fibers leave the cortex to pass through this and the spinal cord.
- part of CNS
brainstem
- under the occipital lobe in the posterior part of the brain
- part of CNS
- coordinates voluntary movement, posture, and muscle tone and maintains special orientation & equilibrium
cerebellum
- includes all of the nerves outside of the brain and spinal cord
- relays messages to the rest of the body
- not protected by the blood-brain barrier or vertebrae, making it vulnerable to injury
Peripheral (Somatic) Nervous System (PNS)
- maintains involuntary functions of cardiac & smooth muscles and glands
- has 2 components: (1) sympathetic [fight-or-flight] & (2) parasympathetic [rest & digest].
- can both sense changes and make changes based on input
- to regulate HR and BP, receives input from chemoreceptors & baroreceptors
- based on input, sympathetic secretes epinephrine to increase BP, HR, & contractility whereas parasympathetic secretes acetylcholine to reduce HR and force of contraction.
- 2 systems work in opposite ways to provide balance to the body’s overall function
Autonomic Nervous System (ANS)
Risk factors for malnutrition include:
1) main cause in U.S. are poverty, alcoholism, hospitalization, aging, and eating disorders
2) others are poor dentition, chronic illness, multiple meds, social isolation, severe burns, and lack of knowledge
