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
