NU 305 Exam 3 Flashcards
What are normal abdominal inspection findings?
Abdomen flat and symmetric.
- No scars, striae, or varicosity.
- Skin even toned.
- Umbilicus midline and inverted.
- No hernias noted.
What are normal abdominal auscultation findings?
Bowel sounds present in all four quadrants.
- No bruits on vascular auscultation.
- No venous hums
- No friction rubs
What are normal abdominal palpation finding?
No tenderness
- Abdomen without masses.
- Tenderness near the xiphoid process, over the cecum, or over the sigmoid colon may be normal.
- Palpable liver edge against your right hand during inspiration
- A normal spleen is not palpable
- It is common to be unable to palpate the kidneys except in slender patients
- Pulsations of the aorta are palpable; the aorta should measure about 3/4 in.
- Empty bladder is neither tender nor palpable
- Inguinal lymph nodes nontender and may be slightly palpable
What organs are in the LUQ
Body of pancreas
- Part of transverse and descending colon
- Stomach
- Left lobe of liver
- Splenic fixture of colon
- Spleen
- Left adrenal and kidney
What organs are in the RUQ?
Part of ascending and transverse colon
- Right kidney and adrenal
- Head of pancreas
- Duodenum
- Liver
- Hepatic fixture of colon
- Gallbladder
What organs are in the LLQ?
Left ovary and tube
- Sigmoid colon
- Left spermatic cord
- Part of descending colon
- Left ureter
What organs are in the RLQ?
Right spermatic cord
- Right ovary and tube
- Cecum
- Right ureter
- Appendix
What organs are in the midline?
Uterus (if enlarged)
- Aorta
- Bladder (if distended)
Describe normal liver palpation
Palpable liver edge against your right hand during inspiration.
- An enlarged liver would be palpable below the costal margin which is abnormal
Describe normal emesis findings
There is no emesis
What are abnormal emesis findings
Green usually indicates reduced peristalsis with irritation.
Coffee-ground is digested blood
Bloody emesis is an active bleed with undigested blood.
S/S of dehydration
hyperthermia
- tachycardia
- thready pulse
- hypotension
- orthostatic hypotension
- decreased CVP
- tachypnea
- dizziness
- cool clammy skin
- diaphoresis
- sunken eyeballs
How do you perform an iliopsoas muscle test?
The iliopsoas muscle test is performed when appendicitis is suspected. With he patient lying supine, lift the right leg straight up, keeping the knee straight. Push down over the lower part of the right thigh while the patient pushes up.
How do you perform a rebound tenderness test?
Blumberg sign or rebound tenderness is used to assess for peritonitis. In a site away from the painful area, push down your hand at a 90 degree angle slowly and deeply, then lift up quickly.
- Pain when pressure removed = (+) sign= peritonitides
What is McBurney’s point?
The name given to the point over the right side of the abdomen that is one third of the distance front he anterior superior iliac spine to the umbilicus. This point roughly corresponds to the most common location of the base of the appendix where it is attached to the cecum. Deep tenderness at McBurney point, know as McBurney sign, is a sign of acute appendicitis.
What is Murphy’s sign?
A clinical test used to assess for cholecystitis; performed by palpating near the client’s gallbladder during inhalation.
What is Atony?
Lack of normal muscle tone or strength
What is hypotonicity?
diminished tone of the skeletal muscles
What is spasticity?
Hypertonic, so the muscles are stiff and movements awkward
What is a spasm?
sudden, violent involuntary muscle contraction
What is fasciculation?
involuntary twitch of muscle fibers
What are tremors?
involuntary contraction of muscles
How is muscle strength graded?
scale 0-5 (ex. 1/5 or 5/5)
Describe rheumatoid arthritis
Usually due to physical and emotional stress
Upper extremities
Onset in young adulthood
Stiffness is worse in mornings and after inactivity
Typically complains of weakness, fatigue, low fever
Joints may be tender, swollen, or warm
Will check for this through elevated serum proteins in blood and synovial fluid
Ulnar deviation neck and boutonnière/Swan
Describe osteoarthritis
What it is, who it occurs to, what causes it, tests, and symptoms
The wearing down of the protective tissue at the ends of bones
Occurs mostly due to obesity and aging
Occurs in lower extremities
Onset around 50s and 60s
Worse later in day and after activity
No generalized complaints
Joints may be tender
Test for this by X-ray, CT, or MRI
Herberden and Bouchard Nodes
Describe s/s for urgent assessment of the breast
A here breast lump or mass
- Swelling of all or part of a breast
- Skin irritation or dimpling
- Breast or nipple pain
- Nipple retraction (turning inward)
- Redness, scaliness,or thickening or nipple or breast skin
- Nipple discharge other than breast milk
Describe s/s for an urgent assessment of the abdomen
- Acute abdominal pain can indicate a ruptured appendix or diverticula which needs emergency surgery.
- A ruptured aortic aneurysm, ruptured fallopian tube, ruptured ovarian cyst, ectopic pregnancy, or penetrating trauma can cause abdominal bleeding, resulting in hypovolemic shock and death.
- Massive amounts of blood can collect in the cavity quickly.
Describe an urgent assessment of the musculoskeletal system
Do not attempt to correct malalignment because it can compound injury to muscle, nerves, or blood vessels. Instead, mobilize the extremity. Fractures require prompt care to prevent further injury or deformity. Focus your efforts on keeping the patient calm, quiet, still, and comfortable.
Describe s/s urgent assessment of the neurological system
Critical changes in the neurological system
Acute changes in mental status or change in consciousness
- Seizure activity
- Onset of flexor or extensor posturing
- Change in size and decreased reactivity to light in pupils
- Onset of conjugate or dysconjugate eye deviation
- Progressing weakness of extremities or one side of body
- Changes in sensation identification
- Changes in vitals sings
- Fever (infection)
How to best communicate with someone who has aphasia
Remember that with aphasia you may need to make your questions simple and close-ended (yes or no). Also, you may need to incorporate visual or audio assistance. You may could give a note pad and pen so the patient can write how they feel if this is possible with the patient. Sometimes that can be affected as well.
What does the cerebellum do?
- Coordinates voluntary movement, posture, and muscle tone
- Maintains special orientation and equilibrium.
- It ensures adjustments to maintain overall balance and coordination
- It integrates info from the cerebral cortex, inner ear, muscles, and joints.
What are the 12 cranial nerves?
I. Olfactory
II. Optic
III. Oculomotor
IV. Trochlear
V. Trigeminal
VI. Abducens
VII. Facial
VIII. Vestibulocochlear
IX. Glossopharyngeal
X. Vagus
XI. Accessory
XII. Hypoglossal
Describe the test for cranial nerve I
Eyes closed, occlude one nostril, present familiar aromatic substance. Identify older with each side of nose.
Describe the test for cranial nerve II
Test visual acuity and visual fields by confrontation.
- Using ophthalmoscope, examine ocular fundus to determine color, size, and shape of optic disc
Test for cranial nerves III, IV, and VI
Check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation
- Assess extraocular movements by cardinal positions of gaze
Test for cranial nerve V
Motor: assess muscles of mastication by palpating temporal and masseter muscles as person clenches teeth
Sensory: eyes closed, test light touch sensation buy touching a cotton wisp to designated areas on person’s face, forehead, cheeks, and chin
Test for cranial nerve VII
Motor: Note mobility and facial symmetry as person responds to requests to smile, frown, close eyes tightly (against your attempt to open them), lift eyebrows, show teeth. Then, have person puff cheeks, then press puffed cheeks in, to see that air escapes equally from both sides.
Sensory: Test only when suspected facial nerve injury. When indicated, test sense of taste by applying cotton tip applicator covered with solution of sugar, salt, or lemon juice to tongue and ask person to identify taste
Test for cranial nerve VIII
Test hearing acuity by ability to hear normal conversation and by whispered voice test
Test for cranial nerves IX and X
Motor: depress tongue with tongue blade, and note pharyngeal movement as person says “ahhh” or yawns; uvula and soft palate should rise in midline and tonsil lair pillars should move medially. Touch posterior pharyngeal wall with tongue blade, and note gag reflex; voice should sound smooth not strained.
Sensory: Cranial nerve IX does mediate taste on posterior one third of tongue, but technically too difficult to test
Test for cranial nerve XI
Examine sternomastoid and trapezius muscles for equal size.
- Check equal strength by asking person to rotate head against resistance applied to side of chin
- Ask person to shrug shoulders against resistance
- These movements should feel equally strong on both sides
Test for cranial nerve XII
Inspect tongue; no wasting or tremors should be present
- Note forward thrust in midline as person protrudes tongue.
- Ask person to say “light, tight, dynamite,” and note that lingual speech (sounds of letter l,t,d,n) is clear and distinct
How is the DTR scale graded?
4 point scale
- 4 = very brisk, hyperactive with clonus, indicative of disease
- 3= brisker than average, may indicate disease
- 2 = average, normal
- 1 = diminished, low normal, or occurs with reinforcement
- 0 = no response
Describe a colorectal screening
Starting at age 50, both men and women should follow one of these more common testing plans for bowel cancer:
- Colonoscopy every 10 years
- Flexible sigmoidoscopy every 5 years
- Yearly guaiac-based fecal occult blood test (gFOBT)
- Stool DNA test (sDNA) every 3 years)
What is the Glasgow Coma Scale
A tool for assessment a patient’s response to stimuli. Score ranges from 3 (deep coma) to 15 (normal)
Describe the Glasgow Coma Scale ratings
Eye opening: 4 (spontaneous), 3 (to voice), 2 (to pain), 1 (none)
Verbal response: 5 (oriented), 4 (confused), 3 (inappropriate words), 2 (incomprehensible words), 1 (none)
Motor response: 6 (obeys command), 5 (localized pain), 4 (withdraws), 3 (flex ion), 2 (extension), 1 (none)
Describe Migraine headaches
A throbbing, severe, unilateral headache that lasts 6-24 hours and is associated with photophobia, nausea, and vomiting suggests migraine
- A constant, unremitting, general headache that is described as a feeling of a tight band around the head and lasts for days, weeks, or even months is usually characteristic of a tension muscle contraction headache.
What are risk factors for breast cancer?
Alcohol
- Overweight or obesity
- Physical inactivity
- History of childbirth
- Birth control
- Hormone replacement after menopause
- Breastfeeding
What are risk factors for abdominal problems?
Risk factors for developing abdominal problems
Past medical history
- Chewing and swallowing
- Breathing
- Weight gain
- Genitourinary issues
- Last menstrual period in females
- Prostate difficulties in males
- Joint pain
- Numbness, back problems, or loss of bladder/bowel control
- Diabetes
- Skin changes
- Food allergies or infection
- Substance abuse
What are risk factors for musculoskeletal problems?
What in a person’s lifestyle puts them at risk?
Past medical history
- Dairy product consumption
- Sunlight exposure
- Type of work you do
- Hobbies and sports
- Income and people that live on it
- Cigarette/Alcohol use
- Meds and family history
What are risk factors for neurological problems?
- Past medical history
- diabetes, CAD, A-fib, or Sickle cell disease
- smoking, have a high fat diet, obesity, or are physically inactive
- not using a seat belt, not wearing a bike helmet, drink and drive, have fall risk, or ignore firearm safety
- Meds
- Family history
What are the parts of the cerebrum and their functions?
Frontal: complex cognition (insight), language, and voluntary motor function
- Temporal: hearing, speech, behavior, memory
- Parietal: Sensory- temp, touch, pressure, and pain;
- Occipital: Vision
- Left control right, right controls left
Describe nerves of the Brain stem (medulla, midbrain, pons, and reticular formation) and what they control
Cranial Nerves I-XII. Cell bodies housed in brain stem
- Breathing, sneezing, coughing, swallowing, et
What do Protective structures (Cerebrospinal fluid) do?
Allows for nutrient delivery and cushion
- Be aware as increased CSF can lead to herniation and compression of brain stem ——> loss of basic vital functions
Describe Proper documentation for musculoskeletal
Posture is erect with head midline above the spine. Shoulders are equal in height.
- Walking is normally smooth and rhythmic, with arms swinging in opposition to the legs. The patient rises from sitting with ease
- Patient is balanced when standing and has a negative Romberg test
- Patient performs rapid alternating movements of the arms and finger thumb opposition and runs the heel of one foot down the opposite shin
- No swelling, lacerations, lesions, deformi
Describe Proper documentation for neurological assessment
Patient alert; opens eyes spontaneously
- Oriented x4
- Speech is clear, fluent, and articulate
- Pupils equal, round, and reactive to light (PERRL)
- PERRLA (A for accommodation)
- Pupils constrict and converge bilaterally. Gaze is purposeful and conjugate
- Movements smooth and symmetrical
Describe Proper documentation for abdominal assessment
Abdomen flat and symmetric. No scars, striae, or varicosity. Skin even-toned. Umbilicus midline and inverted. No hernias noted.
- No dissension, visible pulsation, or peristaltic wave noted. Respiration even, no use of accessory muscles.
- Urine is clear and light yellow.
- No emesis.
- Stool is soft, light brown, moderate amount
- Bowel sounds present in all four quadrants
- No bruits, venous hums, or friction rubs
- Abdomen tympanic. No dullness over the liver in the RUP and hollow tympanic notes in the LUQ over the gastric bubble.
- No tenderness
- Abdomen without masses
Describe Proper documentation for breast exam
Females:
- Skin tone determines color.
- Wide variation exists for size
- Symmetrical, or a left breast slightly larger than the right.
- Contour uninterrupted
- Areola round or oval, and pink to dark brown
- No change in color, seize, symmetry, or contour of the breast or change in nipple characteristics
- No signs of rashes, infection, texture changes, or unusual pigmentation
- One or more small, soft, nontender nodes
- Nipple smooth without masses, nodules, or discharge
Describe Weber test
Assessing for sensorineural hear loss
- Likely in ear ear pathology if sound is not equal in both ears
- Tuning fork on top of head
Describe the Rinne Test
Air conduction should be twice bone conduction
- If air conduction is < or = to bone conduction, suspect conductive hearing loss.
- Tuning fork right behind the ear
What are Age related changes for GI
Difficulty swallowing and absorbing food
Constipation
Chewing difficulty and alter dietary choice
Liver and Kidney alters med metabolization, decreases thirst sensation increases risk for dehydration, UTIs, and constipation
What are Age related changes for musculoskeletal
Increase risk for fall
- Kyphosis
- Shortened height
- Decrease ROM
- Loss of muscle
- Less flexible
- Changes in subq fat
- Osteoporosis
What are age related changes for neuro?
- Reduction in brain volume most likely related to shrinkage or neurons and reduction in number synaptic spines and synapses.
- Reduce cognitive abilities, such as processing speed, executive function, episodic memory, reduced response to stimuli, delayed reflexes, decreases ability to respond to multiple stimuli, and the ability to manage multiple tasks at the same time.
- Peripheral nerve function and impulse conduction decrease, causing decrease proprioception and potential for a Parkinson-like gait
- At risk for poor balance, postural hypotension, falls, and injury
- Light touch and pain sensation are reduced, wit
What is nystagmus
A jerking movement of the eye that can be quick and fluttering or slow and rolling, similar to a tremor
- Causes include meds (anti seizure meds), cerebellar disease, weakness in the extra-ocular muscles, and damage to CN III (oculomotor)
What is carpal tunnel?
Median nerve compression causing Paresthesia and weakness in hands
-Diagnosis: Phalen and Tinel
What is scoliosis?
Lateral curvature of spine
- Critical time for assessment: adolescents
- Inspect back, hips, scapulae, shoulders for symmetry. Bend forward with arms hanging and stand up
- Palpate spine
What is osteoporosis?
Women experience rapid loss of bone density for the first 5-7 years after menopause. After initial rapid phase, bone loss continues but slows. Men also experience bone loss but at more advanced ages and at much slower rates. Bone mass is related to race, heredity, hormonal factors, physical activity, and calcium intake
What are risks for osteoporosis?
Small, boney framed women
- Smoking
- Low calcium
- High salt intake
- Alcohol
- Physical inactivity
What kind of screening is done for osteoporosis?
bone density test (DEXA scan) is recommended for women who 65 and older and for women who are 50-64 and have certain risk factors
How can you prevent osteoporosis?
- Maintaining an active lifestyle and healthy weight. 30 min weight bearing exercise 3 times per week
- Protection of joints while performing simple tasks
- Daily recommended amount of calcium and vitamin D. Limit caffeine
- Discuss risks of osteoporosis with provider
- Bone density test and meds
What can cause an enlarged spleen?
Mono
Where is the spleen?
Left upper quadrant
What are the abnormal contours for the abdomen?
Scaphoid, rounded, or protuberant
What can cause the abnormal abdomen contours?
Ascites, tumors, gas, pregnancy
What does a normal abdomen look like?
Flat and symmetric. No scars, striae or varicosity. Skin-even toned, no hernias, no dissension or pulsation.
Describe abnormal urine color
Cloudy (infection), bloody (bacteria, kidney stones), dark (bilirubin, dehydration)
Describe abnormal vomit (emesis)
Green (bile), coffee ground (old blood), bloody (bleeding in upper GI tract)
Describe abnormal stool
Foul-smelling, very liquid, dark stools, melanotic (black,tarry)
Describe normal urine
Clear and light yellow
Describe normal vomit
None present
Describe normal stool
Soft, light brown, and formed
