TOPIC 12 Flashcards
Mouth and Throat-Preparation
o Position person sitting up straight with his or her head at your eye level.
o If person wears dentures, offer a paper towel and ask person to remove them.
lips: african americans
o African Americans normally may have bluish lips and a dark line on gingival margin
normal gum appearance
o Pink or coral with a stippled (dotted) surface
o Tight and well-defined
gums: african american
o African Americans normally have a dark melanotic line along gingival margin
Stensen’s duct
opening of parotid salivary gland
Leukoedema
benign grayish opaque area - normal finding in African Americans & East Indians
Fordyce’s granules
o small white or yellow papules on mucosa, tongue and lips (not significant)
anterior hard palate appearance
white with irregular transverse rugae
posterior soft palate appearance
pinker, smooth, and upwardly movable
Torus palatinus
normal; nodular bony ridge down middle of hard palate
Tonsils graded in size as follows:
- 1+ Visible
- 2+ Halfway between tonsillar pillars and uvula
- 3+ Touching uvula
- 4+ Touching each other
normal healthy tonsil grade
1+ or 2+
Touching posterior wall with tongue blade elicits what? testing…
gag reflex; this tests cranial nerves IX and X, the glossopharyngeal and vagus.
Test cranial nerve XII, hypoglossal nerve, by
asking person to stick out tongue;
§ should protrude in midline; note any tremor, loss of movement, or deviation to side.
Edentulous person appearance
mouth and lips fold in, giving a “purse-string” appearance
aging adult: GI function
-Salivation decreases (dry mouth and decreased sense of taste)
-Esophageal emptying and gastric acid secretion are delayed
-Incidence of gallstones increases
-Decreased liver size, most liver functions remain normal; (however, drug metabolism is impaired)
-frequent constipation
aging adult: common causes of constipation
o Decreased physical activity
o Inadequate intake of water
o Low-fiber diet
o Side effects of medications
o Irritable bowel syndrome
o Bowel obstruction
o Hypothyroidism
o Inadequate toilet facilities, difficulty ambulating to toilet
recommendations for obesity
o healthy food patterns,
o decreased consumption of sweetened/processed foods,
o increased physical activity
when doing the physcal exam of teh abdomen, you always want to…
Auscultate prior to palpation and percussion
inspection of the abdomen: contour
Determine profile from rib margin to pubic bone; contour describes nutritional state and normally ranges from flat to rounded
-FLAT, ROUNDED, SCAPHOID, PROTUBERANT
normally the umbilicus is
midline and inverted, with no sign of discoloration, inflammation, or hernia
good skin turgor on the abdomen reflects…
healthy nutriton
how do you assess skin turgor
gently pinch up a fold of skin; then release to note skin’s immediate return to original position
striae
striae, silvery white, linear, jagged marks about 1 to 6 cm long
Occur when elastic fibers in reticular layer of skin are broken after rapid or prolonged stretching, as in pregnancy or excessive weight gain
recent striae are what color
pink or blue
older striae are what color
silvery white
Pigmented nevi (moles)
circumscribed brown macular or papular areas, common on abdomen
abdomen: pulsation or movement
Normally you may see pulsations from aorta beneath skin in epigastric area, particularly in thin persons with good muscle wall relaxation
ascites
free fluis in the peritoneal cavity
what are signs of ascites
distented abdomen, bulging flanks, umbilicus that is protruding and displaced forward
Surgical scar alerts you to
possible presence of underlying adhesions and excess fibrous tissue.
Percussion and palpation can increase peristalsis, which…
would give a false interpretation of bowel sounds.
what side of the stethoscope do you use for bowel sounds and how do you hold it?
diaphragm; hold it lightly,
where do you begin when auscultating the abdomen
Begin in RLQ at ileocecal valve area because bowel sounds are normally always present here.
Bowel sounds originate from…
movement of air and fluid through small intestine
character of bowel sounds
Bowel sounds are high pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute; do not bother to count them
bowel sounds can either be…
normal, hypoactive, or hyperactive
borborygmus
sound of hyper peristalsis
when listening to vascular sounds in the abdomen, what are we listening for
no sound usually, abnormal is bruits and thrills
To assess kidney, place one hand over…
12th rib at costovertebral angle on back
durinf costovertebral angle tenderness the person normally feels…
thud but no pain
when doing palpation in the abdomen, tender areas are examined…
last
mcburney’s point
appendix tenderness
Murphy’s sign
gall bladder tenderness
when should you AVOID palpation
when Trauma, injury, distention, or infection can make organs enlarged and friable-prone to rupture with palpation
aging adult: abdomen
-increased deposits of subcutaneous fat on abdomen and hips because it is redistributed away from extremities
-Abdominal musculature is thinner and has less tone than that of younger adult, so in absence of obesity you may note peristalsis
-Because of thinner, softer abdominal wall, organs may be easier to palpate, in the absence of obesity
-With distended lungs and depressed diaphragm, liver can be palpated lower, descending 1 to 2 cm below costal margin with inhalation
obesity: inspection
uniformly rounded. Umbilicus sunken
obesity: ausultation
normal bowel sounds
obesity: palpation
Normal. may be hard to feel through thick abdominal wall.
air or gas: inspection
single round curve
air or gas: auscultation
Depends on cause of gas (decreased or absent bowel sounds w ileus); hyperactive bowel sounds with early intestinal blockage
air or gas: palpation
May have muscle spasm of abdominal wall
ascites: inspection
Single curve. Everted umbilicus. Bulging flanks when supine. Taut, glistening skin; recent weight gain; increase in abdominal girth
ascites: auscultation
Normal bowel sounds over intestines. Diminished over ascitic fluid
ascites: palpation
taut skin and increased intra-abdominal pressure limit palpation
ovarian cyst: inspection
Curve at lower half of abdomen, midline, everted umbilicus
ovarian cyst: auscultation
Normal bowel sounds over upper abdomen where intestines pushed superiorly
ovarian cyst: palpation
Transmits aortic pulsation, whereas ascites does not
pregnancy: inspection
Single curve. Umbilicus protruding. Breasts engorged.
pregnancy: auscultation
Fetal heart tones. Bowel sounds diminished.
pregnancy: palpation
uterine fungus. Fetal parts. Fetal movements
feces: inspection
localized distention
feces: auscultation
normal bowel sounds
feces: palpation
Plastic-like or rope-like mass with feces in intestines
tumor: inspection
localized distention
tumor: ausculation
normal bowel sounds
tumor: palpation
Define borders. Distinguish from enlarged organ or normally palpable structure
bowel obstruction characteristics
-Would hear decrease/absent bowel sounds past/near obstruction
-Absence of stool or gas passage
-Change in VS (decrease BP, increase pulse, and cool skin)
-Tenderness to palpation
-Fever, vomiting, colicky pain from peristalsis above obstruction
umbilical hernia
A soft, skin covered mass, the protrusion of the omentum or intestine through a weakness or incomplete closure in the umbilical ring.
hiatal hernia
protrusion of a part of the stomach upward through the opening in the diaphragm
epigastric hernia
Protrusion of abdominal structures presents as a small, fatty nodule at epigastrium in midline, through the linea alba. Usually one can feel it rather than observe it. May be palpable only when standing.
incisional hernia
A bulge near an old operative scar that may not show when person is supine but it’s apparent when the person increases intraabdominal pressure buy a sit-up, by standing or by the Valsalva maneuver
Valsalva maneuver
forceful exhalation against a closed glottis, which increases intrathoracic pressure and thus interferes with venous blood return to the heart
diastasis recti
midline longitudinal ridge in the abdomen, a separation of abdominal rectus muscles
succussion splash
Unrelated to peristalsis, this is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach, as seen with pyloric obstruction or large hiatus hernia.
hypoactive bowel sounds
diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. Also occurs with pneumonia.
bruit
systolic pulsatile blowing
anorexia
A loss of appetite from GI disease as a side effect to some medications, with pregnancy, or mental health disorders.
dysphagia
difficulty swallowing
-Occurs with disorders of the throat or esophagus, such as thrush, neurological changes or obstruction
pyrosis
heartburn; burning sensation in upper abdomen due to reflux of gastric acid
visceral abdominal pain
from an internal organ (dull, general, poorly localized)
parietal abdominal pain
from inflammation of overlying peritoneum (sharp, precisely localized, aggravated by movement)
hepatitis
inflammation of the liver
melana
black, tarry stools; blood is stool
Male rectal exam position
left lateral decubitus or standing position; instruct standing male to point his toes together; this relaxes regional muscles, making it easier to spread buttocks
female rectal exam position
o lithotomy position if examining genitalia as well
-Use left lateral decubitus position for rectal area alone
what is the best position for rectal exams in male and female patients
left lateral
when inspecting the perianal region, instruct the client to
spread buttocks wide apart
when inspecting the sacrococcygeal area, describe any abnormality in…
clock-face terms, with 12:00 as the anterior point toward symphysis pubis and 6:00 toward coccyx
normal stool
color is brown and consistency is soft
abnormal stool
Black, gray, tan, pale yellow, greasy, occult blood
occult blood test
test used to detect hidden blood in the feces
-negative response is normal
what can cause a false positive in an occult blood test
if person has ingested red meat within 3 days of test
colorectal cancer (CRC) screening
Screening identifies precancerous polyps so they can be removed before they become cancer
CRC is most often found in people age 50 and older
CRC screening tests include: older adult tests
o Fecal occult blood test (FOBT)
o Flexible sigmoidoscopy
o Combination of FOBT and flexible sigmoidoscopy
o Colonoscopy
o Double-contrast barium enema
abscess
o A localized cavity of pus from an infective anorectal gland. Characterized by persistent throbbing rectal pain, and appears red, hot, swollen, indurated, and tender.
rectal polyp
protruding growth from the rectal mucous membrane that is fairly common;
The polyp maybe pendunculated (on a stock) or sessile (on the surface close to the mucosa wall)
fecal impation
o A complete colon blockage by hard, desiccated immovable stool, which presents as constipation or overflow incontinence.
carcinoma: subjective data
frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination; Continuous pain in lower back, pelvis, thighs
carcinoma: objective data
a malignant neoplasm often starts as a single hard nodule on the posterior surface, producing a symmetry and a changing consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland feels stone hard and fixed. The median sulcus is obliterated
pilonidal cyst or sinus
a hair-containing cyst or sinus located in the midline over the coccyx or lower sacrum
anorectal fistula
Anorectal Abscess starts from an effective anorectal gland; The infection channels through the perianal tissues to form a fistula, a connection between the infected gland and the outside perineum
fissure
An exquisitely painful longitudinal tear in the superficial mucosa at the anal margin
hemorrhoids
varicose veins in rectum
-Swollen, painful rectal veins; often a result of constipation
rectal prolapse
The complete rectal mucous membrane protrudes crew the anus, appearing as a moist red donut with radiating lines
Pruritus ani
o intense itching and burning in the perineum has myriad causes: soaps, restrictive clothing , fecal soiling or hemorrhoids, eczema or psoriasis, sexually transmitted infections , candida infection from moist or sweaty folds of skin and obese or aging persons, systemic causes such as diabetes and liver disease, and pinworm infestation in children.
o Persistent scratching makes an inflammatory response and shows as red raised thickened excoriated skin may be swollen moist.
Dyschezia
painful or difficult bowel movement; Pain due to local condition (hemorrhoid, fissure) or Constipation
steatorrhea
Excessive fat in stool: malabsorption as in celiac disease, cystic fibrosis, chronic pancreatitis, Crohn’s disease.
Male does not experience a definite end to fertility as female does, around age ___ years, production of sperm begins to decrease, although it continues into _____
40; 80s and 90s
testosterone production
o declines after age 30 but continues very gradually so resulting physical changes are not evident until later in life
o Pubic hair decreases and penis size decreases
o Testes decrease in size and are less firm to palpation
Circumcision
surgical removal of the foreskin; religious and cultural indications
prostate cancer is more common in…
North America and northwestern Europe
Two main causes of ESRD (End Stage Renal Disease):
Hypertension & Diabetes
Prevalence of diabetes & hypertension is higher in some racial groups:
African Americans, Native Americans & Hispanics are more likely to be affected
contributing factors to prevalence of diabetes and hypertension
low socioeconomic status lead to poor health outcomes by limiting access to care and/or diagnosis/treatment being delayed
It is normal for a male to feel apprehensive about having his genitalia examined, especially by a female examiner, so…
CHAPARONE may be needed during exam-request another staff person to be present
when inspecting the inguinal region of a male what is normal
normall no bulge is region
-Normal to palpate an isolated node on occasion; it then feels small, 1 cm, soft, discrete, and movable
what is abnormal when inspecting the inguinal region of a male
Enlarged, hard, matted, fixed nodes are abnormal findings
penis: normal findings
-Skin normally looks wrinkled, hairless, and without lesions; dorsal vein may be apparent
-Glans looks smooth and without lesions;
-Normally, penis feels smooth, semifirm, and nontender
scrotal size varies with
ambient room temperature; asymmetry is normal, with left scrotal half usually lower than right
what age should you encourage TSE
every male from 13 to 14 years old through adulthood
testicular cancer is most common in
young men age 15 to 35
Points to include during health teaching of TSE are:
o T - timing, once a month
o S - shower, warm water relaxes scrotal sac
o E - examine, check for and report changes immediately
TSE Teaching Points
Phrase your teaching something like this:
A good time to examine testicles is during shower or bath, when your hands are warm and soapy and scrotum is warm; cold hands retract scrotal contents
Procedure is simple; hold scrotum in palm of your hand and gently feel testicles using thumb and first two fingers
normal testivle findings
Testicle is egg-shaped and movable; it feels rubbery with a smooth surface
abnormal testicle findings
lumps are very rare and usually not worrisome, but if you ever notice a firm, painless lump, a hard area, or an overall enlarged testicle, call your physician for further check
How is prostate cancer detected?
detected by testing blood for prostate-specific antigen (PSA) and/or on digital rectal examination (DRE)
abnormal findings: male gentialia
Urethritis, urethral discharge, and dysuria
assessment of urinary function
-Observe urine color
Note pH & specific gravity
-Serum analysis of kidney function correlates with creatinine level which is relatively stable (end product of muscle metabolism)
-BUN measures urea which can vary based on several factors (end product of protein metabolism)
renal calculi
kidney stones; Renal stones (crystals of calcium oxalate or uric acid) form in kidney tubules and then migrate and become urgent when they pass into ureter, become lodged, and obstruct urine flow, causing hydronephrosis.
acute urinary retention
Inability to pass urine with bladder distention and lower abdominal pain.
urethral stricture
narrowing of the urethra; Pinpoint, constricted opening at meatus or inside along urethra.
external female genitalia
vulva or pudendum
mons pubis
a round, firm pad of adipose tissue covering the symphysis pubis
labia majora
two rounded folds of adipose tissue extending from mons pubis down and around to perineum
labia minora
o inside labia majora as two smaller, darker folds of skin
Female circumcision, known as infibulation or female genital mutilation
Invasive surgical procedure (removal partial or total of the clitoris) usually performed on girls before puberty - social custom
what does vaginal bleeding aftera woman has gone through menopause indicate?
RED FLAG can indicate cancer
menopause
cessation of menstruation (1 whole year without a period)
positioning for exam on female genitalia
o Left lateral
o Lithotomy
Hair distribution in usual female pattern of..
inverted triangle, although it normally may trail up abdomen
With your gloved hand, separate labia majora to inspect:
o Clitoris
o Labia minora are dark pink and moist, usually symmetric
o Urethral opening appears stellate or slitlike and is midline
o Vaginal opening, or introitus, may appear as narrow vertical slit or as larger opening
o Perineum is smooth; a well-healed episiotomy scar, midline or mediolateral, may be present after vaginal birth
o Anus has coarse skin of increased pigmentation
Sexually Transmitted Virus
HPV
To screen for STIs, and if you note any abnormal vaginal discharge, what should you do
obtain gonorrhea (GC)/chlamydia culture
if HPV lingers in a womans cervix, what can it cause
cervical cancer
why do most people never know that they have HPV
because virus usually does not cause any symptoms and body is able to fight it off
HPV Teaching Points
Remind women that obtaining vaccine does not mean they can forget about routine pelvic examinations and Pap tests
Vaccine will protect against major types of HPV that cause cervical cancer, but not all types
Pap tests detect cell changes in cervix before they turn into cancer, at an early, curable stage
Only other way to prevent HPV is to abstain from all sexual activity
Condoms may not protect against HPV because areas not covered by condom can be exposed to virus
