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Unit 2 Lecture Flashcards

1
Q

integumentary system

A
  • skin, hair, nails
  • changes may be the first clue to other health problems
  • functioning skin is essential for health/life
  • reflects pt hydration, nutrition, emotional status
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2
Q

skin fun facts

A
  1. ) largest/heaviest organ
  2. ) waterproof
  3. ) insulating shield
  4. ) 16% body weight
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3
Q

epidermis

A
  • outermost layer
  • first line of defense against pathogens/irritants/moister loss
  • thickness remains constant
  • melanocytes
  • cell that perceive pain, light touch, vibration, temp
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4
Q

melanocytes

A
  • 2 types
  • determine skin color
  • in epidermis
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5
Q

dermis

A
  • connective tissue- elastin and collagen
  • contains bld vessels, nerves, sebaceous/sweat glands, lymph vessels, hair follicles
  • thickness varies throughout life and between genders
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6
Q

collagen and elastin

A
  • found in dermis

* provide resiliency, distensibility, elasticity, and turgor of skin

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7
Q

dermal thickness

A
  • thinest at birth
  • thickens until 4th decade and thins again
  • thicker in men b/c more androgens
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8
Q

subcutaneous layer

A
  • fat, loose connective tissue
  • insulation
  • storage of caloric reserves
  • cushioning
  • lose w/ aging
  • provides skin recoil
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9
Q

pigments that determine skin color

A
  • melanin
  • carotene
  • oxyhemoglobin
  • deoxxygemoglobin
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10
Q

melanin

A
  • amt genetically determined
  • Amt increases by exposure to sunlight
  • protects skin agains UV
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11
Q

carotene

A
  • golden yellow

* in SQ fat, palms, soles

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12
Q

hemoglobin

A
  • carries most of O2
  • bright red when carrying O2 (oxyhemoglobin)
  • blue when loses O2 (deoxyhemoglobin)
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13
Q

jaundice

A

•yellowish color
•deposition of bilirubin
•observed in sclera, nails, palms, soles
*hard to see in artificial light

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14
Q

cyanosis

A
  • bluish color
  • lack of O2 (central)
  • lack of blood flow (peripheral)
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15
Q

albinism

A
  • pale, milky skin, flaxen hari, and light irises
  • 1/17,000 Americans
  • lack melanin
  • defenseless against sunlight and more prone to skin cancer
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16
Q

hair

A
  • protects body from debris/invasion

* insulation

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17
Q

vellus

A
  • short, fine, inconspicuous, unpigmented hair

* all over body

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18
Q

terminal

A
  • course, thick, conspicuous, pigmented hair

* scalp, brows, eyelids, axillae, perineum, legs, chest

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19
Q

sebaceous glands

A
  • support each hair follicle
  • secrete sebum for moister/conditioning
  • reduce H2O loss
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20
Q

sweat glands

A

•fxn in thermoregulation by controlling evaporation and resorption

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21
Q

eccrine sweat glands

A
  • widely distributed
  • open directly onto surface
  • secrete sweat in response to environmental and psychological changes
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22
Q

apocrine sweat glands

A
  • found in axillae, perineal areas
  • stimulated by emotional stress
  • responsible for BO
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23
Q

nails

A
  • matrix in epidermal layer at distal fingers/toes
  • nail plated (hardened keratine) grows at varying rates
  • lunula- half moon just above cuticle
  • growth/thickness can be affected by DZ
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24
Q

fxn skin

A
  • barrier
  • thermoregulation
  • synth vit D
  • sensory
  • nonverbal comm.
  • ID
  • wound repair
  • excretion metabolic waste
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25
skin as barrier
* protects against injury (physical, chemical, thermal, UV) * prevents penetration of organisms * prevents loss of H2O and elecrolytes
26
skin and perception
•touch, pain, temp, pressure
27
skin and thermoregulation
* sweat glands- cool | * subcutaneous tissue- insulates
28
skin and expression
•huge role as canvas for the artistic/spiritual
29
pediatric skin
* apocrine immature fxn until puberty * eccrine produced in lower amounts * more terminal hair in axillae/perineum at puberty
30
comedones
* blackheads and acne * form during puberty when apocrine glands mature and large ants sebum is builds up on hair follicles of face, neck, chest, back
31
Linea nigra
•hormonal changes in preggo cause darkened line from umbilicus to pubic area
32
older adult skin
* atrophy * loss of elastin/collagen * sub fat -> decreased resilience, sagging, wrinkling * increased visibility of superficial vascular structures * increased shearing/bruising * rougher- less epi repain * slower wound heal
33
health history subjective data of integument
•ID of 1. ) disease 2. ) abuse 3. ) risk for pressure ulcer/cancer
34
concerning integument symptoms
* rash * pruritis- itching * non healing * moles/lesions * ecchymosis * dry/too moist * hair loss
35
melanoma
* first degree relatives w/ increase pt risk * 10% of pt have relative * key is to teach early signs and use of sunscreen * results from exposure to UV-B * increased risk if dysplastic nevi or > 50 moles * found in face, shoulder, upper arms, back (men), legs (women)
36
integument past history
* skin diseases * diabetes/peripheral vascular disease * allergies/sensitivities * (sun)burns
37
inspecting skin
* start at head/scalp * use good lighting/draping * note areas of brittle/broken/absent hair * note pigmented areas- freckles/moles/birthmarks * look for widespread color change * progress down body to feet * palpate for moisture, temp, texture, mobility, and turgor * inspect skin folds
38
benign lesions
•freckles, moles, birth marks, skin tags, cherry angiomas
39
turgor
* measure of skin elasticity * speed at which skin returns to normal after lifted * decreases w/ thinning of dermis and reduced elastin production (aging) * affected by hydration status
40
tenting
•skin with decreased turgor remains elevated after being pulled and released •loss of elasticity due to dehydration/aging * test at sight w/ less sun exposure
41
edema
* excess fluid in interstitial spaces * skin puffy/tight * localized indicates injury * systemic- fluid goes to dependent part of body * pitting/nonpitting
42
1+ pitting
* 2 mm depression * barely detectable * immediate rebound
43
2+ pitting
* 4 mm deep pit | * few sec rebound
44
3+ pitting
* 6 mm deep pit | * 10-12 sec rebound
45
4+ pitting
* 8 mm deep pit * very deep * >20 sec rebound
46
physical exam lesions
``` •locations/distribution •pattern/shape/color •type •elevation •exudate *must describe exactly what is seen ```
47
primary lesion
•lesion develops on skin that was normal
48
secondary lesion
* changes in lesion over time | * seen in over treatment, scratching, infection of primary
49
vascular lesion
* develop b/c of blood supply problem to skin * purpura * port wine stain * telangiectasias * venous lake- varicose veins
50
pt w/ decreased mobility
* susceptible to skin damage/ulceration/microorganisms * sustained compression obliterates blood flow * distortion of soft tissue * moisture promotes maceration of tissue and skin breakdown
51
pressure ulcers
* caused by sustained compression, friction, shearing forces, moisture * easier to prevent than heal * use Braden scale- low score= high risk * common at sacrum, butt, greater trochanter, knees, heels, elbows, skin folds, back of head, under tubing
52
Braden Scale
``` •an assessment tool for predicting the risk of pressure ulcers •score of less than 18 is risk •based on the total of scores in 1.) sensory perception 2.) moisture 3.) activity 4.) mobility 5.) nutrition 6.) friction/shear ```
53
stages of pressure ulcers (I-IV)
I- alteration of intact skin; changes in temp, consistency, sensation, color II- partial thickness skin loss of eli/dermis III- full thickness skin loss w/ damage to subcutaneous tissue and maybe muscle; necrosis IV- full thickness skin loss w/ damage to underlying muscle/bone/etc; necrosis
54
assessing for vascular blood supply
* direct pressure of finger or on skin surface of nail beds * skin should blanch (pale) and promptly return to normal upon release * delayed return of color indicates decreased circulation
55
arterial insufficiency
* vascular lesion * poor arterial perfusion * pale around b/c blood not getting to * punched outlook * well defined margins * painful
56
venous stasis ulcer
* vascular lesion * red around b/c blood not getting out * venous valves don't work * blood pools/leaks, causing breakdown * chronic pain
57
macule
``` •1° lesion •non palpable •change in color of skin •up to 1.0 cm *freckle ```
58
patch
* 1° lesion * non palpable * macule > 1.0 cm
59
vesicle
* 1° lesion * palpable * serous fluid filled * up to 1.0 cm * Ex: chix pox; blister; herpes
60
bulla
``` •1° lesion •palpable • > 1.0 cm vesicle •serous fluid *big vesicle ```
61
pustule
•1° lesion •puss filled *acne
62
burrow
* 1° lesion * fluid filled * slightly raised tunnel in epi * mites/scabes
63
papule
``` •1° lesion •solid •distinct borders •up to 1.0 cm *mole ```
64
nodule/tumor
•1° lesion •solid • > 1 cm *wart; cyst
65
plaque
* 1° lesion * solid mass * > 1.0 cm * often coalescence of papules * flat top (plateau)
66
wheal
•1° lesion •solid mass *hives/insect bites
67
crust
* 2° lesion * dried residue of skin exudates * dried serum, pus, blood
68
scale
* 2° lesion * thin flak of dead * psoriasis; dandruff
69
fissure
* 2° lesion * linear crack in skin due to excessive dryness * tinea pedis
70
erosion
* 2° lesion * nonscarring loss of superficial epi * moist * doesn't bleed
71
ulcer
* 2° lesion * deeper loss of eli/dermis * bleed and scar
72
excoriation
* 2° lesion | * linear or punctate erosions caused by scratching
73
lichenification
* 2° lesion * visible/palpable thickening of epi w/ roughing of skin * thick, leathery skin due to rubbing/scratching * atopic dermatitis, eczema
74
scar
* 2° lesion | * extra connective tissue arises from injury/disease
75
keloid
``` •2° lesion •hypertrophic scarring that extends beyond borders of initial injury •overgrowth of granulation tissue •firm/rubbery *Mike's arm ```
76
purpura
* vascular lesion * deep reddish purple * flat * > 3 mm
77
petechiae
* vascular lesion | * small purpura (1-3 mm)
78
port wine stain
* vascular lesion * ruby red mark on skin * due to abnormal aggregation of caps. * vascular birth mark
79
telangiectasias
* vascular lesion * dilated small vessels * spider veins
80
venous lake
* vascular lesion | * varicose veins
81
mongolian spots
* common in dark-skinned native am. and hispanic babies * flat gray-blue in color * caused by pigment that didn't make it to top layer of skin when formed * harmless and fade with age
82
striae gravidarum
* atrophic, pinkish/purplish scar-like lesions that later become white * due to weakening of elastic tissues during pregnancy * on breasts, thighs, and butt * also associated with overweight, rapid growth during puberty, Cushing's syndrome, and corticosteroid use
83
ephelides freckles
•flat light brown spots that appear in sun and fad in winter
84
lentigines freckles
* small tan, brown, or black spots that do not fade in winter * bigger than freckles * in older people- sun exposure
85
dermatophyte
* mold-like fungi that thrives in warm, moist ares * contagious * tx w/ topical agents
86
tinea capitis/corporis
* ringworm | * capitis- of scalp
87
tinea pedis
•athletes foot
88
hirsutism
* female has male pattern hair distribution | * found often with polycystic ovarian syndrome
89
performing skin self examination (SSE)
``` •ABCDE method Asymmetry Border irregularity Color variation (esp. blue/black) Diameter 6 mm or greater Evolving shape/size/color ```
90
melanoma prevention
* reduce midday sun exposure- when UV-B rays most intense * use at least 15 SPF * reapply every 2 hrs
91
older adult nose/ears
* continue to grow * skin sags w/ loss of subcutaneous fat * lesions likely
92
silent thyroiditis
•slight enlargement of thyroid in some preggo
93
fontanel
* a space between the bones of the skull in an infant or fetus, where ossification is not complete and the sutures not fully formed * main one is between the frontal and parietal bones
94
hypothyroidism
* cold intolerance * coarse hair * thinning brows * fatigue * anorexia * dry skin * irregular menstruation * weight gain
95
hyperthyroidism
* heat intolerance * thin hair * weight loss * anxiety * increased BP, HR, diaphoresis * muscle weakness/fatigue * exophthalmia- bulging eyes
96
facial features not symmetrical
•indicates CN7 (facial) nerve damage
97
preorbital edema
•swelling around eyes
98
trachea not midline
•indicates respiratory abnormality
99
thyroid cartilage
•superior lump of trachea
100
cricoid cartilage
* inferior lump of trachea | * thyroid gland inferior to it
101
jugular venous distention
* blood flow refluxes (flows backward) from R atrium into jugular vein * most easily observed in visible upright position w/ head of bed elevated to 30°
102
check for JVD
* have pat. turn head * look for pulsation * if see pulsation determine if carotid pulse or JVD
103
carotid vs JVD
* palpate radial pulse while observing neck | * if single pulsation that coincides w/ radial pulse -> CAROTID PULSE
104
documentation of head findings
•shape of skull and distribution of hair
105
documentation of neck findings
* describe trachea * neck symmetry * thyroid gland- palpable? nodules?
106
documentation of lymph nodes
* palpable? * location of adenopathy * tenderness * movement
107
hyperopia
•farsightedness
108
presbyopia
•aging w/ vision loss of near vision
109
myopia
•nearsightedness
110
scotoma
•areas of lost/depressed vision surrounded by normal vision
111
diplopia
•double vision
112
strabismus
•muscle weakness
113
cranial nerve III
•ocular motor
114
cranial nerves IV and VI
* extracoular movements * IV- trochlear * VI- abducens
115
extraocular structures
* support and protect eye * eyelids * palperbral fissure * limbus * conjunctiva * lacrimal apparatus
116
palpebral fissure
•almond shaped open space between eyelids
117
limbus
•border between cornea and sclera
118
conjunctiva
•thin mucous membrane that lines palpebral (inner eyelids) and bulbar (covers sclera)
119
meibomian glands
* sebaceous glands inside tarsal plate at rim of eyelids * supply oil meibium, preventing evaporation of eye's tear film * prevents tear spillage * makes closed lids airtight
120
lacrimal apparatus
* lacrimal gland/sac/duct * protects and lubricates cornea and conjunctiva * produces and drains tears
121
extra ocular eye muscles
* oppose each other- ctx vs rlxn | * controlled by cranial nerves 3, 4, and 6
122
cornea reflex
* CN 5, & 7 * cornea is very sensitive to touch * tested w/ cotton ball touch
123
middle layer eye
``` *vascularized •iris- light in/out •lens- focus •ciliary body- aq. humor/lens shape •choroids- bld vessels ```
124
inner layer of eye
*nerual •retina •optic disk •macula
125
what opthalmoscope shows
* look thru pupil into retina | * look at choroids, optic disk, and macula for signs of dz
126
subjective data eye examination
* vision changes * pain/redness/swelling * stabismus, diplopia * discharge/watering * past hx * glaucoma, cataracts, diabetic retnopathy * use of glasses * self care- regular exams * environmental hazards
127
order of eye exam
•inspect •palpate •percuss *assessing visual activity, fields, and fxn of CN 2, 3, 4, and 6
128
eye exam key
* wash hands * wear gloves if suspect infection * clean equip. between eyes * examine infected eye last
129
inspection of external eye
* brows * lids/lashes * moist/glossy eyeballs * conjunctiva/sclera color * cornea/lens * iris/pupil
130
conjunctiva coloring
* pink- normal * red- infection * pale- anemia
131
cornea/lens inspection
* shine light from side to side | * look for smoothness/clarity
132
iris/pupil inspection
* size/shape | * should be 2-6 mm and round
133
Cranial III damage
* unilateral dilated pupil | * doesn't react to light/accomodation
134
aging adult eye
* decrease fxn lacrimal glands * presbyopia * cararacts * glaucoma
135
color blindness
* x-linked * 8% of males * rare in females * diagnosed b/t 4-8 y/o
136
Snellen eye chart
•test central visual acuity •top # distance from chart (should be 20 ft) •bottom # distance normal eye could see specific line on chart, that pt can't see *larger denominator -> poor vision
137
confrontation test
* test visual fields * place hands 2 ft apart (lat to pt ears) * wiggle fingers and move into line of gaze- pt indicate seeing
138
Hirschberg test
* corneal light reflex * inspect extraocular fxn * pt look at nurse nose * shine pen light at pt nose * cornea reflection should be =
139
cover test
* inspect extraocular fxn * pt look at nurse nose * cover one eye * note if gaze shifts in opp. eye * uncover eye- note if gaze steady * if gaze jumps to focus -> muscle weakness
140
cardinal fields of gaze test
``` •inspect extraocular fxn •hold finger 14 inches from eye •start in center •move finger up and right •move back midline •lateral right •midline •down right •midline •repeat to left *should move smoothly and symmetrically ```
141
pupillary light reflex
•darken room and gaze at spot behind nurse •advance light from side to side *testing CN 3
142
direct light reflex
•pupillary light reflex when there is constriction of same side pupil that light is shining on
143
consensual light reflex
•pupillary light reflex when there is constriction of other pupil that light is not shining on
144
testing pupil accommodation
•reflects CN 3 •far-to-near focus •pt stare at diet. for 30 sec •pen light 14 in in front of nose •pt focus on light as move toward nose •pupils should constrict and eyes should converge *pupils should dilate when looking far away- let light in
145
PERRLA
``` *pupil documentation Pupils Equal Round React to Light & Accommodation •Ex: pupil 4 mm, round and equal bilaterally; react to light/accom. equally ```
146
3 levels auditory system
1. ) peripheral- ear converts vibration to impulse 2. ) brain stem- ID/localize sound 3. ) cortex- interpret/respond
147
conductive hearing loss
* external/middle ear dysfunction * sound wave transmission disrupted * partial loss only * foreign bodies, perforated drum, infection * caused by excessive noise exposure in adults
148
inner ear
* provides body w/ proprioception/equilibrium | * dysfunction indicated by staggering gait, or vertigo
149
hearing in > 70 y/o
* men highest incidence of loss * greater delays in AP response of brain * longer auditory rxn time
150
inspection/palpation of ear
* size/shape * skin conditions * tenderness * external auditory meatus
151
otoscopic examination
* used to inspect ear canal and tempanic membrane * 4 mm speculum for adults * pull ear back to straighten canal before inserting * insert halfway then look into as advance toward tympanic membrane * look for redness, fluid, or foreign bodies
152
infant eustachian tube
* horizontal | * pull helix back and up when inserting otoscope
153
> 3 y/o eustachian tube
* sloped | * pull helix down when inserting otoscope
154
voice test
* testing hearing acuity (high frequency loss) * push tarsus in (plug) opp. ear * whisper 2 syllable word * have pt repeat
155
tuning fork tests
* test air and bone conduction | * AC > BC (normal)
156
Rinne Test
``` •tuning fork test •place stem of fork on mastoid process (BC) •pt signal when sound goes away •place tines of fork next to ear (AC) •pt signal when sound goes away *AC should be 2x long as BC ```
157
Weber Test
* tuning fork test for pt w/ eating better in 1 ear * tests BC only * fork at midline of skull * should hear equally in both ears
158
patency of nares (nostrils)
* are nostrils open * sniff on each side * test CN 1
159
palpating sinuses
* frontal above eyes * maxillary below eyes * tenderness or fullness indicates infection
160
inspecting mouth
* wear gloves * condition of teeth major indication of health * use gauze for tongue * use finger for floor * use tongue blade for buccal mucosa * hard and soft palate * uvula * tonsils * gag reflex
161
inspecting uvula
* should be midline | * pt says "agh"- should rise (CN 10-vagus- in tact)
162
tonsil grading
* absent * 1+ barely visible * 2+ halfway to uvula * 3+ touching uvula * 4+ touching each other
163
testing gag reflex
* place tongue blade on post. dorsum of tongue | * if gag, CN 12 (hypo), 9 (gloss), and 10 (vagus) in tact
164
suprasternal notch
•top of manubrium
165
sternal angle
* b/t manubrium and sternal body * at 2nd rib * trachea bifurcates behind into primary bronchi
166
cardiac notch
* left lung | * 5th intercostal space
167
costal angle
* below sternum | * part of abdomen between ribs
168
midsternal line
•vertical down sternum
169
midclavicular line
* middle clavicle to end * verticle * encompasses nipple
170
anterior axillary line
* vertically at most anterior below axillary | * also have mid and post. axillary line
171
scapular line
•vertically through center of scapula
172
vertebral line
•down spine
173
inferior angle
* bottom, medial corner of scapula | * 7th intercostal space
174
lower lungs
* where to listen for pulmonary edema | * majority in posterior of body
175
inspiration
* muscles ctxn * thorax expands * pressure in lungs lower -> air in
176
expiration
* muscles relax * thorax contracts * pressure in lungs greater than atm
177
4 fxn respiraton
1. ) supply O2 2. ) expel CO2 3. ) acid/base balance 4. ) heat exchange
178
adult respiratory system
* muscle strength decline at 50 * increased dyspnea * increased risk pneumonia * decreased lung elasticity
179
sudden onset dyspnea indicates
* anaphylaxis * pulmonary embolism * pneumothorax * anxiety
180
wheezes indicates
* airway obstruction * tissue inflammation * asthma
181
cough indicates
* L side heart failure-blood reflux into lungs * upper resp. infection * bronchitis/pneumonia
182
assess resp. and thorax
* rate, rhythm, effort * use of accessory muscles * facial expression * LOC * shape of chest
183
tactile fremitus
* palpable vibrations transmitted through brochopulmonary tree to chest wall as pt is speaking * use ball of your hand * not used much b/c x ray would reveal more
184
normal percussion supraclavicular
* resonance | * where apex of lungs is located
185
normal percussion scapular
* flat * don't want to be over scapula * want to go b/t scapula and spinal column
186
normal percussion lungs
•resonant | *not tympany
187
normal percussion LLL/diaphragm
•visceral dullness
188
normal percussion RLL/diaphragm
•liver dullness
189
normal breath sounds
``` •tracheal •broncho-vesicular- b/t scaulae •bronchiole- manubrium •vesicular- majority of lungs *inspiration longer than expiration ```
190
adventitious breath sounds
* abnormal * crackles (rales) * wheezes
191
crackles (rales)
* air passing through fluid or re-expanding collapsed small airways * discontinuous * brief * intermittent * non musical * fine vs course * not cleared when coughing
192
wheezes and Rhonchi
``` •turbulent air flow •continuous •higher pitched •musical *wheezes over tissue; Rhonchi over main bronchi *Rhonchi are coarse (mucus related) ```
193
when hear abnormal breath sounds
* location * bilateral? * during inspiration/expiration/both * amnt * clear w/ coughing?
194
respiratory auscultation key
* hold diaphragm firmly on chest wall * move from side to side to compare for symm * 14 locations post. * 12 locations ant
195
abdomen facts
* every structure except respiratory found there * xyphoid process to pubic bone * 4 flat muscle joined by Linea alba
196
GI fxn
* ingestion * digestion * absorption of nutrients * elimination of solid waste
197
peritoneum
* serous membrane beneath muscle layer of abdomen | * cover/holds organs in place
198
parietal layer
•lines walls of abdomen
199
visceral layer
•coats outer surface of organs
200
diastasis recti
* separation of rectus abdomens muscles at linea alba | * looks like a hernia, but it's not
201
organs in RUQ (5)
* liver * gallbladder * duodenum * pancreas * R kidney/adrenal
202
organs in LUQ (4)
* spleen * stomach * pancreas * L kidney/adrenal
203
organs in RLQ (3)
•cecum •appendix •R ovary *where you begin examination
204
organs in LLQ (2)
* L ovary | * sigmoid colon
205
organ in hypogastric region
•bladder
206
spleen
* stores RBCs/platelets * produces new RBCs * produces WBCs * not normally palpable
207
mesentery
* a fold of the peritoneum that attaches the stomach, small intestine, pancreas, spleen, and other organs to the posterior wall of the abdomen * supplies blood vessels and nerves to intestinal tract
208
costovertebral angle tenderness
•indicates possible kidney problems
209
pediatric abdomen
* less muscle -> easier palpation of organs | * protuberant abdomen until 7 y/o b/c of spine curvature
210
aging adult abdomen
* slower gastric motility * smaller liver/decreased fxn * decreased activity -> constipation * increased risk for gallstones
211
abdomen during preggo
* muscles rlx * organs displaced * diastatsis recti * compression of intestines -> constipation * increased venous pressure -> hemorrhoids
212
visceral abdominal pain
* difficult to localize * gnawing, burning, cramping, aching * may be associated with diaphoresis, pallor, nausea, vomiting, etc
213
parietal abdominal pain
* results from inflammation of peritoneum * severe and localized * Sx: ache, sharp, more w/ movement
214
referred abdominal pain
* in more distant sites innervated at same spinal level of affected structure * may be where organ was during fetal development
215
chronic upper abdominal pain
* dyspepsia * discomfort * pyrosis * atypical resp. symptoms
216
RLQ acute abdominal pain
* sharp/continuous * cramping * rebound tenderness * double over
217
LLQ acute abdominal pain
* fever * loss of appetite * absent bowel sounds * firm * guarding * rebound tendernes
218
Urinary tract pain
* suprapubic * kidney/flank * ureteral colic (spasmodic)
219
preparing pt for abdominal exam
* bladder empty * supine w/ knees bent * exposed abdomen from xiphoid to pubis * groin visible, genitals draped
220
examining abdomen order
* inspect, auscultate, percuss, palpate | * ALWAYS begin in RLQ at ileo-cecal valve and move clockwise
221
abdominal profiles (4)
1. ) flat 2. ) rounded 3. ) scaphoid- inward 4. ) protuberant- outward
222
bowel sounds
* use diaphragm softly * normal if peristalsis generates noise * listen in each quad for 15-20 sec * MUST listen for 5 min in all quads to determine absent
223
hyperactive bowel sounds
* > 30/min * gastroenteritis/diarrhea * hunger * behind obstruction
224
hypoactive bowel sounds
* < 5/min * preggo * peritonitis * constipation * post surgery
225
normal bowel sounds
* 5-30 sounds/min | * high pitched clicks an gurgles
226
high pitched bowel sounds
* cramping | * intestinal obstruction
227
bruits
* heard as blowing or swishing sounds that reflect turbulent blood flow (use bell) * determined when auscultating bowel sounds and carotid arteries * more common in atherosclerosis patients
228
thrill
•palpated vibration over artery w/ turbulent blood flow
229
tympany
* gas/air * LUQ * high pitched * stomach, sm. intestine, lg. intestine
230
dullness
``` •solid masses (dense) •distended bladder •liver (RUQ) •spleen •kidney *if in area that is normally hollow -> abnormality ```
231
reasons for dullness in area that should have tympany percussion sound
* masses * ascites * GI obstruction * preggo
232
costovertebral angle (CVA) percussion
* do if pt complains of pain/suspect kidney dz * place hand over 12th rib * thump ulnar area of fist * no pain rules out kidney infection/disease
233
light abdominal palpation
•1-2 cm deep w/ fingers •temp, texture, lesions, tender •same pattern as auscultation *be sure to observe facial expressions
234
deep abdominal palpation
•5-8 cm w/ hands •masses, organs, thrill, fluid wave •same pattern as auscultation *be sure to observe facial expressions
235
splenomegaly
* enlarged spleen * tip is palpable * indicates mono, HIV, cancer, infection, RBC abnormality
236
rebound tenderness
•pain induced or worsened by withdrawal of palpation •suggests peritonitis *assess for tenderness last
237
McBurney's point
* ⅓ of distance from anterior superior iliac spine (ASIS) to umbilicus * location of pain w/ appendicitis
238
abdominal distension
* ascites * obesity * tumor * tumor * ovarian cyst * gas * feces
239
fecal impaction
* seen w/ constipation and excessive use of laxatives * muscles forget how to move stool on their own * immobile/dehydrated pts at risk
240
bladder
* normally cannot be palpated unless distended | * dull upon percussion

Health Assessment (8 decks)

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