week 4: skin, hair, nails; gastrointestinal; genitourinary gastrointestinal assessment

Question 1

right upper abdominal quadrant

Answer 1

Bowel and Liver

Question 2

right lower ab quadrant

Answer 2

Bowels and appendix

Question 3

left upper ab quadrant

Answer 3

Stomach, bowel, spleen, pancreas

Question 4

left lower ab quadrant

Answer 4

Mostly just bowels here

Question 5

Epigastric region

Answer 5

(+Left/Right Hypochondriac): Stomach area; pancreas, aortic artery

Question 6

Umbilical region

Answer 6

(+Left/Right Lumbar): Is above the umbilicus

Question 7

Suprapubic/Hypogastric region

Answer 7

(+L/R Iliac): Bladder and Pubic bone, Female Reproductive System
Often the 4 quadrants and suprapubic area are used together (bladder)

Question 8

GI subjective assessment

Answer 8

appetite
dysphagia
food allergies/intolerances/foods you avoid
vomiting/nausea
bowel movements
med or surgical abdominal history
meds
nutrition
weight
colon cancer
self care habits

Question 9

GU subjective assessment

Answer 9

• how frequent is urination
• urgent? hesitant?
• what colour?
• smell?
• do you get up to pee in the middle of the night? (nocturia)
• is it painful when you urinate? (dysuria)
• history of infections, childhood infections, inguinal hernia?
• history of kidney problems?
• sexual health history: STI’s, lesions, pain, discharge

male: scrotum/testicular history
female: painful urination? discharge or bleeding? menopause? obstetrical history?

Question 10

abdominal assess inspection

Answer 10

Bring your eyes down level with the abdomen
Contour/Symmetry: Are both sides the same? Is the abdomen flat, scaphoid (concave), rounded or protuberant?
Skin Colour/Condition: Any jaundice, pallor, should be smooth/even
Umbilicus: Are they an innie or an outie
Pulsations: You may see aortic pulsations (epigastric area) or peristalsis
Hair Distribution: Pubic growth
Demeanor: Relaxed, even respirations, normal expression

Question 11

abdominal assess auscultation

Answer 11

Listening for bowel sounds; minimum of 3 gurgling sounds or up to 5 minutes
Listen starting in RLQ then clockwise (RUQ,LUQ,LLQ)
Bowel Sounds:
Normal (Clicking/Gurgling/Bubbling every 5-15 seconds)
Absent (No sounds after 5 minutes; obstructions, ileus, peritonitis)
Sluggish/Hypoactive (Fewer than 3 per minute)
Hyperactive (Prolonged gurgling, borborygmus [could be stomach], increased activity)
Vascular Sounds: 7 areas to listen in
Aortic Area: Between the sternum and umbilicus
Renal Arteries: Left/Right and slightly below aortic
Iliac area: Slightly below umbilicus, left and right; by iliac crest
Femoral area: By femoral artery; groin crease, below iliac
Listening for: bruits (blowing sounds), friction rub (dry grating), venous hum (faint humming)

Question 12

abdominal assessment percussion

Answer 12

Will vary between tympany (air in intestines) and dullness (organs, masses, adipose)
Start in RLQ, sort of zig zag up and then go across to LUQ then zig zag down

Question 13

abdominal assessment palpation

Answer 13

Must be light (about 1cm deep)
With four fingers together, press lightly and rotate a bit to get impression of skin, musculature
Is it soft or firm?
Is it tender or involuntarily guarded (constant rigidity); voluntary guarding = nervous, ticklish
You want to go around from RLQ, clockwise, perhaps two hands, make sure to reach bladder (suprapubic), save any painful areas for last because it will result in guarding

Question 14

GU assessment M/F palpate

Answer 14

Lower abdominal wall/pelvic area over bladder: soft/hard/painful?
Bladder scanners can estimate urine in the bladder if they’re voiding completely
Costovertebral Tenderness: Kidney examination (at Costovertebral Angle/CVA)
On back, subscapular: place hand where kidneys would be; punch hand
Kidney problems = scream out in pain

Question 15

GU assessment on male

Answer 15

Inspect and Palpate: Penis & Scrotum, Inguinal Canal for Hernia, Lymph node enlargement
Hernia: When bowel protrudes through abdominal wall/cavity
Testicular Self Exam: TSE: Timing = Monthly, Shower = Warm, Examine = Any changes
Lumps, bumps, bruises, enlargements, changes in shape
Testicular cancer is common from 15-49; treatable if detected early
Risk Factors: Delayed descent of testicles, family history

Question 16

GU assessment on female

Answer 16

Inspect external genitalia for: structural abnormalities, skin conditions (rashes, irritation, lesions, prolapse, infections)
ADVANCED: Pap smear/Pelvic exam (not us)
Cervical Screening: Pap smear at 21 and every 3 years after if normal
Tests for abnormal (precancerous/cancer) cells, NOT HPV or STD’s
Cancer Care Ontario has guidelines for what’s normal/abnormal
Abnormal tests are reported to public health, they may contact you
STI Screening for those who are sexually active
HPV vaccine is a thing now, often in high schools

Question 17

things to note when working w transgender patients

Answer 17

Describes range of people whose gender ID/expression differs from assigned sex and or sociocultural expectations of assigned sex
Provide best, objective care, be aware of personal biases regardless
Approach with professional attitude, every patient is different
Ask them how they would like to be addressed/approached, anything to keep in mind when doing an assessment — communicate, consent, include important info on chart, pronouns

Question 18

SOAP Documentation

Answer 18

Form of charting other than DARP charting
Subjective: Things you get from health history/subjective assessment
Objective: Things you get from the examination
Assessment: Nursing/medical diagnosis for existing problems
Plan: What interventions are done, follow-up, medications prescribed/changed, further testing or investigation required, next visit

Question 19

Skin and wound assessment

Answer 19

Consists of epidermis/dermis/subcutaneous layers of variable density;
5 strata of epidermal cells - Basale -> Spinosum -> Granulosum -> Lucidum -> Corneum
Top layer (corneum) is the one you can visualize; scaly stuff
Skin is avascular (no blood), has pH of 5-5.9 (acid mantle against bacteria, being in a pool alkalizes)
It’s like a brick and mortar structure of layers on each other
Irritants can’t invade into deeper compartments between corneocytes
Skin protects the hydration status: burns = lots of fluid loss (transepidermal moisture loss is prevented)

Question 20

hair

Answer 20

Has Anagen (growing phase), Catagen, then Telogen (resting phase)
We examine follicles to see if they’re anagen/telogen; if it’s going to regrow or balding
Men generally bald genetically; women can be genetic but could be disease/malnutrition (B12)
People bald in stressful situations/hospital stays

Question 21

typically skin abnormalities

Answer 21

Sunburns/tans (UV light, use at least SPF 30), occupation/exposure, medications (steroids thin skin, antibiotics kill flora, blood thinners promote clotting)
Comorbidities like eczema, diabetes, psoriasis, lupus, hypothyroidism
Rashes, discolouration, irritation, itching (stop scratching! It releases histamines)

Question 22

skin and aging

Answer 22

Aging makes skin thinner (20%), less elastic, fragile, reduced sweat, more tearing, slow heal
Intrinsic Factors: Cell function/turnover, skin function, immune function, fat, vascularity, sweat glands
Factors in the body that make your skin age
Extrinsic Factors: UV light, smoking, pollution, lifestyle
Out of body factors that age your skin

Question 23

skin tears

Answer 23

Shear/friction/blunt force wounds; skin layers are separated
Partial (epidermis) or Full Thickness (deeper)
No skin loss, Partial Flap loss, Total Flap loss

Question 24

solar lentigo

Answer 24

(Liver spots): Melanin freckles; assoc. with sun exposure; totally benign

Question 25

flat lesions

Answer 25

Flat, circumscribed areas graded by size; <1cm = macule, >1cm = patch
Confluent lesions are many that come together as a patch; tinea versicolor infection

Question 26

Raised Skin Lesions:

Answer 26

<1cm = papule (acne), 1-2cm = Nodule (prurigo), >2cm = tumour

Question 27

Fluid-filled Lesions

Answer 27

<1cm = vesicle (chickenpox), >1cm = bulla (blister)

Question 28

Discolouration Lesions

Answer 28

Red-purple, non-blanchable; <0.5cm = petechiae, >0.5cm = purpura, variable (usually >0.5cm) = ecchymosis [bruising]

Question 29

Pustule

Answer 29

Collection of free pus (blister), indicates infection

Question 30

Cyst

Answer 30

Nodule/encapsulated cavity consisting of epithelium-lined cavity filled fluid, tissue, fatty
Treated by lanceting open, evacuating sebaceous material

Question 31

Wheal

Answer 31

Transitory, urticarias (allergies), compressible papule (plaques), dermal edema

Question 32

Maceration

Answer 32

(White discolouration); swell with superhydration; skin is normally staggered/tightly bound but swelling stretches junctions and skin is weaker

Question 33

Fissure:

Answer 33

Linear breaks in skin

Question 34

Erosion:

Answer 34

Partial thickness wound; loss of epidermal layer due to scraping at skin

Question 35

Ulcer:

Answer 35

Deeper, concave compartment, full thickness

Question 36

Moles (Nevus):

Answer 36

Vary in size, pigmentation; present on most anywhere on the body; can be flat, raised, benign, not benign; evaluated with ABCDE
Asymmetry, Border (ragged, blurred), Colour (non-uniform), Diameter (>6mm), Evolution (changes from year to year), can be a melanoma

Question 37

melanoma

Answer 37

Basically an irregular looking mole
Check primary site, sentinel lymph (first place to metastasize), lab studies, family history, clinical exam (because melanomas are aggressive)

Question 38

Basal Cell Carcinoma

Answer 38

Smaller, long time to grow, translucent, has telangiectasia (spider legs)

Question 39

Squamous Cell Carcinoma

Answer 39

Has a mushroom like, pepperoni pizza presentation (20% of all skin cancers); may not be related to sun exposure

Question 40

Braden Pressure Injury Risk Assessment

Answer 40

4 is least impaired, 1 is most impaired
Response to Sensory Perception (Pain) 1-4
Moisture (Perspiration, Urine) 1-4
Activity (Bedfast -> Chairfast -> Walk -> Frequent) 1-4
Mobility (Immobile to No Limitation) 1-4
Nutrition (1/3 of food -> 1/2 of food -> more than half -> most of food) 1-4
Friction/Shear (Assistance in moving) 1-3
Severe Risk: <9, High RIsk = 10-12, Moderate = 13-14, Mild = 15-18
Pressure ulcer

Question 41

skin subjective assessment

Answer 41

• history of skin disease
• changes in pigmentation
• moles?
• dryness or moisture?
• pruritus (is ur skin itchy)
• excess bruising?
• rashes or lesions
• hair loss?
• any changes in nails?
• meds?
• occupation
• self care?

Question 42

objective assessment skin

Answer 42

Any discolouration of the skin (pallor, cyanosis, erythema [redness], jaundice [liver])
Also any moles (ABCDE), lesions
Temperature of the skin: Warm, equal bilaterally
Moisture: Perspiration (diaphoresis), dehydration (in mouth)
Texture: Smooth and firm skin, even surface
Thickness: Uniformly thin; calluses only on hands and feet
Edema: Fluid accumulation; pitting (0-4 grade depending on how long it lasts)
Mobility/Turgor: Pinch skin fold; does it rise easily and does it return quickly (elasticity)
Vascularity/Bruising: Cherry angiomas are normal (1-5mm dots), bruises, tattoos
Lesions: Note the colour, elevation, shape/pattern, size, location/distribution, exudate (stuff seeping out; colour + odour)

Question 43

objective assessment hair

Answer 43

Colour: Is it even, grey, dark (melanin production)
Texture: Is it fine, thick, straight, curly, kinky, shiny – note dull, coarse, brittle
Distribution: Fine hair covering body; pubic/axillary/facial hair, note absent patches
Alopecia, Male pattern baldness
Lesions/Inhabitants: Observe surface to lice, dandruff, itchy lesions

Question 44

nails objective assessment

Answer 44

Shape and Contour: Nail surface is slightly curved or flat, smooth, clean
Lovibond angle: Nailbed of >180deg
Curth’s angle: Distal IP joint is <160deg (observe for clubbing), sign of COPD
Consistency: Smooth and regular, not brittle/splitting or pitted
Colour: Nail plate is window to even, pink nail bed under: Black people may have linear bands of pigmentation or white horizontal streaks from trauma, picking at cuticle
Capillary Refill: Shouldn’t take longer than 1-2 seconds; cardiovascular check