week 4: skin, hair, nails; gastrointestinal; genitourinary gastrointestinal assessment Flashcards
right upper abdominal quadrant
Bowel and Liver
right lower ab quadrant
Bowels and appendix
left upper ab quadrant
Stomach, bowel, spleen, pancreas
left lower ab quadrant
Mostly just bowels here
Epigastric region
(+Left/Right Hypochondriac): Stomach area; pancreas, aortic artery
Umbilical region
(+Left/Right Lumbar): Is above the umbilicus
Suprapubic/Hypogastric region
(+L/R Iliac): Bladder and Pubic bone, Female Reproductive System
Often the 4 quadrants and suprapubic area are used together (bladder)
GI subjective assessment
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
GU subjective assessment
- 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?
abdominal assess inspection
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
abdominal assess auscultation
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)
abdominal assessment percussion
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
abdominal assessment palpation
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
GU assessment M/F palpate
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
GU assessment on male
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
GU assessment on female
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
things to note when working w transgender patients
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
SOAP Documentation
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
Skin and wound assessment
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)
hair
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
typically skin abnormalities
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)
skin and aging
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
skin tears
Shear/friction/blunt force wounds; skin layers are separated
Partial (epidermis) or Full Thickness (deeper)
No skin loss, Partial Flap loss, Total Flap loss
solar lentigo
(Liver spots): Melanin freckles; assoc. with sun exposure; totally benign
flat lesions
Flat, circumscribed areas graded by size; <1cm = macule, >1cm = patch
Confluent lesions are many that come together as a patch; tinea versicolor infection
Raised Skin Lesions:
<1cm = papule (acne), 1-2cm = Nodule (prurigo), >2cm = tumour
Fluid-filled Lesions
<1cm = vesicle (chickenpox), >1cm = bulla (blister)
Discolouration Lesions
Red-purple, non-blanchable; <0.5cm = petechiae, >0.5cm = purpura, variable (usually >0.5cm) = ecchymosis [bruising]
Pustule
Collection of free pus (blister), indicates infection
Cyst
Nodule/encapsulated cavity consisting of epithelium-lined cavity filled fluid, tissue, fatty
Treated by lanceting open, evacuating sebaceous material
Wheal
Transitory, urticarias (allergies), compressible papule (plaques), dermal edema
Maceration
(White discolouration); swell with superhydration; skin is normally staggered/tightly bound but swelling stretches junctions and skin is weaker
Fissure:
Linear breaks in skin
Erosion:
Partial thickness wound; loss of epidermal layer due to scraping at skin
Ulcer:
Deeper, concave compartment, full thickness
Moles (Nevus):
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
melanoma
Basically an irregular looking mole
Check primary site, sentinel lymph (first place to metastasize), lab studies, family history, clinical exam (because melanomas are aggressive)
Basal Cell Carcinoma
Smaller, long time to grow, translucent, has telangiectasia (spider legs)
Squamous Cell Carcinoma
Has a mushroom like, pepperoni pizza presentation (20% of all skin cancers); may not be related to sun exposure
Braden Pressure Injury Risk Assessment
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
skin subjective assessment
- 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?
objective assessment skin
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)
objective assessment hair
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
nails objective assessment
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
