Advanced Nursing Final Exam Guide: Abdominal Assessment 2025 | Complete Solutions

FINAL EXAM ADVANCED ASSESSMENT Abdomen - 1. Review the landmarks that guide the assessment of the abdomen a. between the thorax and pelvis b. bordered i. superiorly by the inferior surface of the dome of the diaphragm (at about the fifth anterior intercostal space) ii. posteriorly by the lumbar vertebrae iii. anterolaterally by flexible multilayered walls of muscles and sheet-like tendons (rectus abdominis, transversus abdominis, internal and external oblique) iv. inferiorly by the pelvic brim, which consists of the iliac crest, anterior superior iliac spine, inguinal ligament pubic tubercle, and symphysis pubis c. abdominopelvic cavity lies between the thoracic diaphragm and the pelvic diaphragm i. two continuous cavities, the abdominal cavity, and the pelvic cavity ii. extended cavity houses most of the digestive organs, the spleen, and parts of the urogenital system 2. What specific nursing interventions are necessary prior to the assessment of the abdomen a. Health History i. The interview of patients presenting with symptoms concerning the abdomen requires a systematic approach. It is often advisable to align your history taking in parallel with the structures within the abdominopelvic cavity as well as its layers. Keep the anatomical placement of the structures in the abdomen in mind to guide your questions. Ask clarifying questions to exactly know what is meant by each symptom. Qualify each symptom by learning about the acuity of onset, triggering events, quality, progression, and exacerbating and relieving factors. 3. List medical disorders that may produce abnormal findings in the abdomen a. Peritonitis i. positive cough test, involuntary guarding, rigidity, rebound tenderness, and percussion tenderness. b. Chronic liver disease i. finding an enlarged palpable liver edge below the ribs is suggestive of an enlarged liver and cirrhosis c. Splenomegaly i. it expands anteriorly, downward, and medially, often replacing the tympany of the stomach and colon with the dullness of a solid organ d. Renal colic or Pyelonephritis i. Pain with pressure or fist percussion supports pyelonephritis if associated with fever and dysuria but may also be musculoskeletal. e. Urinary bladder distention i. not palpable unless it is distended above the symphysis pubis. Causes of bladder distention are outlet obstruction from a urethral stricture or prostatic hyperplasia; medication side effects; and neurologic disorders, such as stroke and multiple sclerosis. Suprapubic tenderness is common in bladder infections f. AAA i. A periumbilical or upper abdominal mass with expansile pulsations that is ≥3 cm in diameter suggests an AAA. g. Ascites i. A protuberant abdomen with bulging flanks is suspicious for ascites, the most common complication of cirrhosis. h. Appendicitis i. Acute Cholecystitis j. Ventral Hernias (abdominal wall hernias) k. Abdominal Wall Mass i. A mass in the abdominal wall remains palpable; an intraabdominal mass is obscured by muscular contraction. 4. Describe and list the variation in techniques required when performing an assessment of the abdomen a. Inspect i. Skin, the contour of the abdomen, pulsations b. Auscultation i. Auscultate the abdomen before performing percussion or palpation, maneuvers that may alter the characteristics of the bowel sounds. ii. Place the diaphragm of your stethoscope gently on the abdomen for a maximum of 5 minutes. iii. Frequency <5 per minute is considered to arise from hypoactive bowel sounds and of >34 per minute from hyperactive bowel sounds. c. Percussion i. Percussion helps you assess the amount and distribution of gas in the abdomen, viscera, masses that are solid or fluid-filled, and the size of the liver and spleen. ii. Percuss the abdomen lightly in all four quadrants to determine the distribution of tympany and dullness. d. Palpation i. Light Palpation. Gentle palpation aids detection of abdominal tenderness, muscular resistance, and some superficial organs and masses ii. Deep Palpation. Deep palpation is usually required to delineate the liver edge, the kidneys, and abdominal masses. 5. Name the organs that are normally palpable in the abdomen a. Several organs are often palpable except for the stomach and much of the liver and spleen, which lie high in the abdominal cavity close to the diaphragm, where they are protected by the thoracic ribs beyond the reach of the palpating hand b. RUQ i. the liver edge can be palpable at the right costal margin ii. gallbladder, which rests against the inferior surface of the liver, and the more deeply lying duodenum are generally not palpable unless pathologic. iii. Moving medially, the examiner encounters the rib cage with its xiphoid process, which protects the stomach iv. abdominal aorta can have visible pulsations and may be palpable in the upper abdomen, or epigastrium in thin patients v. the lower pole of the right kidney and the tip of the 12th floating rib may be palpable, especially in children and thin individuals with relaxed abdominal muscles c. LUQ i. the spleen is lateral to and behind the stomach, just above the left kidney in the left midaxillary line. Its upper margin rests against the dome of the diaphragm. The 9th, 10th, and 11th ribs protect most of the spleen. The tip of the spleen may be palpable below the left costal margin in a small percentage of adults (in contrast to readily palpable splenic enlargement, or splenomegaly) ii. In healthy people, the pancreas cannot be detected d. LLQ i. contains the sigmoid colon. Portions of the distal colon (descending and sigmoid) may be palpable, especially if stool is present ii. In the lower midline are the urinary bladder, which can often be palpated when distended iii. in women, the uterus and ovaries e. RLQ i. The appendix is located at the base of the cecum, the first part of the large intestine where the terminal ileum enters the large intestine at the ileocecal valve. In healthy people, these are not palpable f. The kidneys lie posteriorly in the abdominal cavity behind the peritoneum (retroperitoneal). The ribs protect their upper poles. The costovertebral angle (CVA), formed by the lower border of the 12th rib and the transverse processes of the upper lumbar vertebrae, defines where to elicit for kidney tenderness, called costovertebral angle tenderness 6. State the rationale for performing auscultation of the abdomen before palpation or percussion a. Auscultate the abdomen before performing percussion or palpation, maneuvers that may alter the characteristics of the bowel sounds. 7. Differentiate between and explain the purpose for each: a. Light palpation i. Gentle palpation aids detection of abdominal tenderness, muscular resistance, and some superficial organs and masses ii. Keeping your hand and forearm on a horizontal plane, with fingers together and flat on the abdominal wall, palpate the abdomen with a light gentle dipping motion. As you move your hand to different quadrants, raise it just off the skin. Gliding smoothly, palpate in all four quadrants iii. Identify any superficial organs, masses, or hernias and any area of tenderness or increased resistance to palpation. If resistance is present, try to distinguish voluntary guarding from involuntary guarding or rigidity. Voluntary guarding usually decreases with the techniques listed below. 1. Involuntary guarding or rigidity typically persists despite these maneuvers, suggesting peritonitis. 2. Ask the patient to bend the lower extremities at the hip to make the abdominal muscles less tense 3. Ask the patient to mouth-breathe with the jaws wide open 4. Palpate after asking the patient to exhale, which usually relaxes the abdominal muscles b. deep palpation i. Deep palpation is usually required to delineate the liver edge, the kidneys, and abdominal masses ii. Use one hand over the other to perform this technique. Again, using the palmar surfaces of your fingers, press down in all four quadrants. Identify any masses; note their location, size, shape, consistency, tenderness, pulsations, and any mobility with respiration or pressure from the examining hand. Correlate your findings from palpation with their percussion notes. 8. Describe palpation of the: a. Liver i. Estimate the liver size along right midclavicular line by percussion ii. Palpate and characterize the liver edge (surface, consistency, tenderness) iii. Palpate for the liver edge below the right costal margin 1. Place your right hand on the patient’s right abdomen lateral to the rectus muscle, with your fingertips This is done to prevent mistaking the rectus muscle for the underlying and adjacent liver. Also place your hand well below where you would expect the lower border of the liver, which you previously percussed. Starting palpation too close to the right costal margin risks missing the lower edge of an enlarged liver that extends into the RLQ. Some examiners point their fingers up toward the patient’s head, whereas others prefer a somewhat more oblique position. In either case, press gently in and up. 2. Ask the patient to take a deep breath. Try to feel the liver edge as the air-filled lungs and the diaphragm push the liver down to meet your fingertips. When palpable, the normal liver edge is soft, distinct in outline, and with a smooth surface. If you feel the edge, slightly lighten the pressure of your palpating hand so that the liver can slip under your fingerpads, and you can feel its anterior surface. Note any tenderness (the normal liver may be slightly tender) iv. Firmness or hardness of the liver, bluntness or rounding of its edge, and surface irregularity are suspicious for liver disease. v. On inspiration, the liver is palpable about 3 cm below the right costal margin in the midclavicular line. Some patients breathe more with the chest than with the diaphragm. It may be helpful to ask such patients to “breathe with the abdomen,” which brings the liver, as well as the spleen and kidneys, into a palpable position during inspiration. vi. An obstructed distended gallbladder may merge with the liver, forming a firm oval mass below the liver edge and an area that is dull to percussion. vii. To palpate the liver edge, you may have to adapt your examining pressure to the thickness and resistance of the abdominal wall. If you cannot feel the edge, move your palpating hand closer to the costal margin and try again. A palpable liver edge does not reliably indicate hepatomegaly. viii. Trace the liver edge both laterally and medially. Palpation through the rectus muscles is especially difficult. Describe the liver edge and measure its distance from the right costal margin in the midclavicular line. ix. Hooking Technique. The “hooking technique” may be helpful, especially when the patient is obese. Stand to the right of the patient’s chest. Place both hands, side by side, on the right abdomen below the border of liver dullness. Press in with your fingers and up toward the costal margin. Ask the patient to take a deep breath. The liver edge is palpable with the fingerpads of both hands. b. Spleen i. Percuss for splenic enlargement along Traube space ii. Palpate for the splenic edge with the patient supine and in the right lateral decubitus position iii. Palpate for the splenic edge. To enhance relaxation of the abdominal wall, the patient should keep arms at the sides and, if needed, flex the hips and legs. With your left hand, reach over and around the patient to support and press forward the lower left rib cage and adjacent soft tissue. With your right hand below the left costal margin, press in toward the spleen. Begin palpation low enough so that you can detect an enlarged spleen. If your hand is too close to the costal margin, you will not be able to reach up under the rib cage. The examiner may miss an enlarged spleen by starting palpation too high in the abdomen. iv. Splenomegaly is eight times more likely when the spleen is palpable.32 Causes include portal hypertension, hematologic malignancies, HIV infection, infiltrative diseases like amyloidosis, and splenic infarct or hematoma. v. Ask the patient to take a deep breath. Try to feel the tip or edge of the spleen as it comes down to meet your fingertips. Note any tenderness, assess the splenic contour, and measure the distance between the spleen’s lowest point and the left costal margin. Approximately 5% of normal adults have a palpable spleen tip. vi. The spleen tip is just palpable deep to the left costal margin. vii. Repeat with the patient lying on the right side with the hips and knees partially flexed. In this position, gravity may bring the spleen forward and to the right into a palpable location c. Kidney i. Check for costovertebral angle (CVA) tenderness using fist percussion ii. The kidneys are retroperitoneal and usually not palpable unless markedly enlarged 9. Describe the procedure and rationale for determining costovertebral angle (CVA) tenderness a. Place the palm of one hand along the CVA area. Then make a fist with the other hand and strike the hand already on the CVA with the ulnar surface of your fist Use enough force to cause a perceptible but painless jar or thud on the area. b. Pain with pressure or fist percussion supports pyelonephritis if associated with fever and dysuria but may also be musculoskeletal 10. Review the following techniques a. Murphy’s sign i. Assessing Possible Acute Cholecystitis 1. When a patient presents with RUQ pain suspicious for acute cholecystitis but does not have any tenderness on palpation in the RUQ, the test for Murphy sign can be performed 2. Deeply palpate the RUQ at the location of the patient’s pain. Ask the patient to take a deep breath, which forces the liver and gallbladder down toward the examining fingers 3. A sharp halting in inspiratory effort due to pain from palpation of the gallbladder on examination is a positive Murphy sign. When positive, Murphy sign triples the likelihood of acute cholecystitis. This finding is only useful in a patient who does not have tenderness in the RUQ with regular palpation b. Rebound Tenderness i. Assessing Possible Appendicitis 1. Appendicitis is a common cause of acute abdominal pain especially in the RLQ. Assess for signs of McBurney point tenderness, Rovsing sign (indirect tenderness), the psoas sign, and the obturator sign 2. Appendicitis is twice as likely in the presence of RLQ tenderness, Rovsing sign (indirect tenderness), and the psoas sign; it is three times more likely if there is McBurney point tenderness (McBurney sign) 3. Palpate carefully for an area of local tenderness. Classically, McBurney point lies 2 in from the anterior superior iliac spine on a line drawn from that process to the umbilicus 4. Localized tenderness anywhere in the RLQ, even in the right flank, suggests appendicitis 5. Palpate the tender area for guarding, rigidity, and rebound tenderness 6. Early voluntary guarding may be replaced by involuntary muscular rigidity and signs of peritoneal inflammation. There may also be RLQ pain on quick withdrawal or deferred rebound tenderness c. Rovsing’s sign i. Assessing Possible Appendicitis 1. Palpate for Rovsing sign (indirect tenderness) and referred rebound tenderness. With the patient supine, press deeply and evenly in the LLQ. Then quickly withdraw your fingers. 2. Pain in the RLQ during left-sided pressure is a positive Rovsing sign d. Iliopsoas muscle test i. Assessing Possible Appendicitis 1. Assess the psoas sign. With the patient supine, place your hand just above the patient’s right knee and ask the patient to raise that thigh against your hand. Alternatively, ask the patient to turn onto the left side. Then extend the patient’s right thigh at the hip. Flexion of the thigh at the hip makes the psoas muscle contract; extension stretches it 2. Increased abdominal pain on either technique is a positive psoas sign, suggesting irritation of the right psoas muscle by an inflamed retrocecal appendix e. Obturator muscle test i. Assessing Possible Appendicitis 1. Though less helpful, assess the obturator sign. Flex the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle 2. Right hypogastric pain is a positive obturator sign, from irritation of the right obturator internus muscle by an inflamed appendix located in the pelvis. This sign has very low sensitivity f. How do you estimate liver span i. Estimate the size of the liver by percussion 1. Measure the vertical span of liver dullness in the right midclavicular line after carefully locating the midclavicular line to improve accurate measurement. Use a light to moderate percussion strike because a heavier strike can lead to underestimates of liver size. Starting at a level well below the umbilicus in the RLQ (in an area of tympany, not dullness), percuss upward toward the liver. Identify the lower border of dullness in the midclavicular line 2. Next, identify the upper border of liver dullness. Starting at the nipple line, percuss downward in the midclavicular line until lung resonance shifts to liver dullness. Gently displace a woman’s breast as necessary to be sure that you start in a resonant area. Now, measure the distance between your two points in centimeters —this is the vertical span of liver dullness. If the liver seems enlarged, outline the lower edge by percussing medially and laterally. 3. The span of liver dullness is increased when the liver is enlarged. The span of liver dullness is decreased when the liver is small or when there is free air below the diaphragm, as from a perforated bowel or hollow viscus. 4. Liver dullness may be displaced downward by the low diaphragm of COPD. Span, however, remains normal. g. What methods used to assess for ascites i. A protuberant abdomen with bulging flanks is suspicious for ascites, the most common complication of cirrhosis. Because ascitic fluid characteristically sinks with gravity, whereas gas-filled loops of bowel rise, dullness appears in the dependent areas of the abdomen. There are two techniques for comparative percussion for detecting ascites: 1. Percuss from the area of central tympany to the area of dullness on the supine patient. Start with the patient supine then percuss for dullness outward in several directions from the central area of tympany in the abdomen. Map the border between tympany and dullness Ascites reflects the increased hydrostatic pressure in cirrhosis (the most common cause of ascites), heart failure, constrictive pericarditis, or inferior vena cava or hepatic vein obstruction. It may signal decreased osmotic pressure in nephrotic syndrome, malnutrition, or ovarian cancer. 2. Test for shifting dullness. Percuss the border of tympany and dullness with the patient supine, then ask the patient to roll onto one side. Percuss and mark the borders again. In a person without ascites, the border between tympany and dullness usually stays relatively constant 3. In ascites, dullness shifts to the more dependent side, whereas tympany shifts to the top. 4. A previously utilized test to detect an impulse transmitted through ascitic fluid from one flank to the opposite side (test for a fluid wave) is often negative until ascites is quite obvious, and the test is sometimes positive even in people without ascites. 11. Analyze potential disorders of the abdomen that may be influenced by developmental, psychosocial, cultural, and environmental variations in assessment techniques and abnormal findings of the abdomen Thorax & Lungs - 1. Review the landmarks for Respiratory assessment a. Key Components of the Thorax and Lung Examination i. Survey respiration (rate, rhythm, depth, effort of breathing, signs of respiratory distress). ii. Examine the anterior and posterior chest: iii. Inspect the chest (deformities, muscle retraction, lag). iv. Palpate the chest (tenderness, bruising, sinus tracts, respiratory expansion, fremitus). v. Percuss the chest (flat, dull, resonant, hyperresonant or tympanitic). vi. Auscultate the chest (breath sounds, adventitious, transmitted voice sounds). b. Note special landmarks: i. 2nd intercostal space for needle insertion for decompression of a tension pneumothorax. ii. Intercostal space between the 4th and 5th ribs for chest tube insertion. iii. Level of 4th rib for the lower margin of a well-placed endotracheal tube on a chest x-ray. iv. Posterior: intercostal space between 7th & 8th ribs as a landmark for thoracentesis with needle insertion immediately superior to the 8th rib. c. Chest Circumference i. Midsternal line—drops vertically along the sternum ii. Midclavicular line—drops vertically from the midpoint of the clavicle iii. Anterior axillary line—drops vertically from the anterior axillary fold iv. Midaxillary line—drops vertically from the apex of the axilla v. Posterior axillary line—drops vertically from the posterior axillary fold vi. Scapular line—drops from the inferior angle of the scapula vii. Vertebral line—overlies the thoracic spinous processes d. Lungs, Fissures, and Lobes. i. The left lung has superior and inferior lobes separated by an oblique fissure ii. right lung has oblique and horizontal fissures dividing it into superior, middle, and inferior lobes 2. Describe and list at least 3 types of normal breath sound a. Bronchial - high pitch, loud, inspiration < expiration, harsh hollow tubular, trachea & larynx. b. Bronchovesicuclar - moderate pitch, moderate amplitude, inspiration = expiration, mixed quality, over major bronchi with few alveoli; posterior = b/n scapulae, more on right side. anterior = upper sternum in 1st and 2nd intercostals spaces. c. Vesicular - low pitch, soft, inspiration > expiration, rustling sounding (wind through trees), over peripheral lung fields air flows through smaller bronchioles and alveoli. 3. Define at least three types of adventitious breath sounds a. Fine Crackles - high pitched, short crackling during inspiration b. Coarse Crackles - loud, low pitched sounds start in early inspiration and maybe in expiration c. Atelectatic Crackles - like fine crackles, but do not last, not pathologic, and disappear d. Pleural Friction Rub - superficial, coarse and low pitched, inspiration and expiration e. Wheeze - high pitched, squeaking sounds, dominant in expiration, present in inspiration. f. Wheeze - low pitched, monophonic snoring/moaning, dominant in expiration present in inspiration g. Stridor - high pitched, monophonic, inspiratory, louder in neck than chest wall. 4. What is the difference between abnormal and adventitious breath sounds a. Adventitious (Added) sounds are the medical term for respiratory noises beyond that of normal breath sounds. The sounds may occur continuously or intermittently and can include crackles, rhonchi, and wheezes. b. Adventitious sounds are abnormal breath sounds. Other abnormal sounds could be introduced by auscultating over clothing causing friction, or air movement through a partially obstructed nose or nasopharynx. 5. What is the clinical significance when comparing the anterior-posterior diameter of the chest to the transverse diameter, what is the expected ratio a. Observe the shape of the chest, which is normally wider than it is deep. The ratio of the anteroposterior (AP) diameter to the lateral chest diameter is usually 0.7 to 0.75 up to 0.9 and increases with aging. (The AP ratio may exceed 0.9 in COPD, producing a barrel-chest appearance, although evidence of this correlation is conflicting.) b. AP diameter is < transverse diameter (should be 1:2 - 5:7). Note equal anteroposterior-to- transverse diameter and ribs that are horizontal instead of the normal downward slope, also called Barrel Chest, has a costal angle >90 degrees. This is associated with normal aging and also with chronic emphysema and asthma as a result of hyperinflation of lungs. 6. How do you assess diaphragmatic excursion (descent of the diaphragm) a. You are identifying the boundary between the resonant lung tissue and the duller structures below the diaphragm. Percussing to identify lower borders of lung upon holding deep inspiration and holding deep exhalation. Now, estimate the extent of diaphragmatic excursion by determining the distance between the level of dullness on full expiration and the level of dullness on full inspiration. 7. What is the normal measurement and at what level (diaphragmatic excursion). a. [Normal = 3 to 5.5 cm] b. An abnormally high level suggests a pleural effusion or an elevated hemidiaphragm from atelectasis or phrenic nerve paralysis. c. The diaphragm is attached anteriorly to the xiphoid process and costal margin, laterally to the 11th and 12th ribs, and posteriorly to the lumbar vertebrae. 8. How do you assess for a. Consolidation i. Consolidation refers to the increased density of the lung tissue, due to it being filled with fluid and/or blood or mucus. Ask the patient to say the words: “ninety-nine” while you listen through the stethoscope. Normally the sound of “ninety-nine” will sound very faint and muffled. b. Tactile Fremitus i. Tactile fremitus is decreased or absent when the voice is higher pitched or soft or when the transmission of vibrations from the larynx to the surface of the chest is impeded by a thick chest wall, an obstructed bronchus, COPD, pleural effusion, fibrosis, air (pneumothorax), or an infiltrating tumor. ii. Use either the ball or the ulnar surface of your hand to optimize the vibratory sensitivity of the bones in your hand. Ask the patient to repeat the words “ninety- nine” or “one-one- one.” Use both hands to palpate and compare symmetric areas of the lungs in the pattern shown in Figure 15-18. Identify and locate any areas of increased, decreased, or absent fremitus. If fremitus is faint, ask the patient to speak loudly or in a deeper voice. iii. Asymmetric decreased fremitus raises the likelihood of unilateral pleural effusion, pneumothorax, or neoplasm; asymmetric increased fremitus occurs in unilateral pneumonia which increases transmission through consolidated tissue. c. Bronchophony i. Ask the patient to say “ninety-nine.” Normally the sounds transmitted through the chest wall are muffled and indistinct. Louder voice sounds are called bronchophony. ii. Localized bronchophony and egophony are seen in lobar consolidation from pneumonia. In patients with fever and cough, the presence of bronchial breath sounds and egophony more than triples the likelihood of pneumonia d. Egophony i. Ask the patient to say “ee.” You will normally hear a muffled long E sound. ii. If “ee” sounds like “A” and has a nasal bleating quality, an E-to-A change, or egophony, is present. e. Whispered Pectoriloquy i. Ask the patient to whisper “ninety-nine” or “one-two-three.” The whispered voice is normally heard faintly and indistinctly, if at all. ii. Louder, clearer whispered sounds are called whispered pectoriloquy. Heart and Neck Vessels - 1. Review the conduction system of the heart a. Stimulates and coordinates the contraction of cardiac muscle i. Atrium contracts first then the ventricles b. Electrical impulses originate in the sinus node (aka. Cardiac pacemaker) i. Discharges an impulse anywhere between 60-100x a minute c. Sinus node  AV node  Bundle of His  Bundle branches  Purkinje fibers 2. Discuss the pulmonary and systemic circulation i. Left ventricle  aorta supplies cells  right atrium  right ventricle  pulmonary arteries  lungs  left atrium  starts cycle again b. Pulmonary i. Moves blood between the heart and lungs ii. Transports deoxygenated blood to the lungs to absorb oxygen and release carbon dioxide iii. Oxygenated blood then flows back to the heart c. Systemic i. Moves blood between the heart and rest of the body ii. It sends oxygenated blood out to cells and returns deoxygenated blood to the heart 3. Locate the main structures and vessels of the cardiac system 4. Compare the assessment of carotid pulses versus other peripheral pulses a. Carotid i. Auscultate 1. Auscultate both carotid arteries and listen for a bruit 2. The presence of a bruit could mean carotid atherosclerosis or narrowing of the carotid arteries 3. Ask patient to stop breathing for about 10 seconds 4. Place diaphragm near the upper end of the thyroid cartilage below the angle of the jaw ii. Palpate 1. Palpate the carotid pulse including the upstroke, amplitude and contour a. Amplitude and contour patient should be supine with head of bed at 30 degrees b. Place index and middle fingers or thumb on the artery in the lower third of the neck and palpate for pulsations c. Never palpate both carotid arteries at the same time d. Thrills or throat vibrations can indicate aortic stenosis e. Pulsus alternans: rhythm remains regular but the force of the arterial pulse alternates indicates severe left ventricular dysfunction b. Peripheral pulses i. Radial 1. Palpate the radial pulse with the pads of your fingers on the flexor surface of the lateral wrist. 2. Compare both arms ii. Brachial 1. Flex the patient’s elbow slightly and palpate the artery just medial to the biceps tendon at the antecubital crease iii. Femoral 1. Press deeply below the inguinal ligament about midway between the anterior superior iliac spine and the symphysis pubis iv. Popliteal 1. Patient’s knee should be somewhat flexed, with the leg relaxed 2. Place fingertips of both hands so that they meet in the midline behind the knee and press them deeply into the popliteal fossa v. Pedal Pulses 1. Dorsalis pedis a. Palpate the dorsum of the foot just lateral to the extensor tendon of the great toe 2. Posterior tibial a. Curve fingers behind and slightly below the medial malleolus of the ankle 5. Review characteristics of heart sounds and additional heart sounds such as murmurs and classifications of heart murmurs a. Use the bell of the stethoscope to assess murmurs b. Different heart sounds are distinguished by four characteristics: i. Timing (systolic or diastolic) ii. Intensity (loud or soft) iii. Duration (long or short) iv. Pitch (low or high frequency) c. Attributed to turbulent blood flow and usually indicate valvular heart disease d. Stenotic valve i. Abnormally narrowed orifice that obstructs blood flow e. Regurgitation i. Valve allows blood to leak backward in a retrograde direction f. Location of Murmurs i. Aortic valve 1. Right second intercoastal space or cardiac apex ii. Pulmonic valve 1. Left second and third intercostal spaces close to the sternum, but also at higher or lower levels iii. Tricuspid valve 1. At or near the lower left sternal border iv. Mitral valve 1. At and around the cardiac apex 6. Identify the landmarks for cardiac assessment including the location of each heart sound and cardiac risk factors a. Cardiac Risk Factors i. Obesity (BMI>25 kg/m2) ii. Smoking iii. Dyslipidemia (high cholesterol >200 mg/dL) iv. Hypertension (BP > 120/80 mmHg) v. High fasting glucose (>100 mg/dL) vi. Family History of CVD vii. Unhealthy diet viii. Diabetes (HgbA1C >5.7%) ix. Atrial Fibrillation x. Metabolic Syndrome 1. Any three of the following a. Elevated waist circumference b. Elevated triglycerides c. Reduced HDL d. Elevated BP e. Elevated fasting glucose 7. What physical assessment techniques are utilized when performing the cardiovascular system and list the appropriate sequence a. Note general appearance and measure BP and HR. b. Estimate the level of jugular venous pressure (JVP). i. JVP is usually measured in vertical distance above the sternal angle (angle of Louis) ii. Raise head of the bed to 30 degrees and turn patient’s head to the left c. Auscultate the carotids (bruit) one at a time. d. Palpate the carotid pulse including carotid upstroke (amplitude, contour, timing) and presence of a thrill. e. Inspect the anterior chest wall (apical impulse, precordial movements). i. Stand on patient’s right side and raise head of bed to 30 degrees f. Palpate the precordium for any heaves, thrills, or palpable heart sounds. g. Palpate and locate the PMI or apical impulse. i. Have patient lay in left lateral decubitus position h. Palpate for a systolic impulse of the right ventricle, pulmonary artery, and aortic outflow tract areas on the chest wall i. Auscultate S1 and S2 in six positions from the base to the apex. j. Identify physiologic and paradoxical splitting of S2 k. Auscultate and recognize abnormal sounds in early diastole, including an S3 and OS of mitral stenosis and an S4 later in diastole. l. Distinguish systolic and diastolic murmurs, using maneuvers when needed. If present, identify their timing, shape, grade, location, radiation, pitch, and quality. 8. Identify and discuss medical disorders that may produce abnormal findings in the cardiovascular system a. Myocardial Infarction i. Loss of blood flow to the heart ii. Most commonly reported symptom is chest pain b. Heart Failure i. Shortness of breath is a classic symptom of HF c. Valve Disease i. Common cause of HF ii. Shortness of breath is a common symptom iii. Includes 1. Stiffened valves (stenosis) 2. Valves that close improperly (prolapse) 3. Blood that flows backward (regurgitation) 4. Improperly formed valves (atresia) d. Stroke i. Occurs when a blood vessel to the brain is blocked or bursts ii. Common symptoms 1. F – facial droop 2. A – arm weakness 3. S – slurred speech 4. T - time e. Heart Rhythm Disorders i. Also called arrhythmias ii. Described as abnormal heartbeats or palpitations iii. Other symptoms include: fatigue, SOB, and dizziness f. Peripheral Artery/Vascular Disease i. Decreased blood flow to the veins and arteries in the legs 1. Peripheral Artery Disease (PAD) a. Claudication (pain in the legs) with walking 2. Peripheral Vascular Disease (PVD) a. Achiness, heaviness, tightness in the legs 9. Discuss potential disorders of the cardiovascular system that may be influenced by developmental, psychosocial, cultural, and environmental considerations a. CVD is the leading cause of death in women b. The black population has a higher risk of CVD Peripheral Vascular System - 1. Analyze techniques required for assessment of the peripheral vascular system a. Arms: i. Inspect the upper extremities (size, symmetry, swelling, venous pattern, color). 1. Swelling from lymphedema of the arm and hand may follow axillary node dissection and radiation therapy. 2. Visible venous collaterals, swelling, edema, and discoloration signal upper extremity DVT. ii. Palpate the upper extremities (radial pulse, brachial pulse, epitrochlear lymph nodes). 1. If an artery is widely dilated, it is aneurysmal. 2. Bounding carotid, radial, and femoral pulses are present in aortic regurgitation. 3. Pulsus parvus refers to weak pulses, usually seen with atherosclerotic PVD, while pulsus tardus refers to sluggish pulses, usually occurring in the setting of aortic stenosis or low cardiac output. 4. Raynaud disease, wrist pulses are typically normal, but spasm of more distal arteries causes episodes of sharply demarcated pallor of the fingers. iii. Allens Test 1. Compressing both the radial and ulnar arteries. = Pallor hand when relaxed. 2. Release pressure on ulnar artery. = Palmar flushing. 3. If palm doesn’t flush within 3-5 seconds indicates possible occlusion. b. Abdomen: i. Palpate the inguinal lymph nodes (size, consistency, discreteness, any tenderness). Inspect and palpate the abdomen (aortic width and pulsation). 1. Palpate and estimate the width of the abdominal aorta in the epigastric area by measuring the aortic width between two fingers. Assess for a pulsatile mass. a. Note that an inguinal mass suspicious for an incarcerated hernia is often diagnosed as an AAA at surgery. 2. Palpate the superficial inguinal nodes, including both the horizontal and the vertical groups (Fig. 17-15). Note their size, consistency, and discreteness, and note any tenderness. Nontender, discrete inguinal nodes up to 1 cm or even 2 cm in diameter are commonly palpable in healthy people. ii. Auscultate the abdomen for aortic, renal, and femoral bruits. c. Legs: i. Inspect the lower extremities (size, symmetry, swelling, venous pattern, skin color, temperature, ulcers, hair loss). 1. Calf asymmetry >3 cm increases the risk for DVT to >2.20 Also consider muscle tear or trauma, Baker cyst (posterior knee), and muscular atrophy. 2. Local swelling, redness, warmth, and a subcutaneous cord signal superficial thrombophlebitis, an emerging risk factor for DVT. Asymmetric warmth and redness over the calf signal cellulitis. 3. Unilateral calf and ankle swelling, and edema suggest venous thromboembolism (VTE) from DVT, chronic venous insufficiency from prior DVT, or incompetent venous valves; or it may be lymphedema. If you detect unilateral swelling or edema, measure the calves 10 cm below the tibial tuberosity. Bilateral edema is present in heart failure, cirrhosis, and nephrotic syndrome. Venous distention suggests a venous cause of edema. 4. Ulcers or sores on the feet raise the likelihood ratio (LR) of peripheral vascular disease to 7. 5. Brownish discoloration or ulcers just above the malleolus suggest chronic venous insufficiency. 6. Thickened, brawny skin suggests lymphedema and advanced venous insufficiency. 7. Atrophic and hairless skin is commonly present in PAD but not diagnostic. ii. Palpate the lower extremities (femoral pulse, popliteal pulse, dorsalis pedis pulse, posterior tibial pulse, temperature, swelling, edema). 1. If the femoral pulse is absent, the risk of PAD is >6. If the occlusion is at the aortic or iliac level, all pulses distal to the occlusion are typically affected and may cause postural color changes. 2. An exaggerated, widened femoral pulse suggests the pathologic dilatation of a femoral aneurysm. 3. An exaggerated, widened popliteal pulse suggests a popliteal artery aneurysm. Popliteal and femoral aneurysms are uncommon. They are usually from atherosclerosis and occur primarily in men age ≥50 years. 4. Absent pedal pulses with normal femoral and popliteal pulses raise the risk of PAD to >14. 5. Acute arterial occlusion from embolism or thrombosis causes pain and numbness or tingling. The limb distal to the occlusion becomes cold, pale, and pulseless. Pursue emergency treatment. 6. Asymmetric coolness of the feet has a positive risk of >6 for PAD. 7. Poikilothermia is the relative hypothermia of one extremity as compared with another. It is usually seen in peripheral vascular disease. iii. Pitting edema scale: 1. 1+: Barely detectable impression when finger is pressed into skin 2. 2+: Slight indentation; 15 seconds to rebound 3. 3+: Deeper indentation; 30 seconds to rebound 4. 4+: >30 seconds to rebound. iv. A painful, pale, swollen leg, together with tenderness in the groin over the femoral vein, suggests deep iliofemoral thrombosis. Risk of PE in proximal vein thrombosis is 50%. v. Only half of patients with DVT in the calf have tenderness or venous cords, and absence of calf tenderness does not rule out thrombosis. 2. Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system a. See above… 3. List and describe potential disorders of the peripheral vascular system that may be influenced by developmental, psychosocial, cultural, and environmental considerations (See Image Below) Breast and Axillae, Female and Male Genitalia, Anus, Rectum, and Prostate - 1. Review the anatomy and physiology of the female and male reproductive system 2. Describe techniques required for assessment of the a. Breast i. best time for breast examination in a patient who is still menstruating is 5 to 7 days after the onset of menstruation ii. For postmenopausal women and for men, any time is appropriate iii. Nodules appearing during the premenstrual phase should be re-evaluated after the onset of menstruation. iv. It is advisable that you adopt a standardized approach, especially for palpation, and to use a systemic up-and-down search pattern, varying palpation pressure, and a circular motion with the fingerpads in the breast examination v. In women: 1. Inspect the breasts in four views: arms at sides, arms over head, arms pressed against hips, and leaning forward (skin appearance, size, symmetry, contour, nipple characteristics). 2. Palpate the breasts (consistency, tenderness, nodules, nipple for color, consistency, and quantity of any discharge). 3. Inspect the axillae (rash, irritation, infection, unusual pigmentation). 4. Palpate the axillary nodes (size, shape, delimitation, mobility, consistency, and any tenderness). vi. In men: 1. Inspect the nipple and areola (nodules, swelling, ulceration). 2. Palpate the areola and breast tissue (nodules). b. Female reproductive system i. Perform an external examination: ii. Assess sexual maturity (if adolescent). Inspect the mons pubis, labia, perineum (inflammation, ulceration, discharge, swelling, nodules, any lesions). iii. Perform an internal examination: iv. Inspect the cervix (color, position, surface characteristics, any ulcerations, nodules, masses, bleeding, discharge). v. Inspect the vagina (masses, lesions, or abnormal discharge or bleeding). vi. Perform a bimanual examination: vii. Palpate the cervix (position, shape, consistency, regularity, mobility, tenderness). viii. Palpate the uterus (size, shape, consistency, mobility, any tenderness or masses). ix. Palpate the ovaries (size, shape, consistency, mobility, any tenderness). x. Assess the pelvic floor muscles (strength and tenderness). xi. Perform a rectovaginal examination (if indicated). xii. Pap 1. patient a. Avoids intercourse, douching, or use of vaginal suppositories for 24 to 48 hrs before examination Empties her bladder before the examination b. Lies supine, with head and shoulders elevated, and arms at her sides or folded across the chest to enhance eye contact and reduce tightening of abdominal muscles 2. Examiner a. Obtains permission; selects chaperone Explains each step of the examination in advance b. Drapes the patient from mid-abdomen to knees; depresses the drape between the knees to provide eye contact with patient. Avoids unexpected or sudden movements. Chooses a speculum that is the correct size. Warms the speculum with tap water Monitors the comfort of the examination by watching the patient’s face and obtaining verbal feedback c. Uses excellent but gentle technique, especially when inserting the speculum c. Male reproductive system i. Inspect the skin, prepuce, and glans (ulcers, scars, nodules, inflammation). ii. Inspect the urethral meatus (discharge), and, if indicated, strip or “milk” the penile shaft. iii. Palpate the shaft of the penis (induration, tenderness). Inspect the scrotum including skin, hair, and contour (lesion, swelling, veins, bulging masses, asymmetry). Palpate each testis including the epididymis and spermatic cord (presence, size, shape, consistency, symmetry, tenderness, masses, nodules). iv. Perform special techniques as indicated: v. Evaluate for groin hernias: vi. Inspect for a groin bulge. vii. Palpate for an inguinal hernia (direct or indirect). Palpate for a femoral hernia. viii. Evaluate for scrotal mass. 3. Differentiate normal and abnormal findings in the physical assessment of the: a. Breast i. Common or concerning 1. Breast lump or mass a. Palpable lumps or nodularity and premenstrual enlargement and tenderness are common. If your patient reports a lump or mass, identify the precise location, how long it has been present, if there is any history of trauma, if it is tender, and if there has been any change in size or variation within the menstrual cycle. Ask if there has been any change in breast contour, dimpling, swelling, or puckering of the skin over the breasts. Also, ask about changes of the nipple including skin changes, itchiness, redness, or flakiness. Obtaining a family history of breast cancer and other cancers and additional risk factors, such as age at menarche, age at first birth, age at menopause, prior breast biopsies, and use of hormonal medications are also important. b. Lumps may be physiologic or pathologic, ranging from cysts and fibroadenomas to breast cancer. 2. Breast discomfort or pain a. Breast pain alone (mastodynia or mastalgia) is not typically a sign of breast cancer. Determine if the pain is diffuse (defined as involving >25% of the breast) or focal (involving <25% of the breast), cyclic (pain that occurs prior to menses and generally resolved at the completion of the menstrual period) or noncyclic, or related to medications. b. Medications associated with breast pain include hormone replacement therapy; psychotropic drugs such as selective serotonin reuptake inhibitors; and haloperidol spironolactone, and digoxin. 3. Nipple discharge a. Ask about any discharge from the nipples and when it occurs. It is important to differentiate physiologic discharge from pathologic discharge. Physiologic hypersecretion is seen in pregnancy, lactation, chest wall stimulation, sleep, and stress. If the discharge is spontaneous, note its color, quantity, and frequency of occurrence. b. Nipple discharge is more likely to be pathologic when it is bloody or serous, unilateral, spontaneous, associated with a mass, and occurring in women age ≥40 years. True galactorrhea, or the discharge of milk- containing fluid unrelated to pregnancy or lactation, is most commonly caused by hyperprolactinemia. b. female reproductive system i. Common or concerning 1. Menarche and menstruation a. Menarche—onset of menses b. Dysmenorrhea—pain with menses, often with bearing down, aching, or cramping sensation in the lower abdomen or pelvis c. Premenstrual syndrome (PMS)—a cluster of emotional, behavioral, and physical symptoms occurring 5 d before menses for three consecutive cycles d. Amenorrhea—absence of menses 2. Abnormal bleeding a. Abnormal uterine bleeding—bleeding between menses; includes infrequent, excessive, prolonged, or postmenopausal bleeding b. Postmenopausal bleeding—bleeding occurring 6 mo or more after cessation of menses 3. Menopause a. Menopause—absence of menses for 12 consecutive months, usually occurring between ages 48 and 55 yrs 4. Pelvic pain—acute and chronic a. Acute pelvic pain i. in menstruating adolescent girls and women warrants immediate attention. The differential diagnosis is broad but includes life- threatening conditions such as ectopic pregnancy, ovarian torsion, and appendicitis. ii. As you identify onset, timing, features of the pain, and associated symptoms, you will need to consider infectious, gastrointestinal (GI), and urinary causes. Be sure to ask about STIs, recent insertion of an intrauterine device (IUD), and any symptoms in the sexual partner. A careful pelvic examination, with attention to vital signs, and testing for pregnancy will help narrow your diagnosis and guide further testing. iii. The most common cause of acute pelvic pain is PID, followed by ruptured ovarian cyst and appendicitis. STIs and recent IUD insertion are red flags for PID. Always rule out ectopic pregnancy first with serum or urine testing and possible ultrasound. iv. Also consider mittelschmerz, which is typically a mild unilateral pain lasting for a few hours to a few days arising at midcycle from ovulation, ruptured ovarian cyst, or tubo-ovarian abscess. b. Chronic pelvic pain i. refers to pain that lasts for more than 6 months and does not respond to treatment. It accounts for approximately 10% of ambulatory referrals to gynecologists and 20% of hysterectomies., Risk factors are advancing age, prior pelvic surgery or trauma, parity and childbirth, clinical conditions (obesity, diabetes, multiple sclerosis, Parkinson disease), medications (anticholinergics, α- adrenergic blockers), and chronically increased intra-abdominal pressure (chronic obstructive pulmonary disease, chronic constipation, obesity). Explore gynecologic, urologic, GI, musculoskeletal, and neurologic causes. The Pelvic Pain Assessment Form of the International Pelvic Pain Society, which includes screening questions for depression and physical and sexual abuse, as well as a pain map that women complete, is a helpful resource. Asking the woman to keep a daily pain journal, noting any changes in situational, dietary, or seasonal conditions, may also be useful. ii. Endometriosis, from retrograde menstrual flow and extension of the uterine lining outside the uterus, affects 50% to 60% of women and girls with pelvic pain. Other causes include PID; adenomyosis; and fibroids, which are tumors in the uterine wall or submucosal or subserosal surfaces arising from the smooth muscle cells of the myometrium. iii. Chronic pelvic pain is a red flag for a history of sexual abuse. Also consider pelvic floor spasm from myofascial pain with trigger points on examination 5. Vulvovaginal symptoms a. The most common vulvovaginal symptoms are vaginal discharge and out its amount, color, consistency, and odor. Ask about any local sores or lumps in the vulvar area. Are they painful? Because patients vary in their understanding of anatomical terms, be prepared to try alternative phrasing such as “Any itching (or other symptoms) near your vagina?...between your legs?...where you urinate?” 6. Sexually transmitted infections (STIs) 7. Sexual health 8. Pregnancy 4. Describe developmental, cultural, psychosocial, and environmental variations in assessment and findings 5. List screening measures recommended for early detection of a. Breast i. Breast cancer is the most commonly diagnosed cancer in the world and the leading cause of cancer death among women. ii. Mammography is the primary screening modality for breast cancer. iii. Concerning findings on mammography may be further evaluated with special mammographic views, breast ultrasound, magnetic resonance imaging (MRI), or digital breast tomosynthesis (DBT). b. colon/rectal i. Adults age 50 to 75 yrs—options (grade A recommendation) 1. Stool-based tests a. Fecal immunochemical test (FIT) annually b. High-sensitivity guaiac-based fecal occult blood testing annually c. FIT-DNA testing every 1 or 3 yrs 2. Direct visualization tests a. Colonoscopy every 10 yrs b. Sigmoidoscopy every 5 yrs c. Flexible sigmoidoscopy every 10 yrs with FIT every 3 yrs d. CT colonography every 5 yrs ii. Adults age 76 to 85 yrs 1. individualized decision making (grade C recommendation), decisions should take into consideration life expectancy and previous screening. Previously unscreened adults might benefit from screening. iii. Adults older than age 85 a. do not screen (grade D recommendation), because “competing causes of mortality preclude a mortality benefit that would outweigh the harms” c. prostate cancer i. Prostate cancer is the leading cancer diagnosed in men in the US, and the third leading cause of death. ii. The prostate-specific antigen (PSA) blood test is the primary prostate cancer screening test. 6. Define a. Hemorrhoids i. External hemorrhoids are dilated hemorrhoidal veins that originate below the pectinate line that is covered with skin. They seldom produce symptoms unless thrombosis occurs. Thrombosis causes acute local pain that increases with defecation and sitting. A tender, swollen, bluish, ovoid mass is visible at the anal margin ii. Internal hemorrhoids are enlargements of the normal vascular cushions located above the pectinate line, usually not palpable. Internal hemorrhoids may cause bright-red bleeding, especially during defecation. They may also prolapse through the anal canal and appear as reddish, moist, protruding masses, typically located in one or more of the positions illustrated. b. Melena i. Black tarry stools c. Fissure i. An anal fissure is a very painful tear/ulceration of the anoderm, found most commonly in the midline posteriorly, less commonly in the midline anteriorly. Its long axis lies longitudinally. There may be a swollen “sentinel” skin tag just below it. Gentle separation of the anal margins may reveal the lower edge of the fissure. The sphincter is spastic; the examination is painful. An examination under anesthesia may be necessary to fully characterize the lesion. d. Steatorrhea i. Fatty diarrheal stools 7. How would you teach a. breast self-examination (BSE) i. A thorough examination takes at least 3 minutes for each breast ii. Use the pads of the second, third, and fourth fingers, keeping the fingers slightly flexed iii. Important to be systematic iv. The Vertical strip pattern is currently the best-validated technique for detecting breast masses v. Palpate in small, concentric circles applying light, medium, and deep pressure at each examining point vi. Press more firmly to reach the deeper tissues of a large breast b. testicular self-examination (TSE) i. This examination is best performed after a warm bath or shower. This way, the scrotal skin is warm and relaxed. It is best to do the test while standing. ii. Standing in front of a mirror, check for any swelling on the skin of the scrotum. iii. With the penis out of the way, gently feel your scrotal sac to locate a testicle. Examine each testicle separately. iv. Use one hand to stabilize the testicle. Using the fingers and thumb of your other hand, firmly but gently feel or roll the testicle v. between your fingers. Feel the entire surface. Find the epididymis. This is a soft, tube-like structure at the back of the testicle that collects and carries sperm and is not an abnormal lump. Check the other testicle and epididymis the same way. vi. If you find a hard lump, an absent or enlarged testicle, a painful swollen scrotum, or any other differences that do not seem normal, do not wait. See your healthcare provider right away. 8. List at list six risk factors for breast cancer a. Age b. Race/Ethnicity c. Personal History of breast cancer d. Chest radiation e. Genetic mutation f. First-degree relatives w/ breast cancer 9. Your patient just turns 55 years old and is menopausal. How often should the following tests be performed a. Mammogram i. every 2 years b. physical examination i. Insufficient evidence to assess the additional benefits and harms beyond screening mammography c. breast self-examination i. Recommends against teaching breast self-examination, supports breast self-awareness 10. List some of the changes that occur in the breast with aging a. After menopause, there is atrophy of glandular tissue and a notable decrease in the number of lobules. 11. How would these changes affect the breast examination Elderly, Children, and Infant Assessment - 1. Review several theories of aging a. Biologic theories of aging i. Concerned with answering basic questions regarding physiologic processes that occur in all living organisms over time b. Sociologic theories of aging i. Focused on the roles and relationships within which individuals engage in later life. c. Psychologic theories of aging i. Influenced by both biology and sociology; address how a person responds to the tasks of his or her age. d. Moral/spiritual theories of aging i. Examine how an individual seeks to explain and validate his or her existence 2. Identify normal anatomical and physiological changes in older adults iii. BP: SBP tends to rise with aging, especially in Europe, as well as many countries with substantial European ancestral populations in the Americas. The aorta and large arteries stiffen and become atherosclerotic. iv. V/S: In older adults, resting HR remains unchanged. Older adults are more likely to have abnormal heart rhythms such as atrial or ventricular ectopy. Respiratory rate and temperature remain unchanged. v. Skin, hair, nails: 1. With age, the skin wrinkles, becomes lax and loses turgor. The dermis is less vascular, causing lighter skin to look paler and opaquer. Skin on the backs of the hands and forearms appears thin, fragile, loose and transparent. There may be purple patches or macules, termed actinic purpura, that fade over time. These spots and patches come from blood that has leaked through poorly supported capillaries and spread within the dermis. 2. Nails lose luster with age and may yellow and thicken, especially on the toes. Hair undergoes a series of changes. Hair loss on the scalp is genetically determined. vi. Eyes 1. Eyes, ears and mouth show more visible changes of aging. The fat that surrounds and cushions the eyes within the bony orbit may atrophy, making the eyeballs appear to recede. The skin of the eyelids becomes wrinkled and may hang in looser folds. 2. Pupils become smaller, making it more difficult to examine the ocular fundi. Visual acuity remains fairly constant between ages 20 and 50 years. Aging increase the risk of developing cataracts, glaucoma and mascular degeneration. vii. Ears: 1. Hearing acuity usually declines with age viii. Nose, mouth, teeth, lymph nodes 1. Decreased salivary secretions and loss of taste. Decreased olfaction and increased sensitivity to bitterness and saltiness also affect test. Teeth may wear down , become abraded, or fall out due to dental caries or periodontal disease. Bony ridges of the jaws that once surrounded the tooth sockets are gradually resorbed, especially in the lower jaw. 2. Cervical lymph nodes become less palpable. ix. Thorax and lungs 1. People lose lung capacity during exercise. The chest wall becomes stiffer and harder to move, respiratory muscles may weaken and the lungs lose some of their elastic recoil. Diaphragmatic strength declines. 2. There is a decrease in arterial pO2, but the O2 saturation normally remains above 90%. x. Cardiovascular system 1. A number of changes occur in the neck vessels, cardiac output, heart sounds and murmurs 2. Risk of heart failure increases with loss of atrial contraction and onset of A-fib due to decreased ventricular filling 3. Decreased ventricular compliance and impaired ventricular filling result in a fourth heart sound, often heard in otherwise healthy older people 4. Middle-aged and older adults commonly have a systolic aortic murmur xi. Peripheral vascular system: 1. Peripheral arteries tend to lengthen, become tortuous and feel harder and less resilient. There is increased arterial stiffness and decreased endothelial function xii. Breast/axillae: 1. Normal adult female breast is soft but may be granular, nodular or lumpy. With aging, breasts tend to get smaller, more flaccid and more pendulous as glandular tissue atrophies and is replaced by fat xiii. Abdomen: 1. Abdominal muscles tend to weaken, fat may accumulate in the lower abdomen and near the hips xiv. Male/female genitourinary system: 1. As men age, sexual interest appears to remain intact 2. Several physio changes accompany decreasing testosterone levels 3. Penis decreases in size, testicles drop lower in the scrotum 4. Pubic hair may decrease and become gray 5. ED affects approximately 50% of older men 6. Ovarian function usually starts to decline during the 5th decade 7. Menstrual periods cease between age 45-52 8. Many women experience hot flashes as estrogen stimulation falls 9. Vagina narrows and shortens, vaginal mucosa becomes thin, pale, dry, with loss of lubrication. Uterus and ovaries diminish in size. 10. Within 10 years after menopause, the ovaries are usually no longer palpable. 11. Prevalence of urinary incontinence increases with age due to these age-related changes. Changes include decreased innervation and contractility of the detrusor muscle, loss of bladder capacity, urinary flow rate, and the ability to inhibit voiding xv. Musculoskeletal system: 1. Increased risk of fracture with age due to losing cortical and trabecular bone 2. Calcium resorption from bone, rather than diet, increases with aging as parathyroid hormone levels rise 3. Most loss of height occurs in the trunk and reflects thinning of the intervertebral discs leading to kyphosis 4. Added flexion at knees and hips also contributes to shortened stature 5. ROM diminishes due to osteoporosis xvi. Nervous system 1. Aging affects all aspects of the nervous system, from mental status to motor and sensory function and reflexes 2. Most older adults maintain their self-esteem and adapt well to their changing capacities and circumstances 3. Describe techniques required to assess older adults xvii. Assessing and establishing functional status provides a baseline for making interventions that optimize the patient’s level of function and for identifying geriatric syndromes that can be treated or delayed. Assessment begins as the patient enters the room i. 10-minute geriatric screener (covers 3 important areas) 1. Cognitive 2. Psychosocial 3. Physical ii. Timed Get Up and Go (TUG) (tests for gait and balance, excellent screening tool for risk of falling) iii. To identify causes of transient incontinence, DIAPPERS mnemonic may be helpful: xviii. Delirium xix. Infection (e.g. UTI) xx. Atrophic urethritis or vaginitis xxi. Pharmaceuticals (e.g. diuretics, calcium channel blockers, opoiods, etc) xxii. Psychological disorders (e.g. depression) xxiii. Excessive urine ouput (e.g. HF, uncontrolled diabetes) xxiv. Restricted mobility (hip fracture, environmental barriers, restraints) xxv. Stool impaction 4. Differentiate between the normal and abnormal findings in the comprehensive assessment of older adults a. Hypothermia is more common in older patients b. Low weight is a key indicator of poor nutrition c. Kyphosis or abnormal gait can impair balance and increase risk of falls d. Any lumps or masses in older women, and more rarely, in older men, mandate further investigation for possible breast cancer e. Enlarging uterine fibroids can be normal OR malignant leiomyosarcoma f. Male and female pattern hair loss are normal with aging cal disor lts with h fib ases risk st common ences be e ach bod mal openi p e in infants fections. y occasion a in infancy. uld use to ment Downloaded by Mike Splendid () a. See charts below. 8. What general approaches to the pediatric assessment may help your patient be more comfortable and cooperative a. For an infant b. For a Toddler or preschooler c. For an older child i. The child should remain dressed during the interview to minimize the child’s apprehension ii. Gain the child’s confidence and allay the child’s fears from the start of the encounter iii. Engage child in age-appropriate conversation. Ask simple questions about their illness or toys iv. If a child is shy, turn your attention to the parent to allow the child to warm up gradually v. Many older children are modest. Providing gowns and leaving underwear in place as long as possible are wise approaches. Consider leaving the room while they change with their parents’ help. vi. Always examine painful aeras last and forewarn children about areas you are going to examine. If a child resists part of the examination, you HEEADSSS Assessment – Home environment, Education and Employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression, and Safety from injury and violence. a. Valuable tool for assessing the physical, emotional and social well-being of adolescents. 9. Analyze the physical, cognitive, and emotional development of children when performing a physical assessment Downloaded by Mike Splendid () a. Information about the child’s development and behavior are gathered from multiple sources which can involve direct observation of the child’s behavior as well as expressed concerns from parents and others b. Physical development encompasses both gross and fine motor abilities i. Examples of gross motor skills: walking, sitting, transferring from one position to another, manipulation of objects with hands c. Cognitive development is a measure of the child’s ability to problem solve through intuition, perception and verbal and nonverbal reasoning i. Also involves the child’s ability to retain information and then apply it when appropriate d. Social/emotional development encompasses the child’s ability to form and maintain relationships i. Also measures their responsiveness to the presence of others ii. Involves the formation of self-help skills through ADLs such as feeding, dressing and toileting 10. How might children view or respond to illness and hospitalization a. Normal toddlers are occasionally alarmed at the examiner. b. Some will be uncooperative, but most will eventually warm up to you. If this behavior continues or is not developmentally appropriate, there may be an unde