NR 304 Exam 1 Study Guide Health Assessment II - Chamberlain

NR 304 Exam 1 Study Guide: Health Assessment II – Chamberlain NR 304 Exam 1 Study Guide: Health Assessment II - Chamberlain 50 Questions – Multiple Choice, Select All That Apply, HOTSPOT, Multiple Sequences Chapter 18 – Peripheral Vascular location 2 Pediatric (BP measurements; lymph nodes) • • Do not take blood pressure measurements until the child is 18 months of age. • There is an increased pulse rate with fever • Lymphatic system o At birth it is well developed o Grows rapidly until 10 to 11 years of age o Lymph nodes are relatively large and often palpable Pregnant (BP changes throughout, varicosities) • Need to monitor blood pressure throughout pregnancy o Vasodiation due to hormone change o There is hyotension during the third trimester o Preeclampsia may result in hypertension ▪ Preeclampsia is when a pregnant woman develops high blood pressure and protein in the urine after the 20th week (late 2nd or 3rd trimester) of pregnancy. • Varicosities in the legs and the rectal area o This is because the uterus obstructs the iliac veins and inferior vena cava ▪ This causes an increase in the venous pressures of the lower legs. Geriatric (Systolic BP & pulse changes; enlargement of calf veins; lymph nodes) • There is an increase in blood pressure, especially the systolic o Arteriosclerosis - peripheral blood vessels more rigid • Decrease in pulse with some irregularities • Progressive enlargement of calf veins o You have an increased risk for deep vein thrombosis (DVT) ▪ Deep vein thrombosis (DVT) occurs when a blood clot (thrombus) forms in one or more of the deep veins in your body, usually in your legs. o possible pulmonary embolism (PE) ▪ Pulmonary embolism is when one or more pulmonary arteries in your lungs become blocked. In most cases, pulmonary embolism is caused by blood clots that travel to the lungs from the legs o DVT and PE cause prolonged bed rest, immobility, and CHF o Low-dose anticoagulation (ASA 80-160mg) reduces risk • There is a loss of lymph tissue o There are less lymph nodes and a decrease in size of the nodes Subjective Leg pain or cramps – differences between acute and chronic arterial and venous pain (see handout) Claudication distance; 6 Ps; Leriche syndrome; risk factors/conditions • Claudication distance – number of blocks or stairs climbed to produce pain; relieved by rest • To relieve arterial pain you dangle your legs over a ledge • To relieve venous pain raise your legs up • Night leg pain is common with aging • Restless leg syndrome, muscle cramping or rest pain associated with vascular disease. In addition, some patients suffer from restless leg syndrome pain at night, worsening with rest and relief with motion of the legs. One diagnoses restless leg syndrome by history and physical examination • Nocturnal cramping is much more common in older patients. As noted earlier, nocturnal cramping is typically associated with dehydration, low calcium, low sodium, low potassium or low magnesium, which one may assess by standard laboratory studies and treat by appropriate supplement therapy. • Leriche's syndrome is the term used for a group of symptoms that are caused by a certain type of peripheral arterial disease of the legs. In Leriche's syndrome, blood flow in the aorta is blocked in the stomach area. This blocks blood flow to the legs. In men, blood flow to the penis is also blocked. • When your iliac arteries narrow or become blocked, your legs may not receive the blood and oxygen they need. This lack of oxygen is called ischemia and it can cause pain. Skin changes – color (redness, pallor, blueness, brown); varicose veins; ulcers (arterial versus venous) • Color- redness, pallor, blueness, brown • Varicose veins- leg veins bulging or cooked • Temperature- excessive warm or cool Swelling – bilaterally versus unilateral; aggravating and relieving factors; associated symptoms • Bilaterally is CHF • Unilateral is obstruction and inflammation Lymphedema • Lymphedema refers to swelling that generally occurs in one of your arms or legs. Although lymphedema tends to affect just one arm or leg, sometimes both arms or both legs may be swollen. • Lymphedema is caused by a blockage in your lymphatic system, an important part of your immune and circulatory systems. The blockage prevents lymph fluid from draining well, and as the fluid builds up, the swelling continues Medications (oral contraceptives, hormone replacement) • Oral risk of stroke and breast cancer Objective Techniques (inspection, palpation, auscultation, BP measurement) BP measurement – NIH guidelines normal for systolic and diastolic BP Inspection & Palpation of Arms (normal findings for color, temperature, texture, turgor, clubbing, capillary refill, pulses, and lymph nodes) • R Inspect and Palpate the Arms o Color of skin and nail beds o Temperature, texture, turgor o Lesions, edema, or clubbing o Capillary refill (< 1-2 seconds) o Symmetric in size o Radial, brachial arteries (2+) Epitrochlear, axillary lymph nodes (non-palpableaynaud’s Disease (description, tricolor changes, associated symptoms, risk factors) • Raynaud’s Disease o Abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress: ▪ White (pallor) from arteriospasm ▪ Blue (cyanosis) slight relaxation ▪ Red (rubor) in heel of hand due to return of blood o Associated symptoms ▪ Cold, numbness, pain ▪ Burning, throbbing pain, swelling o Lasts minutes to hours; bilaterally; drugs, smoking Normal characteristics of peripheral pulses (Rate, rhythm, symmetry, amplitude) Normal and Abnormal Pulses (Normal, Absent, Bounding, Pulsus Alternans, Pulsus Bigeminus, Pulsus Paradoxus) – Know characteristics and contributing conditions Allen Test (Know technique and normal findings) • Evaluate patency of radial and ulnar arteries • Steps: • Compress radial arteries both wrists with your thumbs • Ask person open and close fists several times • While still compressing the radial arteries, ask the person to open his hands • Palms should become pink immediately, indicating patent ulnar arteries (2 to 5 seconds) • Next occlude the ulnar arteries and repeat the same procedure to test the patency of the radial arteries Inspection & Palpation of Legs (normal findings for color, hair distribution, venous pattern, size, lymph nodes, pulses, pretibial edema) • Skin color ▪ Pallor – vasoconstriction ▪ Erythema – vasodilation ▪ Brown discoloration with chronic venous stasis • Stasis dermatitis • Hair distribution is even and on the dorsal on the toes • Venous pattern is flat and barely visible • Size is symmetrical without swelling or atrophy ▪ Measure calf circumference with tape measure at widest point Stasis dermatitis; Ulcers (arterial versus venous) • Stasis dermatitis is skin inflammation caused by blood pooling in the veins in your legs. Pooling of blood in the veins of the legs is called venous insufficiency or venous stasis. • Arterial Insufficiency o Tips of toes or between toes; over phalangeal heads; above lateral malleolus, over metatarsal heads, on side of sole of feet; deep, pale base; regular borders; necrotic tissue • Chronic Venous Insufficiency o Anterior to medial malleolus, irregular borders; ruddy granulation tissue, no necrotic tissue; reddish brown pigmentation; edema may leak or weeping Pitting edema (grading system); Non-pitting edema (measurement) Venous tests (Manual compression test; Homan’s sign) • Manual compression test o Compress vein o Feel for wave o No wave = competent valves o Wave felt = incompetent valves Arterial test (Color change; Ankle-Brachial Index and normal/abnormal findings) • Ankle-Brachial Index (ABI) o Extent of peripheral arterial disease (PAD) o BP cuff above ankle, doppler stethoscope over posterior tibial or dorsalis pedis artery o Normal ankle BP slightly greater than or equal to brachial BP o 132 ankle systolic pressure = 1.06 or 106% o 124 arm systolic pressure No flow reduction Chapter 19 – Abdomen Abdominal landmarks; 4 versus 9 quadrants • The abdominal landmarks are o Xiphoid process o Umbilicus o Costal margin o Iliac crest o Pubic bone Pediatric – contour, respirations, peristalsis; hernias • There is rounding of the infants abdomen • Presence of the umbilical cord • Toddlers are more abdominal breathers (respirations are more abdominal) • Visible peristaltic waves o Muscles contract in a wave-like motion to move the food along through the digestive tract. This muscle movement is called, peristalsis, or peristaltic waves. • Congenital defects • Umbilical hernia o An umbilical hernia occurs when part of the intestine protrudes through an opening in the abdominal muscles. o Umbilical hernias are most common in infants, but they can affect adults as well. In an infant, an umbilical hernia may be especially evident when the infant cries, causing the baby's bellybutton to protrude. • Incisional hernia o An incisional hernia happens when a weakness in the muscle of the abdomen allows the tissues of the abdomen to protrude through the muscle. The hernia appears as a bulge under the skin, and can be painful or tender to the touch. Pregnant – fundal height, GI symptoms, skin changes (linea nigra, straie) Enlarging of the abdomen Fundal height measurements Gastrointestinal discomfort Skin changes o Linea nigra ▪ dark vertical line between your belly button and pubic area o straie ▪ These are slightly depressed linear marks with varying length & width in pregnancy. ▪ Striae gravidarum are a cutaneous condition characterized by stretch marks on the abdominen during and following pregnancy. Geriatric considerations – contour, intestinal activity, teeth and dietary changes • Rounding and protrusion of the abdomen • Decrease in intestinal activity • Changes in the teeth • Dietary changes Subjective Appetite change, anorexia • Anorexia is the loss of appeptite Anorexia nervosa versus anorexia bulimia • People with anorexia nervosa have intense fears of becoming fat and see themselves as fat even when they are very slender. These individuals may try to correct this perceived "flaw" by strictly limiting food intake and exercising excessively in order to lose weight. • Bulimia is an illness in which a person binges on food or has regular episodes of overeating and feels a loss of control. The person then uses different methods -- such as vomiting or abusing laxatives -- to prevent weight gain. Many (but not all) people with bulimia also have anorexia nervosa. Dysphagia • Dysphagia difficulty swallowing Food intolerance (types of foods and reactions; pyrosis; eructation; GERD • Pyrosis is heartburn • GERD- Gastroesophageal reflux disease (GERD) is a condition in which the stomach contents (food or liquid) leak backwards from the stomach into the esophagus (the tube from the mouth to the stomach). This action can irritate the esophagus, causing heartburn and other symptoms • Eructations- Bleching • Celiac disease is an immune reaction to eating gluten, a protein found in wheat, barley and rye. • Lactose- Lactose intolerance is a condition in which people have digestive symptoms—such as bloating, diarrhea, and gas—after eating or drinking milk or milk products. Abdominal pain (visceral versus parietal; colic); referred cutaneous pain areas; acute versus chronic • Visceral- Dull, general, poorly localized • peritonitis Parietal from inflammation over peritoneum • Sharp, precisely localized, aggravated by movement • Referred -disorder in another site • Acute pain is short term pain • Chronic is longer than 6 months • Colic- cramping Nausea/Vomiting (hematemesis; symptom analysis questions) • Hematemesis- vomiting up blood. • Bowel Habits (symptom analysis questions; meaning of different colors of stool) • Melena- is the passage of black tarry stools. • Non-tarry stool is due to iron medication • Gray stool- is due to hepatitis and • Red Blood in stool- This means GI bleeding or localized around anus bleeding Past Abdominal history (conditions) Medications/Habits/Conditions (NSAIDs, alcohol, smoking, H-pylori) • Peptic ulcer disease refers to painful sores or ulcers in the lining of the stomach or first part of the small intestine, called the duodenum. • NSAIDs can cause ulcers in the stomach and promote bleeding. o Aspirin o Ibuprofen o Naproxen Nutritional Assessment (Differences between toddlers, geriatric, and teenagers) • Toddlers often eat things that are non-foods such as grass and dirt. This is called pica. • Geriatrics have a risk of nutritional loss and loss of weight. 24 hour food diary or weekly patterns help. • Adolescents o Anorexia nervosa ▪ Loss of appetite, voluntary starvation, grave weight loss ▪ May exercise, often hyperactive; amenorrhea ▪ Associated with family problems, control issues, psychological o Bulimia nervosa ▪ Binging (eats a lot of food in short period of time) plus ▪ Purging (vomiting, use of laxatives) ▪ Unlike anorexia, people with bulimia can be normal range for their age and weight. But like people with anorexia, bulimics: ▪ Fear gaining weight, want desperately to lose weight, unhappy with their body size and shape Objective Techniques (Inspection, auscultation, percussion, palpation) – note order change ▪ Techniques o Inspection o Auscultation o Percussion o Palpation Inspection (normal findings for contour, symmetry, umbilicus, skin, pulsation, hair distribution, demeanor); Know all different types of contours and conditions associated with each • Umbilicus o , Midline, inverted, no inflammation or redness • Anterior-posterior, epigastric area just left of midline • Abdominal aortic aneurysm (AAA)- is an enlarged area in the lower part of the aorta, the major blood vessel that supplies blood to the body. The aorta, about the thickness of a garden hose, runs from your heart through the center of your chest and abdomen. Because the aorta is the body's main supplier of blood, a ruptured abdominal aortic aneurysm can cause life-threatening bleeding. o As an abdominal aortic aneurysm enlarges, some people may notice: ▪ A pulsating feeling near the navel ▪ Deep, constant pain in your abdomen or on the side of your abdomen ▪ Back pain Auscultation (Why is this technique second? Which quadrant do you start? Which side of stethoscope? Stomach growling bowel sounds are called? ) Characteristics of normal, hypoactive, and hyperactive bowel sounds. Know 3 types of vascular sounds, stethoscope use, auscultatory areas for vascular sounds, and causative factors for each sound. • When you palpate and percuss the bowels you may stimulate bowel movements that does not represent the true state of the bowels. You want to listen to the bowel “we they are” • Percussion and palpation can increase peristalsis • Begin in RLQ, normally sounds always present here • Diaphragm • Normal bowel sounds o High-pitched, gurgling, cascading, irregular from 5 to 30 times per minute • Hypoactive or absent; listen for 5 minutes o Post-operative period, peritonitis, paralytic ileus, pneumonia • Hyperactive o Loud, high-pitched, rushing, tinkling sounds o “borborygmus” – stomach growling conditions increased peristalsis o Early bowel obstruction, gastroenteritis, diarrhea, laxative use, subsiding paralytic ileus • Vascular Sounds o Bruits ▪ Turbulent blood flow (stenosis, AAA) ▪ Bell; murmurs o Venous hums ▪ Rare, originates from inferior vena cava (portal HTN, cirrhosis) ▪ Bell; medium pitch, continuous sound; may have thrill o Peritoneal friction rubs ▪ Peritonitis (liver or spleen abscess, infection, or tumor) ▪ Bell; rough, grating sound, like 2 pieces of leather rubbing together Percussion (General note over abdomen? Normal liver span @ RMCL and midsternal?) Percussive notes over liver, spleen? Technique and meaning of CVA tenderness? Percussive notes associated with ascites and techniques to detect extent of fluid? • General Tympany • Liver Span • Splenic Dullness • Costovertebral Angle Tenderness (CVA) o Flat hand, ulnar surface; Dull thud normal o Negative CVA tenderness, no pain o Positive CVA tenderness, sharp pain kidney inflammation • Special Procedures Palpation (General instructions; light versus deep palpation; bimanual technique; abnormal findings and characteristics of a mass if detected; normal findings for liver, spleen, kidneys and aorta; why should you not palpate enlarged spleen or abdominal aorta? • General Instructions o Bend the person’s knees, empty bladder o “Ticklish person”, keep person’s hand under your own • Light and Deep Palpation o Light – 1cm; first 4 fingers, rotary motion; clockwise; o Deep – 5 to 8 cm (2 – 3 inches) ▪ Very large or obese, use bimanual technique ▪ Try to palpate organs; deep breath (no organomegaly) o Abnormal findings ▪ Muscle guarding, rigidity, large masses, tenderness ▪ Mass • Size, shape, consistency (soft, firm, hard), surface (smooth, nodular), mobility (including with respirations), pulsate, tenderness • Liver (RUQ) o 2 techniques ▪ Left hand under back, right hand push deep and under the right costal margin; take a deep breath ▪ Hooking technique – alternative method o Normal palpate edge of liver (firm, regular ride) ▪ Less than 1-2cm below costal margin • Spleen (LUQ) o Normal (non-palpable) o If palpable, needs to be 3X’s size, stop palpation due to it can rupture easily • Kidneys o “Duck-bill” position right kidney o May feel the lower pole of the right kidney; left kidney (non-palpable) sits 1 cm higher • Aorta o Upper quadrant, slightly left of midline, right thumb and fingers o Normal 2.5 to 4cm wide adult, pulsates anterior o Aneurysm > 2 fingers apart, pulsates lateral ▪ > 95% located below renal arteries and extend to umbilicus; auscultate a bruit Special Procedures Psoas muscle test (technique and meaning of positive test) Rebound tenderness (Blumberg sign) (technique and meaning of positive test) Inspiratory arrest (Murphy sign) (technique and meaning of positive test) McBurney’s Point • Special Procedures o Iliopsoas Muscle Test ▪ Person supine, lift the right leg straight up, flexing at the hip, then push down over the lower part of the right thigh as the person tries to hold the leg up ▪ Negative, if person feels no change ▪ “Positive psoas sign“ when acute pain is felt in the RLQ • Suggestive of appendicits; also psoas abscess or retroperitoneal irritation o Rebound Tenderness (Blumberg Sign) ▪ Reliable sign indicative of peritonitis, which accompanies appendicitis ▪ Choose a site away from the painful abdominal area. Hold your hand 90 degrees, or perpendicular to the abdomen. Push down slowly and deeply. ▪ Normal or negative response, no pain on release ▪ “Positive Blumberg sign” is pain on abrupt release of steady pressure (rebound tenderness) over the affected site. o McBurneys Points or McBurney’s sign ▪ Deep tenderness, sign of acute appendicitis ▪ Inflammation no longer limited to the lumen of the bowel (which localizes pain poorly), and is irritating where the lining of the peritoneum contacts the appendix • Positive Blumberg Sign – Positive Rebound Tenderness ▪ Suggests the evolution of acute appendicitis to a later stage, and thus, the increased likelihood of rupture ▪ Many cases of appendicitis, no tenderness at this location ▪ Most open appendectomies, incision at McBurney's point ◦ Inspiratory Arrest (Murphy Sign) □ Test for gallbladder disease (cholecystitis) □ Person asked to inhale while the examiner's fingers are hooked under the liver border at the bottom of the rib cage □ Normal “no pain” with a deep breath □ “Positive Murphy sign” if person feels sharp pain and abruptly stops inspiration midway □ Less accurate in person’s > 60 years of age □ 25% will have no abdominal tenderness Hernias (hiatal, ventral, umbilical) • Hernias o Hiatal- a condition in which part of the stomach sticks upward into the chest, through an opening in the diaphragm. The diaphragm is the sheet of muscle that separates the chest from the abdomen. It is used in breathing. o Umbilical- n outward bulging (protrusion) of the abdominal lining or part of the abdominal organ(s) through the area around the belly button. o Incisional- caused by an incompletely-healed surgical wound. o Ventral- bulging of the abdominal wall, often at the midline. However, it can occur at any location on the abdominal wall. Many are called incisional hernias because they often form at the healed site of past surgical incisions where the skin has become weak or thin. ascites