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147 Cards in this Set
- Front
- Back
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normal findings for abdomen |
Abdomen flat with active bowel sounds every 10 to 20 seconds in all four quadrants. No bruits or frictionrubs. Abdomen soft, nontender, and without masses or enlargement of spleen or liver. Liver span 8 cm. Norebound or costovertebral tenderness. Bladder not palpable. No pain or discomfort in abdominal region. |
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older adults findings for abdomen |
Weaker abdominal muscles declining in tone and more adipose tissue result in arounder, more protruding abdomen.› Peritoneal inflammation is more difficult to detect due to less pain, guarding, fever,and rebound tenderness.› Saliva, gastric secretions, and pancreatic enzymes decrease.› Esophageal peristalsis and small-intestine motility decrease. |
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order for abdomen assessment |
Inspection |
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percussion findings in abdomen |
tympany over most of the abdomen |
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bowel sounds result from= |
the movement of air and fluid in the intestines. The most appropriate timeto auscultate bowel sounds is in between meals. |
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borborygmi |
loud growling sounds, are hyperactive sounds and indicateincreased gastrointestinal motility. Possible causes include diarrhea, anxiety, bowel inflammation,and reactions to some foods. |
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friction rubs result from |
the rubbing together of inflamed layers of the peritoneum. |
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#1 cause of working injury among health care workers |
musculo-skeletal injury |
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5 functions of the skin |
1.Protection: from external factors in the environment, like harmful micro-organisms, toxins and pollutants, and the ability to sense injury by being able to feel pain, hot, cold and pressure 2.Heat regulation: to maintain our bodies at the proper temperature, we sweat, or the blood vessels in our skin contract to preserve heat 3.Secretion: oil, or sebaceous, glands secrete sebum to lubricate our skin and hair, keeping us hydrated and preventing us from losing too much water via evaporation 4. Excretion: sweat, or sudoriferous, glands excrete sweat, and help detoxify our bodies, by removing excess salts and unwanted waste chemicals 5.Absorption: only a select amount of the ingredients we apply to the skin can be absorbed through it, and in this way it protects our internal environment |
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What are the characteristics of skin that need to be included in a skin assessment? |
1) Colour 3) Temperature 4) Texture 5) Turgor 6) Vascularity 7) Edema 8) Lesions |
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a.What does the assessment of skin tell nurses? |
ASSESMENT OF SKIN: reveals changes in oxygenation, circulation, nutrition, local tissue damage, and hydration
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erythema? |
red discolouration |
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eczema? |
a medical condition in which patches of skin become rough and inflamed, with blisters that cause itching and bleeding, sometimes resulting from a reaction to irritation |
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petechiae? |
pinpoint-sized red or purple spots on the skin caused by small hemorrhages in the skin layers |
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basal cell carcinoma |
most common form of cancerous lesion, in sun exposed area and frequently occurs in a background of sun damaged skin |
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v.squamous cell carcinoma |
is more serious than basal cell carcinoma, and develops in the outer layers of the sun-exposed skin; these cells may travel to lymph nodes and other parts of the body
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vi.hirsutism |
abnormal growth of hair on a person's face and body, especially on a woman. |
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alopecia |
hair loss , or thinning of the hair |
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capillary refill time |
is defined as the time taken for color to return to an external capillary bed after pressure is applied to cause blanching. typical time is 1-2 seconds and anywhere above 4 seconds is abnormal - indicates circulatory insufficiency |
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inspection of the nail includes: |
1) colour 2) cleanliness 6) Texture |
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increased angle > 160 degrees reveals |
chronic oxygenation problems |
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ROM |
Range of Motion |
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i.body alignment, |
is the optimal placement of the body parts so that the bones are efficiently used, so the muscles have to do less work for the same effect. Pilates is a form of exercise that stresses proper body alignment. Many pains and problems in the body are associated with long-term mis-alignments. |
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friction |
isa force that occurs in a direction to oppose movement. As you turn,trasfer, or move a client up in bed, friction must be overcome. Thelarger the surface area of the object to be moved, the greater is thefriction. Ie: place clients arms across chest, this positiondecreases surface area and reduces friction. |
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muscle tone |
in skeletal muscle, a state of tension that is maintained continuously - minimally even when relaxed - and which increases in resistance to passive stretch. Pathologically, loss of tone (flaccidity) can be caused, e.g. by peripheral nerve damage, and exaggerated tone (spasticity) by overstimulation |
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.atrophy |
a decrease in muscle size due to disuse; feels soft and boggy |
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gait |
manner or style of walking |
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deconditioning |
the loss of muscle tone and endurance due to chronic disease, immobility, or loss of function. |
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weight bearing |
isthe amount of weight apatient puts on the leg on which surgery has been performed. Ingeneral, it is described as a percentage of the body weight,because each leg of a healthy person carries the fullbody weight whenwalking, in an alternating fashion. Weight- is the force exerted on abody by gravity. To lift safely, the lifter must overcome the weightof the object to be lifted. Centre of gravity in a person is usually55%-57%. |
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foot drop |
isthe amount of weight apatient puts on the leg on which surgery has been performed. Ingeneral, it is described as a percentage of the body weight,because each leg of a healthy person carries the fullbody weight whenwalking, in an alternating fashion. Weight- is the force exerted on abody by gravity. To lift safely, the lifter must overcome the weightof the object to be lifted. Centre of gravity in a person is usually55%-57%. |
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fracture |
isa disruption of bone tissue continuity, most commonly result fromdirect external trauma but can also occur as a consequence of somedeformity of the bone |
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developmental changes throughout the life cycle on posture, balance, and movement? |
Infants- school age- spine in infants lacks the curves of adults. First curve occurs when the infant extends the neck from the prone position. Toddlers posture is awkward because of slight swayback and protruding abdomen, body is slimmer taller and better balanced by the age of 3. Child appears more coordinated adolescence- growth spurt Growth is frequently uneven. Hips widen in females, fat is deposited in upper arms, thighs and buttocks young-middle adults- Coordination to carry out ADL's, Posture changes in women due to pregnancy, adaptive response to weight gain. Slightly sway backed older adults- a progressive loss of bone mass occurs , physical inactivity, hormonal changes etc.. Weaker bones, causing vertebrae to be softer, older adults may appear less coordinated, may take smaller steps changes in muscle tissue, energy may be reduced. |
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ROM of neck ( pivot joint) |
flexion
extension hyperextension lateral flexion rotation |
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ROM of shoulder( ball & socket joint) |
Flexion extension hyperextension abduction adduction circumduction external rotation internal rotation |
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ROM of elbow( hinge joint) |
Flexion Extension Rotation for supination rotation for pronation |
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ROM of wrist ( Condyloid joint) |
Flexion
Extension Hyperextension Radial Flexion ( abduction) Ulnar Flexion ( Adduction) |
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Rom of hand and Fingers ( meta carpal= condyloid, interphalangel= hinge joint) |
Flexion
Extension Hyperextension Abduction Adduction |
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ROM of thumb- saddle joint |
Flexion
Extension Abduction Adduction Opposition |
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ROM of Hip= Ball & Socket joint |
Flexion
Extension Hyperextension Abduction Adduction Circumduction Internal Rotation External Rotation |
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ROM of trunk- gliding joint |
Flexion Extension Hyperextension Lateral Flexion Rotation |
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ROM of Knee= hinge joint |
Flexion
Extension |
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ROM of Toes- hinge /gliding joint |
Flexion Extension |
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Rom for foot- gliding joint |
Eversion Inversion |
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Ankle- Hinge joint |
Extension Flexion |
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2 types of ROM |
Active and passive |
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expected curvatures for spine |
Concave cervical spine■Convex thoracic spine■Concave lumbar spine■Convex sacral spin |
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what should a nurse assess joints for? |
for warmth, inflammation, edema, stiffness, crepitus, deformities, tenderness, limitations, and instability. |
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hypertrophy |
an enlargement of muscle due to strengthening |
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expected changes with aging for musculoskeletal |
Reduced muscle mass›Declines in speed, strength, resistance to fatigue, reaction time, coordination›Osteoporosis (fragility of bones, loss of bone mass and height)›Greater risk of fractures and vertebral compression›Degenerative alterations in joints›Limited range of motion›Flexed elbows, hips, and knees›Thinning intervertebral discs, kyphosis (with height loss), wider stance altering posture |
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normal findings example |
Full range of motion without pain in all joints and spine. No joint deformities, warmth, or swelling. Posture erect. Spine midline with expected cervical, thoracic, and lumbar curvatures. No scoliosis. Muscle strength equal and strong bilaterally. |
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pallor |
loss of colour ( anemia or lack of blood flow) |
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cyanosis |
blueish nail beds, lips, mouth , skin ( hypoxia or impaired venous return) |
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jaundice |
yellow-orange skin, sclera, mucous membrane ( liver dysfunction) |
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erythmea |
redness- inflammation, localized vasodilation |
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clubbing ( angle of nail bed greater than 160 degrees) can result from |
chronic low oxygen saturation (emphysema, chronic bronchitis) |
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tenting is: |
a delay in the skin returning to its usual place. |
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poor turgor indicates |
dehydration or aging and increases the risk for skin breakdown |
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edema is: |
fluid in the tissues causing swollen, tight, and shiny skin surfaces, most often from direct trauma or impaired venous return. |
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pitting edema |
compressing the skin for at least 5 seconds over a bony prominence (behind the medial malleolus, the dorsum of foot, or over the shin) and then assess. The depth of pitting reflects the degree of edema. |
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scale of pitting edema |
1+ = 2mm and rapid response 2+= 4mm ( mild) and 10-15 second response 3+ = 6mm ( moderate) and 1-2 min response 4+ = 8mm ( severe) and 2-5 minute response |
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macule |
freckle |
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papule |
elevated nevus |
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nodule/tumor |
wart |
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vesicle |
herpes/ blister/ varicella/simplex |
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pustule |
acne |
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tumor |
epithelioma
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wheal |
insect bite |
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secondary lesions: result in a change of a primary lesion examples are: |
erosion= ruptured vesicle ulcer= pressure ulcer ( loss of epidermis or even dermis) |
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expected changes of the skin with aging |
Skin thin and translucent, dry, flaky, tears easily, loss of elasticity and wrinkling›Thinning of hair›Slow growth of nails with thickening›Decline in glandular structure and function (less oil, moisture, sweat)›Uneven pigmentation›Slow wound healing›Little subcutaneous tissue over bony prominences |
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sample documentation of the skin |
Skin pink, warm, and dry. Turgor brisk, skin elastic. Rough, thickened skin over heels, elbows, and knees; otherwise, smooth. A 0.5 cm brown papule on right forearm and a 2.5 cm scar on left knee. Scalp dry with slight dandruff. Hair brown, clean, smooth, straight, evenly distributed on the head. Axillary and pubic hair evenly distributed with no infestations. Nails short and firm with no clubbing. Capillary refill < 3 seconds. No edema. Pulses palpable and equal bilaterally. |
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TSE |
Testicular Self Examination |
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BMI |
Body Mass Index |
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Ranges for normal waist circumfrence |
Male <102cm Female< 88 cm |
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Low range for BMI |
Less than 18.5 |
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Least risk of developing health problems for BMI |
18.5-24.9
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Increased Risk for BMI health problems |
25-29.9 |
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High risk |
30.0-34.9 |
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Very High risk of health problems |
35.0-39.9 |
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the waist to hip ratio |
reflects body fat distribution as an indicator of health risk |
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Extremely high risk for developing health problems |
> 40 |
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BMI =( calculation) |
weight in kilograms -------------------------------- height in metres 2 ( squared) OR weight in pounds --------------------- x703 height in inches |
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purpose of a call bell |
A nurse call button is a button found around a hospital bed that allows patients in health care settings to alert a nurse or other health care staff member remotely of their need for help. When the button is pressed, a signal alerts staff at the nurse's station, and usually, a nurse or nurse assistant responds to such a call. |
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call button allows the following benefits ( 3) |
1.Enables a patient who is confined to bed and has no other way of communicating with staff to alert a nurse of the need for any type of assistance 2.Enables a patient who is able to get out of bed, but for whom this may be hazardous, exhausting, or otherwise difficult to alert a nurse of the need for any type of assistance 3.Provides the patient an increased sense of security |
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4 quadrants of the abdomen |
RUQ-right upper quadrant RLQ-right lower quadrant LUQ-left upper quadrant LLQ- left lower quadrant |
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Organs contained within RUQ |
Liver gallbladder dudenum head of pancreas kidney and adrenal gland part of ascending and transverse colon |
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Organs contained within LUQ |
Stomach Spleen Left lobe of liver Body of pancreas Left kidney and adrenal gland Splenic flexure of colon Parts of transverse and descending colon |
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Organs in RLQ |
Cecum Appendix Right ovary and fallopian tube Right ureter Right spermatic cord |
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Organs in LLQ |
Part of descending colon Sigmoid colon Left ovary and fallopian tube Left ureter Left spermatic cord |
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Prep of abdominal assessment |
Empty bladder Keep room warm Position supine with pillow, knees bent, arms at their side or across chest Warm stethoscope Inquire for pain, assess area last Learn distraction techniques for relaxation 9 emotive imagery) |
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Factors that may influence an abdominal assessment |
Appetite Dysphagia Food intolerance Abdominal pain (past and present) Nausea/vomiting Bowel habits Medications Alcohol and tobacco |
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why do we perform auscultation before percussion and palpation when assessing abdomen? |
to avoid increasing peristalsis, and changing normal bowel sounds and give a false interpretation of bowel sounds |
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factors that may influence anal assessment |
Bowel routine (change in bowel routine) Rectal bleeding, blood in stool Medications Rectal conditions Family history Self-care behaviours |
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Body positions for Male and Female when assessing anus |
Male- Left Lateral or Standing (with toes facing together) Female- Left Lateral or Lithotomy (if examining genitals) |
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normal features for assessing anus |
Normal: moist, hairless, coarse folded skin, anal opening is tightly closed, no lesions |
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normal outcomes for assessing male genitalia |
Pubic hair- distribution appropriate for age without infestations Skin of penis Wrinkled Hairless Without lesions Dorsal vein may be apparent Smooth glans (ask uncircumcised patient to retract foreskin) Urethral meatus is positioned centrally Compress glans of penis, meatus edge should be pink, smooth, without discharge Palpate shaft: smooth, semifirm and nontender Scrotum Request the patient hold penis out of the way Asymmetry is normal; the left scrotal half is lower Spread rugae out between fingers Lift sac to inspect posterior surface: sebaceous cysts are commonly found Palpate each scrotal half: contents should slide easily Testes: oval, firm, rubbery, smooth, equal bilaterally, freely move, slightly tender Epididymis: feels discrete, softer than testis, smooth, nontender Spermatic Cord: smooth, nontender Transillumination: Darken room and shine light behind the scrotal conents |
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what does TSE stand for |
T=timing, once a month S=showering, warm water relaxes scrotal sac E=examining, checking for changes, report immediately |
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Factors that may influence assessment of female genitalia |
Menstruation history Obstetrical history Menopause Self-care behaviours Urinary symptoms Vaginal discharge History Sexual activity Contraceptive use STI (STI risk reduction) |
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Organs in the midline of the abdomen |
Aorta ( epigastric) Umbilicus( umbilical region) Bladder Uterus(suprapubic/ hypogastric) |
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developmental considerations in older adults when assessing abdomen |
. fat accumulation in suprapubic area ( mostly in females) . salivation decreases and decrease sense of taste . esophageal emptying is delayed . gastric acid secretion decreases with aging ( as a result drugs are not absorbed as quickly) . more susceptible to dehydration because of the ability to conserve water is reduced . liver size decreases with age . renal functions decreases with age . incidence of gallstones increases with age hypothyroidism increases |
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abnormal findings of abdomen |
- scaphoid / protruberant abdomens and abdominal distention |
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what to look for when inspecting the abdomen |
. contour- flat to rounded . symmetry .umbilicus- midline . skin- smooth and even . pulsation of movement .hair distribution . demeanour |
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what should a nurse do when assessing an obese abdomen? |
use the bimanual technique ( use 2 hands for palpation) |
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ascites |
free fluid in the peritoneal cavity - if abdomen is distended, the flanks are bulging, umbilicus is protruding and displaced downward |
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documentation of normal inspection of abdomen |
abdomen flat, symmetrical, with no apparent masses, skin smooth with no striae, scars, or lesions. |
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documentation of normal ausculation of abdomen |
bowel sounds present in all 4 quadrants, no bruits |
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percussion normal findings of abdomen |
tympany predominates in all 4 quadrants, liver span =8cm in right midclavicular line. Splenic dullness located at tenth intercostal space in left midaxillary line |
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palpation normal findings of abdomen |
abdomen soft, no organomegaly, no masses, no tenderness |
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normal findings of anus |
has one BM daily, soft, brown, no pain, no change in bowel routine, taking no medications, has no history of pruritus, hemmorrhoids , fissure, or fistulas |
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functional unit of the musculotskeletal system |
joints |
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non synovial joints |
immovable
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synovial joints |
freely movable because they have bones that are separated from each other ( filled with lubricant called synovial fluid) |
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what cushions bones and provides a smoth surface to facilitate movement? |
cartilage |
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what are fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions? |
ligaments |
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what is a bursa? |
is an enclosed sac filled with viscous synovial fluid in area with potential friction ( prepateller bursa) |
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flexion |
bending a limb at a joint |
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extension |
straightening a limb at a joint |
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abduction |
moving a limb away from the midline of the body |
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adduction |
moving a limb toward the midline of the body |
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pronation |
turning the forearm so that the palm is down |
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supination |
turing the forarm so that the palm is up |
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circumduction |
moving the arm in a circle around the shoulder |
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inversion |
moving the sole of the foot inward at the ankle |
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eversion |
moving the sole of the foot outward at the ankle |
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rotation |
moving the head around a central axis |
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protraction |
moving a body part forward and parallel to the ground |
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retraction |
moving a body part backward and paralllel to the ground |
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elevation |
raising a body part |
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depression |
lowering a body part |
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major problem in older adults with effect of resorption happening faster than deposition in bones |
osteoporosis |
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if you see a limitation in ROM what should be done? |
gently attempt passive motion: Anchor the joint with one hand while your other hand slowly moves it to its limit |
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what is used to measure ROM? |
goniometer ( measures angles) |
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body mechanics |
are the coordinated efforts of the musculotskeletal and nervous systems to maintain , balance, posture and body alignment. ( during lifting, bending, moving, and performing ADL's) |
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use of proper body mechanics? |
reduces risk of injury, to the musculo-skeletal system, facilitates mobility and allows for efficient use of energy |
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body alignment means? |
referring to the positioning of joints, ligaments, and tendons, and the individuals center of gravity is stable and body strain is minimized |
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correct body alignment reduces? |
strain, risk of injury, aids in maintaining muscle tone, and contributes to balance |
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deconditioning |
clinical syndrome that results in reduced functioning of multiple body systems |
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in a person the center of gravity is usually at : |
55-57% of standing height ( usually at the midline) |
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foot drop |
inability to dorsiflex and evert foot because of peroneal nerve damage |
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thromus is:? |
an accumulation of platelets, fibrin, clotting factors and cellular elements of the blood attached to the interior wall of a vein or artery. |
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pressure ulcer |
is an impairment of the skin as a result of prolonged ischemia |
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most common body injury of nurses? |
back injuries- direct result of improper lifting and bending. - most common of the lumbar muscle group |
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good lifting techniques? ( 4) |
1. keep weight to be lifted as close to the body as possible 2. Bend at the knees- helps to maintain center of gravity- avoid twisting 3. tighten abdominal muscles and tuck the pelvis; this provides balance and helps protect the back 4. maintain the trunk erect and knees bent so that multiple groups worth together in a coordinated matter |
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what system is responsible for muscle tone and regulates and coordinates the amount of pull exerted by individuals muscles? |
nervous system |
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body balance is acheived? |
when a relatively low center of gravity is balanced over a wide, stable base of support and a line falls from the center of gravity |
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body loses balance when? |
the line of center of gravity does not fall vertically through the base of support |
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2 ways to increase body balance? |
1. widen the base of your support by widening your feet 2. bring the center of gravity closer to the base of the support |
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medical asepsis techniques when changing a bed |
When handling linens and making beds, practise medical asepsis. Perform hand hygieneCheck linen for misplaced personal belongings Dentures, hearing aids, eyeglasses, watches, jewellery Your uniform is considered dirty.Your uniform is considered dirty.Always hold linens away from your body and uniform. Always hold linens away from your body and uniform. Never shake linens this spreads microbes.Place clean linens on a clean surface Never put clean or dirty linens on the floor |
