Health Assessment Across The Lifespan Exam 1

Front 1

Factors Influencing Communication

Back 1

-Culture

-Perceptions

-Values

-Social class

-Relationships

-Setting

-Education/Literacy

Front 2

The Nursing Process

Back 2

Assessment (Evaluate the client's condition)

Diagnosis (Identify the client's problems)

Planning (Set goals of care and desired outcomes)

Implementation (Perform the nursing actions identified in planning)

Evaluation (Determine if goals met and outcomes achieved)

Front 3

Components of Health Assessment

Back 3

-Health history (subjective data)

-Physical Examination (objective data)

Front 4

Phases of the Interview

Back 4

-Pre-introductory Phase (review medical record)

-Introductory Phase (Introduction & explanation of interview)

-Working Phase (Actual Interview)

-Summary & closing phase (summary of working phase )

Front 5

TYPES OF HEALTH ASSESSMENT

Back 5

The four basic types of assessment are:

1.Initial comprehensive assessment

2.Ongoing or partial assessment

3.Focused or problem-oriented assessment 4.Emergency assessment

Front 6

STEPS OF HEALTH ASSESSMENT

Back 6

The assessment phase of the nursing process has four major steps:

1.Collection of subjective data

2.Collection of objective data

3.Validation of data

4.Documentation of data

Front 7

COLLECTING SUBJECTIVE DATA

Back 7

-Biographical information

-History of present health concern

-Personal health history

-Family history

-Health and lifestyle practices

Front 8

COLLECTING OBJECTIVE DATA

Back 8

-Physical characteristics (e.g., skin color, posture)

-Body functions (e.g., heart rate, respiratory rate) -Appearance (e.g., dress and hygiene)

-Behavior (e.g., mood, affect)

-Measurements (e.g., blood pressure, temperature, height, weight)

-Results of laboratory testing (e.g., platelet count, x-ray findings)

Front 9

PROCESS OF DATA ANALYSIS

Back 9

1.Identify abnormal data and strengths.

2.Cluster the data.

3.Draw inferences and identify problems.

4.Propose possible nursing diagnoses.

5.Check for defining characteristics of those diagnoses.

6.Confirm or rule out nursing diagnoses.

7.Document conclusions.

Front 10

Subjective data consist of:

Back 10

Sensations or symptoms

Feelings

Perceptions

Desires

Preferences

Beliefs

Ideas

Values

Personal information

Front 11

Nonverbal Communication

Back 11

-Appearance

-Silence

-Demeanor

-Facial expression

-Attitude

-Listening

Front 12

Verbal Communication

Back 12

-Open-ended questions

-Closed-ended questions (used to obtain facts)

-Laundry list (helps obtain specific answers)

-Rephrasing (helps clarify information)

-Providing information

-Well-placed phrases ( encourage client verbalization)

-Inferring

Front 13

Health history sections

Back 13

1.Biographic data

2.Reasons for seeking health care

3.History of present health concern

4.Personal health history

5.Family health history

6.Review of body systems (ROS) for current health problems

7.Lifestyle and health practices profile

8.Developmental level

Front 14

COMPONENTS OF THE COLDSPA SYMPTOM ANALYSIS MNEMONIC

Back 14

Character (describe the signs or symptoms)

Onset (when did it begin?)

Location (where does it hurt the most?)

Duration (How long does it last? Does it recur?)

Severity (How intense is the pain? Rate it on a scale of 1 to 10)

Pattern (What makes it better or worse?)

Associated factors (What other symptoms occur with it?)

Front 15

Techniques of Spiritual Assessment

Back 15

Non-formal technique:

S-Spiritual belief system

P-Personal Spirituality

I-Integration with a spiritual community

R-Ritualized practices and restrictions

I-Implications for medical care

T-Terminal events planning

Front 16

PIAGET’S THEORY OF COGNITIVE DEVELOPMENT

Back 16

Piaget believed that individual cognitive development occurred as the result of one’s organization and adaptation to the perceived environment.

Front 17

Techniques of physical exam

Back 17

a. Inspection (very important)

b. Palpation

c. Percussion (used for lungs & abdomen)

d. Auscultation (used cardiac, lungs, or abdomen)

Front 18

Hand Surfaces

Back 18

Palmar Surface (position, texture, size, consistency, fluid, creptitus, form a mass, or structure)

Ulnar Surface (vibration)

Dorsal Surface (temperature)

Front 19

Respiratory Physical Examination (inspection)

Back 19

-Respiratory Rate

-Posture/position - tripoding

-Level of consciousness

-Skin & nails (clubbing finger)

Front 20

Bronchial

Back 20

Pitch: High

Intensity: Loud

Duration: Short during inspiration, long in expiration

Location: Trachea and thorax

Front 21

Bronchovesicular Breath Sounds

Back 21

Pitch: Moderate

Intensity: Mixed Moderate

Duration: Same during inspiration and expiration

Location: In the first and second intercostal spaces anteriorly and between the scapulae.

Front 22

Vesicular Breath Sounds

Back 22

Pitch: Low

Intensity: Soft

Duration: Long in inspiration, short in expiration

Location: Over most of the lungs

Front 23

Tracheal Breath Sounds

Back 23

Duration: Equal inspiration & expiration

Intensity: very loud

Pitch: High

Location: Over the trachea in neck

Front 24

Normal Breath Sounds

Back 24

1. Vesicular

2. Bronchovesicular

3. Bronchial

4. Tracheal

Front 25

Abnormal Breath Sounds (Adventitious)

Back 25

1. Crackles/Rales

2. Wheeze

3. Rhonchus

4. Pleural Rub

5, Stridor

Front 26

Breathing patterns

Back 26

Such involuntary control of respiration is the work of the medulla and pons, located in the brainstem.

The hypothalamus and the sympathetic nervous system also play a role in involuntary control of respiration in response to emotional changes such as fear or excitement.

Front 27

Hypercapnia & Hypoxmia

Back 27

Hormonal regulation, changes in oxygen or carbon dioxide levels in the blood, or changes in the hydrogen ion (pH) level cause changes in breathing patterns. Under normal circumstances, the strongest stimulus to breathe is an increase of carbon dioxide in the blood (hypercapnia). A decrease in oxygen (hypoxemia) also increases respiration but is less effective than a rise in carbon dioxide levels.

Front 28

Auscultate for adventitious sounds

Back 28

Adventitious sounds are sounds added or superimposed over normal breath sounds and heard during auscultation. Be careful to note the location on the chest wall where adventitious sounds are heard as well as the location of such sounds within the respiratory cycle.

Front 29

Voice Sounds

Back 29

1.Bronchophony

2.Whispered pectoriloquy

3.Egophomy

Front 30

Bronchophony

Back 30

Ask the client to repeat the phrase “ninety-nine” while you auscultate the chest wall.

Normal Findings: The sound of the voice may be heard but the actual phrase cannot be distinguished.

Abnormal Findings: The words are easily understood and louder over areas of increased density. This may indicate consolidation from pneumonia, atelectasis, or tumor.

Front 31

Egophony

Back 31

Ask the client to repeat the letter “E” while you listen over the chest wall.

Normal Findings: Voice transmission will be soft and muffled but the letter “E” should be distinguishable.

Abnormal Findings: Over areas of consolidation or compression, the sound is louder and sounds like “A.”

Front 32

Whispered pectoriloquy

Back 32

Ask the client to whisper the phrase “one–two–three” while you auscultate the chest wall.

Normal Findings: Transmission of sound is very faint and muffled. It may be inaudible.

Abnormal Findings: Over areas of consolidation or compression, the sound is transmitted clearly and distinctly. In such areas, it sounds as if the client is whispering directly into the stethoscope.

Front 33

Percussion Sounds

Back 33

1.Resonance (normal lung)

2.Hyper-resonance (lung w/ emphysema)

3.Tympany (puffed-out cheek, gastric bubble)

4.Dullness (diaphragm, pleural effusion, liver)

5.Flatness (muscle, bone, sternum, thigh)

Front 34

Adventitious Breath Sounds (Abnormal breath sounds)

Back 34

1. Discontinuous Sounds (fine & course crackles)

2. Continuous Sounds (Pleural friction rub, sibilant or sonorous wheeze)

Front 35

Wheeze (sonorous)

Back 35

Low-pitched snoring or moaning sounds heard primarily during expiration but may be heard throughout the respiratory cycle. These wheezes may clear with coughing.

Sonorous wheezes are often heard in cases of bronchitis or single obstructions and snoring before an episode of sleep apnea. Stridor is a harsh, honking wheeze with severe broncholaryngospasm, such as occurs with croup.

Front 36

 Wheeze (sibilant)

Back 36

High-pitched, musical sounds heard primarily during expiration but may also be heard on inspiration.

Sibilant wheezes are often heard in cases of acute asthma or chronic emphysema.

Front 37

Pleural friction rub

Back 37

Low-pitched, dry, grating sound; sound is much like crackles, only more superficial and occurring during both inspiration and expiration.

Sound is the result of rubbing of two inflamed pleural surfaces.

Front 38

Crackles (coarse)

Back 38

Low-pitched, bubbling, moist sounds that may persist from early inspiration to early expiration; also described as softly separating Velcro.

May indicate pneumonia, pulmonary edema, and pulmonary fibrosis.

Front 39

Crackles (fine)

Back 39

High-pitched, short, popping sounds heard during inspiration and not cleared with coughing.

Crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia and congestive heart failure. Crackles occurring early in inspiration are associated with obstructive disorders such as bronchitis, asthma, or emphysema.

Front 40

Age related changes (Respiratory life considerations)

Back 40

-lungs lose elasticity

-skeletal muscles being to weaken

-bones lose their density

-appearance of barreled chest

-Fibrotic alveoli

-calcification of cartilage

Front 41

Pregnant Clients (Respiratory life considerations)

Back 41

-increases in tidal volume

-diaphragm rises and costal angle widens to accommodate the enlarging fetus

-shortness of breath & dyspnea occur

Front 42

Infants (Respiratory life considerations)

Back 42

-Nose breathers

-abnormal respiration

-louder breath sounds

-irregular rhythm with periods of apnea

Front 43

Breasts

Back 43

paired mammary glands that lie over the muscles of the anterior chest wall, anterior to the pectoralis major and serratus anterior muscles

Front 44

Tail of Spence

Back 44

upper outer quadrant, most breast tumors occur in this quadrant

Front 45

Montgomery glands

Back 45

secrete a protective lipid substance during lactation (within the areola)

Front 46

Major axillary lymph nodes

Back 46

1.anterior (pectoral)

2.posterior (subscapular)

3.lateral (brachial)

4.central (mid-axillary) nodes

Front 47

Lymphatics Drainage Patterns

Back 47

The anterior nodes drain the anterior chest wall and breasts.

The posterior chest wall and part of the arms are drained by the posterior nodes.

The lateral nodes drain most of the arms, and the central nodes receive drainage from the anterior, posterior, and lateral lymph nodes.

Front 48

Breast Self Exam

Back 48

1.Circular or clockwise.

2.Wedged

3.Vertical Strip

The up-and-down vertical pattern is most effective for covering the entire breast.

Front 49

Tissue in the breast

Back 49

1.Glandular (lactiferous ducts and sinuses)

2.Fibrous (cooper's ligaments)

3.Adipose (fatty tissue)

Front 50

PEAU D’ORANGE

Back 50

Resulting from edema, an orange peel appearance of the breast is associated with cancer.

Front 51

PAGET’S DISEASE

Back 51

Redness, mild scaling, and flaking of the nipple may be seen early stages of the nipple and then disappear. This does not mean that the disease is gone, thus further assessment is needed. Tingling, itching, increased sensitivity, burning, discharge and pain in the nipple are late signs of disease.

Paget disease of the nipple can occur in both breasts, but is rare. In approximately half of patients with Paget’s disease of the nipple, a lump or mass in the breast can be felt.

Front 52

RETRACTED NIPPLE

Back 52

A retracted nipple suggests malignancy.

Front 53

DIMPLING

Back 53

Dimpling suggests malignancy.

Front 54

RETRACTED BREAST TISSUE

Back 54

Retracted breast tissue suggests malignancy.

Front 55

CANCEROUS TUMORS

Back 55

These are irregular, firm, hard, not defined masses that may be fixed or mobile. They are not usually tender and usually occur after age 50.

Front 56

FIBROADENOMAS

Back 56

These lesions are lobular, ovoid, or round. They are firm, well defined, seldom tender, and usually singular and mobile. They occur more commonly between puberty and menopause.

Front 57

BENIGN BREAST DISEASE

Back 57

Also called fibrocystic breast disease, benign breast disease is marked by round, elastic, defined, tender, and mobile cysts. The condition is most common from age 30 to menopause, after which it decreases.

Front 58

Ateries

Back 58

Carry oxygenated blood from the heart to the capillaries

Front 59

Major arteries of the arm

Back 59

Brachial

Radial

Ulnar

Front 60

Major arteries of the leg

Back 60

Femoral

Popliteal

Dorsalis Pedis

Posterior Tibial

Front 61

Veins

Back 61

Carry deoxygenated blood from the tissues to the heart.

Front 62

Three types of veins

Back 62

Deep veins

Superficial Veins

Perforator Veins (connect the superficial & deep veins)

Front 63

Veins of the leg

Back 63

Femoral (deep vein)

Popliteal (deep vein)

Great & Small Saphenous veins (superficial vein)

Front 64

Lymphatic system structure

Back 64

lymphatic capillaries
lymphatic vessels
lymph nodes

Front 65

Capillaries

Back 65

Small blood vessels that form connection between the arterioles and venules and help maintain equilibrium between the vascular and interstitial space.

*the capillary bed is very important in maintaining the equilibrium of interstitial fluid and preventing edema.

Front 66

lymph nodes

Back 66

where microorganisms, foreign materials, dead blood cells, and abnormal cells are trapped and destroyed

Front 67

Functions of the Lymphatic System

Back 67

1. Drain excess fluid (prevent edema)

2. defending the body against microorganisms

3. absorb fats (lipids) from the small intestine into the bloodstream

Front 68

Vascular Abnormalities

Back 68

1. Deep Vein Thrombosis (DVT)

2. Venous Stasis

3. Peripheral Artery Disease

4. Venous & Arterial Inefficiencies

Front 69

Deep Vein Thrombosis Risk factors

Back 69

-reduced mobility

-dehydration

-increased viscosity of the blood

-venous stasis

*Heparin & warfarin or coumadin used as medications; Green field filter can be used to prevent it from traveling.

Front 70

ARTERIAL INSUFFICIENCY

Back 70

Pain: Intermittent claudication to sharp, unrelenting, constant

Pulses: Diminished or absent

Skin Characteristics: Dependent rubor, Dry, shiny skin, Loss of hair over toes and dorsum of foot

*Minimal leg edema

Front 71

VENOUS INSUFFICIENCY

Back 71

Pain: Aching, cramping

Pulses: Present but may be difficult to palpate through edema

Skin Characteristics: May be reddish-blue in color,associated with dermatitis

*moderate to severe leg edema

Front 72

EDEMA ASSOCIATED WITH LYMPHEDEMA

Back 72

-Caused by abnormal or blocked lymph vessels-Nonpitting

-Usually bilateral; may be unilateral

-No skin ulceration or pigmentation

Front 73

EDEMA ASSOCIATED WITH CHRONIC VENOUS INSUFFICIENCY

Back 73

-Caused by obstruction/insufficiency of deep veins

-Pitting, documented as: 1+ = slight pitting 2+ = deeper than 1+ 3+ = noticeably deep pit; extremity looks larger 4+ = very deep pit

-gross edema in extremity

-Usually unilateral; may be bilateral

Front 74

Peripheral Artery Disease Risk Factors

Back 74

-<50 y: diabetes, smoking, hypertension

-50 to 64 y: history of smoking & diabetes

->65 y: atherosclerotic coronary, carotid, renal artery disease, ischemic pain will at rest

Front 75

Lower Extremity PAD

Back 75

-Smoking

-Diabetes

-Obestity

-High BP

-High cholesterol

-Stroke

-Excess homocysteine (protein)

-African American

Front 76

Venous Stasis Risk factors

Back 76

-long periods of standing, sitting or lying down

-lack of muscular activity

-varicose veins

Front 77

Reduce Risk factors associated with PAD

Back 77

-quit smoking

-control blood sugar (diabetes pt)

-Exercise regularly

-Lower cholesterol & BP

-eat foods low in saturated fat

-maintain healthy weight

Front 78

Subjective Data related to Peripheral Vascular system

Back 78

-skin changes

-leg pain

-varicose veins

-leg sores

-swelling

-ED in men

-swollen nodules

-coronary Bypass

-oral contraceptive use

Front 79

Precordium

Back 79

The anterior chest area that overlies the heart and great vessels

Front 80

Superior Vena Cava

Back 80

return blood to the right atrium from the upper torso

Front 81

Inferior Vena Cava

Back 81

return blood to the right atrium from the lower torso

Front 82

Chambers of the heart

Back 82

two upper chambers, the right and left atria,

and

two lower chambers, the right and left ventricles

Front 83

pericardium

Back 83

a tough, inextensible, loose-fitting, fibroserous sac that attaches to the great vessels and surrounds the heart

Front 84

parietal pericardium

Back 84

secretes a small amount of pericardial fluid that allows for smooth, friction-free movement of the heart.

Front 85

Epicardium

Back 85

type of serous membrane that covers the outer surface of the heart

Front 86

Myocardium

Back 86

the thickest layer of the heart, made up of contractile cardiac muscle cells

Front 87

Endocardium

Back 87

a thin layer of endothelial tissue that forms the innermost layer of the heart and is continuous with the endothelial lining of blood vessels

Front 88

Septum

Back 88

separates the right and left sides of the heart

Front 89

Atria

Back 89

thin walls, serve as blood reservoir; boost amount of blood moving into ventricles (Atrial kick)

-receive blood returning to the heart and pump blood into the ventricles (atrial kick)

Front 90

Ventricles

Back 90

thicker walls, pumps blood out of heart

Front 91

Great vessels

Back 91

-Inferior Vena Cava

-Superior Vena Cava

-Aorta

-Pulmonary Artery

-Four pulmonary veins

Front 92

aorta

Back 92

transports oxygenated blood from the left ventricle to the body

Front 93

pulmonary veins

Back 93

(two from each lung) return oxygenated blood to the left atrium

Front 94

Right Atrium

Back 94

deoxygentated blood returns to the RA through the SVC, IVC, & coronary sinuses

Front 95

ELECTRICAL CONDUCTION OF THE HEART

Back 95

Front 96

Valves

Back 96

-keep blood flowing in one direction

-open/close passively and due to pressure within heart chambers

Front 97

Sinoatrial Node (SA node)

Back 97

regulates contractions; located on the posterior wall of the right atrium near the junction of the superior and inferior vena cava.

Front 98

Vascular System

Back 98

-delivers oxygen, nutrients, and other substances to the body's cells

-removes waste products of cellular metabolism

Front 99

Peripheral Vascular System

Back 99

Network of:

-Arteries

-Arterioles

-Capillaries

-Venules

-Veins

constantly filled with 5L of blood

Front 100

Systole

Back 100

period when the heart contracts and sends blood through the body

-mitral & tricuspid valves close

Front 101

Diastole

Back 101

period when heart relaxes and fills with blood

-aortic & pulmonic valves close

Front 102

Cardiac Cycle

Back 102

Front 103

Major Arteries

Back 103

-Temporal Arteries

-Carotid

-Brachial

-Popliteal

-Posterior Tibial

-Dorsalis Pedis

-Ulnar

-Femoral

-Radial

Front 104

Neck Vessel Assessment

Back 104

Carotid Artery

-Inspect

-Palpate

-Ausculate (used bell of the diaphragm)

Front 105

Heart Assessment (Inspect)

Back 105

-Inspect Chest

-Note landmarks

-Note location of apical pulse (PMI)

Front 106

Heart Assessment (Auscultate)

Back 106

-Listen to entire precordium (APE To Man)

-zigzag pattern over precordium

-Note heart rate and rhythm

-Identify S1 and S2

-If faint lye patient down

Front 107

Collecting Subjective Data (Heart & Neck Vessels)

Back 107

-ability to perform ADLs

-assess for risk

-family hx

-lifestyle

-health practices

Front 108

Colleting Objective Data (Heart & Neck Vessels)

Back 108

-Exam to identify signs of heart disease

-assess BP, skin, nails head, thorax, lungs, peripheral pulses

-auscultate

Front 109

Modifiable Risk Assessment (Heart & Neck Vessels)

Back 109

-BP

-Smoking

-Diabetes

-weight (obese)

-PAD

-diet (poor)

-high cholesterol level

-high blood glucose

Front 110

Non-modifiable Risk Assessment (Heart & Neck Vessels)

Back 110

-Age (65 or older)

-Male

-Family hx

-Race/Ethnicity

Front 111

Abdominal muscles (T.I.R.E.)

Back 111

-Transverse Abdominis
-Internal Oblique
-Rectus Abdominis
-External Oblique

Front 112

Abdominal Solid Viscera

Back 112

•Liver

•Pancreas

•Spleen

•Adrenal glands

•Kidneys

•Ovaries

•Uterus

* organs that maintain their shape consistently

Front 113

Abdominal Hollow Viscera

Back 113

•Stomach

•Gallbladder

•Small intestine

•Colon

•Bladder

*change shape depending on their contents

Front 114

What is the largest solid organ in the abdominal cavity?

Back 114

Liver

Front 115

Abdominal Wall Quadrants

Back 115

Regions commonly used: Epigastric, Umbilical, Hypogastric, Suprapubic (old quadrants)

Front 116

Subjective data health hx questions

Back 116

•Appetite

•Dysphagia

•Food intolerance

•Abdominal pain

•Nausea/vomiting

•Bowel habits

•Abdominal history

•Medications

•Nutritional assessment

Front 117

Objective DataThe Physical Exam

Back 117

Order:Inspect, Auscultate, Percuss, PalpateHavepatient void – empty bladder

Maintainpatient privacy with draping

Explainbefore completing assessment

Assesspainful area last

Equipment:Draping, Stethoscope, Ruler, Skin Marker and Alcohol Swab

Breathethrough the mouth; take slow, deep breaths.

Front 118

Inspect the abdomen

Back 118

•Contour

•Symmetry

•Umbilicus

•Skin (color, note striae, scars)

•Pulsationor movement (ortic pulsations, peristalic waves)

•Hairdistribution

•Demeanor

Askthe person to cough – any hernia? Doescoughing exacerbate abdominal pain – may be r/t peritonitis

Front 119

Contour

Back 119

Front 120

Abnormal FindingsAbnormalities on Inspection

Back 120

•Umbilical hernia

•Epigastric hernia

•Incisional hernia

•Diastasis recti

Front 121

Objective DataAuscultate Bowel Sounds

Back 121

•Auscultatein all four quadrants with diaphragm

•Normal5-30 gurgles/minute

•Ifnot audible, listen for a full 5 minutes•Abnormal:Hyperactive, hypoactive or absent

Front 122

Objective DataAuscultation Vascular Sounds

Back 122

•Listen with bell for bruits

Front 123

Objective DataPercussion: Liver Span

Back 123

•Upperliver border: Begin percussion at 3 ICS MCL. Note where resonantshifts to dullness

•Lowerliver border: Begin percussion at MCL equal with umbilicus. Note where tympanyshifts to dullness.

Front 124

Palpate the liver

Back 124

•Measures to enhance musclerelaxation

•Light palpation(1-2 cm down)

•Deep palpation (3-4 cm down)

•Bimanual palpation (5-8 cm down with one hand on top of the other)

•Normally palpable structures(should not feel the spleen)

Technique: usual or hooking

Front 125

Virchow'snode (or signal node)%5D%7D

Back 125

alymph node in the left supraclavicular fossa (the area above the leftclavicle).

Thefinding of an enlarged, hard node (also referred to as Troisier's sign) has long been regarded asstrongly indicative of the presence of cancer in the abdomen, specificallygastric cancer, that has spread through the lymph vessels.

Front 126

Liver Palpation Technique

Back 126

or hooking

Front 127

Acute Assessment

Back 127

Peritonitis

Appendicitis

Pancreatitis

Cholecystitis

Diverticulitis

Key Words•Dysphagia•Odynophagia•Rebound Tenderness•Referred Pain

Front 128

SpecialtyAssessment Rebound Tenderness

Back 128

Palpate deeply in the LLQ and quickly release pressure.

Pain in the RLQ during pressure in the LLQ is a positive Rovsing’s sign. It suggests acute appendicitis.

Front 129

SpecialtyAssessment Psoas Sign

Back 129

Pain in the RLQ (psoas sign) is associated with irritation of the iliopsoas muscle due to appendicitis (an inflamed appendix).

Front 130

SpecialtyAssessmentRovsing’s Sign

Back 130

Pain in the RLQ during pressure in the LLQ is a positive Rovsing’s sign. It suggests acute appendicitis.

Front 131

SpecialtyAssessmentObturator Sign

Back 131

Pain in the RLQ indicates irritation of the obturator muscle due to appendicitis or a perforated appendix.

Front 132

SpecialtyAssessmentMcBurney’s Point

Back 132

The client has rebound tenderness when the client perceives sharp, stabbing pain as the examiner releases pressure from the abdomen (Blumberg’s sign). It suggests peritoneal irritation (as from appendicitis). If the client feels pain at an area other than where you were assessing for rebound tenderness, consider that area as the source of the pain.

Front 133

Specialty AssessmentMurphy’s Sign

Back 133

Accentuated sharp pain that causes the client to hold his or her breath (inspiratory arrest) is a positive Murphy’s sign and is associated with acute cholecystitis.

Front 134

Specialty AssessmentGrey-Turner and Cullen Sign

Back 134

Purple discoloration at the flanks (Grey-Turner sign) indicates bleeding within the abdominal wall, possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis.

Front 135

SpecialtyAssessmentFluid Wave

Back 135

A second special technique to detect ascites (fluid) is the fluid wave test.

Front 136

Lifespan and Cultural Considerations

Back 136

•African Americans: Sickle Cell Disease

•Asian Americans: Higher risk for GastricCancer•Older Adults: Physiological Alterations–Decreased saliva, gastric motility,peristalsis•Pregnancy

•Newborns, Infants & Children

Front 137

Abdominal Structures in Right Upper Quadrant (RUQ)

Back 137

Ascending and transverse colon

Duodenum

Gallbladder

Hepatic flexure of colon

Liver

Pancreas (head)

Pylorus (the small bowel—or ileum—traverses all quadrants)

Right adrenal gland

Right kidney (upper pole)

Right ureter

Front 138

Abdominal Structures in Right Lower Quadrant (RLQ)

Back 138

Appendix

Ascending colon

Cecum

Right kidney (lower pole)

Right ovary and tube

Right ureter

Right spermatic cord

Front 139

Abdominal Structures in Left Upper Quadrant (LUQ)

Back 139

Left adrenal gland

Left kidney (upper pole)

Left ureter

Pancreas (body and tail)

Spleen

Splenic flexure of colon

Stomach

Transverse descending colonLeft

Front 140

Abdominal Structures in Midline

Back 140

Bladder

Uterus

Prostate gland

Front 141

Abdominal Structures in Lower Quadrant (LLQ)

Back 141

Left kidney (lower pole)

Left ovary and tube

Left ureter

Left spermatic cord

Descending and sigmoid colon

Front 142

Risk factors for nutrition disorders & disease

Back 142

1. Lower socioeconomic status

2. Lifestyle of long work hours

3. Poor food choices

4. Chronic dieting

5. Illness of trauma

Front 143

Impact of risk factors

Back 143

1. Edematous (requires a low sodium diet)

2. Osteoporosis

3. Poor self-concept

4. Diet high in meat proteins & fats

5. Constipation

Front 144

Nutrition assessment

Back 144

Assess for:

Usual foods

Fluids

Supplements

Front 145

COMPONENTS OF A NUTRITIONAL ASSESSMENT

Back 145

1.collection of objective data

2.anthropometric measurements (height & weight, BMI, IBW)

3.development

4.nutritional status

5.laboratory tests

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Hydration Assessment

Back 146

-Weight

-Skin tugor

-Pitting Edema

-Skin for moisture

-Venous filling

-Ling sounds

-Tongue (color)

-Eye position (sulken or normal)

Front 147

Factors affecting hydration

Back 147

1. Exposure to high temps.

2. Inability to access adequate fluids

3. Excess intake fluid

4. Taking diuretic meds

5. Impaired thirst mechanisms

6. High fevers

Front 148

Overhydration

Back 148

-weight gains of 6-10lbs/week

-pitting edema

-visible neck veins

-cracking lung sounds

-elevated pulse rate & blood pressure

Front 149

Dehydration

Back 149

-weight loss of 6-10lbs

-tenting

-filling or emptying of venous filling more than 6-10 s

-flat veins in supine client

-dry tongue

-sunken eyeballs

-decreased BP

=elevated pulse rate

Front 150

Interactive Substances

Back 150

-Ginger

-Garlic

-Ginkgo

-Grapefruits