Assessment

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Assessment
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2011-12-23 15:07:49
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Assessment Flash Cards
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  1. What organs are in the Right Upper Quadrant (RUQ)?
    • Liver
    • Gallbladder
    • Duodenum
    • Head of pancreas
    • Right Kidney & adrenal
    • Hepatic flexure & and colon
    • Part of ascending & transverse colon
  2. What is the procedure for auscultation of Bowel sounds?
    • Use diaphragm end piece because sounds are high pitched.
    • hold lightly against skin
    • Begin in RLQ at ileocecal valve
    • Note character and frequency of bowel sounds
  3. What is the rationale for performing auscultation of abdomen before light palpation?
    This is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds
  4. What are the findings that should be noted when Inspecting the abdomen?
    • Contour – Scaphoid, protuberant, distention
    • Hair distribution – Altered patterns
    • Symmetry – Localized bulging, visible mass, asymmetric shape
    • Demeanor – Restlessness, absolute stillness, knees flexed increased
    • Umbilicus – Everted with acites, deeply sunken with obesity, red, crusted
    • Skin – Lesions, rash, redness, glistening skin and taut
    • Pulsation & Movement – Visible peristalsis with distended abdomen
  5. What are the history topics that must be reviewed during history portion of the GI Assessment?
    • History of GI problems? Ulcer, gallbladder disease
    • any operations on abdomen?
    • any problems after surgery?
    • Any pain in the abdomen?
  6. Something you can feel caused by superficial thickening in the epidermis. Examples: Elevated nevus (mole), wart
    Papule
  7. State the significance of skin tone (color) changes.
    • Pallor (white) skin takes on color of collagen when the oxygenated hemoglobin in the blood is lost
    • Erythema (red) Excess blodd/ Expected with fever, inflammation, or emotionalreactions
    • Cyanosis (blue) decreased perfusion/ check LOC & respiratory distress
    • Jaundice (yellow) Rising amounts of bilirubin in blood
  8. A white, cheesy, curdlike patch on the buccal mucosa and tongue. It scapes off leaving raw, red surface that bleeds easily.Termed “trush” in newborns
    Candidiasis
  9. What are some age related changes in the mouth?
    • Tongue papillary atrophy (looks smooth)
    • Taste diminishes: loss of taste buds, decrease in saliva, may have upper dentures
    • oral ulcers
    • Gums recede, tooth erosion, osteoporosis, poor oral care, maloccusion, yellow teeth, vertical cracks
    • Buccal mucosa thin and shiny
  10. What are the ABCDE method of assessing skin lesions for cancer.
    • A: Asymmetry (both sides of lesion different)
    • B: Border irregularity (edges notched as opposed to smooth)
    • C: Color Variation (mixture of black, blue, red, and white)
    • D: Diameter (greater than 6mm or head of a pencil)
    • E: Elevated (growing in width and height)
    • F: Feeling (sensation around mole or spot changed)
  11. What are the functions of the mouth?
    • Taste – 1st segment of digestive system
    • Beathing – airway for the respiratory system
  12. What are the variations in the 6 major categories of skin assessment
    -Color
    -moisture
    -temperature
    -Texture
    -Moisture
    -Thickness
    -Mobility
    • Color – General pigmentation, widespread color change, pallor, erythema, cyanosis, or jaundice
    • Temp – Should be warm equally bilaterally
    • Moisture – perspiration, diaphoresis, dehydration
    • Texture Smooth & Firm, with an even surface
    • Thickness – Epidermis, - uniformally thin with callus on palms & soles. [Edema]
    • Mobility/Turgor – Ease of skin rising & ability to return to place promptly when released
  13. Describe the equipment & use of for oral examination.
    • Tongue blade: retract structures like lips & inspect throat
    • Bright penlight: Optimal visualization (use for palpation)
    • Cotton gause pad: for traction & to swing tongue out & to each side
  14. What is the procedure for light palpation of the abdomen?
    With 1st 4 fingers close together, depress the skin about 1 cm. Make a gentle rotary motion, sliding the fingers & skin together. Lift fingers (do not drag) move clockwise to next location around abdomen objective is to form an overall impression of the skin surface & superficial musculature.
  15. In bowel sounds, what is the difference between:
    1. normal sounds
    2. hyperactive
    3. hypoactive sounds
    • Normal: high pitched, gurgling, cascading sounds, occuring irregularly 5-30 times per minute
    • Hyperactive: Loud, high pitched, rushing, tinkling sounds that signal increased motility
    • Hypoactive: “silent abdomen” follows abdominal surgery of with inflammation of the peritoneum. You must listen 5 minutes by your watch by deciding bowel sounds are absent
  16. What are the structures of mouth?
    • Hard palate
    • soft palate
    • uvula
    • buccal mucosa
    • tongue – dorsal & ventral
    • teeth
    • gums
    • lips
  17. Elevated cavity containing free fluid, up to 1 cm;
    a “blister” clear serum flows if wall is ruptured.
    Examples: herpes simplex, Chicken Pox, Shingles (zoster), contact dermatitis
    Vesicle
  18. Solely a color change, flat and circumscribed, of less than 1 cm
    Examples: Freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever
    Macule
  19. The thickened, dried-out exudate left when vesicles/pustules burst or dry up. Color can be red-brown, honey, or yellow depending on fluid’s ingredients.
    Examples: Impetago(dry, honey colored), Scab after abrasion
    Crust
  20. Turbid fluid (pus) in the cavity circumscribed & elevated.
    Example: Impetigo, acne
    Pustule
  21. Encapsulated fluid filled cavity in dermis or subcutaneous layer, tensely elevating skin
    Examaple: Sebaceous cyst
    Cyst
  22. Larger than 1 cm diameter; usually single chambered; superficial in epidermis; It is then walled so it ruptures easily
    Example: Friction blister, pemphigus, burns, contact dermatitis
    Bulla
  23. Solid elevated, hard or soft larger than 1 cm. May extend deeper into the dermis than papule.
    Examples: xanthoma, fibroma, intradermal, nevu
    Nodule
  24. Papules coalesce to form surface elevation wider than 1 cm. A platesu like disk shaped lesion
    Example: Psoriasis
    Plaque
  25. Macules that are larger than 1 cm
    Examples: Mongolian spot, measles, rash
    Patch
  26. Superficial, raised, transient, and erythematous; slightly irregular shape due to edema
    Examples: Mosquito bite, allergic reactions, dermographism
    Wheal
  27. Larger than a few cm in diameter, firm or sotf, deeper into dermis; may be benign of malignant, although “tumor” implies “cancer” to most people.
    Example: Lipoma, Hemagioma
    Tumor
  28. Raised, thickened areas of pigmentation that look crusted, scaly, warty “stuck on”.
    Develop mostly on trunk, face, hands
    Keratoses
  29. Describe the normal skin of an older adult
    • loss of elastin, collagen & subcutaneous fat
    • Sweat & subacous glands decrease leading to a risk for heat stroke & dry skin
    • Sun and smoking:
    • -↓ wound healing
    • -↓ cell replacement
    • -↓ hair growth
  30. Compact, desiccated flakes of skin, dry or greasy, silvery or white from shedding of dead excess keratin cells.
    Examples: Psoriasis, dry skin, seborrhea dermatitis (yellow, greasy), eczema
    Scale
  31. Describe shape & surface landmarks of the normal spine
    • 7 cervical
    • 12 thoracic
    • 5 lumbar
    • 5 sacral
    • 3-4 coccygeal
    • C7 & T1 are prominent at base of neck
    • Inferior angle of scapula is at level of interspace T7 & T8
    • An imaginary line connecting the highest point on each iliac crest crosses L4
    • an imaginary line joining two symmetric dimples that overlie the posterior superior iliac spine crosses the sacrum
    • flexion, extension, abduction, rotation:motion of V. Column
  32. What organs are in the Left Lower Quadrant (LLQ)?
    • Part of descending colon
    • sigmoid colon
    • Left ovary & tube
    • Left ureter
    • Left spermatic cord
  33. Small. Flat, brown macules. Appear after extensive sun exposure.
    AKA: “liver spots”
    Senile Lentigines
  34. Describe the difference between
    Active ROM and Passive ROM.
    • Active: Patient can do it by themselves
    • Passive: It is done for them
  35. Describe the normal musculoskeletal system of the older adult
    • Loss of bone matrix → osteoporosis
    • height decreases → loss of water and gravity
    • Posture changes
    • ↓ in muscle cells →atrophy
  36. What are the organs in the Left Upper Quadrant (LUQ)?
    • -Stomach
    • Spleen
    • Left lobe of liver
    • Body of pancreas
    • Left kidney and adrenal
    • Splenic flexture of colon
    • Part of the transverse & descending colon
  37. Describe the difference between
    Solid viscera and Hollow viscera
    • Solid:Those that maintain a characteristic shape (liver, pancreas, spleen, adrenal glands, kidneys, ovaries, uterus
    • Hollow:Shape depends on contents(Stomach, gallbladder, small intestine, colon, bladder)
  38. Distinct, individual lesions that remain separate
    Discrete
  39. What are the organs in the Left Upper Quadrant (LUQ)?
    • Stomach
    • Spleen
    • Left lobe of liver
    • Body of pancreas
    • Left kidney and adrenal
    • Splenic flexture of colon
    • Part of the transverse & descending colon
  40. Distinct, individual lesions that remain separate
    Discrete
  41. Lesions run together
    Example: Hives
    Confluent
  42. What are the organs in the Right Upper Quadrant (RUQ)?
    • Cecum
    • Appendix
    • Right Ovary & Tube
    • Right Ureter
    • Right spermatic cord

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