Nursing Assessment test 2

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  1. visceral pleura
    coats outer surface of organs
  2. parietal pleura
    lines wall of abdomen
  3. Abdomen Developmental for infants
    • bladder above symphisis pubis
    • extends below rib cage
    • muscles weak
    • abdomen protrudes
  4. Abdoment Development children
    • abdomen larger than adults (diminish at adolescents)
    • belly breathing
    • organs easily palpated
  5. Abdomen Development Pregnant Women
    • fetus growth rise stomach, interfere with diaphragm leads to GERD/constipation
    • Decreased bowel sounds: bowel compressed by fetus, decreased activity, prenatal iron
    • hemorrhoids: increased venous pressure in lower abdomen
    • Appendix displaced: move up and lateral to right
    • linea nigra
    • stria
  6. linea Nigra
    line down abdomen: normal when pregnant
  7. Stria
    stretch marks
  8. Abdomen Development Older Adults
    • GI decreased/ change in chewing ability and digestion, decreased saliva, stomach acids, gastric motility, peristalsis
    • fat in lower abdomen
    • liver small-decreased function: harder to process meds
  9. Solid Viscera
    • maintains shape, encapsulated
    • liver, spleen, kidney
  10. Hollow Viscera
    • Shape depends on contents
    • stomach, gallbladder, SI, colon, bladder
  11. Abdominal Pain: Visceral
    • from distention of abdomen/stretch organs
    • burning, cramping
    • diffuse and poorly localized
  12. Abdominal pain: Parietal
    • inflammation of parietal peritoneum
    • worse with movement
  13. Abdominal Pain: Referred
    • Felt at site away from origin
    • appending :RLQ middle
    • Gallbladder: right scapula
  14. what should I do... acute abdominal pain??
    • first rule out cardiac, shock, infection
    • check vitals
    • RTQSP
  15. Pain in shoulder
    spleen, ectopic pregnancy, pancreatic
  16. Pain in Scapula
    Cholelithiasis, MI, Angina, biliary colic, pancreatic
  17. Pain in thighs
    genitals, lower back, renal, urethral
  18. Pain lower back/middle back
    abdominal aortic aneurysm
  19. Normal Weight change
    • 2-3 pounds within 48 hrs is fluid
    • more: abnormal (GI diseases, cancer, CHF, etc)
  20. Cathartics
    • use of laxatives to lose weight
    • don't give laxatives to patient with absent bowel sounds
  21. Purgative
  22. Normal bowel patters
    establish baseline (2 per day to 2-3 times per week can be normal)
  23. Black tarry stool
    upper Gi
  24. Red, Bloody stool
    lower GI
  25. Clay colored stool
    increased bile
  26. indigestion
    • heart burn
    • common
  27. Nausea
    due to stress on stomach/esophagus
  28. Vomiting
    • reversed peristalsis and esophageal sphincter opens
    • chemical, trauma, distention
  29. projectile vomiting
    • unexpected vomiting
    • head injury, neuro, vascular abnormal in brain
  30. coffee colored emesis (vomiting)
    blood in stomach
  31. Dysphagia
    difficulty swallowing
  32. Guarding
    Tense abdominal muscle
  33. Abdomen Inspection
    • shape, symmetry
    • skin: color, hair distribution, lesions, edema
    • straie, distension
  34. 7 F's
    fat, fluid, feces, fetus, full bladder, false pregnancy, fatal tumor, fibroid
  35. Abdomen Auscultation
    • listen before palpation
    • use diaphragm for bowel sounds, bell for vascular sounds
    • listen for 5 minutes before determine bowel sounds are absent
    • normal is 5-30 per minute
  36. Auscultate abdomen hypoactive bowel sounds
    if hypoactive listen at ielocecal valve (right of umbilicus)
  37. Abdominal Percussion
    • CVA
    • liver size-scratch test
    • bladder (if dull bladder full)
    • high pitched sounds on hollow areas
    • dull sound on masses
  38. CVA Costovertebral Angel
    • Costovertebral Angel
    • assess for tenderness of kidney
    • kidney sones
  39. Abdomen Palpation
    • Light: 1 cm, circular motion 1/2"
    • deep: 5-8 cm (1-2")

    –Normally, slightly tender over sigmoid colon
  40. involuntary guiding
  41. Palpating Liver
    • with left hand under 11th or 12th rib lift up
    • take deep breath
    • smooth and tender
  42. ascites
    • accumulation of fluid in peritoneal cavity
    • causes: CHF, cirrhosis, nephrosis
    • assess; shifting dullness, fluid wave, puddle sign
  43. Constipation
    causes: meds, decreases exercise, low dietary fiber, low muscle tone, cancer, dehydration, intestinal obstruction
  44. Arterial and venous sounds Abdomen
    • Bruits: use bell over midline, epigastric area
    • Venous Hums: over liver with bell
    • Friction Rub: over inflamed organs or tumors
  45. Ileus
    • blockage/obstruction leads to decreased peristalsis
    • decreased blood supply
  46. Bowel Perforation
    • leakage into abdominal cavity, leads to
    • peritonitis
    • organ failure
    • septic shock
  47. Ballottement
    used to displace fluid so that a floating mass or organ be palpated
  48. Kerh's Sign
    referred pain to left shoulder caused by splenic rupture.
  49. Ballance's Sign
    present when dullness is percussed in the LUQ. indicated peritoneal irritation or injury to the spleen
  50. Murphy's Sign
    used to detect inflamed gallbladder. palpate at right midclavicular line under costal angel, take deep breath if patient feels pain, positive.
  51. Ileopsoas Test
    • appendix
    • pressure over right tight ask patient to raise leg
  52. Rupture of peritonitis
    • paralyze GI
    • absent bowel sounds
  53. Peripheral vascular system
    network of vessel transport of oxygenated blood to organs and tissue and return deoxygenated blood to lungs

    • veins: deoxygenated
    • arteries: oxygenated
  54. Lymphatic
    • collect and drain excess tissue fluid
    • lymph nodes, tonsils, thymus, spleen, peyers patch
  55. Lymph Nodes
    filter large molecules and debris
  56. Tonsils
    destroys microorganisms/substances at entry of resp or digest
  57. Thymus
    in thorax, forms antibodies: t cells
  58. Spleen
    filter blood, make lymphocytes and monocytes
  59. Payers patch
    respond to antigens, make antibodies
  60. developmental Lymph infants/children
    • development at 20 wks, immature when born get immunity from mom (colustum)
    • thymus grows rapidly at birth-2 yrs
    • lymphatic tissue greatest between 6-10 yrs
  61. Developmental Lymph: pregnant
    • decreased systematic vascular resistance/decreased BP
    • palmar erythema
    • telangiactasis
  62. Palmar Erythema
    • redness of palms in pregnant women
    • decreased systemic vascular resistance/decreased blood pressure
  63. Telangiectasis
    • spider like skin
    • decreased systemic vascular resistance/decreased blood pressure
  64. Developmental Lymph: Older Adults
    • decreased lymph nodes with age
    • decreased resistance infection
    • increased PV=increased Blood pressure
    • (increased fibrosis and decreased elasticity in vessels)
  65. Varicosites
    due to decreased venous elasticity increase
  66. Inspection: lymp
    upper and lower extremeties: skin color, nail, capillary refill, lesions, edema, erythema, clubbing, cyanosis, vericosites

    Abdomen: aortic pulsation, contour, ascites (fluid in abdominal cavity from vascular system)

    Note: lymphatic syst drains towards middle of body.
  67. Capillary Refill
    • less than 3 seconds is normal
    • otherwise arterial occlusion/hypothermia
  68. Edema
    Fluid accumulation=increased capillary refill caused by venous obstruction, heart failure, renal disease, lymphatic conditions etc


  69. Parathesia
    • change in sensation
    • numbness, tingling, pins and needles or burning

  70. Pulse Measurement
    • 0: absent
    • 1: diminished
    • 2: normal
    • 3: full, increased
    • 4: bounding

    note rate, rhythm, equality, amplitude
  71. Pulses
    upper extremities
    lower extremities
    • head: temporal, carotid
    • upper: brachial, radial, ulnar
    • lower: femoral, popliteal, posterior tibialis, dorsalis pedis
  72. lymph nodes
    note size, shape, tenderness, motility, location, erythema, warmth
  73. Auscultation Bruits
    • with bell
    • temporal, carotid, abdominal aorta, renal, iliac
  74. orthostatic blood pressure
    • positional blood pressure
    • decreased bp of 20 mm hg 
    • drop in diastolic with increase pulse: abnormal
  75. 6 P's of extremities
    • Arterial occlusion:
    • pain, pallor, pulselesness, pressure, poor sensation, paralyze
  76. Lymph abnormalities
    • decreased capillary refill: arterial occlusion
    • arterial insufficiency: hair loss, thin, shinny skin, thick nails
    • chronic venous inssuf: eczema, dermatitis, spiderlike skin
    • skin ulcers: trauma or venous/arterial insuff.
    • Abdomen: tense, shinny, ascites, edema
  77. Allen test
    • arterial flow to hands
    • Patient makes a fist, compress ulnar and radial arteries, pt opens hand observe pallor, release and watch color return in 3-5 seconds
  78. Ankle-Brachial index
    • circulation to feet
    • ankle systolic pressure divided by brachial systolic pressure
    • normal is 1 or greater
  79. Manual compression test
    • venous valve competence in patients with varicose veins
    • patient stand and compress distal protion of vein and then proximal.
    • normal: no backflow
  80. Trendelenburg Test
    • valve competence
    • patient supine, elevate leg, place tourniquet around thigh and proximal portion. veins should fill slowly from the lower leg up, after 30 seconds remove. if veins fill rapidly from upper leg down valves are incompetent.
  81. Color change test
    • arterial insufficiency
    • patient supine, elevate leg and have patient sit with legs dangled. note color change. normal if color returns to feet within 10 seconds.
  82. Dyspepsia
  83. Percussion of Spleen
    • LUQ below costal margin
    • tympany heard unless spleen is enlarged
  84. Typany
    loud high-pitched hollow sound
  85. Lymphatic abnormal findings:
    • —Swelling
    • —Fatigue
    • —Fever—
    • Joint pain
    • —Slow healing wounds
  86. Peripheral abnormal findings
    • —Swelling
    • —Limb Pain
    • —Change in sensation
    • —Fatigue
    • —Vision changes
  87. Breast inspection
    • conical shape and often unequal
    • part of reproductive system
  88. Breast structures
    • mammary gland
    • sucking stimulates hypothalamus: stimulates:
    • prolactin: milk production
    • oxytocin: force milk into ducts
    • estrogen and progesterone (from ovaries) stimulates breast growth

    lumps/mass may be normal
  89. Developmental Breast: infants
    supernumerous nipples (normal)
  90. Developmental Breast:children/adolescents:
    growth begins prepubertal period
  91. Developmental Breast: pregnant women
    • fuller, firmer, areola and nipples darken and enlarge
    • 3rd trimester: colostrum
  92. Developmental Breasts: Older Adults
    Fibrous, less firm, pendulous (hang)
  93. Breast pain/tenderness
    • usually menstrual cycle
    • can be metastic disease/pain cysts infection, mastitis, hematoma etc.
  94. Breast nipple dischange
    • normal or abnormal
    • unless lactating not normal
  95. menarch early risk for:
    • early is earlier than 12 yrs
    • risk for breast cancer
  96. Breast Inspection
    • all five positions
    • size, shape, contour, symmetry, skin, pain, tenderness, discharge
  97. Palpation: breast

    plus lymph nodes
    • feel for lumps, masses
    • use finger pads and move in small circles thorugh entire breast and axilla
    • nipples nontender, elastic

    • lymph nodes including
    • supraclavicular
    • infraclavicular
    • central/lateral (inside arm)
    • posterior/scapular (toward scapula)
    • anterior/pectoral (toward axillary fold)
    • epitrochelar (elbow)
  98. Female Genitourinary: considerations
    • no douche, spray, coitus for 24-48 hrs prior to exam
    • consider culture, have other female present
    • explain procedure
    • lithotomy position
  99. Female Genitourinary: Inspection
    • external inspection
    • hair distribution, infection, infestation
    • clitoris: size, infection, discharge
    • mons pubis: masses, lesions, lymph node
    • labia: swelling, trauma, size, symmetry
    • urethra: redness, leakage
    • anus: hemorrhoids, lesions, warts, discharge.

    • prominent labia minora: normal
    • internal inspection: need specialized training
  100. Pap smear
    • collect 3 specimens (endocervix, cervix, vaginal pool)
    • purpose: detect cancer
    • when: 21 yrs or 3 years after sexually active
  101. Male Genitourinary: Inspection
    • hair distribution: norm is coarse and sparse on scrotum and inner thigh, absent on penis
    • Penis: color, lesions, swelling, discharge, circumcision, urethral location, uncircumcised (retract skin), inspect glands
    • scrotum/testes: 4-6cm, right usually anterior, note lesions, shape, hair distribution, color (more deeply pigmented)
    • urethral meutus: position, gently open and note discharge, lesion, redness
    • rectum: hemorrhoids, prolapse
    • epididymis: posterior of testes, masses, thickness
    • vas deferense: tube from epididymis
  102. Male genitourinary: Palpation
    • bladder/kidney
    • penis
    • urethral matus
    • scrotum: one at a time: note size, shape, consistency, motility and epididymis and vas deferense, note swelling/nodules
  103. Testicular trans illumination, when?
    if masses present
  104. Testicular Torsion
    Testicular torsion occurs when the spermatic cord (from which the testicle is suspended) twists, cutting off the testicle's blood supply, a condition called ischemia
  105. Orchitis
    swelling, acute of testes
  106. Cryptochidism
    • absence of testes and epididymis in scrotal sac, if pt age  refer
    • inguinal area: horizontal and vertical lmp nodes
    • Hernias in scrotal sac: feel for bulges
  107. Transgender
    psych state mental disorder if causes significant distress or disability
  108. Breast Cancer
    • prevention: diet, exercise, alcohol intake, family history
    • most commonly diagnosed cancer.
  109. Respiration muscles:
    • External Intercostal muscles: pull ribs up and out
    • Internal Intercostal muscles: pull ribs down and in
    • both decrease intrathoracic pressure
  110. Developmental Musculoskeletal: Infant/children
    • skeleton forms in fetus first as cartilage
    • growth at shaft (ends); stops at ~2yrs
    • spine is single c-shaped,
    • 3/4 months rise head so form cervical, once walk at
    • 12-18 develops lumbar (wide feet)
  111. Tendon
    attach skeletal muscle
  112. Ligaments
    attach bone to bone
  113. Genu Valgum
    • knock knees
    • knees touch and medial malleoli are 3 inches or more apart
    • normal 2-3 yrs and may be present until age 7
  114. Genu Varum
    • bowlegs
    • knees are greater than 2 inches apart ad medial malleoli touch
    • normal 2-3 yrs, even up to 7 yrs
  115. Kyphosis
    accentuated thoracic curve
  116. Scoliosis
    lateral S spinal deviation
  117. Pregnant women Lordosis/kyphosis
    • Lordosis: progressive, shift center of gravity, strain lower back
    • Kyphosis: during 3rd trimester, compensate for lordosis
    • upper back changes pressure ulnar and median nerves causes aches etc
    • waddling gait: due to mobility in the sacroiliac, symphisis pubis.
  118. Dowager's hump
    hyphosis + decrease height
  119. Developmental Musculoskeletal: older adults
    • decrease bone density
    • decrease muscle mass (dec agility, abnormal gait, uneven rhythm, short steps)
    • osteoporosis
    • kyphosis
    • decreased height: thinning of intervertrebal discs/shortening of vertebral column (begins at 40-60 yrs.)
    • weight gain in hips/abdomen
    • loss of subcutaneous fat of bony prominences
    • physical activity can prevent/delay bone loss
  120. Symptom analysis musculoskeletal: weakness
    • proximal: myopathy
    • distal: neuropath
  121. Symptom Analysis musculoskeletal: Always consider...

    • pain: muscle, joint etc
    • stiffness: time of day?
    • balance/coordination: often neuro
    • swelling, fever, numbness, tingling
  122. Abdomen Normal Findings
    • no abdominal pain
    • contour flat/round (no distention)symmetric/ no masses
    • bowel sounds present, high pitched, gurgle, irregular from 5-30/min
    • Percussion: tympanic sound
    • Soft, no palpable masses

    NOTE: empty bladder, supine, flex knee (relaxes muscles), assess painful area last!!!
  123. Lymph Normal Findings
    • skin color uniform, no erythema, no edema, no lesions, even hair distribution
    • lymph nodes non-palpable
    • abdomen contour flat, veins barely visible
    • extreme ties warm bilateral, capillary refill less than 3 seconds
    • all pulses 2+, regular, equal and bilateral
  124. Musculoskeletal: physical assessment
    • 1) assess posture, gait, cerebral fuction
    • 2) measure limbs
    • 3) joints movement
    • 4) muscle strength/ROM
  125. Assess posture
    • erect, head midline
    • spine: lordosis (against wall), kyphosis and scoliosis (bend at waist)
  126. Assess Gait
    wide base and shortened stride=balance problem
  127. Assess balance
    • look at gait, if gait is not normal cant move on, otherwise assess balance by:
    • heel-toe walk, hop in place, etc
  128. Romberg Test
    • assess balance
    • stand, close eyes
  129. Assess coordination
    • by rapid alternating movement
    • finger-thumb, toe tapping
  130. Assess accuracy movement
    finger to finger, finger to nose
  131. When palpating and inspecting extremities...
    simultaneously palpate/inspect each joint and muscle

    • Assess ROM
    • test muscular strenth
  132. Abnormal Gait: Propulsive
    Propulsive: rigid, stooped posture, head forward, shuffle steps
  133. Abnormal Gait: Scissors gait
    walks on toes, bilateral spastic paresis of legs, legs flexed at hip and knees, knees adduct and meet or cross like scissors.
  134. Abnormal gait: Spastic gait
    unilaterally stiff, dragging legs
  135. Abnormal Gait: waddling
    • duck like with wide base support
    • normal in toddlers and late pregnancy
  136. Abnormal Gait: Steppage
    foot drop with eternal rotation of hip. foot slaps when hits the ground.
  137. Musculoskeletal Inspection
    • skin color
    • hair distribution
    • rash/lesions
    • nail beds (clubbing and capillary refill)
    • symmetry
    • curvature of spine
  138. Musculoskeletal Palpation
    • edema
    • heat/moisture
    • pain/tenderness/crepitus
    • muscle bulk
    • joints: size, shape, color, symmetry, clicking
  139. Internal Rotation/External Rotation
    • Turn around midline
    • turn away midline
  140. Inversion/Eversion
    • turn inward
    • turn outward
  141. Pronation/Supination
    • turn downward
    • turn upward
  142. Flexion/Extension
    • decrease angle
    • increase angle
  143. Abduction/adduction
    • away from midline
    • towards midline
  144. Depression/elevation
    • lower
    • raise
  145. Retraction/protraction
    • move backward
    • move forward
  146. ROM: active vs passive
    • active: patient does
    • passive: nurse does
  147. Muscle Strength ratings:
    • 5: active motion against full resistance (normal)
    • 4: Active motion against some resistance (slight weakness)
    • 3: active motion against gravity (average weakness)
    • 2: passive ROM (poor ROM)
    • 1: slight flicker/contraction (severe weakness)
    • 0: no muscular contraction (paralysis)
  148. Phalen's test
    • wrist: carpal tunnel
    • flex hands 90 degrees back to back
    • for 1 minute abnormal if feel numbness or tingling
  149. Tinel's test
    • percuss over median nerve on inner aspect of wrist
    • carpal tunnel if numbness
  150. Upper extremities measurements of arm
    • from acromion process to tip of middle finger
    • arm circumference at midpoint of forearm and upper arms
    • dominant hand often 1cm larger

    ..also test strength: equal and bilateral
  151. Lower Extremities measurements:
    • measure length from anterior superior iliac crest cross over to knee to medial malleolus
    • discrepancy should be less than 1 cm
    • measure circumference at midpoint of calves/thighs
  152. Thomas Test
    • Hip flexure contraction excessive lumbar lordosis
    • patient lies supine with both legs extended then flex one leg to chest
    • positive if opposite rises off table.
  153. Trendelenburg test
    • assess for dislocated hip and gluteus medius muscle strength
    • patient stand erect check iliac crest level, if even... stand on one foot and check again. if iliac remains level or drops on the side opposite the weight bearing leg then gluteus medius is weak or joint is not stable (dislocation on weight bearing side)
  154. Bulge Test
    • if suspect small amounts of fluid
    • patient supine, stroke medial side of knee upward to displace fluid, then press lateral side of knee to inspect for bulge on medial side.
  155. Patellar Ballottement
    • if suspect large amounts of fluid
    • supine, with finger on each side of patella, tap on knee cap
    • positive if knee cap bounces back
  156. Lachman Test
    • Knee stability
    • flex knee 30 degrees, move leg from bottom
  157. McMurray test
    • supine with knee fully flexed. one hand on heel other on knee and rotate internally or externally
    • positive if hear clicks
  158. Apley's Test
    • supine, knees at 90 degrees. place one hand heel and other on knee. apply pressure with both hand and rotate foot.
    • positive if hear clicks
  159. Spinal deviation:
    • structural: spinal deviation present after bend at waist c shape
    • functional: spinal deviation disappears
  160. Senile Kyphosis
    • elder
    • backward head tilt, slight flexion of hips and knees, decreased height
    • have patient bend forward at waist
  161. Peripheral
    • somatic: voluntary skeletal
    • autonomic: level of consciousness/ visceral functions (HR, digestions, respiratory distress, salivation)
  162. Autonomic system divided into two: what are they?
    • sympathetic: fight or flight
    • parasympathetic: recover
  163. Developmental Neuro: Infants
    • screening done withing 24 hrs.
    • check appearance, alertness, motor sensory

    note: neuro development complete at toddler
  164. Development Neuro children/adolescents
    • consider lead poisoning
    • behavioral: check with parent
    • child abuse
  165. Development Neuro: pregnant women
    • folic acid: neural tube defect
    • spinal bifida
  166. Development Neuro: older adults
    • neuron lost= neural impulses slow down
    • sensory neurons decrease
    • reflexes diminish
  167. Mental status chance caused by
    • neuro problems
    • dehydration
    • hypoxia
    • nutritional deficiencies
    • liver disease
  168. Dizziness
    fainting sensation
  169. Syncope
  170. Virtigo
    spinning sensation
  171. Neuro Physical Assessment
    • mental/Emotional Status (facial expressions/posture/ alert and oriented)
    • cranial nerves
    • sensory status
    • motor
    • reflexes
  172. Cincinnati Prehospital Stroke Scale
    • facial droop
    • motor weakness
    • speech problems
  173. LOC: alert
    follows commands in a timely manner
  174. Dysmenorrhea
    menstrual pain or discomfort
  175. LOC: lethargic
    drowsy, may drift
  176. LOC: stuporous
    requires rigorous stimuli
  177. LOC: Comatose
    does not respond to verbal or painful stimuli
  178. Painful stimuli
    • trapezioius squeeze
    • sternal rub
    • supraorbital pressure
    • mandibular pressure
    • nail pressure
    • Achilles tendon
  179. Sterengnosis
    ability to recognize object
  180. graphesthesia
    recognize outlines, numbers, words
  181. Parathesia
    numbness or tingling
  182. Two point discrimination
    differentiate between two points of stimuli ( no more than .5 cm apart
  183. Point localization
    ability to sense area being stimulated (eyes closed)
  184. Sensory extinction
    simultaneously touch both sides of patients body, ask to point where.
  185. Deep tendon reflex
    • 0 absent
    • + present but diminished
    • ++ normal
    • +++ increased by not necessarily pathologic
    • ++++hyperactive
  186. Primitive reflexes
    • seen in newborns
    • grasp
    • sucking
    • snout (lips pucker)
    • rooting (touch side of face should turn towards stimuli)
    • Glabellar (tap on forehead=blink)
Card Set:
Nursing Assessment test 2
2013-05-31 05:38:21
Nursing Assessment

test 2
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