Nursing Assessment test 2

coats outer surface of organs

lines wall of abdomen

• bladder above symphisis pubis
• extends below rib cage
• muscles weak
• abdomen protrudes

• abdomen larger than adults (diminish at adolescents)
• belly breathing
• organs easily palpated

• 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

line down abdomen: normal when pregnant

stretch marks

• 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

• maintains shape, encapsulated
• liver, spleen, kidney

• Shape depends on contents
• stomach, gallbladder, SI, colon, bladder

• from distention of abdomen/stretch organs
• burning, cramping
• diffuse and poorly localized

• inflammation of parietal peritoneum
• worse with movement

• Felt at site away from origin
• appending :RLQ middle
• Gallbladder: right scapula

• first rule out cardiac, shock, infection
• check vitals
• RTQSP

spleen, ectopic pregnancy, pancreatic

Cholelithiasis, MI, Angina, biliary colic, pancreatic

genitals, lower back, renal, urethral

abdominal aortic aneurysm

• 2-3 pounds within 48 hrs is fluid
• more: abnormal (GI diseases, cancer, CHF, etc)

• use of laxatives to lose weight
• don't give laxatives to patient with absent bowel sounds

vomiting

establish baseline (2 per day to 2-3 times per week can be normal)

upper Gi

lower GI

increased bile

• heart burn
• common

due to stress on stomach/esophagus

• reversed peristalsis and esophageal sphincter opens
• chemical, trauma, distention

• unexpected vomiting
• head injury, neuro, vascular abnormal in brain

blood in stomach

difficulty swallowing

Tense abdominal muscle

• shape, symmetry
• skin: color, hair distribution, lesions, edema
• straie, distension

fat, fluid, feces, fetus, full bladder, false pregnancy, fatal tumor, fibroid

• 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

if hypoactive listen at ielocecal valve (right of umbilicus)

• CVA
• liver size-scratch test
• bladder (if dull bladder full)
• high pitched sounds on hollow areas
• dull sound on masses

• Costovertebral Angel
• assess for tenderness of kidney
• kidney sones

• Light: 1 cm, circular motion 1/2"
• deep: 5-8 cm (1-2")

–Normally, slightly tender over sigmoid colon

peritonitis

• with left hand under 11th or 12th rib lift up
• take deep breath
• smooth and tender

• accumulation of fluid in peritoneal cavity
• causes: CHF, cirrhosis, nephrosis
• assess; shifting dullness, fluid wave, puddle sign

causes: meds, decreases exercise, low dietary fiber, low muscle tone, cancer, dehydration, intestinal obstruction

• Bruits: use bell over midline, epigastric area
• Venous Hums: over liver with bell
• Friction Rub: over inflamed organs or tumors

• blockage/obstruction leads to decreased peristalsis
• decreased blood supply

• leakage into abdominal cavity, leads to
• peritonitis
• organ failure
• septic shock

used to displace fluid so that a floating mass or organ be palpated

referred pain to left shoulder caused by splenic rupture.

present when dullness is percussed in the LUQ. indicated peritoneal irritation or injury to the spleen

used to detect inflamed gallbladder. palpate at right midclavicular line under costal angel, take deep breath if patient feels pain, positive.

• appendix
• pressure over right tight ask patient to raise leg

• paralyze GI
• absent bowel sounds

network of vessel transport of oxygenated blood to organs and tissue and return deoxygenated blood to lungs

• veins: deoxygenated
• arteries: oxygenated

• collect and drain excess tissue fluid
• lymph nodes, tonsils, thymus, spleen, peyers patch

filter large molecules and debris

destroys microorganisms/substances at entry of resp or digest

in thorax, forms antibodies: t cells

filter blood, make lymphocytes and monocytes

respond to antigens, make antibodies

• 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

• decreased systematic vascular resistance/decreased BP
• palmar erythema
• telangiactasis

• redness of palms in pregnant women
• decreased systemic vascular resistance/decreased blood pressure

• spider like skin
• decreased systemic vascular resistance/decreased blood pressure

• decreased lymph nodes with age
• decreased resistance infection
• increased PV=increased Blood pressure
• (increased fibrosis and decreased elasticity in vessels)

due to decreased venous elasticity increase

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.

• less than 3 seconds is normal
• otherwise arterial occlusion/hypothermia

Fluid accumulation=increased capillary refill caused by venous obstruction, heart failure, renal disease, lymphatic conditions etc

cm/2=rating

lymphatic

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

lymphatic

• 0: absent
• 1: diminished
• 2: normal
• 3: full, increased
• 4: bounding

note rate, rhythm, equality, amplitude

• head: temporal, carotid
• upper: brachial, radial, ulnar
• lower: femoral, popliteal, posterior tibialis, dorsalis pedis

note size, shape, tenderness, motility, location, erythema, warmth

• with bell
• temporal, carotid, abdominal aorta, renal, iliac

• positional blood pressure
• decreased bp of 20 mm hg 
• drop in diastolic with increase pulse: abnormal

• Arterial occlusion:
• pain, pallor, pulselesness, pressure, poor sensation, paralyze

• 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

• 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

• circulation to feet
• ankle systolic pressure divided by brachial systolic pressure
• normal is 1 or greater

• venous valve competence in patients with varicose veins
• patient stand and compress distal protion of vein and then proximal.
• normal: no backflow

• 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.

• 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.

heartburn

• LUQ below costal margin
• tympany heard unless spleen is enlarged

loud high-pitched hollow sound

• —Swelling
• —Fatigue
• —Fever—
• Joint pain
• —Slow healing wounds

• —Swelling
• —Limb Pain
• —Change in sensation
• —Fatigue
• —Vision changes

• conical shape and often unequal
• part of reproductive system

• 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

supernumerous nipples (normal)

growth begins prepubertal period

• fuller, firmer, areola and nipples darken and enlarge
• 3rd trimester: colostrum

Fibrous, less firm, pendulous (hang)

• usually menstrual cycle
• can be metastic disease/pain cysts infection, mastitis, hematoma etc.

• normal or abnormal
• unless lactating not normal

• early is earlier than 12 yrs
• risk for breast cancer

• all five positions
• size, shape, contour, symmetry, skin, pain, tenderness, discharge

• 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)

• no douche, spray, coitus for 24-48 hrs prior to exam
• consider culture, have other female present
• explain procedure
• lithotomy position

• 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

• collect 3 specimens (endocervix, cervix, vaginal pool)
• purpose: detect cancer
• when: 21 yrs or 3 years after sexually active

• 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

• bladder/kidney
• penis
• urethral matus
• scrotum: one at a time: note size, shape, consistency, motility and epididymis and vas deferense, note swelling/nodules

if masses present

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

swelling, acute of testes

• 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

psych state mental disorder if causes significant distress or disability

• prevention: diet, exercise, alcohol intake, family history
• most commonly diagnosed cancer.

• External Intercostal muscles: pull ribs up and out
• Internal Intercostal muscles: pull ribs down and in
• both decrease intrathoracic pressure

• 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)

attach skeletal muscle

attach bone to bone

• knock knees
• knees touch and medial malleoli are 3 inches or more apart
• normal 2-3 yrs and may be present until age 7

• bowlegs
• knees are greater than 2 inches apart ad medial malleoli touch
• normal 2-3 yrs, even up to 7 yrs

accentuated thoracic curve

lateral S spinal deviation

• 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.

hyphosis + decrease height

• 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

• proximal: myopathy
• distal: neuropath

ADL'S!!!

• pain: muscle, joint etc
• stiffness: time of day?
• balance/coordination: often neuro
• swelling, fever, numbness, tingling

• 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!!!

• 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

• 1) assess posture, gait, cerebral fuction
• 2) measure limbs
• 3) joints movement
• 4) muscle strength/ROM

• erect, head midline
• spine: lordosis (against wall), kyphosis and scoliosis (bend at waist)

wide base and shortened stride=balance problem

• look at gait, if gait is not normal cant move on, otherwise assess balance by:
• heel-toe walk, hop in place, etc

• assess balance
• stand, close eyes

• by rapid alternating movement
• finger-thumb, toe tapping

finger to finger, finger to nose

simultaneously palpate/inspect each joint and muscle

• Assess ROM
• test muscular strenth

Propulsive: rigid, stooped posture, head forward, shuffle steps

walks on toes, bilateral spastic paresis of legs, legs flexed at hip and knees, knees adduct and meet or cross like scissors.

unilaterally stiff, dragging legs

• duck like with wide base support
• normal in toddlers and late pregnancy

foot drop with eternal rotation of hip. foot slaps when hits the ground.

• skin color
• hair distribution
• rash/lesions
• nail beds (clubbing and capillary refill)
• symmetry
• curvature of spine

• edema
• heat/moisture
• pain/tenderness/crepitus
• muscle bulk
• joints: size, shape, color, symmetry, clicking

• Turn around midline
• turn away midline

• turn inward
• turn outward

• turn downward
• turn upward

• decrease angle
• increase angle

• away from midline
• towards midline

• lower
• raise

• move backward
• move forward

• active: patient does
• passive: nurse does

• 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)

• wrist: carpal tunnel
• flex hands 90 degrees back to back
• for 1 minute abnormal if feel numbness or tingling

• percuss over median nerve on inner aspect of wrist
• carpal tunnel if numbness

• 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

• 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

• 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.

• 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)

• 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.

• if suspect large amounts of fluid
• supine, with finger on each side of patella, tap on knee cap
• positive if knee cap bounces back

• Knee stability
• flex knee 30 degrees, move leg from bottom

• supine with knee fully flexed. one hand on heel other on knee and rotate internally or externally
• positive if hear clicks

• 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

• structural: spinal deviation present after bend at waist c shape
• functional: spinal deviation disappears

• elder
• backward head tilt, slight flexion of hips and knees, decreased height
• have patient bend forward at waist

• somatic: voluntary skeletal
• autonomic: level of consciousness/ visceral functions (HR, digestions, respiratory distress, salivation)

• sympathetic: fight or flight
• parasympathetic: recover

• screening done withing 24 hrs.
• check appearance, alertness, motor sensory

note: neuro development complete at toddler

• consider lead poisoning
• behavioral: check with parent
• child abuse

• folic acid: neural tube defect
• spinal bifida

• neuron lost= neural impulses slow down
• sensory neurons decrease
• reflexes diminish

• neuro problems
• dehydration
• hypoxia
• nutritional deficiencies
• liver disease

fainting sensation

faint

spinning sensation

• mental/Emotional Status (facial expressions/posture/ alert and oriented)
• cranial nerves
• sensory status
• motor
• reflexes

• facial droop
• motor weakness
• speech problems

follows commands in a timely manner

menstrual pain or discomfort

drowsy, may drift

requires rigorous stimuli

does not respond to verbal or painful stimuli

• trapezioius squeeze
• sternal rub
• supraorbital pressure
• mandibular pressure
• nail pressure
• Achilles tendon

ability to recognize object

recognize outlines, numbers, words

numbness or tingling

differentiate between two points of stimuli ( no more than .5 cm apart

ability to sense area being stimulated (eyes closed)

simultaneously touch both sides of patients body, ask to point where.

• 0 absent
• + present but diminished
• ++ normal
• +++ increased by not necessarily pathologic
• ++++hyperactive

• seen in newborns
• grasp
• sucking
• snout (lips pucker)
• rooting (touch side of face should turn towards stimuli)
• Glabellar (tap on forehead=blink)