-
visceral pleura
coats outer surface of organs
-
parietal pleura
lines wall of abdomen
-
Abdomen Developmental for infants
- bladder above symphisis pubis
- extends below rib cage
- muscles weak
- abdomen protrudes
-
Abdoment Development children
- abdomen larger than adults (diminish at adolescents)
- belly breathing
- organs easily palpated
-
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
-
linea Nigra
line down abdomen: normal when pregnant
-
-
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
-
Solid Viscera
- maintains shape, encapsulated
- liver, spleen, kidney
-
Hollow Viscera
- Shape depends on contents
- stomach, gallbladder, SI, colon, bladder
-
Abdominal Pain: Visceral
- from distention of abdomen/stretch organs
- burning, cramping
- diffuse and poorly localized
-
Abdominal pain: Parietal
- inflammation of parietal peritoneum
- worse with movement
-
Abdominal Pain: Referred
- Felt at site away from origin
- appending :RLQ middle
- Gallbladder: right scapula
-
what should I do... acute abdominal pain??
- first rule out cardiac, shock, infection
- check vitals
- RTQSP
-
Pain in shoulder
spleen, ectopic pregnancy, pancreatic
-
Pain in Scapula
Cholelithiasis, MI, Angina, biliary colic, pancreatic
-
Pain in thighs
genitals, lower back, renal, urethral
-
Pain lower back/middle back
abdominal aortic aneurysm
-
Normal Weight change
- 2-3 pounds within 48 hrs is fluid
- more: abnormal (GI diseases, cancer, CHF, etc)
-
Cathartics
- use of laxatives to lose weight
- don't give laxatives to patient with absent bowel sounds
-
-
Normal bowel patters
establish baseline (2 per day to 2-3 times per week can be normal)
-
Black tarry stool
upper Gi
-
Red, Bloody stool
lower GI
-
Clay colored stool
increased bile
-
-
Nausea
due to stress on stomach/esophagus
-
Vomiting
- reversed peristalsis and esophageal sphincter opens
- chemical, trauma, distention
-
projectile vomiting
- unexpected vomiting
- head injury, neuro, vascular abnormal in brain
-
coffee colored emesis (vomiting)
blood in stomach
-
Dysphagia
difficulty swallowing
-
Guarding
Tense abdominal muscle
-
Abdomen Inspection
- shape, symmetry
- skin: color, hair distribution, lesions, edema
- straie, distension
-
7 F's
fat, fluid, feces, fetus, full bladder, false pregnancy, fatal tumor, fibroid
-
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
-
Auscultate abdomen hypoactive bowel sounds
if hypoactive listen at ielocecal valve (right of umbilicus)
-
Abdominal Percussion
- CVA
- liver size-scratch test
- bladder (if dull bladder full)
- high pitched sounds on hollow areas
- dull sound on masses
-
CVA Costovertebral Angel
- Costovertebral Angel
- assess for tenderness of kidney
- kidney sones
-
Abdomen Palpation
- Light: 1 cm, circular motion 1/2"
- deep: 5-8 cm (1-2")
–Normally, slightly tender over sigmoid colon
-
involuntary guiding
peritonitis
-
Palpating Liver
- with left hand under 11th or 12th rib lift up
- take deep breath
- smooth and tender
-
ascites
- accumulation of fluid in peritoneal cavity
- causes: CHF, cirrhosis, nephrosis
- assess; shifting dullness, fluid wave, puddle sign
-
Constipation
causes: meds, decreases exercise, low dietary fiber, low muscle tone, cancer, dehydration, intestinal obstruction
-
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
-
Ileus
- blockage/obstruction leads to decreased peristalsis
- decreased blood supply
-
Bowel Perforation
- leakage into abdominal cavity, leads to
- peritonitis
- organ failure
- septic shock
-
Ballottement
used to displace fluid so that a floating mass or organ be palpated
-
Kerh's Sign
referred pain to left shoulder caused by splenic rupture.
-
Ballance's Sign
present when dullness is percussed in the LUQ. indicated peritoneal irritation or injury to the spleen
-
Murphy's Sign
used to detect inflamed gallbladder. palpate at right midclavicular line under costal angel, take deep breath if patient feels pain, positive.
-
Ileopsoas Test
- appendix
- pressure over right tight ask patient to raise leg
-
Rupture of peritonitis
- paralyze GI
- absent bowel sounds
-
Peripheral vascular system
network of vessel transport of oxygenated blood to organs and tissue and return deoxygenated blood to lungs
- veins: deoxygenated
- arteries: oxygenated
-
Lymphatic
- collect and drain excess tissue fluid
- lymph nodes, tonsils, thymus, spleen, peyers patch
-
Lymph Nodes
filter large molecules and debris
-
Tonsils
destroys microorganisms/substances at entry of resp or digest
-
Thymus
in thorax, forms antibodies: t cells
-
Spleen
filter blood, make lymphocytes and monocytes
-
Payers patch
respond to antigens, make antibodies
-
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
-
Developmental Lymph: pregnant
- decreased systematic vascular resistance/decreased BP
- palmar erythema
- telangiactasis
-
Palmar Erythema
- redness of palms in pregnant women
- decreased systemic vascular resistance/decreased blood pressure
-
Telangiectasis
- spider like skin
- decreased systemic vascular resistance/decreased blood pressure
-
Developmental Lymph: Older Adults
- decreased lymph nodes with age
- decreased resistance infection
- increased PV=increased Blood pressure
- (increased fibrosis and decreased elasticity in vessels)
-
Varicosites
due to decreased venous elasticity increase
-
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.
-
Capillary Refill
- less than 3 seconds is normal
- otherwise arterial occlusion/hypothermia
-
Edema
Fluid accumulation=increased capillary refill caused by venous obstruction, heart failure, renal disease, lymphatic conditions etc
cm/2=rating
lymphatic
-
Parathesia
- change in sensation
- numbness, tingling, pins and needles or burning
lymphatic
-
Pulse Measurement
- 0: absent
- 1: diminished
- 2: normal
- 3: full, increased
- 4: bounding
note rate, rhythm, equality, amplitude
-
Pulses
head
upper extremities
lower extremities
- head: temporal, carotid
- upper: brachial, radial, ulnar
- lower: femoral, popliteal, posterior tibialis, dorsalis pedis
-
lymph nodes
note size, shape, tenderness, motility, location, erythema, warmth
-
Auscultation Bruits
- with bell
- temporal, carotid, abdominal aorta, renal, iliac
-
orthostatic blood pressure
- positional blood pressure
- decreased bp of 20 mm hg
- drop in diastolic with increase pulse: abnormal
-
6 P's of extremities
- Arterial occlusion:
- pain, pallor, pulselesness, pressure, poor sensation, paralyze
-
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
-
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
-
Ankle-Brachial index
- circulation to feet
- ankle systolic pressure divided by brachial systolic pressure
- normal is 1 or greater
-
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
-
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.
-
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.
-
-
Percussion of Spleen
- LUQ below costal margin
- tympany heard unless spleen is enlarged
-
Typany
loud high-pitched hollow sound
-
Lymphatic abnormal findings:
- Swelling
- Fatigue
- Fever
- Joint pain
- Slow healing wounds
-
Peripheral abnormal findings
- Swelling
- Limb Pain
- Change in sensation
- Fatigue
- Vision changes
-
Breast inspection
- conical shape and often unequal
- part of reproductive system
-
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
-
Developmental Breast: infants
supernumerous nipples (normal)
-
Developmental Breast:children/adolescents:
growth begins prepubertal period
-
Developmental Breast: pregnant women
- fuller, firmer, areola and nipples darken and enlarge
- 3rd trimester: colostrum
-
Developmental Breasts: Older Adults
Fibrous, less firm, pendulous (hang)
-
Breast pain/tenderness
- usually menstrual cycle
- can be metastic disease/pain cysts infection, mastitis, hematoma etc.
-
Breast nipple dischange
- normal or abnormal
- unless lactating not normal
-
menarch early risk for:
- early is earlier than 12 yrs
- risk for breast cancer
-
Breast Inspection
- all five positions
- size, shape, contour, symmetry, skin, pain, tenderness, discharge
-
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)
-
Female Genitourinary: considerations
- no douche, spray, coitus for 24-48 hrs prior to exam
- consider culture, have other female present
- explain procedure
- lithotomy position
-
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
-
Pap smear
- collect 3 specimens (endocervix, cervix, vaginal pool)
- purpose: detect cancer
- when: 21 yrs or 3 years after sexually active
-
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
-
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
-
Testicular trans illumination, when?
if masses present
-
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
-
Orchitis
swelling, acute of testes
-
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
-
Transgender
psych state mental disorder if causes significant distress or disability
-
Breast Cancer
- prevention: diet, exercise, alcohol intake, family history
- most commonly diagnosed cancer.
-
Respiration muscles:
- External Intercostal muscles: pull ribs up and out
- Internal Intercostal muscles: pull ribs down and in
- both decrease intrathoracic pressure
-
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)
-
Tendon
attach skeletal muscle
-
Ligaments
attach bone to bone
-
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
-
Genu Varum
- bowlegs
- knees are greater than 2 inches apart ad medial malleoli touch
- normal 2-3 yrs, even up to 7 yrs
-
Kyphosis
accentuated thoracic curve
-
Scoliosis
lateral S spinal deviation
-
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.
-
Dowager's hump
hyphosis + decrease height
-
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
-
Symptom analysis musculoskeletal: weakness
proximal
distal
- proximal: myopathy
- distal: neuropath
-
Symptom Analysis musculoskeletal: Always consider...
ADL'S!!!
- pain: muscle, joint etc
- stiffness: time of day?
- balance/coordination: often neuro
- swelling, fever, numbness, tingling
-
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!!!
-
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
-
Musculoskeletal: physical assessment
- 1) assess posture, gait, cerebral fuction
- 2) measure limbs
- 3) joints movement
- 4) muscle strength/ROM
-
Assess posture
- erect, head midline
- spine: lordosis (against wall), kyphosis and scoliosis (bend at waist)
-
Assess Gait
wide base and shortened stride=balance problem
-
Assess balance
- look at gait, if gait is not normal cant move on, otherwise assess balance by:
- heel-toe walk, hop in place, etc
-
Romberg Test
- assess balance
- stand, close eyes
-
Assess coordination
- by rapid alternating movement
- finger-thumb, toe tapping
-
Assess accuracy movement
finger to finger, finger to nose
-
When palpating and inspecting extremities...
simultaneously palpate/inspect each joint and muscle
- Assess ROM
- test muscular strenth
-
Abnormal Gait: Propulsive
Propulsive: rigid, stooped posture, head forward, shuffle steps
-
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.
-
Abnormal gait: Spastic gait
unilaterally stiff, dragging legs
-
Abnormal Gait: waddling
- duck like with wide base support
- normal in toddlers and late pregnancy
-
Abnormal Gait: Steppage
foot drop with eternal rotation of hip. foot slaps when hits the ground.
-
Musculoskeletal Inspection
- skin color
- hair distribution
- rash/lesions
- nail beds (clubbing and capillary refill)
- symmetry
- curvature of spine
-
Musculoskeletal Palpation
- edema
- heat/moisture
- pain/tenderness/crepitus
- muscle bulk
- joints: size, shape, color, symmetry, clicking
-
Internal Rotation/External Rotation
- Turn around midline
- turn away midline
-
-
-
Flexion/Extension
- decrease angle
- increase angle
-
Abduction/adduction
- away from midline
- towards midline
-
-
Retraction/protraction
- move backward
- move forward
-
ROM: active vs passive
- active: patient does
- passive: nurse does
-
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)
-
Phalen's test
- wrist: carpal tunnel
- flex hands 90 degrees back to back
- for 1 minute abnormal if feel numbness or tingling
-
Tinel's test
- percuss over median nerve on inner aspect of wrist
- carpal tunnel if numbness
-
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
-
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
-
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.
-
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)
-
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.
-
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
-
Lachman Test
- Knee stability
- flex knee 30 degrees, move leg from bottom
-
McMurray test
- supine with knee fully flexed. one hand on heel other on knee and rotate internally or externally
- positive if hear clicks
-
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
-
Spinal deviation:
structural
functional
- structural: spinal deviation present after bend at waist c shape
- functional: spinal deviation disappears
-
Senile Kyphosis
- elder
- backward head tilt, slight flexion of hips and knees, decreased height
- have patient bend forward at waist
-
Peripheral
-somatic
-autonomic
- somatic: voluntary skeletal
- autonomic: level of consciousness/ visceral functions (HR, digestions, respiratory distress, salivation)
-
Autonomic system divided into two: what are they?
- sympathetic: fight or flight
- parasympathetic: recover
-
Developmental Neuro: Infants
- screening done withing 24 hrs.
- check appearance, alertness, motor sensory
note: neuro development complete at toddler
-
Development Neuro children/adolescents
- consider lead poisoning
- behavioral: check with parent
- child abuse
-
Development Neuro: pregnant women
- folic acid: neural tube defect
- spinal bifida
-
Development Neuro: older adults
- neuron lost= neural impulses slow down
- sensory neurons decrease
- reflexes diminish
-
Mental status chance caused by
- neuro problems
- dehydration
- hypoxia
- nutritional deficiencies
- liver disease
-
Dizziness
fainting sensation
-
-
Virtigo
spinning sensation
-
Neuro Physical Assessment
- mental/Emotional Status (facial expressions/posture/ alert and oriented)
- cranial nerves
- sensory status
- motor
- reflexes
-
Cincinnati Prehospital Stroke Scale
- facial droop
- motor weakness
- speech problems
-
LOC: alert
follows commands in a timely manner
-
Dysmenorrhea
menstrual pain or discomfort
-
LOC: lethargic
drowsy, may drift
-
LOC: stuporous
requires rigorous stimuli
-
LOC: Comatose
does not respond to verbal or painful stimuli
-
Painful stimuli
- trapezioius squeeze
- sternal rub
- supraorbital pressure
- mandibular pressure
- nail pressure
- Achilles tendon
-
Sterengnosis
ability to recognize object
-
graphesthesia
recognize outlines, numbers, words
-
Parathesia
numbness or tingling
-
Two point discrimination
differentiate between two points of stimuli ( no more than .5 cm apart
-
Point localization
ability to sense area being stimulated (eyes closed)
-
Sensory extinction
simultaneously touch both sides of patients body, ask to point where.
-
Deep tendon reflex
- 0 absent
- + present but diminished
- ++ normal
- +++ increased by not necessarily pathologic
- ++++hyperactive
-
Primitive reflexes
- seen in newborns
- grasp
- sucking
- snout (lips pucker)
- rooting (touch side of face should turn towards stimuli)
- Glabellar (tap on forehead=blink)
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