NR 304 Health Assessment II Exam #1 questions and answer with detailed rationales

arteries

active blood flow, heart pumps fresh oxygenated blood through arteries

veins

passive blood flow - do not have a pulse, returns to the heart via movement through the skeletal muscles

femoral pulse site

groin

popliteal pulse site

back of knee

radial pulse site

Located at the wrist on the thumb side

dorsalis pedis pulse site

top of foot

posterior tibial pulse site

on medial surface of ankle near ankle bone

ischemia

Lack of blood supply, causes pain

necrosis

long term lack of blood supply, tissue death

axillary lymph nodes

located under the arms in the armpits

cervical lymph nodes

located along the sides of the neck

Epitrochlear lymph nodes

Epitrochlear lymph nodes- drains from the hand and forearm

inguinal lymph nodes

located in the inguinal (groin) area of the lower abdomen

lymphatic system

Composed of a network of vessels, ducts, nodes, and organs. Provides defense against infection.

conserve fluid of proteins that leak out of capillaries

Children and Lymph Nodes

nodes can be enlarged with no pain/infection

Pregnancy and PV

dependent edema, varicose veins

peripheral artery disease

A form of peripheral vascular disease in which there is partial or total blockage of an artery, usually one leading to a leg or arm. 50% of cases are African Americans. RF: smoking, HTN, diabetes

intermittent claudication

when walking, muscle needs more O2 blood, and you have any kind of occlusion, when walking pain is increased

Pulse Scale

0: absent

1+: weak

2+: normal

3+: increased, full, bounding

Allen test

determining the patency of the radial and ulnar arteries by compressing one artery site and observing return of skin color as evidence of patency of the other artery, determine if radial artery has been damaged, press radial artery then see if ulnar artery perfuses to hand

venous ulcers

bleed, medial malleolus

arterial (ischemic) ulcers

does not bleed, has a necrotic black crust, lateral malleolus

neuropathic ulcer

destroys nerve endings, burning pain/numbness

Edema Scale

• 1+ Mild pitting, slight indentation, no perceptible swelling of the leg

• 2+ Moderate pitting, indentation, subsides rapidly

• 3+ Deep pitting, indentation remains for a short time, leg looks swollen

• 4+ Very deep pitting, indentation lasts a long time, leg is very swollen

Doppler ultrasound

determine location of pulse

Raynaud's disease

autoimmune, sporadic vasoconstriction then relaxation, happens in hands/toes usually

Lymphadema

enlarged lymph nodes, hard edema

Varicose veins

abnormally swollen, twisted veins with defective valves; most often seen in the legs

DVT

inflammatory process, swelling, redness, heat, pain, happens from venastasis, pooling of blood in calf

-tachycardia, low grade temp

-women on birth control who smoke are at a higher risk, and also those who are dehydrated since blood is more viscous

-Do not perform homan's sign test (flexing foot back)

anneurysm

can be born with or develop, serious with abdominal aorta/coronary arteries/brain

Decreased Arterial Flow

doesn't work well around gravity, blue then pallor

Decreased Venous Flow

brown, using muscles improves

What happens when valves of the veins do not work right

edema/varicose veins

arterial insufficiency

not getting enough arterial blood flow = ischemic pain, usually happens on one leg, leg appears shiny, hairless, red/blue then pallor, limb gets cool, pain gets better when resting since the limb doesn't need as much O2 blood flow (intermittent claudication), gravity works for it when legs are down, causes impotence in males, can affect nails/toes

venous insufficiency

constant, achy, fullness, pain. Pain gets better by moving. When you stand/sit pain gets worse. Gravity works against when legs are down. Usually happens on both legs, skin turns red/brown, starts below the knee to the ankle, skin is scaly, can get slits in skin (weeping edema), there is no cure, no change in skin temp.

pulse

rhythm, rate, symmetry, amplitude/strength

arterial occlusion

-extreme coolness

-pain

-loss of sensation

-hair loss and skin changes

-pallor

-pulselessness

arterial insufficiency

-intermittent claudation (pain brought on by exercise and relieved with rest)

-hair loss on toes and shiny skin

-impotence

-pain (gnawing, sharp or stabbing and increases with exercise, relieved with rest)

-decreased pulses

-rusty discoloration due to blood leaking out of vessel and difficulty being reabsorbed

-skin ulcers on pressure points, toes, and lateral malleoli

-necrosis

-bluish/red feet with dependence and pallor with elevation

-sensory and motor loss

-thickened, yellow toenails

-cool skin

venous insufficiency

-pitting edema due to fluid leaking into tissue due to incompetent valves

-pain (aching or feeling of fullness and increases with standing/sitting and improves with elevating legs or walking)

-varicosities may be present

-possible leg ulcers on medial malleoli

-normal temperature

-skin thickened with brown discoloration of ankles and flaky

deep vein thrombosis

-edema (only on one leg)

-pain - no pain or sharp, intense pain/tenderness

-red skin area

-warmth

-mass

-low grade fever

-tachycardia

Peripheral Neuropathy

-burning skin

-numbness

-loss/decreased sensation

GERD

(pyrosis) - failure of pyloric valve, dont eat before bed or in middle of night, dont lie down after eating for at least 30 mins

What causes peptic ulcers?

H. pylori - loved acid

Small Bowel

-small in diameter, huge in length 20ft

-where most digestion/breakdown ocurrs

-where enzymes from pancreas go

-most of absorption of nutrients ocurrs

large bowel

-shorter but larger diameter

-condense stool into formed stool (pulls water out)

-where you metabolize fats to absorb vit. D

E.coli

-essential bacteria that breaks down food in bowel

-if it is any other placer than the gut, it can kill you

-in wound = infection

-bladder = UTI

-lungs = dangerous pneumonia

C. Diff

-if you take antibiotics you kill e.coli in gut, so you have an overgrowth of other microbes (importance of probiotics)

-when you kill all this bacteria you get C.diff - terrible bacteria that can kill you

-explosive diarrhea, highly contagious, gown/glove precautions, horrible smell

-can prevent C. Diff by probiotics - can have yogurt with live cultures or need probiotic with 50 million bacteria

Peristalsis

Involuntary waves of muscle contraction that keep food moving along in one direction through the digestive system.

hyperactive peristalsis

diarrhea

slowed peristalsis

constipation, any type of narcotic slows peristalsis a lot and can even cause a bowel obstruction/impaction

-prevention: have pt. take a stool softener with pain pill

-anesthesia, immobility, and dehydration can also slow peristalsis

Ileostomy

removal of part of small bowel, can lead to malnutrition

Colostomy

removal of part of large bowel, reversible

hernia

protrusion of an organ or part through the tissues and muscles normally containing it

chron's disease

autoimmune, destroying parts of lining of bowel, nutritionally depleted, anemia from bleeding

Can you live without a liver?

no, it is extremely important

Liver Functions

-produces bile (enzyme that breaks down fat)

-metabolizes proteins/fats/CHO

-stores vitamins - B vitamins

-detoxifies alcohol and Tylenol

-produces all coag factors, controls clotting, if failed then bleed easily

-produces AB's

Leading cause of liver transplant in children

extra doses of tylenol

Pancreas

-produces pancreatic enzymes/insulin

-pancreatitis: very painful, inflammation of pancreas

Gallbladder

stores bile

Spleen

-provides a site for lymphocyte proliferation (filter microorganisms from blood)

-cleans blood then sends breakdown to liver ( destroys old blood cells)

-can live without

Pregnancy and Abdominal

-morning sickness, heart burn (pushing up on stomach), cant eat a big meal since stomach is smaller, constipation, striae, linea nigra

Tonsils

located at entrance to respiratory and gastrointestinal tracts, respond to local inflammation

Thymus

An immune organ located near the heart. THe thymus is the site of T cell maturation and is larger in children and adolescents.

Aging and Abdominal

-decreased saliva, taste, smell, teeth become lose/diseased, more frequent constipation = malnutrition

anorexia

loss of appetite

Infants and children and Lymphatic System

lymph nodes are large in children and with infection, excessive swelling and hyperplasia occur

Pregnant Women and Lymphatic System

hormonal changes cause vasodilation and decrease blood pressure

growing uterus obstructs drainage of iliac veins ( dependent edema ,varicosities in legs and hemorrhoids)

Aging adult and lymphatic system:

anorexia nervosa

bad self image, starvation

dysphagia

difficulty swallowing

hepatitis c

- no vaccine

-shared needle - can show later in life

-damage on liver, can kill you

-very prevalent in third world countries

-heroin use - increases in HIV and hep c

bulimia

binge eat then vomit, takes enamel off of teeth

Order in which you assess abdomen

-start in RLQ and move clockwise, IAPP

Inspection of Abdomen

-looks for symmetry, color, masses, buldges, hernias (common in children)

Hernias

most are related to inguinal hernias, common in men, striae muscle wall gets weak, bowel protrudes, men more likely because when testes move down in fetal development, causes weakness in abdominal wall

-if you cant push hernia back in, if it gets cut off by abdominal muscle, the bowel has necrosis which causes bacteria in the abdomen - peritonitis

Ausculation of Abdomen

-listen until you hear 5-30 bowel sounds in each quadrant, if you dont hear any, listen for 1 full minute in each quadrant for a total of 5 minutes.

-listen for a bruit in the aorta

-listen for a venous hum in the vena cava

Venous Hum

increased portal hypertension

Hyperactive Bowel Sounds

diarrhea, IBS, laxative

borborygmus

the rumbling noise caused by the movement of gas in the intestine

Hypoactive Bowel Sounds

peristalsis is slow

No bowel sounds

problem

Obstruction in Bowel

hypoactive above blockage, absence below

Percussion of Abdomen

listen for hollow sound (tympany)

-dull = fluid, stool, or organ

-LLQ can have dullness from stool

Ascites

fluid in abdomen, from cirrhosis, osmotic shift, protein pulls fluid into abdomen, will push up on diaphragm, hard belly, petechiae, bruises -> cirrhosis

Peritoneum

covering of abdomen

Palpation of abdomen

-if it is painful dont push hard

-aorta: dont push on if you notice pulsations/thrill

-if liver or spleen is enlarged, if it causes pain, dont push, same with appendix

-use pads of fingers in circular motion, press fingers an inch, start at RLQ and go clockwise

-have patient take a breath in, on exhalation palpate liver, repeat for spleen

Light Palpation

1 inch

Deep Palpation

2 inches

Murphy Sign

tenderness in the right subcostal area on inspiration, associated with acute cholecystitis

Pain in RLQ

appendicitis, mcburney's point, assess with rebound tenderness on opposite side

Rebound Tenderness

pain that increases when pressure (as from a hand) is removed

Psoas Sign

RLQ pain with extension of right thigh indicative of appendicitis

Fluid Wave Test

this test for ascites

by standing on the right side of the person-place the ulnar edge of another person's hand or patient's hand firmly in the middle of the abdomen-place your hands on the patient's right and left flank-give left flank a firm strike

if ascites is present= a wave will generate through abdomen & you will feel a distant tap on your left hand

a positive test occurs with large amounts of ascitic fluid

if distention is due to gas or adipose tissue=no change

Liver Failure can lead to

sanguination - bleeding from all orifec

Green vomit

bile

fowl, brown vomit

feces

coffee ground vomit

blood that is partially digested, upper GI bleed

melena

anytime feces has blood in it

occult blood

hidden blood - test is a hemocult

frank blood

bright red, fresh (hemorrhoids)(colon cancer)