NURS 222 Exam 4

What is the correct order of completing abdominal assessment?

1. Health History
2. Inspection
3. auscultation
4. Percussion
5. Palpation

Light Palpation

Light touch in a circular motion. Assess for tenderness, enlarged organs, masses. Avoid designated pain areas until last.

Deep Palpation

Press down 2/3 inches. May need to use biannual technique. Asses for Pain, tenderness, masses, enlarged organs.

Percussion

Percuss all 4 quadrants
Predominant Sound is tympany
Air in intestines to rise to surface when patient is supine
May hear dullness due to distended bladder, adipose tissue, fluid, mass, organs
Percuss up to lower level of liver

Inspection

Usually none, if you do see any they would be over artery areas (aorta, iliac, renal)
Hair distribution-should be even
Facial expression, position-watch for guarding, signs of pain or discomfort, curled up or fetal position
Hydration and nutrition-malnourished/undernourished

Auscultation

Use diaphragm of stethoscope to auscultation bowel sounds
Hold it lightly against skin
Start in RLQ - ileocecal valve
Note any vascular sounds none should be present

How do you assess for kidney inflammation

CVA tenderness (Flat and and thud)
-First percussion on back
-Thumb that hand with other hand
-should feel thud but not pain

Regions of the abdomen

Right hypochondriac region
Right lumbar region
Right iliac region
Epigastric region
Umbilical region
Hypogastric region
Left hypochondriac region
Left lumbar region
Left iliac region

Quadrants of the abdomen

RUQ
LUQ
RLQ
LLQ

Aging adult considerations (GI)

salivation decreases
Esophageal emptying delayed
Gastric acid secretion decreases
Incidence of gallstones increases
Liver size decreases (25%)
Constipation

Contours of the abdomen

Flat
Scaphoid
Rounded
Protuberant

Considerations while palpating the spleen

Mono makes spleen enlarged and palpable

Why should women perform breast self-examinations?

To assess for any abnormal lumps which could indicate breast cancer.

When is the best time to perform a self breast exam for women who still have their periods?

Right after a menstrual period, Day 4-7 of the cycle. Breasts are the smallest and least congested. If a women is in menopause/no longer has period, encourage her to pick a day of the month to always do the exam (ex: 1st of the month)

How should a women perform a breast self exam?

Incidence of breast cancer

30% (1 in 3) of all new female cancers/ year

Racial differences and breast cancer

-White women have higher incidence starting at age 45
-African American women have higher incidence before age 40
-Asian American, Hispanic, American Indian have lower incidence and lower death rates

Mortality of breast cancer

Decreasing, especially after age 50
—decreases thought to be the result of treatment advances, earlier detection thru screening and increased awareness
—women in the US: breast cancer death rates are higher than those for any other cancer, besides lung

What conditions can the male develop in relation to the breast?

Gynecomastia

Gynecomastia

Condition of breast tissue enlargement
Common in adolescence
Can reappear in aging male due to declining testosterone levels
Can appear w/ certain medications

Testicular Abnormalities

Cryptorchidism
Small Testis
Testicular Torsion
Epididymitis
Varicocele
Spermatocele
Hydro electric
Scrotal Hernia
Orchid is
Scrotal Edema

Cryptorchidism

Undescended testicles
Can have testicular cancer
Infertility in adulthood
Treatable w/ surgery

small testis

Possible infertility
Estrogen therapy in the transgendered
Possible hormone therapy

Testicular torsion

Sudden twisting of spermatic cord
Very painful (excruciating)
Infertility (if untreated)
Requires surgery

Epididymitis

Sudden onset, painful
Does not cause infertility directly
Treatable w/ antibiotics

varicocele

May require surgery depending on severity
May affect fertility

spermatocele

Should not affect fertility
Generally no treatment required unless there’s growth

Hydrocele

differs from Spermatocele (fluid collection in the tunica vaginalis)
Should not affect fertility or require treatment

Scrotal Hernia

May need treatment if hernia becomes incarcerated
Does not affect fertility

Orchitis

Acute inflammation of testis
Cause is infection (most common is mumps)
Medication for treatment
Should not affect fertility directly

Scrotal Edema

Treatment is of underlying causes of edema

tumor

Early-painless, found on examination
-most all are malignant (18-35 at most risk)
More common in white men
Most important risk factor is undescended testicle
Will require surgery
Will cause infertility
Diffuse-enlarged testis
-tumor maintains shape of testis
Takes up most of the testicle
Will cause infertility

Testicular cancer statistics

~8000-10000 men develop cancer each year
Chance of developing testicular cancer is about 1/270
Cure rate greater than 95%
400 men die each year (1/5000)
White men are 4-5 times more likely to have testicular cancer than black men and 3x more likely than Asian American men

What are some possible responses while performing reflexes?

0= no response
+1= Diminished, low normal, or occurs w/ reinforcement
+2= Average, normal
+3= brisker than average, may indicate disease
+4= very brisk, hyperactive with clonus, indicative of disease

Frontal lobe

Descion making, voluntary movement

Parietal lobe

Sensation, touch, proprioception, stereognosis

Cerebellum

Responsible for coordination of movement, equilibrium, proprioception, and maintaining of muscle tone

Occipital lobe

Vision

Temporal lobe

Hearing, taste, smell

Wernicke’s area

Language comprehension

Brock’s area

Motor speech

Afferent

Carries sensory messages to CNS

Efferent

Carries motor message from CNS

Kinesthesia

Awareness of the position and movement of the parts of the body by means of sensory organs (proprioception)

stereognosis

Mental perception of depth or 3 dimensionality

Graphesthesia

Recognition of movements drawn on the skin

Romberg test

Ask person to stand up, with feet together and arms at sides; when in stable position, ask person to close eyes and to hold position for about 20 seconds
—normally person can maintain posture and balance even with visual orienting information blocked
Shallow knee bend
—demonstrates normal position sense, muscle strength, and cerebella function

rapid alternating movements

Supination/pronation (quick pace)
Finger to finger
Finger to nose
Heel to shin

CN I

Olfactory nerve
Smell
Present familiar aromatic substance and ask to identify

CN II

Optic nerve
Snellen and Jaeger test

CN III, IV, VI

Oculomotor, Trochlear, Abducens Nerves
Pupil size w/ light reaction and accommodation (III and IV)
Assess extraocular movement by diagnostic positions tests (6 cardinal positions of gaze) CN VI

CN V

Trigeminal nerve
Motor function: muscles of mastication
Clench jaw and try to open
Sensory: feel cotton ball on sides of face

CN VII

Facial nerve
Smile, frown, close eyes tightly
Puff cheeks in, to see that air escape equally from both sides

CN VIII

Acoustic (Vestibulocochlear)
Test hearing by doing whispered voice test

CN IX and X

Glossopharygeal and vagus nerves
Depress tongue with tongue blade and note pharyngeal movement as person says “ahh”, uvula and soft palate rise in midline
Gag reflex

CN XI

Spinal accessory nerve
Rotate head against resistance applied to side chin and lateral bending to left and right against resistance
Shrug against resistance

CN XII

Hypoglossal nerve
Inspect tongue: no wasting or tremor should be present
Light, tight, dynamite

Abnormal contours of the spine

kyphosis
Scoliosis
Lordosis

ROM Shoulders

Flexion
Extension
Abduction
Addiction
Internal rotation
External rotation

ROM Elbows

Flexion, extension, pronation, supination

Knees ROM

Flexion, extension, walk, shallow knee bend, butt kick

Hips ROM

Flexion, extension, knee bent Flexion, external rotation, internal rotation, abduction, adduction

Ankle ROM

Doris Flexion, plantar Flexion, inversion, eversion

Wrists/Finger ROM

Wrist Flexion/extension, ulnar deviation, radial deviation, finger Flexion/extension, spread fingers (abduction, adduction), make fist (Flexion, extension), touch thumb to each finger (opposition)

Neck ROM

Flexion, extension, lateral bending (R/L), rotation (r/L)

Contours of the cervical spine

Concave

Contours of the thoracic spine

convex

Contours of the lumbar spine

Concave

contours of the sacral spine

Convex

Osteoporosis

reduced bone mass