hollistic health info before finals

anatomy of muscles in abdomen

internal anatomy of abdomen

peritoneal organs

abdomen lined with peritoneum (2 layers)

peritoneal cavity contains intraperitoneal organs: stomach, liver, parts of colon

retroperitoneal contains organs outside of peritoneal cavity: kidney, ureters, adrenals, part of colon and pancreas

abdominal quadrants and regions

specific questions for abdominal assessment

changes in weight (eating disorder, cancer), bowel movement colour and frequency, vomiting color and frequency, problems with chewing/swallowing (dysphagia), ADLs, Lifestyle

subjective assessment for abdominal assessment

demographic or identifying data, hobbies, work (PPE) - hepatitis, travel hepatitis- hep A

past history in abdominal exam

past surgeries: appendicitis, bowel resection, cholecystectomy, hysterectomy

injuries: trauma, work injury

degrees of family

first degree- individual’s parents, full siblings or children

second degree- grandparents, grandchildren, aunts and uncles, nieces or nephews or half sibilings

third degree- great grandparents, great grandchildren, first cousins

***must be related by blood

relevant family history for abdominal exam

ex- colorectal cancer, GERD, peptic ulcer disease, inflammatory bowel disease- ulcerative colitis, crohn’s disease; anemia/thalassemia, splenomegaly, celiac disease, DM, pancreatic cancer, sickle cell anemia, thyroid disease

medications in abdominal assessment

meds specific to GI or GU, prescription + OTC + vitamins and herbals, narcotics lead to constipation, antacids interact with other meds

malabsorbtion in abdominal assessment

lactose intolerance, food allergies, celiac

DADSPIES for abdomen

diet- water, fibre (bowels), fat (gall bladder), spices (gastro), 24 hr diet recall, special diets like vegetarian, appetite and food intolerances

alcohol- cirrhosis

drugs- hepatitis (sharing needles)

smoking- bladder cancer

physical exam- FIT at 50, last pap test/prostate exam

immunisations- hepatitis and shingles vaccine

excersize

stress

OPQRSTUA for abdominal pain

o- when did it start, gradual or sudden

p- anything make it better or worse? positioning, medications, food?

q- sharp, burning, stabbing, dull

r- located? referred pain?

s- 0-10, ADLs,

t- better or worse at times of day

u- what do u thing is wrong

a- other symptoms

referred pain for abdomen

visceral pain (abdomen)

hollow organs are distended, stretched or contracted forcefully, may be difficult to localise, described as gnawing, burning, cramping or aching, may be associated with sweating, pallor, nausea, vomiting or restlessness

parietal pain (abdomen)

inflammation of the peritoneum, severe and localised over the involved structure, described as steady, aching, sharp esp with movement

referred pain (abdomen)

occurs in more distant sites innervated at approximately the same spinal level as the disordered structure

associated symptoms for GI

nausea, vomiting, indigestion, anorexia, diarrhea, fever, changes to skin colour, changes in weight, dysphagia, painful swallowing (odynophagia), constipation or changes to normal bowel pattern

• find out what is normal for pt, normal frequency for bowel movements is from 3 times a day to 1 time a week

associated symptoms for GU

hematuria (colour), dysuria, frequency, urgency, change in stream (males- prostate), increased amount of urine with voiding (polyuria), nocturia, urinary incontinence, flank or back pain

urinary incontinence- stress

coughing, sneezing, increased intra abdominal pressure

urinary incontinence- urge

sudden urge and loss of continence with little warning

urinary incontinence- over fliow

continous dribbling or dripping and weaker urinary stream

urinary incontinence- functional

cannot get to the toilet in time due to environmental factors or impaired health

urinary incontinence- total

inability to retain urine, ask also about bowel incontinence

bristol stool chart

ask everyone bowel pattern describe

developmental considerations: pregnancy (abdomen)

morning sickness, heartburn (esophageal reflux), constipation and decreased bowel sounds, smooth muscles relax which results in decreased motility leading to constipation

developmental considerations: older persons (abdomen)

suprapubic fat accumulation in women and abdomnial accumiulation in men, decreased salivation, gastric acid secretion, delayed esophageal emptying (risk of aspiration), more suceptible to dehydration (thirst drive decreased), decreased liver size and increased gallstones, decreased renal function (adverse or toxic drug effects), constipation is a big concern,

developmental considerations: questions to ask older people (abdomen)

help with groceries and meals? lower income and costs for food, constipation concern: gibre, fluids, caffeine intake in previous 24 hrs, bowel patterns, eating difficulties (swallowing and chewing), any meds that affect BMs- laxatives and diuretics

cultural/social considerations (abdomen)

high rates of obesity in women, high prevalence of lactose intolerance, many canadiants have a diagnosis of celiac disease, peptic ulcer disease, IBD, GERD and modifiable risk factors, relationship of hep A and GI illness to socioeconomic factors

preparation for abdominal exam

warm and private, adequate lighting, have pt empty bladder prior, pt lies supine with arms at side and knees bent (to help abdomen relax), drape pt appropriately, gather equipment

specificities to abdominal assessment

painful areas examined last, observe for signs of discomfort, distract patient to avoid tensing, make sure hands are warm

abdominal general survey

distress, upright posture, walking (clutching abdomen), pacing room, eating, crying, grimacing, guarding when you come near, lying flat with knees bent, pale colour

vital signs for abdominal

pain- tachycardia, hypertensive, afebrile, tachypnea

fever- febrile, tachycardia, normotensive, tachypnea

blood loss/shock- tachycardia, hypotensive, afebrile, tachypnea

inspection of abdomen

skin: colour and condition, contour and symmetry, umbilicus: inverted or everted, peristaltic waves, pulsation, any visible organs or masses, unexpected findings: scars, striae, veins, umbilical hernia rashes and lesions, deep breath and bear down: hernia or organomegaly, hair distribution

***inspect tangentially with light

contour of the abdomen

look from above, then stoop lower

abnormalities in abdomen

lipohypertrophy

lump under skin, accumulation of fat, result of many subcutanous inections of insulin- can affect absorbtion and onset, unsightly and mildly painful

normal abdominal aorta vs abdominal aortic aneurysm

abdominal assessment

inspection, auscultation, percussion, palpation

auscultating abdomen

2 spots per quadrant, start at iliocecal valve (RLQ), bowel sounds: high pitched gurgles or clicks,

borborygmi- air through intestines- stomach growling , 5-30/35 sounds, check for up to 5 minutes to detemine if sounds are absent

hyper active bowel sounds

above partial bowel obstruction, diarrhea, gastroenteritis, early intestinal obstruction

hypoactive bowel sounds

constipation, ileus and peritonitis, decreased or nonexistent below point of obstruction

vascular abdominal sounds

use firmer pressure and use bell,

bruit, venous hums,

friction rub- grating sounds that increase with inspiration, liver tumor, spleen infarction, peritoneal inflammation

vascular sounds- bruits

bruit- swishing sounds (turbulent blood flow), constriction of vessel, in hepatic area can indicate liver cancer or hepatitis, during systole are common and may not signify an occluded vessel

vascular sounds- venous hums

venous hums- soft pitched hum, partial obstruction vessel- reduced flow to organ

percussion of abdomen

determines organ size and tenderness, detects fluid, air and masses, percuss mid axilla to mid axilla along costal margins down to supra pubic, normally most of the abdomen is tympanic

tympanic sounds

LUQ (gastric bubble), most of abdomen, gas dullness can be due to feces (stool)

dullness sounds

over organs, masses, or fluid (ascites, GI obstruction, pregnant uterus, ovarian tumor)

percuss Kidney at costovertebral angle (CVA)

blunt percussion: costovertebral anlge, fingertip pressure is enough, pt will feel a perceptable but PAINLESS thud

percuss liver (enlargement)

percuss along costal margin, should go beyond costal margin, enlarged liver will be dull, liver normally found at 5-7 intercostal space, start RMCL at 3rd ics over lung tissue, then percuss downward towards liver to check for resonance to dullness, then start at rt MCL and umbilical area and percuss upward for tympany tp dullness, should be 6-12 cm

percuss spleen (enlargement)

1. costal margin- percuss LMCL along costal margin left mid axilla line, should remain tympanic

2. truabe’s space- triangle shaped area at 6th rib-costal margin and mid axillary line, normally tympanic but dull with splenomegaly

3. castell sign- percuss lowest ics on left anterior axillary line-tympanic, pt takes deep breath and holds (should be tympanic), dull if enlarged

percuss bladder at distension (full)

percuss from umbilicus to symphisis pubis, full bladder will be dull- determine height

palpation of abdomen

light palpation over all 4 quadrants, tenderness normal in adults near xiphoid process, over cecum or over sigmoid colon

light vs deep palpation

light- 1-2 cm in gentle rotating motion, identify superficial organs/masses/areas of tenderness

deep- bimanual (one hand over other), 3-4 cm, assess organs masses or tenderness

palpating inguinal lymph nodes

using pads of fingers, non tender and slightly palpable, not usually done

palpating aorta in abdomen

use opposing thumb and finger, palpate aortic pulsation in upper abdomen slightly left of midline, in adults is approx 2.5 cm wide

palpate liver (enlargement)

palpation: pt holds breath, push up under costal margin, normal to feel edge of liver as diaphragm pushes it down during inspiration

hooking: pt holds breath, hook fingers under costal margin, normal to feel edge of liver as diaphragm pushes down during inspiration

scratch test- scratch gets louder as nearing liver edge (location of liver)

palpating spleen enlargements

pt holds breath, push up under costal enlargement (right side), must be enlarged 3x normal size to be felt

rebound tendernes (blumberg’s sign)

assess all pts, suggests peritoneal inflammation (appendicitis, peritonitis), insert hand at 90 degree angle slowly and deeply- life up quickly, pain will be increased with removal of hand with peritooneal inflammation, then do away from area of pain (different quadrant)

Pain in RLQ tests

psoas signs

obturator test

rovsing’s sign

(inflammation- appendicitis, ovaria, diverticulitis)

Psoas sign

pt is supine with right lef pushed towards head, nurse pushes down on right thigh pushing towards pts head as pt tries to hold leg up, pain in RLQ is psoas sign

obturator test

pt supine with r light up flexing knee and hip at 90 degrees, nurse holds knee and angle and rotates leg internally and externally, pain in RLQ will give positive obturator sign,

rovsing’s sign

nurse presses in LLQ and pt reports pain in RLQ

RUQ complaint- Murphy’s sign

patient supine, support hand underposterior lower ribs, ask pt to take deep breath and hold, nurse pushes up under costal margin, positive- pt attempts to stop inspiratory effort, tenderness alone is NOT a positive, inflammation- possible cholecystitis/liver involvement

Ascites assessment (fluid in abdomen)

protuberant abdomen and bulging flanks indicates fluid it peritoneal cavity, ascites: cirrhosis/liver tumor, blood in abdomen, ascites is detectable after 500mL accumulated, asses for: shifting dullness, fluid wave

shifting dullness (ascites)

Percuss MCL to MAL (tympanic to dull), turn to right side and repeat with percussion, dullness: shift with free fluid

fluid wave (ascites)

hand midline abdomen- pressure will help to stop wave through fat, hands on both sides of abdomen: tap on one side and palpate the other- fluid wave pushed to opposite side means free fluid, positive sign indicates 1.5L of fluid present

superficial abdominal reflex

stroke tongue depressor or handle of reflex hammer 4 quadrants towards umbilicus one at a time, normal is when muscles contract- umbilicus moves towards stimuli, absent in pts with upper and lower motor neuron diseases (ALS)

health promotion for liver

safe sex, do not share items with bodily fluids, ensure safe tattooing practices, use clean needles, drink alcohol in moderation, avoid mixing alcohol with medications, do not use illegal drugs, eat only boiled or thoroughly cooked foods when travelling,***a cirrhotic liver can shrink downn to a fraction of its normal size and function

review hepatitis make slides if needed

bowel obstruction

history of prev abdominal surgery with adhesions, vomiting, distended abdomen after 2nd day, radiograph shows air filled lopps or smal bowel with air fluid levels, hyperactive bowel sounds earlier then hypo or absent sounds, dehydration and loss of electrolytes, accumulation of fluid and gas in bowel above the obstruction, colicky pain from strong peristalsis above obstruction, fever, pressure from excess fluid and gas, hypovolemic shock

colon cancer

use fecal immunochemical test, average risk: 50-74 yrs old with no first degree, after age 50 get FIT every 2 years, increased risk- family history of colerectal cancer, age 50 with colonoscopy every 5 years or 10 years

stool tests

c&s, occult blood (FOBT), ova and parasites

radiologic procedures

x-ray, barium swallows or enemas, IVPs, CT, MRI

rectum

12 cm long, distal portion of large intestine, from sigmoid colon (3rd sacral vertebrae) to anal canal, above anal canal- recutm dilates and turns posteriorly

anal canal

outlet of GI tract, 3.8cm long, lined with modified skin with no hair or sebaceous glands, merges with rectal mucosa at anorectal junction, canal slants forward towards umbilicus

rectal suppository

insert 4cm into anus against wall of rectum, pt should lay flat for 5 minutes, ask abt discomfort and evaluate relief of symptoms

enema

solution promotes peristalsis and defecation, volume breaks up fecal mass, stretches rectal wall and initiates defecation reflex, used to treat constipation, administer meds or empty bowels

types: tap water, normal saline, low volume hypertonic saline, soapspuds solution, oil retension

each of them exter a different osmotic effect to move fluids btwn colon and interstitial spaces beyond intestinal wall, children and infants only receive saline

should not be used regularly

evaluation: stool evacuated, discomfort diminished, inspect fecal return

stop or slow enema if: severe cramping, bleeding, pain, vagal nerve stimulation (light headedness), pt is unable to hold solution

nasogastric tube

provides food and meds, used for feeding sor giving person extra calories, used to suction out stomach contents (OD, bowel obstruction)

measure: earlobe to nose tip, earlobe to xiphpid process

tips: pull back if feeling resistance, once past posterior nasopharynx- have pt swallow, pull back tube for signs of distress, assess placement by withdrawing stomach contents, injecting air or submerging in water

contraindications: nasal bleeding, obstruction, facial trauma, basal skill fracture

MSK assessment consists of

muscles, bones, joints (cartilage, ligaments and tendons)

subjective msk assessment

demographics: (occupation and hobbies)- potential for injuries? are they staying active?, living alone- risk for falls

pt history: fractures, polio, muscle injuries/disorders, parathyroid disorders, menopause, bone infections (osteomyelitis), surgeries and hospitalisations

family history: osteoporesis, bone cancer, rheumatoid arthritis, osteoarthritis, muscular disorders

allergies: food intolerances (lactose), environment and medications

MSK subjective- medications

medications: steroids (inhibits calcium absorption), calcium, phosphorus and magnesium (bone growth + remodeling), vitamins A C D (calcium absorption) K B12 (bone growth + remodeling), anti inflammatory (delay bone healing and calcification), muscle relaxants (injury risk), contraceptives (impair bone density), HT (in menopause can treat osteoporosis), complementary substances like chondroitn and glucosamine (for joint health)

dadspies for bones

d- calcium/vit D

a- alcohol increases parathyroid hormone which causes calcium loss

d- drugs

s- smoking lowers bone density

p- physical (bone mineral density (BMD) check)

i- immunisations

e- physical activity? sedentary lifestyle

s- stress financial, income decreases can lead to obesity and inactivity

diet and excersize (MSK)

weight bearing activities- walking or moderate weightlifting to build and retain bone mass

agins- calcium absorption is high (60%) in infants and young children, decreases to 15-20% in adulthood, increased during pregnancy, decreases with age

OPQRSTUA (varies by complaint)

o- acute (less than 4 weeks) vs chronic

p- rest? medication? ice? weather (worse when cold and damp- arthritis)

q- describe feeling (burning- nerve, aching, dull, deep- bone, cramping, sore- muscle)

r- region and radiation (muscle- myalgia, bone joint- arthralgia), localised (mono vs polyarticular)

s- scale from 1-10, issues with ADLs

t- worse at times (worse in morning- rheumatoid, worse after rest or end of day- arthritis) chronic vs intermittent

u- what do they think it is

a- associated symptoms (nerve impairment- weakness, numbness, tingling, arthritis- stiffness or limited motion, inflammed/infection- swelling and warmth, fever, chills, injury- deformity, bruising, swelling, cancer- weight loss, anorexia

growing bone

finish bone growth at 18 in females and 21 in males (epiphyseal plates close, cells stop dividing, the plate fades and the epiphyseal line remains) salter (growth plate) fractures may alter growth

changes to bone with age

loss of bone mass- reapsorbtion more rapid that deposition (porous - weakened bones is called osteoporosis), britte bones, results in changes in posture, height and fractures, exagerated thoracic spine (kyphosis)

changes to bone with gender

females- small bone frames, rapid loss 5-7 yrs after menopause, female bones are smaller and have higher incidence of osteoporosis in females

males- slower loss, larger and stronger bones

risks to bones

genetic background- shape of bone, melanin- vit D synthesis

hormonal factors, physical activity and calcium intake

diet affecting bones

changes to spine shape

general survey for MSK

posture- sitting/standing erect, assess for symmetry in shoulders, scapulae, iliac crests, posterior superior iliac spines and gluteal folds

gait (walk across room if possible)- do they need device, smooth, balanced, continous, arms swing in opposition to legs, base is 5-10 cm, rises from sitting with ease

balance- walk on tip toes and heels, walk in heel to toe fashion, backwards, hop on one foot (ataxia- irregular, uncoordinated movements or losing balance, cerebellar disorder like parkinsons, MS, bran tumour, inner ear condition or medications)

do we do vital signs for MSK?

YES

INSPECTION of MSK

symmetry, erythema, atrophy, deformity, swelling (SEADS acronym)

review slide for general objective MSK complaints

review slide for specific MSK complaints