NSG 2000 Exam #2

Liver, Gallbladder, Pancreas, Transverse Colon, and Right Kidney

What organs are in the RUQ?

Liver, Pancreas, Spleen, Left Kidney, Stomach, and Transverse Colon

What organs are in the LUQ?

Large Intestine, Small Intestine, and Left Reproductive Organs (F)

What organs are in the LLQ?

Appendix, Large Intestine, Small Intestine, and Right Reproductive Organs (F)

What organs are in the RLQ?

Cullen Sign

bruising and swelling around the umbilicus, due to either acute pancreatitis, failed pregnancy, or a hard hit to the stomach (this is a medical emergency)

Grey Turner Sign

bruising on the flanks between the hips and ribs, due to hemorrhage of the pancreas and AAA (abdominal aortic aneurysm) 

flat

well-muscled

scaphoid

more concave (adolescents, young adults, and thin adults)

rounded

found in young children and adults with poor muscle tone, but still WNL if symmetrical

protuberant

found in obese patients and is excessive subcutaneous fat

gravid

pregnant

How many pregnancies a woman has had

What do you need to document when you mark someone as gravid?

5-35 sounds per minute

regular bowel sounds are…

absent bowl sounds

no bowl sounds for 5 minutes

hypoactive bowl sounds

takes more than 15-30 to hear sounds

hyperactive

very frequent sounds, high-pitched, 1 every 5 seconds

IBS and food sensitivites

What are examples that cause hyperactive bowl sounds?

Bruits

swooshing sounds due to the narrowing of the arteries

ascites

excess fluid in the abdomen

fluid

What does a positive result of shifting dullness mean?

Light Palpation

1 hand and 1 cm, checking for tenderness, distention, and masses

Deep Palpation

2 hands, 4cm, checking for masses and palpating organs

aneurysm

What can a lateral palpation of the aorta show us?

cerebrum

largest part of the brain, 2 hemispheres, and controls mental status

cerebral cortex

gray matter, controls higher mental function, perception, and behavior

frontal lobe

controls speech formation, decision-making, short-term memory, emotions, and concentration

parietal lobe

controls sensory data

temporal lobe

controls perception and localization of sounds, personality, and long-term memory

limbic system

controls survival behavior, mating, fear, love, and anger

reticular activating system

awareness and arousal (damage can lead to confusion and delerium)

change of behavior, anxiety, and depression

What are the signs of a present illness neurologically?

24+

What is a normal cognitive score on a mental exam?

19-23

A mild change in intellectual on a mental exam

10-18

A moderate change in intellectual on a mental exam

< 9

scored as severe dementia on a mental exam

Glass-Cow Coma Scale

Measures conscientiousness and neurological status over time

3-15

What is the score range for the Glass-Cow Coma Scale?

LOC, behavior/appearance, language, and memory

the components of a mental exam

Have them recall 3 unrelated words or numbers

How do you test for short-term (recent) memory?

Have them recall their mother’s maiden name, an event in history, or a birthday

How do you test for long-term (remote) memory?

knowledge

a person’s ability to learn or understand

abstract thinking

able to interpret abstract ideas (“walking on egg shells”)

associations

similarities between concepts (dog + poodle)

judgement

logical decision-making (“why did you seek healthcare?”)

On Old Olympus Towering Top, A Finn & German Viewed Some Hops

How to remember cranial nerve testing!

Pain, temp, position, vibration, and touch

What are the 5 components of sensory function?

sanguinos

red, bloody

serosanguinous

clear and red

purulent

pus

Transient Carriage

An individual picks up a germ temporarily on the body and gets rid of it by handwashing, bathing, or actions of immune system

Colonization

Germ stays (germ lives and multiplies) with them but displays NO symptoms 

Infection

The germ is present on or in the person’s body and causes symptoms

Localized Inflammation

only affect that part of the body

Systemic Inflammation

affects the entire body

localized symptoms

swelling, redness, tenderness, and loss of function

systemic symptoms

increased WBC, malaise, anorexia, lymph enlargement, organ failure (sepsis)

virulence

the ability to make someone sick

Standard Precautions

Applies to ALL patients; includes hand hygiene, gloves/PPE, sharps & equipment, and you can have 2 patients in the room with this type of precaution

Droplet Precaution

6-10ft, humidity and temperature impact the spread, MASK (also for pt when being transported)

Contact Precaution Diseases

hepatitis, c. diff, MRSA, rotavirus

Droplet Precaution Diseases

influenza, pertussis, adenoviruses, and mumps

Airborne Precaution

small particulates, travels long distances, negative air pressure, AIIR, private

Airborne Precautions Diseases

TB and chickenpox