Jen Test 3

cardiovascular assessment, peripheral vascular and lympatic assessment, abdominal asssessment and bowel elimination, assessment of nutritional status and therapeutic diets, and genito-urinary and renal assessment

methods of assessment for cardiovascular assessment

inspection, palpation and auscultation

inspection for cardiovascular system

skin for oxygenation (color), presence of lesions, chest shape (AP diameter) , visualize heave/lift at apical pulse site

palpation for cardiovascular assessment

palpate the aortic, pulomic, tricuspid and mitral valves along with erbs point - for a thrill, due to presence of a murmur.

Auscultation in cardiovascular system

listen at the valve sites, listening for the heart sounds, the heart rate and heart rhythm

what causes the S1 heart sound

the “LUB”, because of closuyre of the atrioventru=icular valves - the tricuspid and bicuspid (mitral) valves.

are S1 sounds heart best at the apex or base of the heart

They are best heard at the apex, or bottom of the heart near the 4/5th intercostal spaces.

what causes the sound of the s2 heart sound

the closure of the semilunar valves - the aortic and pulmonic valves.

are S2 sounds louder at the apex or base of the heart

they are best heard at the base of the heart, near the 2nd/3rd intercostal spaces

what is the acronym for auscultation of heart valves

APE TO MAN

what does APE TO MAN mean?

A- aortic

P- pulmonary valve

E - erbs point

To - Tricuspid valve

Man - Mitral valve

do you listen with the diaphragm or bell of the sthrthoscope for heart sounds

BOTH, first with the diaphragm to hear valve closures and then with the bell to hear murmurs.

what is a murmur

a blowing/swishing sound from turbulent blood flow in the heart

what does a 1+ graded murmur mean

the slightest possible murmur, often overlooked/not discovered

what does a 2+ graded murmur mean

a slight murmur, it should not be missed by HCP under optimal conditions

what does a 3+ graded murmur mean

a moderate murmur with NO PALPABLE thrill

what does a 4+ graded murmur mean

a loud murmur WITH A PALPABLE THRILL

what does a 5+ graded murmur mean

a very loud murmur with an EASILY PALPABLE THRILL

what does a 6+ graded murmur mean

an extremely loud murmuer, can be heard with the stethoscope not even touching the chest wall. EXTREMELY RARE with a PALPABLE THRILL.

what are the methods of assessment for the neck

inspection, auscultation and palpation

what do you inspect for the neck

• skin

• vessels for jugular venous distention (JVD)

what is jugular venous distention

jugular vein bulge/distention is “normal” when torso is flat. When when the torso is raised to about 45 degrees, if jugular vein is still bulging, there is JVD so venous and right atrium pressure is elevated

what can Jugular Venous Distention (JVD) indicate

heart failure, fluid volume overload/hypervolemia.

what do you palpate for the neck for cardiovascular assessment

the carotid arteires, they should have an equal amplitude. CAN ONLY BE PALAPTED UNILATERALLY (1 AT A TIME) SO WE DON’T STOP BLOOD FLOW TO PT BRAIN AND CAUSE AN SYNCOPAL EPISODE. Palpation should be done gently.

what do you ausculate for in the neck for cardiovascular assessment

listen to the carotid arteries with the bell of the stethoscope for a bruit, that indicated turbulent blood flow. Normal = no sound, pt should hold breath so you don’t auscultate breath sounds

what would a bruit in the carotids indicate

narrowing/stenosis of the vessel, atherosclerosis

right sided heart failure

R - rest of body → fluid stays in rest of body = edema

list of symptoms for right sided heart failure

dependent edema, JVd, abdominal distension, anorexia, weight gain, noctunal diuresis, hypertension/hypotension → EXTRA FLUID IN TISSUES

left sided heart failure

L - lungs → fluid builds up in lungs = pulmonary edema. The left ventricle is unable to pump with enough force, so blood backs up into lungs.

list of symptoms of left sided heart failure

dyspnea, tachypna, crackles, dry cough, paroxysmal nocturnal dyspnea, oulmonayr edema, pulmonary hypertension

what is pulmonary edema

when the lungs fill up with fluid

symptoms of pulmonary edema

BLOOD TINGED FROTHY SPUTUM, severe dyspnea, tachycardia, profuse sweating, cyanosis.

cardiovascular changes r/t aging

AP diameter can increase (left lying position helps hear heart sounds clearer), cardiac valves dengerate → mitral and aortic murmurs, pacemaker cells decrease in number → dysrhythmias and ectopic beats, left ventricle size increases and tissues gets more fibrotic = decreased cardiac output, aorta and large vessels walls thicken → increasing systolic BP. Baroreceptors also become less sensitive → orthostatic hypotension

what are the methods of assessment for peripheral vascular system

inspection, palpation and auscultation

what does inspection entail for peripheral vascular assessment

looking at perfusion, observing color of skin, presence of edema and presence of tortious veins

what does palpation entail for peripheral vascular assessment

capillary refill, pulses, temperature and edema

what does auscultation entail for peripheral vascular assessment

listening for bruit in abdominal aorta

what are the methods of assessment for lymphatic system

inspection and palpation

what does inspection entail for lymphatic assessment

observe tonsils, bulging of lymph nodes, and for presence of peripheral lymphedema

what does palpation entail for lymphatic system assessment

feeling of lymph nodes and edema (especially to grade the edema and see if its pitting)

what are the 5 P’s of neurovascular extremity assessment

Pain, pallor, pulse, paresthesia, paralysis

what is the acronym for 6 things to assess/ask the pt to help determine if they have PVD or PAD

VESSEL

to determine if PVD or PAD, what does the V in VESEL stand for

V - various protions help alliviate pain, so which positions help alleviate pain

• Arterial (PAD) - dangling legs helps alleviate pain

• Venous (PVD) - elevation of legs helps allievate pain

what positions are best/worse for peripheral arterial disease

• best = dangling legs, because gravity helps bring the blood down into the legs

• worst = elevating legs, because it makes heart work harder to pump blood into legs

what positions are best/worse for peripheral venous disease?

• best = elevation of legs, because it decreases swelling and helps with blood flow

• worst = dangling legs or standing for long periods of time, because it makes paina nd edema the worst. This is because the blood will pool in legs because of gravity, and the body has to work harder to get blood back up to the heart

to determine if PVD or PAD, what does the E in V(E)SEL stand for

E - explanation of the pain:

• PAD - Sharp pain, worst at night = “REST PAIN”. Activity causes severe pain in the calf muscles, thighs, buttocks, etc.

• PVD - dull, throbbing, achy, heavy feeling/pain.

is intermittent claudication associated with PAD or PVD

PAD - it is the crampy, achy feeling that occurs with exercise for people with PAD

to determine if PVD or PAD, what does the S in VE(S)EL stand for

S - Skin of lower extremity ( color and temperature)

• PAD - skin is cool to touch, with thin, dry/scaly skin, hairless less and thick toenails

  • COLOR = DR. EP → DR = dangle legs =rubor/red color, EP = elevate legs = pallor

• PVD - skin is warm to touch with thick, tough skin

  • Color = brownish color for hemosiderin staining.

to determine if PVD or PAD, what does the E in VES(E)L stand for

E - Edema present?

• PAD - edema not common

• PVD - Edema common, usually soft and may be pitting if severe enough. It tends to be the worst at the end of the day.

to determine if PVD or PAD, what does the L in VESEL stand for

L - Lesions (location and appearance)

• PAD - location = end of toes, top of feet (dorsum), lateral ankle region (malleolus). appearance = very little drainage, little tissue granulation so color is pale/very light pink or necrotic black (BC LIMITED BLOOD FLOW TO LOWER LEGS). It has a deep “punched out” appearance with noticeable margins that gives it a round appearance

• PVD - Location = medial parts of lower legs, medial ankle region. Appearence = swollen with drainage, granulation present so color is deep pink to red. It has irregular edges and are generally shallow lesions.

what is the triad that is associated with risk of DVT/Deep vein thrombosis

Virchows triad (AKA HES triad)

• H = hypercoagulable state

• E = endothelial/vascular wall injury

• S = STASIS of blood

what are risk factors for DVT r/t HYPERCOAGULABLE STATE

pregnancy and peripartum, trauma or surgery of lower extremity, hip, abdomen or pelvis, ibs, nephrotic syndrome, sepsis, thrombophilia.

what are risk factors for DVT r/t circulatory stasis

Afib, left ventricular dysfunction, immobility or paralysis, venous insufficiency, varicose veins, venous obstruction from a tumor, obesity or pregnancy.

what are risk factors for DVT r/t vascular wall injury

trauma, surgery, venepuncture, chemical irritation, heart valve disease or replacement, atherosclerosis, indwelling catheters.

what type of edema is characteristic of a DVT

unilateral, pitting edema that arises quickly.

what are nursing interventions to prevent a DVT

ambulation, compression socks and leg exercises (like pumping the foot) to help promote venous return.

varicose veins

swollen, twisted, blue or purple veins, typically appearing in the legs, caused by weakened vein walls and damaged, one-way valves that allow blood to pool

Raynaud’s phenomenon

a condition where cold temperatures or stress trigger intense spasms in blood vessels (vasospasms), temporarily restricting blood flow to fingers, toes, ears, or the nose - causing blue or white/pale color.

where are the locations for peripheral pulses

radial, brachial, femoral, popliteal, dorsalis pedis, posterior tibial.

diabetic peripheral neuropathy

tingling or loss of sensation in extremities. Can cause microvascular damage, that can lead to diabetic foot ulcers. These are infected easily and are very slow to heal, which increases the risk of lower extremity amputation.

what are symptoms of diabetes-related foot conditions

loss of feeling, thick & yellow toenails, ingrown toenails, tingling, burning, pain, a sore that won’t heal and dry/cracked skin. diabetic ulcers can turn gangrenous and lead to amputation. Charcot foot = neuropathy that leads to joint destruction which gives foot rounded appearance.

functions of lymphatic system

absorbs dietary fat, protects the body, and maintains extracellular fluid volume by returning the excess tissue fluid to the blood through the veins back to the heart for recirculation.

What does inspection of tonsils include

are they red? swollen? touching? have exudate on them? is uvula not midline (infection of tonsils can cause deviated uvula)

what does palpation of lymph nodes include

light pressure applied via the pads of the fingers first in the lymph nodes of the head, then neck, then upper extremities then lower extremities. deeper pressure can be applied to assess deeper nodes.

what to evulate and monitor for lymph node enlargement

• rapid enlargement, since slow enlargement is usually benign

• hard, painless and fixed lymph nodes can indicate cancer

lymphedema

it occurs when lymph vessels are not able to adequately drain lymph fluid, causing often ASYMMETRICAL AND HARD (NON-PITTING) EDEMA.

what are the most common causes of lymphedema?

• cancer: if cancer cells block lymph vessels, lymphedema may result if a tumor is blocking flow of lymph fluid

• radiation treatment: may cause scarring and inflamattion of lymphatic vessels, decreasing flow of lymph fluid

• surgery: with cancer treatment, nodes are often removed if they are close to a cancerous site. This doesn’t always result in lymphedema since it is removal of a node and not blocking a lymph vessel.

lymphedema prevention and treatment

• prevention: prevent trauma, unjury, infection and muscle strain of the affected extremity. Avoid restrictive clothing sleeves, tight bras, watches and jewlry that can cut off lymph fluid flow (avoid compression that isn’t gradual!!!!)

• treatment: to promote lymph drainage, use exercises, compression devices (that apply gradual compression) and weight maintence.

what are the most common symptoms of abdominal disorders that you should address during your subjective assessment

any pain, N/V?, change in bowel movements (frequency or characteristics), any GI bleeding, rectal bleeding, hematemesis (throwing up frank blood - either bright red or coffee ground color/texture)?, presence of abdominal distention? ant appetite changes? changes in weight? food intolerances? current medication? dysphagia?

striae

aka stretch marks, related to pregnancies, rapid growth and/or obesity

spider angioma

a vascular skin lesion characterized by a central red dot with radiating, spider-like legs. One of the skin of the abdomen is usually benign, but multiple can often be a sign of liver disease

methods of assessment for abdomen

inspection, auscultation, palpation

what does inspection entail in abdominal assessment

inspect the skin for characteristics, especially color. Yellow can indicate jaundice, and note any bruising or discoloration present. Look for presence of any scars, striae, spider angiomas. also observe the abdominal countour and if any localized enlargemnts or visible pulsations are present.

Grey Turner’s sign

bruising or discoloration on the flanks (sides of the abdomen/back), indicating severe, underlying retroperitoneal hemorrhage associated with acute pancreatitis.

Cullen Sign

Cullen’s sign is a rare, severe sign of superficial edema and bruising (ecchymosis) in the subcutaneous tissue around the umbilicus. It is commonly caused by acute pancreatitis, ruptured ectopic pregnancy, or abdominal trauma

types of abdominal contour

normal contour = flat → rounded/convex

Scaphoid/concave = sign of malnourishment if significant (and supported by other assessment findings)

distended/protuberant = caused by 6 F’s : fetus, flatulence (gas), feces, fat, fluid, ‘flippin’ big” mass/tumor

inspection of localized enlargements on abdomen

can be due to hernias (bulging of intestines through muscle walls), tumors, cysts, or due to constipation r/t a bowel obstruction

inspection of visible pulsations on abdomen

these may be normal/visible in epigastric area of some thinner individuals, but a marked oulsation can indicate AAA, an abdominal aortic aneurysm.

Ostomy

an ostomy is a surgical procedure that creates an opening from inside the body to the outside

colostomy

opening into colon, to get feces out

gastrostomy

opening into stomach, to get food in

tracheostomy

opening into trachea, to get air in/out

stoma

a connection from the internal body part (organ) to outsode of body. It is usually the intestine is inverted and sewn to the abdominal wall to protect the skin from the intestinal contents

normal appearance of a stoma

pink/red color, slightly protuberant from the skin, the surrounding skin has no visible irritation

common ostomy/stoma abnormalities

stoma blockage, stoma prolapse, stoma retraction, skin irritation surrounding it, leakage present or necrosis of tissue.

what does abdominal auscultation entail

First auscultate the abdominal aorta with BELL to check for AAA.

Then auscultate all four quadrants for BOWEL SOUNDS with the diaphragm of the stethoscope. Auscultate RLQ → RUQ → LUQ → LLQ.

if patinet has hypoactive BS in quadrents 3 and 4, and hyperactice bowel sounds in quadrents 2 and 1, what does this indicate

a GI obstruction, probably in transverse colon between quadrants 2 and 3.

what does palpation for abdominal assessment entail

palpate RLQ → RUQ → LUQ → LLQ, unless part of a focused assessment

Only use light palpation, ask pt if any pain or tenderness is occuring

what is rebound tenderness at mcburney’s point indicative of?

rebound pain, so more pain when palpation/pressure stops than when firm pressure is applied if often indicative of appendicitis. This usually occurs at mcburneys popunt, 2/3 the distance from the naval to the right hip in cases of acute appendicitis.

what are common symptoms of acute apendicitis.

pain/rebound tenderness over mcburneys point, a low grade fever, constipation or diarrhea, N/V

what are common alterations in bowel elimination

constipation (AKA impaction), diarrhea, flatulence, blood in stool (Frank = visible, occult = hidden) - may be caused by diseases of GI tract like IBS, diverticulitis, colon cancer), fecal incontinence, hemorrhoids.

bristol stool chart type 1

separate, hard lumps (like rabbit pellets) that indicate severe constipation

bristol stool chart type 2

Lumpy (like type 1 poop pushed together) and sausage like, indicates mild constipation

bristol stool chart type 3

a sausage shape with cracks in the surface (normal)

bristol stool chart type 4

like a smooth, soft sausage or snake (normal)

bristol stool chart type 5

soft blobs with clear-cut edges. This indicates a lack of fiber in the diet.

bristol stool chart type 6

mushy consistency with ragged edges - categorized as mild diarrhea

bristol stool chart type 7

liquid consistency with no solid pieces - categorized as severe diarrhea

what is the normal consistency of feces

soft and formed

what is abnormal consistency of feces, and what causes it

liquid, from diarrhea or reduced absorption and Hard, from constipation or diarrhea.

what is normal frequency of feces

for adults 2x/day to 3x/week.