Exam 2

Module 5: Abdomen

2/19/24

  • Bordered superiorly by the costal margins, inferiorly by the symphysis pubis and inguinal canals, and laterally by the flanks

  • Divided into 4 quadrants: RLQ, RUQ, LUQ, LLQ

  • R hypochondriac, epigastric, L hypochondriac

  • R lumbar, umbilical, L lumbar

  • R iliac, hypogastric, L iliac


  • Abdominal wall muscles: External abdominal oblique, internal abdominal oblique, and transverse abdominis, rectus abdominis, and linea alba


  • Solid viscera: Liver, pancreas, spleen, kidneys

  • Hollow viscera: Stomach, gallbladder, SI/LI (colon), urinary bladder

  • Palpation of abdominal viscera depends on location, structural consistency, and size

  • Vascular structures: Abdominal aorta; right and left iliac arteries


  • COLDSPA: Characteristics, onset, location, duration, severity, pattern, and associated factors/how it affects the client

    • Characteristics: What does the pain feel like?

    • Onset: When did it begin?

    • Location: Where is the pain located?

    • Duration: How long does it last? Does it come back?

    • Severity: On a scale of 0-10, how intense is the pain?

    • Associated: What caused this to start?

  • Review of systems: Indigestion, nausea/vomiting, appetite, bowel movement symptoms, regurgitation (acidity)


  • Non-Hispanic Black, Hispanic, Asian/Pacific Islander have 40% to 50% higher risk for gastric cancer than Whites

  • Cardia (junction between esophagus and stomach) cancer rates are 35% to 47% lower for Blacks, Hispanics, Asian/Pacific Islanders, American Indian/Alaska Natives

  • Stomach cancer has association with Helicobacter pylori; highest rates in Asia, Latin America, and Caribbean; countries with highest incidence are Korea, Mongolia, and Japan


  • Esophageal adenocarcinoma risen rapidly in general U.S. population; Asian Americans have low rates

  • Esophageal squamous cell carcinoma rates are extremely high for Asians and Asian Americans; generally low for general U.S. population

  • Gallbladder disease/cancer vary by ethnic group; Native Americans and Mexican Americans have high rates; included more women than men; order of cases by ethnic group (Latinos, Japanese Americans, Whites, African Americans, Native Hawaiians)

  • Keloids: excess scar tissue, resulting from trauma or surgery, more common in African Americans and Asians.


  • Elderly complications:

    • Pain sensitivity can diminish with aging; assess acute abdominal conditions

    • Appetite can decline from various factors; altered metabolism, decreased taste sensation, decreased mobility, and depression; risk for nutritional imbalance

    • At risk for potential complications with diarrhea; 

    • Prone to UTIs because protective bacteria in urinary tract declines with age

    • Patternless dilated superficial capillaries may be seen; more visible in sunlight

    • USPSTF recommends one-time screening for abdominal aortic aneurysm for men between 65 and 75 years who have smoked; selectively for men 65 to 75 years who have never smoked; not recommended for women

    • If older than age 50 or has hypertension, assess the width of the aorta


  • Collecting subjective data:

    • Assess abdominal pain

    • Indigestion, nausea/vomiting, appetite, bowel movement symptoms, regurgitation

    • Lifestyle; diet, drinking habits, exercise, stress

    • Family/personal history; cancer, GI disorders, removal, bypass


  • General screen:

    • Observe the coloration, vascularization, scars, rashes, and skin lesions

    • Observe umbilicus (belly button); assess size/protrusion

    • Observe abdominal contour and symmetry

    • Observe for aortic (vascular) pulsations and peristaltic waves (overactive colon/small bowel)

    • Auscultate bowel sounds; important post-op abdominal surgeries to ensure intestines have not paralyzed

      • Listen for 60 sec (15 sec per quadrant)

      • Listen for 3-5 min if bowel sounds are not heard; feeding a patient who has no bowel sounds detected can risk vomiting/aspiration 

    • Percuss tones over four quadrants of the abdomen

    • Lightly palpate four quadrants of abdomen


  • Focused screen:

    • Auscultate for vascular sounds

    • Perform blunt percussion of liver and kidneys

    • Deeply palpate four abdominal quadrants for organs and masses

    • Palpate aorta, liver, spleen, kidneys, urinary bladder, or for shifting or dullness

    • Assess rebound tenderness: There is more pain when pressure on the tender area is released

    • Assess referred rebound tenderness: Palpation of one area may produce tenderness and rebound tenderness in another area

    • Assess for psoas sign: Patient lies on their left side while the right thigh is flexed backward; pain may indicate an inflamed appendix overlying the psoas muscle

    • Assess for obturator sign: Pain on passive internal rotation of the hip when the right knee is flexed; present when the inflamed appendix is in contact with the obturator internus muscle

    • Perform hypersensitivity test

    • Test for cholecystitis (gallbladder inflammation); Murphy’s sign


  • Physical exam:

    • Inspection, auscultation, percussion, palpation

    • Approach client from right side

    • Use tangential lighting

    • Explain every aspect to help client to relax and avoid tensing abdominal muscles 

    • Properly drape clients to protect privacy

    • Warm hands


  • Visceral pain: Internal (organ) pain; deep, aching pain

  • Parietal pain: Somatic; peritoneum pain; sharp and localized pain

  • Costovertebral angle (CVA) pain: Kidney infection


  • Client should have an empty bladder, dressed in a gown, lying supine with arms at sides or folded at chest (abdomen must be exposed), legs slightly flexed, slow deep breaths


  • Inspection: Skin color, vascularity/rashes, stretch marks (striae), scars/lesions, umbilicus, contour, symmetry, respiratory movement, aortic pulsations, peristaltic wave


  • Auscultation: Bowel, vascular (shouldn’t be heard within a healthy adult), venous hum, or friction rub; use bell of stethoscope

  • Percussion: Blunt percussion (tympany), liver dullness, tone over 4 quadrants

  • Palpation: Light (superficial) and deep; aorta, liver, spleen, kidneys, bladder; liver and spleen percussion is not common (spleen especially for mono patients)

  • Ascites: Shifting dullness (fluid collects in spaces within the abdomen)


  • Abdominal girth:

  • Measure abdominal girth at the same time of day (morning)

  • Ideal position is standing otherwise supine with head slightly elevated

  • Record distance via measurable tape in inches/cm


  • Abdominal bulges: Umbilical, epigastric, incisional hernia; diastasis recti


  • Peptic ulcer disease: An open sore that forms in the lining of the esophagus, stomach, or small intestine (H. pylori); NSAIDs can worsen symptoms (aspirin)


  • Gastroesophageal reflux disease: Stomach or gastric acids flow back into esophagus; over time, causes irritation and can erode tissue, leading to scarring and narrowing of esophagus

  • Client education:

    • Avoid alcohol and tobacco intake

    • Assess foods that cause distress and avoid them (very hot/cold, fried, spicy, coffee, tea, peppermint, tomato-based dishes, citrus, sweets, dairy)

    • Avoid foods that cause you to swallow air

    • Eat 5 to 6 small meals a day

    • Eat slowly and chew food well

    • Do not lie down after eating for at least 2 hours

    • Avoid late evening snacks

    • Avoid bending or stooping after eating

    • Avoid lifting heavy objects

    • Avoid wearing tight clothes around the waist, abdomen, or stomach.

    • Lose weight if overweight

    • Raise head of bed 6 to 8 in

    • Try sleeping on the left side.

    • Take medications exactly as prescribed

    • Tell the health care provider you have GERD


Module 5: Male Genitalia

2/19/24

  • Inguinal area: Area contained between anterior superior iliac spine laterally and symphysis pubis medially; common herniation area

  • Anorectal junction: Area where a suppository should be inserted for full therapeutic effect; increased mucosa increases absorption 


  • Subjective data: COLDSPA, lesions, discharge, lumps/swelling masses, urination, sexual dysfunction, bowel patterns, stool, itching/pain, lifestyle practices, personal/family history (STDs, cancer, etc.)


  • Physical assessment:

    • Base of penis, pubic hair, shaft, foreskin, glans, discharge

    • Size, shape, position of scrotum, scrotal skin, palpate scrotal contents

    • Prostate gland palpation; check stool (send for testing if needed)


  • Educate testicular self examination (perform every month); prevents prostate cancer

  • Educate about HIV/AIDS risk


Module 5: Female Genitalia

2/19/24

  • Menarche tends to begin earlier in women living in developed countries and later in women living in undeveloped countries

  • Women living in resource-poor countries have earlier menopause


  • Elderly considerations:

    • More susceptible to vaginal infection due to vaginal atrophy; greater chance of chronic vaginal infections, urinary function problems, and painful sexual intercourse

    • Decreased estrogen production causes atrophy of vaginal mucosa (dyspareunia; genital pain); need lubrication for sexual intercourse

    • Urinary incontinence develops from muscle weakness/loss of urethral elasticity

    • Gray, thinning pubic hair

    • Cervix appears pale after menopause


  • Subjective data: COLDSPA, menstrual cycle (menarche age, frequency, menopause), discharge, pain, masses, sexual dysfunction, urination, bowel patterns, stool, itching/pain, lifestyle patterns, personal/family history

    • Personal history: Prior gynecologic problems, last pelvic exam, last pap test and results, STD’s, HPV, pregnancies, reproductive or genital cancer


  • Physical exam:

    • Inspect mons pubis, labia majora and perineum, labia minora, clitoris, urethral meatus, vaginal opening, angle of the vagina, vaginal musculature, cervix

    • Palpation bartholin’s glands and urethra


Module 8: Assessing Neurologic System

3/11/24

  • Cerebrum: Frontal, parietal, temporal, occipital

  • Diencephalon: thalamus, hypothalamus

  • Brain stem: Midbrain, pons, medulla oblongata

    • Regulate body functions, including breathing and heart rate.

    • Controls balance, coordination and reflexes

  • Cerebellum: Two hemispheres


  • The spinal cord consists of two pairs of columns and is responsible for reflexes as well as transferring nerve impulses from the body to the brain

    • Anterior horn: Motor neurons

    • Posterior horn: Sensory neurons

    • Synapse junction: Exit and entry for fibers carrying signals to and from the periphery; lesion can disrupt activity


  • 31 pairs of spinal nerves; attached to spinal cord with two nerve roots

  • Sensory (afferent) enters through dorsal roots

  • Motor (efferent) exits through ventral roots

  • Dermatomes: Areas of skin that have connections to specific spinal nerves; useful for edema of a spinal root, lesion, or shingles outbreak


  • Peripheral Nervous System: Carries information to CNS; consists of 12 pairs of cranial nerves and 31 pairs of spinal nerves

    • Somatic: Carries CNS impulses to voluntary skeletal muscles; mediates conscious or voluntary activities

    • Autonomic: Carries CNS impulses to smooth, involuntary muscles; mediates unconscious or involuntary activities


  • Autonomic nervous system: Impulses carried to smooth, involuntary muscles of heart and glands; maintains internal homeostasis of body; sympathetic (arise from T1 to L2 level) and parasympathetic (arise in S1 to S4 and cranial nerves III, VI, IX, and X)


  • “Stroke belt” (states with age-adjusted stroke mortality at least 10% above the national rate): NC, SC, GA, AL, MS, LA, AR, TN

  • “Stroke buckle” in the United States: NC, SC

  • “Nerves” or “bad nerves” is a term coined for mental conditions, similar to anxiety

  • Ataque de nervios (nerve attack) mostly Latina Americans, has various expressions

  • Teach patient how to properly define a stroke / nerve disorder


  • Dyskinesia: Can be a side effect of a medication (antipsychotic); involuntary, erratic, writhing movements of the face, arms, legs or trunk


  • Distraction (reinforcement) techniques when conducting DTRs may help older clients who are having difficulty relaxing.

  • Decreased DTRs and unstable balance may be due to peripheral neuropathy, also causes disturbed proprioception, loss of vibratory and temperature sense, possible pain, tingling, and distal weakness


  • Subjective data:

    • Headache

    • Seizures

    • Dizziness

    • Numbness, tingling/prickling (paresthesias)

    • Senses

    • Difficulty speaking

    • Difficulty swallowing (dysphagia)

    • Muscle control

    • Memory loss

    • Past health history (head injuries? traumas?)

    • Family history (cardiovascular)

    • Lifestyle and health practices (cardiovascular, exposure, diet)


  • 5 areas of concern:

    • Mental status (cerebral function)

    • Cranial nerves; dysphagia could indicate cranial nerve dysfunction

    • Motor and cerebellar systems

    • Sensory system

    • Reflexes


  • Neurocheck:

    • Assess LOC (awareness, orientation, memory)

  • Pupillary checks

  • Movement and strength of extremities

  • Babinski (plantar) reflex

  • Vital signs


  • Cranial nerve I: Olfactory; identify a scented object with eyes closed

  • Cranial nerve II: Optic; Snellen chart; assess visual fields, retina, and optic disc

  • Cranial nerve III, IV, VI: Oculomotor, trochlear, abducens;

    • Inspect margins of eyelid of each eye;  ensure face is not drooping

    • Assess extraocular movement

    • Assess pupillary response to light; PERRLA

      • Pupils are equal, round and reactive to light and accommodation

  • Cranial nerve V: Trigeminal; innervates mastication muscle

    • Sensory: Light touch

    • Motor: Assess for TMJ

  • Cranial nerve VII: Facial

    • Motor: Smiling, crease up forehead, puff out cheeks, close eyes against resistance

    • Sensory: Taste on anterior 2/3rds of the tongue

  • Cranial nerve VIII: Acoustic; whisper test, weber test (bilateral conduction); conduction loss can identify nerve damage

  • Cranial Nerves IX, X: Glossopharyngeal, vagus

    • Motor: Gag reflex, swallow, voice (symmetrical rise of uvula)

  • Cranial nerve XI: Accessory; shrug shoulders against resistance (trapezius muscles); turn head against resistance (sternocleidomastoid muscles)

  • Cranial Nerve XII: Hypoglossal; stick tongue out, should not deviate


  • Romberg test:

    • Ask the patient to stand with feet together and eyes closed

    • Increased sway with eyes closed suggests inner ear problem

    • Equal sway with eyes open and closed suggests CNS problem

    • Fall or step = positive test (usually towards side of lesion)

    • Positive usually indicates posterior column disorder

  • Healthy patient should be able to catch their balance (negative test)

  • Spot patient to avoid falls


  • Sensitivity to position: Determines if the patient can comprehend what position their finger is in with their eye closed

  • Point localization: The capacity to find a point on the skin which is aroused

  • Graphesthesia: Ability to recognize symbols written on the skin

  • Two point discrimination: The ability to discern that two nearby objects touching the skin are truly two distinct points, not one


  • Reflex scale: 0 (absent) 1+ (hypoactive), 2+ (normal), 3+ (hyperactive without clonus), 4+ (hyperactive with clonus)

  • Clonus: An abnormal reflex response that involves involuntary and rhythmic muscle contractions; repetitive muscular spasm; common in seizure disorders


  • Brudzinski sign: Neck flexion leads to knee flexion

  • Kernig sign: Knee extension is painful


  • Cerebellar ataxia: Staggering, unsteady gait; base is wide

  • Parkinsonian gait: Shuffle (knees aren’t picked up high enough), stooped posture

  • Scissors gait: Knees are bent and cross over

  • Spastic hemiparesis: Stiff/contratced limbs; swing leg

  • Foot drop: Bed rest patients; diabetes patients (neuropathy); achilles ankle loses motor sense; slapping down foot


  • Strokes: Occurs when blood flow to portion of brain is interrupted or stopped, deprives brain cells of oxygen; cells begin to dead resulting in permanent damage

    • Hemorrhagic: Rupture or leakage of blood vessel

    • Ischemic: Blood clot blocks blood vessel; may be result of emboli or thrombi

    • Transient ischemic attack (TIA): Mini-stroke

  • Teach clients to recognize symptoms of stroke and act FAST

    • FACE drooping: ask the person to smile. Does one side of the face droop?

    • ARMS weakness: Ask the person to raise both arms. Does one arm drift downward?

    • SPEECH: Ask the person to repeat a simple phrase. Is speech slurred or strange?

    • TIME to call 911 if you observe any of these signs to avoid a lifelong disability.


Module 9: Assessing Musculoskeletal System

3/18/24

  • Older adult considerations:

  • Joint-stiffening conditions may be misdiagnosed as arthritis, especially in older adults

  • Some positions during physical examination will be uncomfortable due to decreased flexibility

  • Slower movements, reduced flexibility, decreased muscle strength due to age-related muscle fiber and joint degeneration, reduced elasticity of tendons, joint capsule calcification

  • May have impaired sense of position in space, contributing to risk of falling

  • Kyphosis is common.

  • Do not insist client touches toes when bending forward unless client comfortable with the movement

  • May have bow-legged appearance due to decreased muscle control


  • Collecting subjective data

    • History of present health concern: Pain, weakness, stiffness, deformity, lack of balance and coordination

      • Fractures are a major concern regardless of age; the bone loses its stability

    • Past health history: Trauma, surgery, infection

    • Family history: Cardiovascular, bone trauma, disease

    • Lifestyle and health practices: Smoking, diet, calcium intake

  • Tums (antacid medication) is a good source of calcium

  • The gut can only absorb 500 mg of calcium at a time; 1000-1500 mg of calcium per day is the standard calcium intake


  • Collecting objective data:

    • Provide data regarding client’s posture, gait, bone structure, muscle strength, joint mobility, ability to perform ADLs

    • Inspect and palpate joints, muscles, and bones; testing ROM, assessing muscle strength

    • Inspect and palpate cervical, thoracic, and lumbar spine (lateral bending test); assess for vertebral deformity, position, or any noticeable processes

    • Measure leg length

    • Inspect for carpal tunnel syndrome; hyperflex hands and hold for a minute (phalen’s test); paresthesia indicates nerve impingement

    • Bulge test: detects small amounts of fluid in the knee


  • Rating muscle strength:

    • 5: Active motion against full resistance; normal

    • 4: Active motion against some resistance; slight weakness

    • 3: Active motion against gravity; average weakness

    • 2: Passive ROM; Poor ROM

    • 1: Slight flicker of contraction; severe weakness

    • 0: No muscular contraction; paralysis