Nur Sci 112LA Lecture 8

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Psoas Sign

RLQ pain with extension of right thigh indicative of appendicitis

Abdominal Regions

RUQ, LUQ, RLQ, LLQ, Suprapubic, Epigastric

NGT Assessment

Review chest & abdominal X-ray Test pH of aspirates Skin integrity Aspiration precautions

Stoma Assessment

Should be pink to red and moist *Pallor, cyanosis or dusky color indicates poor blood supply *Black indicated necrosis -Initial edema

Facial Landmarks

Assessing facial symmetry: -Nasolabial folds -Palpebral fissures -Mouth and eyes

Otitis Media

Middle ear infection/inflammation *More common in children b/c smaller eustachian tubes, developing immune system

Costovertebral Angle Tenderness (CVAT)

-CVAT: no pain when kidneys pounded gently +CVAT: pain when kidneys pounded gently *Pyonephrosis or pyelonephritis

Bowel Sound Distinctions

5-30 sound/min = Normal > 30 sounds/min- Hyperactive None after ~ 5 minutes - Absent

Hydrocephaly

A buildup of cerebrospinal fluid within brain

Stoma

AKA ostomy Surgically-created opening on the abdomen which allows stool or urine to exit the body -Colostomy -Ileostomy -Urostomy

Melena

Black, tarry stool -Contains digested blood

CVA vs. TIA

CVA -Sudden death of brain cells due to ischemia from blockage or rupture of arteries -Permanent deficits TIA -Sx for up to 24 hours and then resolve -No deficit problems; does indicate CVA risk though -"mini stroke" **#1 Reason for both: HTN

HEENT Auscultation

Carotid arteries -Check for bruits *No percussion

Clay-like White Stools

Due to Calcium Antacids

Acromegaly

Enlargement of the extremities

Nasal Sinuses

FEMS

FAST

Face Arm Speech Time *Sooner treatment

Neck ROM

Flexion Extension Hyperextension Rotation Lateral Flexion

HEENT Inspection

General appearance/Head and neck position Head size and shape ROM of neck Skin integrity Facial symmetry of structures Observe facial movements - CN VII Eyes, ears, mouth, nose, trachea

Palpation of Abdomen

Gentle pressure then increase Avoid quick, sharp jabs

Assessment of Emesis

Green, bile-stained: intestinal obstruction Hematemesis or "coffee grounds: PUD, GI bleed, coagulopathy Projectile: GI infection, CNS, pyloric stenosis

Facial Symmetry Assessment

Have patient: -Crease up forehead (raise eyebrows) -Puff out cheeks -Smile

HEENT Palpation

Head and Scalp Temporal arteries ROM of TMJ and motion Frontal/maxillary sinuses Ear and mastoid processes Lymph nodes to neck Trachea Thyroid gland

Cushing's Syndrome

Hypersecretion of cortisol

Causes of Bowel Sounds

Hypoactive: inflammation, obstruction, peritonitis Hyperactive: gastroenteritis, diarrhea, hunger, powerful peristalsis Absent: Post-op, paralytic ileus, obstruction

Abdomen Assessment Order

Inspection *Auscultation Palpation

Murphy's Sign

Pain with palpation of the RUQ during inspiration, indicative of cholecystitis

Hematochezia

Passage of blood with bright red mixed or formed stool

Labs for Acute Abdominal Pain

Pregnancy test in females AST, ALT, bilirubin INR, PT, PTT Lipase-elevated in pancreatitis CBC-elevated WBC, blood loss in H&H CMP-calcium levels low in pancreas Lactic Acid-elevated in cirrhosis

Bell's Palsy

Temporary paralysis of CN VII -Causes paralysis only on the affected side of the face

Hematemesis

Vomiting (fresh) blood Bleeding may be from esophagus, stomach, or duodenum

Jaundice

Yellow staining of skin and slcerae caused by high levels of bilirubin in blood


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