health assessment exam 3

auscultating fetal heart tones

FHT's are a positive sign of pregnancy; they can be heard by Doppler US at 8 to 10 weeks' gestation; they are auscultated best over teh back of the fetus; after identifying the position of the fetus, use the fetal heart tones to confirm your findings; count the FHTs for 6 seconds and multiply by 10 to obtain the rate; the normal rate is between 110 and 160 beats/min; spontaneous accelerations of FHTs indicate fetal well-being

second trimester of pregnancy

FHTs are audible by fetoscope (as opposed to Doppler imaging) at approximately 17-19 weeks; the fetal outline is palpable through the abdominal wall at approximately 20 weeks

Tay-Sachs

Jews of Eastern European descent may have the risk of having childrne with _______________, a metabolic disorder;

hyperactive bowel sounds

Loud, gurgling sounds, "borborygmi," signal increased motility. They occur with early mechanical bowel obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus.

MANTRELS score for appendicits

M- migration to right iliac fossa (1) A- anorexia (1) N- nausea and vomiting (1) T-tenderness, RLQ (2) R- rebound tenderness (1) E-elevation of temperature (oral >37.3 C) (1) L- leukocytosis (WBC count >10,000) (2) S- shift to the left (>75% neutrophils) (1)

menstural history

RATIONALE: using Nagele's rule, calculate the expected date of delivery using date of LMP; with a pregnancy wheel, determine the current number of weeks of gestation; LMP may be uncertain because of hormone contraceptives or irregular menses

post-polio muscle atrophy

Right leg & foot muscle atrophy as a result fo childhood polio. poliomyelitis epidemics peaked in the US in the 1940s and 50s; the development of hte oral polio vaccine (1962) has almost eradicated the disease; however, thousands of polio survivors have this muscle atrophy

HELLP syndrome

a serious variation of preeclampsia, the ______________, involves Hemolysis, Elevated Liver enzymes, and Low Platelets and represents an ominous clinical picture; untreated preeclampsia may progress to eclampsia, which is manifested by generalized tonic-clonic seizures; eclampsia may develop as late as 10 days postpartum

Down syndrome

a single transverse crease is a palmar crease that occurs with ______________, accompanied by short broad fingers, incurving of little fingers, and low-set thumbs

placenta

a specalized layer of cells in the blastocyyst become the ____________________, which produces progerone to support the pregnancy at 7 weeks and takes over this function completely from the corpus luteum at about 10 weeks

exercise program (patient-centered care musculoskeltal)

a strict program of regular high-dose exercsies increases bone strength and reduces fracture risk

infant/child assessmenet

a thorought _______________ should be done with each well-child appointment throughotu infancy the infant is supine on a warming or examination table with an overhead heating element; the infant may be nude except for a diaper

spina bifida

a tuft of hair over a dimple in the midline may indicate ______________

malpresentation

____________________ may be detected by the hands of an experienced examiner, confirmed by the FHT location, and further confirmed by ultrasound; before 34 weeks' gestation, any position is normal; the vertex presentation is desirable thereafter because spontaneous turning becomes less likely as the fetus grows in proportion to the amount of space and fluid in the uterus and pelvis

prominent, dilated veins (caput meduase)

____________________ occur with portal hypertension, cirrhosis, ascites, or vena caval obstruction

tested for HIV? when? what was the result? ever had a blood transfuision? used a needle to take street drugs? had a sexual partner who had HIV risk factors? (gynecologic history)

____________________ rationale: HIV screenign must be offered to all pregnatn women to decrease the risk for tranmission to the fetus; *breastfeeding is contraindicated for the HIV positive mother because hte virus is in breast milk*

what are your plans for breastfeeding this baby? (current pregnancy)

____________________ rationale: arrange reading, classes, and other support for hte woman who is breastfeeding for the first time or the woman with an unsuccessful earlier expeirence

pap tests: any history of abnormal? tested for HPV? (gynecologic history)

____________________ rationale: because more women delay childbearing, there may be an increase in gynecologic cancers during pregnancy

UTIs

____________________ rationale: the hormonal milieu of pregnancy predisposes the woman to _____________; pregnancy may mask symptoms; a serious ___________ may irritate the uterus, threatening premature labor; educate the woman in measures to prevent ______________

estrogen

____________________ stimulates the duct formation in the breasts, increases the weight of hte uterus, and increases certain receptors i nthe uterus that are important at birth

syndactyly

Webbed fingers are a congenital deformity, usually requiring surgical separation. The metacarpals and phalanges of the webbed fingers are different lengths, and the joints do not line up. To leave the fingers fused would thus limit their flexion and extension.

extra-articular disease

_______________ (injury to a specific tendon, ligament, nerve) produces swelling and tenderness to that one spot in the joint and affects only certain planes of ROM, especially during active (voluntary) motion

striae

_______________ (lineae albicantes)-silvery, white, linear, jagged marks about 1-6 cm long; they occur when elastic fibers in the reticular layer of hte ski nare broken after rapid or prolonged stretching as in pregnancy or excessive weight gain; recent striae are pink or blue then the turn silvery white

fracture

_______________ a break in a bone

older-adult drivers

_______________ account for 18% of all licensed drivers in the US and 18% of all traffic fatalities; safe driving requires intact cognitive functioning, sensory perception, good physical abilities (E.g. strength to turn steering wheel and use the pedals; enough range of motion to turn head), alertness, and suitable reflexes; early and routine attention to health care maintenance activities such as vision and hearing checks, exercise to maintain flexibility and range of motion, and workup of any cognitive abnormalities may allow the older adult to continue to drive safely

musculoskeletal exam

a screening ____________________ suffices for most people: inspection and palpation of joints integrated with each body region observation of ROM as person proceeds through motions age-specific screening measures such as Ortolani sign for infants or scoliosis screening for adolescents

pain aggrevated by movement/ rest/ position/ weather (joints subjective data)

_______________ rationale: movement increases most joint pain except in RA, in which movement decreases pain

dysphagia (subjective data)

_______________ rationale: occurs with disorders of the throat or esophagus, such as thrush (candida infection), neurologic changes (e.g. stroke), or obstruction (e.g. solid mass or tumor).

does child have abdominal pain? (infant/children subjective data)

_______________ rationale: pain is hard to assess with children; many conditions of unrelated organ system have vague abdominal pain (e.g. otitis media); they cannot articulate specific symptoms and oftne focus on the tummy; abdomain pain accompanies inflammation of the bowel, constipation, urinary tract infection, and anxiety

ever had chickenpox? (medical history)

_______________ rationale: rarely, varicella causes congenital anomalies; the nonimmune woman should avoid exposure

preeclampsia

_______________ rationale: renal disease or HTN increase risk for _________________

taking any medications for musculoskeletal system (bisphosphonates, aspirin, antiinflammatroy, muscle relaxant, pain reliever, hormone) (patient-centered care musculoskeltal)

_______________ rationale: review daily aspirin and NSAID schedule; screen for adverse effects such as GI pain, bleeding; bisphosphonates are first-line therapy for osteoporosis for specific duidelines; hormone therapy is not recommended due to risk factors

affects current pregnancy

_______________ rationale: the subjective quality of previous experiences ______________________

was the pregnancy planneD? how do you feel about it? how does the baby's father/ partner feel about the pregnancy? other family members? (current pregnancy)

_______________ rationale: the woman may need help in gathering her support group; individing significant others to future visits affirms their importance and supports involvement

infant/children musculoskeletal subjective data

_______________ rationale: traumatic delivery increases risk for fractures (e.g. humerus, clavicle) period of anoxia may result in hypotonia of muscles

sexual preference (gynecologic history)

_______________ rationale: woman with same-sex partner may use assisted reporduction; thus important to support this couple

for overweight child (infant/children subjective data)

_______________ rationnale: reduced physical activity and food marketing practices contribute to current obesity epidemic family history of obesity assess body image and social adjustment

functional ability

_______________ refers to one's ability to perform activities of daily living, including bathing and toileting, and independent living skills such as shopping and housework

contracture

_______________ shortening of a muscle leading to limtied ROM of joint

exercise

_______________- does not prevent the process of aging, but it increases functional ability, helping to maximize the older adult's independence

Articular disease

________________ (inside the joint capsule [e.g. arthritis]) produces swelling and tenderness around the whole joint, and it limits all planes of ROM in both active and passive motion

anklyosis

________________ Stiffness or fixation of a joint

muscles

________________ account for 40-50% of the body weight; when they contract they produce movement; ______________ are of three types: skeletal, smooth, and cardiac; this chapter is concerned with skeletal, or voluntary, muscles- those under conscious control

knock-knees (genu valgum)

________________ are present when there is more than 2.5 cm between the medial malleoli when the knees are together; it occurs normally between 2 and 3 1/2 years; treatment is not indicated

cartilaginous joints

________________ are separated by fibrocartilaginous discs and are only slightly movable (E.g. the vertebrae)

German measles (rubella)

________________ rationale: this disease is highly teratogenic, especially in 1st trimester; instruct the woman who has not had ____________ to avoid small children who are ill

weakness in muscles (muscles subjective data)

________________ rationale: weakness may involve musculoskeletal or neurologic systems

history of genital herpes, gonorrhea, chlamydia, syphilis, pellvic inflammatory disease? (gynecologic history)

________________ ratitonale: STIs increase the risk for premature rupture of membranes, preterm labor, preterm delivery (TPL/PTD), postpartum maternal and fetal infections, or birth defects (herpes)

idiopathic scolisosi

________________ shos at 10 years of age through adolescence during the peak of hte growth spurt; usually not progressive nad more common in girls

attitude

________________, the position of fetal parts in relation to one another, may be flexed, military (straight), or extended

aortic aneurysm

________________: murmur is harsh, systolic, or continuous and accentuated with systole. note in person with hypertension aa

knock-knees (genu valgum)

_________________ also occurs with rickets, poliomyelitis, and syphilis

osteoporosis

_________________ is a disease involving the loss of mineralized bone mass and leading to porous bone and thus the risk of fractures; although aging women have a greater amount of bone loss compared with men, decreased levels of estrogen in both sexes are partly responsible because osteopblasts that form new bone have estrogen receptors; resistance and weight-bearing exercise may increase bone density at the hip and lumbar spine, but exercise needs to be regular and high intensity; further, its effects may be lost once exercise is stopped

which tabel foods have you introduced (infant/children subjective data)

__________________ rationale: consider a new food as a possible allergen; adding only one new food at a time to the infant's diet helps identify allergens

limitation of movement in joint (joints subjective data)

__________________ rationale: decreased ROM may be caused by joint injury to cartilage or capsule or to muscle contracture

tick bite (joints subjective data)

__________________ rationale: suggests lymes disease

screening for splenomegaly

__________________ through percussion of splenic dullness is omitted because detection through palpation is more reliable

subuluxation

__________________ two bones in a joint stay in contact, but their alignment is off

hernia

__________________-protrusion of abdominal viscera through abnormal opening in muscle wall

swelling, heat, redness in joints (joints subjective data)

__________________: suggests acute inflammation

synovial joints

___________________ are freely movable because their bones are separated from one another and encloased in a joint cavity; this cavity is lined with a synovial membrane that secretes a lubricant, or synovial fluid; just like grease on gears, synovial fluid allows sliding of opposing surfaces, and this slinding permits movement

assessment of cognition

___________________ are important for discharge planning (e.g. will the person remember to take the prescribed medications) and to assess for readiness for learning; as with screening for ADLs and IADLs, assessment of cognition helps with determining the best discharge plan

probable signs

___________________ are those determined by the examiner, such as an enlarged uterus

gestational diabetes mellitus (GDM)

___________________ disproporitonately affects certain racial and ethic groups with Asians, African Americans, and Hispanics having the highest prevalence; while obesity is a risk factor for developing GDM, the majority of Asian Americans diagnosed with GDM are normal weight, so it appears that other factors affect their risk of developing GDM; family history and advanced maternal age increase risk of GDM in all ethic groups, but disproportionately affect certain groups; Asian Americans with GDM are more likely to develop diabetes later in life than other ethnic groups; based on racial and ethic differences in the prevalence of GDM, the American college of obstetricians and gynecologists now recommend early GDM screening for women who are African American, American Indian, Asian American, Hispanic, or Pacific Islander

mild tenderness

___________________ is normalyl present when palpating the sigmoid colon in the left lower quadrant; any other tenderness should be investigated

subjective, objective, assessment, plan (SOAP)

___________________ is used to organize assessment findings into written or charted communication; now turn to organizing assessment data for verbal communication (e.g. calls to providers, nursing shift reports, patient transfers to other units) for all these verbal reports, use the SBAR framework: situation, background, assessment, and recommendation

preeclampsia

___________________ seems to be a cumulation of maternal, placental, and tefal factors including: 1. placenta implants with abnormal trophoblastic invasion; 2. immunologic intolerance among materal, placental, and fetal tissues; 3. cardiovascular or inflammatory changes; 4. genetic factors

percussion

___________________ to assess the relative density of abdominal contents and to screen for abnormal fluid or masses

mesenteries

___________________, double layers of parietal peritoneum, extend from the abdominal wall as pathways for blood vessels, nerves, and lymphatics; ___________ also serve as supporting networks to suspend and stabilize the abdominal organs, called viscera

exercise

____________________ and activity are essential for health promotion and maintenance in the older adult and to achieve an optimal level of functioning; a sedentary lifestyle is an important contributor to the loss in the ability to independently perform ADLs;

medical indications for early-term delivery

____________________ include placental/uterine issues (E.g. placenta previa), fetal issues (e.g. growth restriction), materal issues (e.g. hypertension, diabetes), and obsetric issues (e.g. premature rupture of membranes)

*flattfoot (pes planus)*

____________________ is pronation, or turning in of the medial side of the foot; the young child may look flatfooted because the normal longitudinal arch is concealed by a fat pad until age 3 years

fetal macrosomia (large for dates)

birth risks to the mother include labor abnormalities, an increased incidence for cesarean delivery, bladder trauma, and vaginal tissue trauma;

signs of caregiver burnout

caregiver burden is linked to the caregiver's ability to cope and handle stress; _________________ include multiple somatic complaints, increased stress and anxiety, social isolation, depression, and weight loss; several formal screening tools are available that identify caregivers of any age who need a more comprehensive assessment; caregiver stress can lead to elder mistreatment; a thorough assessment identify opportunities for prevention of elder abuse

striae

also note ___________, or stretch marks, in areas of weight gain, particularly on the abdomen and breasts of multiparous women; these marks are bright red when they first form, but they will shrink and lighten to a silvery color (in the lightly pigmented woman) after hte pregnancy

appendix

appendicits typically starts as dull, diffuse pain in periumbilical region that later shifts to severe, sharp, persistent pain and tenderness localized in RLQ (McBurney point); pain is aggravated by movement, coughing, deep breathing; associated with anorexia, then nausea nad vomiting, fever

anorexia

appetite (subjective data) rationale: _______________ is loss of appetite from GI disease as a side effect to some medications, with pregnancy, or with mental health disorders

frozen shoulder- adhesive capsulitis

fibrous tissues form in the joint capsule, causing stiffness, progressive limitation of motion, and pain. motion limited in abduction and external rotation; unable to reach overhead. *it may lead to atrophy of shoulder girdle muscles; gradual onset; prevalence in 20% of diabetics*; also associated with prolonged bed rest or shoulder immobility

tobacco and alcohol and osteoporosis

finally, _________________ and excessive ______________ drinking are harmful to bone health; smoking is linked to reduced BMD and excess drinking increases the risk of falls

ulnar deviation or drift

fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbalance; also not subluxation and swelling in the joints and muscle atrophy on the drosa of the hands; this is caused by chronic RA

young child measurement

height, weight, temperature, blood pressure

inferior vena cava

help her to a seated position to check her BP; help her lie down for the breast, abdominal, and extremity examination; use the lithotomy position for the pelvic examination; in the 2nd and 3rd trimesters keep her back elevated to a 30 or 45 degree angle; this increases comfort by avoiding the compression on the descending aorta and _________________ by the pregnant woman

liver pain

hepatitis may have mild-to-moderate dull pain in right upper quadrant (RUQ) or epigastrium, along with anorexia, nasuea, malaise, and low-grade fever l

infant musculoskeletal system

hands and arms: inspect the hands, noting shape, number, and position of fingers and palmar creases palpate the length of the clavicles because the clavicle is hte bone most frequently fractured during birth; the clavicles should feel smooth, regular, and without crepitus; also note equal ROM of arms during Moro reflex

tophi with chronic gout

hard nodules (tophi) most often occur in the metatarsophalangeal joint of hte first toe; tophi are collections of sodium urate crystals caused by chronic gout in and around the joint; crystals are strong inflammation triggers that cause extreme painful swelling and joint deformity; they may erode through skin with a chalky discharge

child abdominal exam

in assessing abdominal tenderness, remember that the young child often answers this question affirmatively no matter how the abdomen actually feels; use objective signs to aid assessment, such as a cry changing in pitch as you palpate, facial grimacing, moving away from you, and guarding

pregnant women abdomen

nausea and vomiting or morning sickness is an early sign of pregnancy for most pregnant women, starting between the 1st and 2nd missed periods; the cause may be the resutl of hormonal changes such as the production of human chorionic gonadotropin (hCG); another symptom is acid indigestion or heartburn (pyrosis) caused by esophageal reflux; gastroitestinal (GI) motiltiy decreases, which prolongs gastric emptying time; the decreased motility causes more water to be resorbed from the colon, which leads to constipation; the constipation, in addition to increased venous pressure in the lower pelvis, may lead to hemorrhoids

gastrointestinal changes of pregnancy

nausea and vomiting, "morning sickness" common at any time of day; constipation common

spine

normal spinal maneuvers only revela gross restriction; movement is still psosible even if some spinal fusion has occurred; finally ask the person to walk on their toes for a few steps and return walking on the heels

umbilicus

normally it is midline and everted, with no sign of discoloration, inflammation, or hernia; it becomes everted and pushed upward with pregnancy the _____________ is a common site for piercings; the shite should not be red or crusted

spleen

normally the ______________ is not palpable and must be enalrged 3 times its normal size to be felt; to search for it, reach your left hand over the abdomen and behind the left side at hte 11th and 12th ribs; lift up for support; place your right hand obliquely on the LUQ with hte fingers pointing toward hte left axilla and just inferior to the rib margin; push your had deeply down and under the left costal margin and ask the person to take a deep breath; you should feel nothing firm; imaging by ultrasound is more prescise

pulsations or movement

normally you may see the puslations from the aorta beneat the skin in the epigastric area, particularly in thin people with good muscle wall relaxation; respiratory movement also shows in the abdomen, particularly in males; ifnally, waves of peristalsis sometiems are visible in very thin people; they ripple slowly nad obliquely across the abdomen

skin

note any scars (particulalry those of previous cesarean delivery); many women have skin changes, such as acne or skin tags, during pregnancy that may spontaneously resolve after the pregnancy; vascular spiders may be present on the upper body; some women have cholasma, known as hte mask fo pregnancy, with is a putterfly-shaped pigmentation of hte face; note the presnce of the linea nigra, a hyperpigmented line taht begins at the sternal notch and extends down the abdomen throgh the umbilicus to the pubis

infant vital signs

note pulse, respirations, and temperautre

careful measurements

note that some measurements such as daily weights, abdominal girth, or the circumference of a limb must be taken very carefully; the utility of such measurements depends entirely on the consistency of hte procedure from nurse to nurse

left upper quadrant (LUQ)

organs in the ____________- include: stomach spleen left lobe of liver body of pancreas left kideny and adrenal splenic flexure of colon part of transverse and descendign oclon

right upper quadrant (RUQ)

organs in the _____________ include: liver gallbladder duodenum head of pancreas right kidney and adrenal hepatic flexure of collon part of ascending and transverse colon

midline

organs in the ______________ include: aorta uterus if enlarged bladder if distended

left lower quadrant (LLQ)

organs in the ________________ include: part of descending colon sigmoid colon left ovary and tube left ureter left spermatic cord

symmetry

shine a light across the abdomen toward you or lengthwise across the person; teh abdomen should by symmetric bilaterally; note any localized bulging, visible mass, or asymmetric shape; even small bulges are highlighted by shadow; step to the food to recheck symmetry

glnohumeral joint

the ________________ is the articulation of hte humerus with hte glenoid fossa of the scapula; note the humeral head's articular surface is much greater than the glenoid's articular surface; this ball-and-socket action allows great mobility of the arm on many axes, more than any other joint

coracoid process

the ________________ of hte scapula is a few centimeters medial to the greater tubercle of the humerus; the ______________ projects anteriorly and laterally from the neck of hte scapula

Katz index of independnece in ADL

the ________________ scale is a useful instrument in many settings and takes only 5 minutes to administer, but it has limitations; in an ambulatory clinic setting, the provider cannot observe the older adult perform the activity and must rely on a self-report or surrogate report; in the hospital, nursing staff may be assisting with trasnferring or grooming activities and may underestimate the ability for self-care; in addition, small changes in the ability to perform these activities may not be identified; a variety of other instruments are available to measure ADLs, but some require formal training and additional time to administer

calcaneus

the ________________, heel, is located under the talus and points posteriorly

areolae and nipples darken

the _________________ because estrogen and progesterone have a melanocyte-stimulating effect, and melanocyte stimulating hormone levels escalate from the 2nd moth of pregnancy until delilvery; for the same reason the midline of the abdomen becomes pigmented and is often called the linea nigra; you may note striae gravidarum (Stretch marks) on the breast, abdomen, and other areas of weight gain

collateral ligaments

the _________________ connect the joint at both sides; they give medial and laterla stability and prevent dislocation

Rome III symptom criteria

the _________________ for functional constipation; these symptotms include reduced stool frequency (less than 3 bowel movements per week) and other common and troublign associated symptoms (i.e. straining, lumpy or hard stool, feeling of incomplete evacuation, feeling of anorectal blockage, use of manual naneuvers)

Genu varum

(bowlegs)

genu valgum

(knock-knees)

frozen shoulder- adhesive capsulitis

*it may lead to atrophy of shoulder girdle muscles; gradual onset; prevalence in 20% of diabetics*; also associated with prolonged bed rest or shoulder immobility

warning signs when to stop driving

1. almost crashing, with frequent close calls 2. finding dents and scrapes on the car, fence, mailbox, etc. 3. getting lost easily; having issues with memory 4. having trouble seeing or following traffic signals, road signs, and pavement markings 5. responding more slowly to unexpected situations; having trouble moving the foot fro mthe gast to hte brake pedal; confusing the two pedals 6. misjudging gaps in traffic at intersectiosn and on highway entrance and exit ramps 7. driving too slow or fast for conditions 8. easily becoming distracted or having difficulty concentrating while driving 9. physical limitations such as having a hard time turning around while backing up or changing lanes 10. having trouble maintaining the correct lane or switching lanes while driving

general apperance

1. appears stated age 2. level of consciousness 3. skin color 4. nutritional status 5. posture and position comfortably erect 6. obvious physical deformities 7. mobility, gait, use of assistive devices, ROM of joints, involuntary movement, able to rise form a seated position easily 8. facial expression 9. mood and affect 10. speech: articulation, pattenr, content appropraite, native language 11. hearing 12. personal hygiene

heart

1. ask person to lean forward and exhale briefly; auscultate cardiac base for any murmurs

musculoskeletal

1. ask the person to walk across the room in his or her regular walk, turn, and then walk back toward you in a heel-to-toe fashion 2. ask the person to walk on the toes for a few steps, then to walk on the heels for a few steps 3. stand close and check for Romberg sign 4. ask the person to hold the edge of the bed and perform a shallow knee bend, one for each leg 5. stand behind and check the spine as the person touches the toes 6. stabilize the pelvis and test the ROM of the spine as the person hyperextends, rotates, and laterally bends

hospital patient abdomen

1. assess contour of abdomen: flat, rounded, protuberant 2. listen to bowel sounds 3. check any drains for color and amount of drainage and insertion site integrity 4. inquire whether passing flatus or stool 5. knowing diet orders, determine whether patient is tolerating ice chips, liquids, solids; order correct diet as it is advanced; not whether patient is at high risk for nutrition deficit

hospital patient cardiovascualr systesm

1. auscultate rhythm at apex: regular irreguar? do not listen over gown 2. check apical pulse against radial pulse, noting perfusion of all beats 3. assess heart sounds in all ausculatory areas: first with diaphragm, repeat with bell 4. check capillary refill for prompt return 5. check pretibial edema 6. palapte posterior tibial pulse, right and left 7. palpate dorsalis pedis pulse, right and left; note: be prepared to assess pulses in the lower extremities by Doppler if you cannot find them by palpation

palpation abdomen

1. bend hte person's knees keep palpating hand low and parallel to the abdomen; holding hand high and point down makes people tesne up teach person to breathe slowly (in through nose and out through mouth) keep voice low and soothing; conversation may relax person try emotive imagery with ticklish person, keep the person's hand under your own with your fingers curled over his or her fingers; move both hands around as you palpate; people are not ticklish to themselves alternatively perform palpation just after auscultation; keep the stethoscope in place and curn your fingers around it, palpating as you pretend to ausculatate

infant general apperance

1. body symmetry, spontaneos position, flexion of head and extremities, and spontaneous movement 2. skin color and characteristics; any obvious deformities 3. symmetry and positioning of the facial features 4. alert, responsive affect 5. strong, lusty cry

young child health history

1. collect the history, including developmental data; include the child in history taking as appropriate 2. during the history note data on general appearance

infant nose exam

1. determine the patnecy of the nares 2. note the nasal discharge, sneezing, and any flaring with respirations

skin

1. examine both hands and inspect hte nails 2. for the rest of the exam, examine the skin with the corresponding regional exam

hospital patient neurologigc system

1. eyes open spontaneously to name 2. motor response is strong and equal bilaterally 3. verbal response makes sense; speech is clear and articulate 4. pupil size in mm and reaction, R and L 5. muscle strenght, R and L upper, using hand grips 6. muscle strength, R and L lower, pushing feet against your palms 7. any ptosis, facial droom 8. sensation (omit unless indicated) 9. communication 10. ability to swallow

hospital patient general apperance

1. facial expression: appropriate to the situation 2. body position: relaxed and comfortable or tense, in pain 3. level of consciousness: alert and oriented, attentive to your questions, responds appropriately 4. skin color: even tone consistent with racial heritage 5. nutritional status: weight appears in healthy range, fat distribution even, hydration appears healthy 6. speech: articulation clear and understandable, pattern fluent and even, content appropriate 7. hearing: responses and facial expression consistent with what you have said 8. personal hygiene: ability to attent to basic hygiene needs such as brushing teeth and bathing

infant genetalia exam

1. females- inspect labia and clitoris (edematous in the newborn), vernix cerosa between labia, and patent vagina 2. males- inspect position of urethral meatus (do not retract foreskin), strength of urine stream if possible, and rugae on scrotum 3. males- palpate the testes in the scrotum

hospital patient genitourinary

1. inquire if voiding regularly; note: needs to void within 4-6 hours after surgery 2. check urine for color, clarity 3. if foley catheter in place, check color, quantity, clarity of urine with every VS check 4. if urine output is below the expected amount, perform a bladder scan according to agency protocol. is the problem in the production of urine or its retention

infant lower extremities exam

1. inspect and manipulate the legs and feet, noting ROM, muscle tone, and skin condition 2. note alignment of feet and toes, look for flat soles, and count toes; note any syndactyly 3. test ortolani sign for hip stability 4. check plantar grasp reflex (present until 8-10 months) 5. check babinski-> fanning of toes until 24 months

infant upper extremities exam

1. inspect and manipulate, noting ROM, muscle tone, and absence of scarf sign (elbow should not reach midline) 2. count fingers, count palmar creases, and note color of hands and nail beds 3. place our thumbs in the infant's palms to note the grasp reflex; then wrap your hands around the infnat's hands to pull up and note the head lag

head/face

1. inspect and palpate scalp, hair, and cranium 2, inspect face: expression, symmetry (cranial nerve VII) 3. palpate the temporal artery, then the temporomandibular joint as the person opens nad closes the mouth 4. palpate the maxillary sinuses and the frontal sinuses

young child ears exam

1. inspect and palpate the auricles; note any discharge from teh auditory meatus; check for any foreign body 2.with an otoscope, inspect hte ear canals and tympanic membranes; gain cooperation by encouraging the child to handle the equipment or to look in the parent's ear as you hold the otoscope; inspect hte canal, then the tympanic membrane for color, position, landmarks, and integrity

male breasts

1. inspect and palpate while palpating the anterior chest wall 2. supporting each arm, palpate hte axilla and regional nodes

young child upper extremity assessment

1. inspect arms and hands for alignment, skin condition; inspect fingers and note palmar creases 2. palpate and count the radial pulse 3. test biceps and triceps reflexes with a reflex hammer

female breasts

1. inspect for symmetry, mobility, and dimpling as the woman lifsts arms over the head, pushes the hands on the hips, and leans forward 2. inspect supraclavicular and infraclavicular areas help the woman to lie supine with head at a flat to 30-degree angle; stand at the person's right side; drape the gown up and across shoulder and place an extra sheet across lower abdomen 3. palpate each breast, lifting the same-side arm up over head; include teh tail of Spence and areola 4. palpate each nipple for discharge 5. support the person's arm and palpate the axilla and regional lymph nodes 6. teach breast self-examination

ears

1. inspect hte external ear: position and alignment, skin conditions, and auditory meatus 2. move auricle and push tragus for tenderness 3. with an otoscope, inspect the canal, then the typnanic membrane for color, position, landmarks, and integrity 4. test hearing: whispered voice test

infant mouth and throat exam

1. inspect hte lips nad gums, high-arched intact palate, buccal mucosa, tongue size, and frenulum of tongue; not absent or minimal salivation in neonate 2. note the rooting reflex 3. insert a gloved little finger, note the sucking reflex, and palpate the palate

neck

1. inspect hte neck: symmetry, lumps, pulsations 2. palpate the cervical lymph nodes 3. inspect and palpate the carotid pulse, one side at a time; if indicated, listen for carotid bruits 4. palpate the trachea in midline 5. test ROM and muscle strength against your resistance: head forward and back, hea dturned to each side, and shoulder shrug (cranial nerve XI) step behind the person, taking stethoscope with you 6. palpate thyroid gland, posterior approach

infant abdomen exam

1. inspect hte shape of the abdomen and skin condition 2. inspect the umbilicus; count vessels (neborn); note condition of cord or stump (immediate neonatal period); note nay hernia 3. palpate skin turgor 4. palpate lightly for muscle tone, liver, spleen tip, and bladder 5. palpate deeply for kidneys, any mass 6. palpate femoral pulses, inguinal lymph nodes 7. percuss all quadrants

lower extremities

1. inspect legs for varicose vein

young child abdomen exam

1. inspect shape of abdomen, skin condition, and periumbilical area 2. ausucltate bowel sounds 3. palpate skin turgor, muscle tone, liver edge, spleen, kidneys, and any masses 4. palpate the femoral pulses; compare strength with radial pulses 5. palpate inguinal lymph nodes

infant ears exam

1. inspect size, shape, alignment of auricles, patency of auditory canals, any extra tags or pits 2. note the startle reflex in response to a loud noise 3. palpate flexible auricles defer otoscopic examination until the end of the complete examination

young child anterior thorax, heart, and lungs exam

1. inspect size, shape, and configuration of chest cage; assess respiratory movement 2. inspect pulsations on the precordium; note nipple and breast development 3. palpate apical impulse and note location, chest wall for thrills, any tactile fremtius 4. auscultate breath sounds and heart sounds in all locations; count respiratory rate and heart rate 5. listen to S1 and S2 across the precordium; note any murmurs

young child genetalia examination

1. inspect the external genetalia 2. on males palpate the scrotum for testes; if masses are present, transilluminate

young child nose xam

1. inspect the external nose and skin condition 2. with a penlight, inspect the nares for foreign body, mucosa, septum, and turbinates

nose

1. inspect the external nose: symmetry, lesions 2. inspect facial symmetry (cranial nerve VII) 3. test the patency of each nostril 4. with a speculum, inspect the nares: nasal mucosa, septum, and turbinates

young child eyes exam

1. inspect the external structures; not any palpebral slant 2. with a penlight, teste the corneal light and pupillary light reflexes 3. ask the child to follow your finger or a moving penlight for cardinal positions of gaze 4. if indicate, perform the cover test, coveering the eye with your thumb in a young child using an index card 5. inspect conjunctivae and sclera 6. with an opthalmoscope, check the red reflex; inspect the fundus as much as possible

infant eyes exam

1. inspect the lids (edematous in the neonate), palpebral slant, conjunctivae, adn nystagmus, and any discharge 2. using a penlight, elicit the pupillary reflex, blink reflex, and corneal light reflex; assess tracking of moving light 3. using an opthalmoscope elicit the red reflex

neck vessels

1. inspect the neck for a jugular venous pulse, turning the person's head slightly to the left 2. estimate jugular venous pressure if indicaed

male genetalia

1. inspect the penis and scrotum 2. palpate the scrotal contents; if a mass exists, transilluminate 3. check for inguinal hernia 4. teach testicular self-examination for an adult male, ask him to bend over the exam table, supporting the torsoe with forearms on the table; assist the bedfast male to a left-lateral position with the right leg drawn up

male rectum

1. inspect the perianal area 2. with a gloved lubricated finger, palpate the rectal walls and prostate gland 3. save a stool specimen for an occult blood test

female genitalia

1. inspect the perineal and perianal areas 2. with a vaginal speculum inspect hte cervix and vaginal walls 3. procure specimens 4. perform a bimanual examination: cervix, uterus, adnexa 5. continue the bimanual examination, checking the rectum and rectovaginal walls 6. save a stool specimen for an occult blood test 7. provide tissues for the female to wipe the pernieal area and help her up to a sitting position

young child posterior thorax exam

1. inspect the posterior chest: configuration, skin characteristics, symmetry of shoulders and muscles 2. palpate for lumps or tenderness, length of spinous processes 3. percuss over lung fields 4. auscultate breath sounds, comparing side to side in upper nad lower lung fields; note any adventitious sounds

chest, posterior, and lateral

1. inspect the posterior chest; configuration of the thorracic cage, skin characteristics, adn symmetry of shoulders nad muscles 2. palpate: symmetric expansion; tactile fremitus; lumps or tenderness 3. palpate length of spinous processes 4. percuss over all lung fields 5. percuss over costovertebral anngle, noting tenderness 6. auscultate breath sounds, comparing side to side in upper nad lower lung fields; not any adventitious sounds

heart

1. inspect the precordium for any pulsations or heave (lift) 2. palpate hte apical impulse and note the location 3. palpate the precordium for any abnormal thrill 4. auscultate apical rate and rhthm 5. auscultate wit hthe diaphragm of the stethoscope to study heart sounds, inching form the apex up to the base, or vice versa in a rough Z pattern 6. auscultate the heart sounds with the bell of the stethoscope, again inching through all locations, noting any murmurs or abnormal sounds 7. turn the person over to the left side while again auscultating the apex with the bell

young child head, face, and neck exam

1. inspect the size nad shape of the head and symmetry of facies 2. palpate the cervical lymph nodes, trachea, and thyroid gland

infant chest and heart

1. inspect the skin condition over the chest and abdomen, chest configuration, and nipples and breat tissue 2. note movement of the abdomen wiwth respirations, and note any ches retraction 3. palpate apical impulse adn note its location; chest wall for thirlls; tactile fremitus if the infant is crying 4. auscultate breath sounds, heart sounds in all locations, and bowel sounds

abdomen

1. inspect: contour, symmetry, skin charaacteristics, umbilicus, and pulsations 2. auscultate bowle sounds 3. auscultate for vascular sounds over the aorta, renal arteries, iliac and femoral arteries 4. percuss all quadrants 5. palpate:: light palpation in all quadrants, then deep palpation in all quadrants 6. palpate for liver, spleen, and kidneys 7. palpate aortic pulsation if indicated

chest, anterior

1. inspect: respirations and skin characteristics 2. palpate: symmetric expansion, tactile fremitus, lumps, or tenderness 3. percuss anterior lung fields 4. auscultate breath sounds, comparing side to side in upper and lateral lung fields; note any adventitious sounds

lower extremities

1. inspect: symmetry, skin characteristics, and hair distribution 2. palpate pulses: popliteal, posterior tibial, dorsalis pedis 3. palpate for temperature and pretibial edema 4. separate toes and inspect 5. test ROM and muscle strenght of hips, knees, ankles, and feet

musculoskeletal exam

1. inspection- size and contour of joint; skin color and characteristics 2. palpation of joint- skin, muscles, bony articulations, joint capsule 3. ROM- active, passive (if limiation in active ROM is present), measure with goniometer (if abnormality in ROM is present) 4. muscle testing

musculoskeletal subjective data

1. joints (pain, stiffness, swelling, heat, redness, limitation of movement) 2. knee joint (if injured) 3. muscles (pain, cramps, weakness) 4. bones (pain, deformity, trauma) 5. functional assessment (ADLs) 6. patient-centered care

hospital patient activity

1. know activity orders; if on bed rest, head of bed should be elevated; is patient at high risk for skin breakdown? 2. are sequential compressio ndeviecs or thromboletic disease hose in place; SCDs must be on patient 22 out of 24 hours to be effective 3. if ambulatory, assist patient as he or she sits up and transfers to a chair 4. note any assistance needed, how movement is tolerated, distance walked to chair, ability to turn and sit 5. assess need for ambulatory aid or equipment

infant neck exam

1. lift the shoulders nad let hte hed lag to inspect hte neck: note midline trachea, any skinfolds, and any lumps 2. palpate hte lymph nodes, the thyroid, and any masses 3. while hte infant is supine, elicit the tonic neck reflex; note a supple neck with movement

hospital patient measurement

1. measure baseline vital signs (VS): temperature, pulse, respirations, blood pressure (BP); note which arm to avoid BP because of surgery, or IV access; collect and document VS more frequently if patietn is unstable or if patient condition changes; know that VS are the ultimate responsibility of the nurse- the nursing assistant is not responsible for interpretation

pregnacy subjective data

1. menstrual history 2. gynecological history 3. obsetric history 4. current pregnancy 5. medical history 6. review of systems 7. nutritional history 8. environmental hazards

young child lower extremity exam

1. note alignment of legs and skin condition 2. note alignment of feet; inspect toes and longitudinal arch 3. check range of motion of hips, knees, ankles 4. palpate the dorsalis pedis pulse 5. gain cooperation with reflex hammer; elicit plantar, Achilles, and patellar reflexes

young child general appearance

1. note child's ability to amuse himself or herself while the caregiver speaks 2. note caregiver and child interaction 3. note gross- and fine-motor skills as the child plays with toys gradually focus on and involve yourself with the child, at first in a play period 4. evaluate developmental milestones by using a Denver II test: gait, jumping, hopping, standing on one foot, building a tower, and throwing a ball 5. evaluate posture while the child is sitting and standing; evaluate alignment of legs and feet while the child is walking 6. evaluate speech acquisition 7. evaluate vision, hearing ability 8. evaluate social interaction

infant head and face exam

1. note molding after delivery, any swelling on cranium, bulging of fontanel with crying or at rest 2. palpate fontaneles, suture lines, and any swellings 3. inspect positioning and symmetry of facial features at rest and while the infant is crying

musculoskeletal

1. note muscle strength as the person sites up

hospital patient skin

1. note skin color, consistent with person's racial or ethic heritage 2. palpate skin temperautre; expect warm and dry 3. pinch a fold of skin under the clavicle or on the forearm to note mobility and turgor 4. note skin integrity, any lesions, and the condition of any dressings; note any bleeding or infection, but do not change dressing until after physical examination 5. assess IV site, and note surrounding skin condition 6.complete any standardized scaluesd used to quantify risk for skin breakdown 7. verify that any air loss or pressure loss surfaces being used are properly applied and operating ath the correct settings

hospital patient respiratory system

1. oxygen by mask, nasal cannula, check fitting and patient comfort 2. note FiO2 3. respiratory effort 4. auscultate breath sounds, comparing side to side; posterior lobes: left upper, right upper, left lwoer, right lower; if paitent is unable to sit up, have patient roll or ask for help to turn patient to the side; anterior lobes: rught upper, left upper, right middle and lower, left lower 5. cough and deep breathe; any mucus? check color and amount 6. incentive spirometer if ordered-encourage patient to use every hour for 10 inspirations; if pusle oximetry percentage drops of adventitious sonds are heard, encourage use more frequently

inguinal area

1. palpate each groin for the femoral pulse nad inguinal nodes; lift hte drape to expose the legs

vital signs

1. radial pulse 2. respirations 3. blood pressure (BP) in arms 4. BP in lower leg; compute ankle brachial index if indicated 5. temperature if indiacted

upper extremities

1. test ROM and muscle strength of hands, wrists, arms, and shoulders 2. palpate the epitrocheal nodes 3. palpate temperature, capillary refill 4. compare radial and brachial pulses

neurologic

1. test sensation in selected areas on hte face, arms, hands, legs, and feet; superficial pain, light touch, and vibration 2. test positon sense of fingers 3. test sterognosis, using a familiar object 4. test cerebellar function of the upper extremities using finger-to-nose test or rapid-alternating movements test 5. elicit deep tendon reflexes: biceps, triceps, brachioradialis 6. test the cerebellar function of the lwoer extremities by askign the person to run each heel down the opposite shin 7. elicit deep tendon reflexes: patellar and Achilles 8. test the Babinski reflex

eyes

1. test visual fields by confrontation (cranial nerve II) 2. test extraocular muscles: corneal light reflex, six cardinal positions of gaze (cranial nerves III, IV, VI) 3. inspect external ee structures 4. inspect conjunctivae, sclera, corneas, iridies 5. test pupil: size, response to light, and accommodation darken room 6. using an opthalmoscope, inspect ocular fundus: red reflex, disc, vessels, and retinal background

mouth/ throat

1. using a light, inspect the mouth: buccal mucosa, teeth and gums, tongue, floor of mouth, palate, and uvula 2. grade tonsils if present 3. note mobility of uvula as the person phonates ahh and test gag reflex (cranial nerves IX and X) 4. ask person to stick out the tongue (cranial nerve XII) 5. with a gloved hand, bimanulally palpate the mouth if indicated

measurement

1. weight 2. height 3. wasit circumference 4. compute body mass index 5. vision using Snellen eye chart

young child mouth and throat exam

1. with a light source, inpsect the mouth, buccal mucosa, teeth, and gums, tongue, palate, and uvula; use a tongue blade as a last resort

infant exam final procedures

1. with an otoscopee inspect the auditory canals and tympanic membranes ; ask the caregiver to hold the infant during the otoscopic exam 2. elicit the morro reflex by letting the infant's head and trunk drop back a short way, jarring the crib sides, or making a loud noise

hospital patient measurement

2. pulse oximetry- maintain > 92% unless otherwise specified; check pulse oximetry as ordered and as needed per nursing judgement; may need to monitor oxygen saturation continuously if patietn is lethargic, receiving oxygen, or receiving narcotic medications for pain management

tell me all you had to eat yesterday, starting with breakfast (aging adult abdomen subjective data)

24- hour recall may not be sufficent because daily pattern may vary; attempt week-long diary of intake; food pattern may differ during the onth if monthly income (e.g. Social security check) runs out

hospital patient measurement

3. ask patient to rate pain level on a 0 to 10 scale at this and every subsequent visit or VS measure; not patient's ability to tolerate pain 4. if pai nmedication given, note response in 15 minutes for IV administration or 1 hour for oral dosing

alvarado score/ Mantrels score

ABNORM: an ______________- of >7 increases the probability of appendicitis

hospital patient activity

6. complete any standardized scales used to quantify the patient's risk for falling 7. initiate or continue appropriate Plan of Care; Check whether any core measurements apply, such as heart failure. implement core measures as appropriate 8. document assessment findings before leaving the room if possible

obturator test

ABNORM: an inflamed appendix irritates the _______________-, and this leg movement produces pain in a positive finding

preeclampsia

ABNORM: brisk or greater than 2+ DTRs and clonus may be associated with elevated BP and cerebral edema in the ________________ woman

hospital patient activity

9. note examination findings requiring immediate attention: high or low BP (<90 or >160 systolic) high or low temperature (<97 or >100) high or low heart rate (<60 or >90) high or low respirations (<12 or >28) O2 saturations < 92% low or no urine output (<30 mL/ hr or <240 mL/ 8 hr) dark amber or bloody urine (except for urology patient) postop nausea and/or vomiting pain not controlled with medication; any unusual pain such as chest pain bleeding altered level of consciousness (LOC), confusion, or difficulty arousing sudden restlessness and/or anxiety

wrist and hand

ABNORM: loss of ROM here is the most common and most significant functional loss of the wrist limited motion pain on movement

peritoneal friction rub

A rough, grating sound, like two pieces of leather rubbed together, indicates peritoneal inflammation. occurs rarely; usually occurs over organs with a large surface are in contact with the peritoneum pfr

symmetry

ABNORM: bulges masses hernia-protrusion of abdominal viscera through abnormal opening in muscle wall Sister Mary Joseph nodule is a hard nodule in umbilicus that occurs with metastic cancer of stomach, large intestine, ovary, or pancreas

skin

AABNORM: multiple brusies suggest physical abuse note nay facial edema after 20 weeks' gestation, which may signal preeclampsia tracks (Scars along easily accessed veins) may indicate IV drug use; dilated breast veins may be used during pregnancy for IV drug use

wrist and hand

ABNORM: RA shows boggy or tender MCPs; this does not occur in osteoarthritis (OA) heberden and bouchard nodules are hard and nontender and occur with osteorarthritis

phalen test

ABNORM: ____________ produces numbness and burning in a person with carpal tunnel syndrome

crepitation

ABNORM: _____________ is an audible and palpable crunching or grating that accompanies movement; it occurs when the articular surfaces in the joints are roughened, as with RA

hyperresonance

ABNORM: ______________ is present with gaseous distension

gestational HTN

ABNORM: _______________ is a persistent elevation of >140/90 mmHg after the 20th week of gestation; chronic _______________ is found in women who have _________ before pregnancy or before the 20th week of gestation; these women are at higher risk for preelampsia

straight leg raising or laseguie test

ABNORM: _______________ stretches hte nerve route over the disk protrusion and gives a painful response of muscle contraction; test is positive if it reproduces or worsens sciatic pain and if person resists further leg elevation; this strongly suggests herniated disc and more so if person has increased pain on dorsiflexion of the foot

undernourshied or obese

ABNORM: _______________; a 1st trimester weight loss of >6% prepregnancy weight is worrisome and may indicate hyperemesis gravidium poor grooming, a slumped posture, and a flat affect may be signs of depression and risk for postpartum depression; poor grooming may reflect a lack of resources and need for a social service referral

limitation in range of motion

ABNORM: ________________ is the most sensitive sign of joint disease; thet amount of limitation may alert you to hte cause of disease; Articular disease (inside the joint capsule [e.g. arthritis]) produces swelling and tenderness around the whole joint, and it limits all planes of ROM in both active and passive motion; extra-articular disease (injury to a specific tendon, ligament, nerve) produces swelling and tenderness to that one spot in the joint and affects only certain planes of ROM, especially during active (voluntary) motion

tenderness

ABNORM: ________________-- occurs with local inflammation, inflammation of the periotneum or underlying organ, and with enlarged organ whose capsule is stretched

involuntary rigidity

ABNORM: _________________ is a constant, boardlike hardness of hte muscles; it is a protective mechanism accompanying acute inflammation of the peritoneum; it may be unilateral and the same area usually becomes painful when the person increases intraabdominal pressure by doing a sit up

uterine fibroids (leiomyomas)

ABNORM: _________________ may be felt during bimanual examination a shortened cervix is <2 cm and is associated with preterm labor or possible cervical insufficiency

limited internal rotation

ABNORM: ______________________ of hip is an early and reliable sign of hip disease limitation of abduction of the hip while supine is the *most common* motion dysfunction found in hip disease

lesions

ABNORM: _______________may indicate an infection, condyloma, or genital herpes infection

scolisosis

ABNORM: ____________is most apparent during the preadolescent growth spurt; marked asymmetry suggests _____________- ribs hump up on one side as child bends forward with unequal landmark elevation

lagging fundal height

ABNORM: a __________________ >2cm may indicate intrauterine growth restriction (IUGR), transverse lie, or oblique presentation of the fetus

herniated nucleus propulsus

ABNORM: a differnece in shoulder elevation and in level of scapulae and iliac crests occurs with scoliosis lateral tilting and foward bending occur with a __________________

fluid wave ascities test

ABNORM: a positive ________________ test occurs with large amounts of ascitic fluid; also note edema in the legs

child abdominal exam

ABNORM: a scaphoid abdomen is associated with dehydration or malnutrition younger than 7 years, the absence of abdominal respirations occurs with inflammation of the peritoneum

infant musculoskeletal system

ABNORM: a true deformity is fixed and assumes a right angle only with forced manipulation or not at all metatarsus varus- adduction adn inversion of forefoot talipes equinovarus

infant musculoskeletal system

ABNORM: a tuft of hair over a dimple in the midline may indicate spina bifida a small dimple in the head to the coccyx suggests dermoid sinus mass such as meningocele a baby who starts to slip between your hand shows weakness of the shoulder muscles

aging adult abdominal exam

ABNORM: abdominal rigidity with acute abdominal conditions is less common in aging with an acute abdomen the aging person often complains of less pain than a younger person would

indicate drug inhaling

ABNORM: complaints of nasal irritation, nasal crusting, nasal stuffiness, or recurrent nosebleeds may ________________; not that some nasal congestion and nosebleeds are normal during pregnancy due to increased blood volume note any suspicious nevi or lesions; it is uncommon for nevi to enlarge or darken just because of pregnancy

preeclampsia

ABNORM: edema, together with increased BP and proteinnuria, is a sign of ______________; edema and pain in one leg occur with deep vein thrombosis (DVT) and warrant doppler studies; carefully evaluate any redness or red, hot, tender swelling to rule out phlebitis; varicosities increase the risk for thombophlebitis; she should not wear restrictive clothing or sit withotu moving legs for a long period; varicostieis will worsen with the weight and ovlume of pregnancy; support hose help minimize them

kidneys

ABNORM: enlarged kidney kidney mass

elbow

ABNORM: epicondyles, head of radius, and tendons are common sites of inflammation and local tenderness or tennis elbow soft, boggy, or fluctant swelling in both grooves occurs with synovial thickening or effusion local heat or redness (Signs of inflammation) can extend beyond synovial membrane

umbilicus

ABNORM: everted wiht ascites or underlying mass deeply sunken with obesity enlarged, everted with umbilical hernia bluish periumbilcal color occurs (through rarely) with intraperitoneal bleding (cullen's sign)

enlarged

ABNORM: except with a depressed diaphragm, a liver palpated more than 1-2 cm below the right costal margin is ________________; record the number of centimeters it descends and note its consistency (hard, nodular) and tenderness; for example, an abnormally firm liver may indicate cirrhosis

Allis test

ABNORM: finding one knee significantly lower than the other is a positive indication of _________ sign and suggests hip dislocation

wrist and hand

ABNORM: ganglion cyst is a localized swellign in wrist synovial swelling on dorsum generalized swelling with arthritis and infection tenderness after a fall- check for fracture rheumatoid arthiritis shows bilateral swelling and tenderness

cervical spine

ABNORM: head tilted to one side asymmetroy of muscles tenderness and hard muscles with muscle spasm; tenderness with arthiritis or postural disorders with desk or office work limited ROM occurs with arthirits pain with movement occurs with arthirits or muscle overuse the person cannot hold flexion

knee

ABNORM: hollows disappear; then they may bulge with synovial thickening or effusion atrophy occurs with disuse or chronic disorders; it first appears in the medial part of the muscle, although it is difficult to note because the vastus medialis is relatively small feels fluctuant or boggy with synovitis of suprapatellar pouch

ballottment of the patella

ABNORM: if fluid has collected, your tap on the patella moves it through the fluid and you will hear a tap as the patella pumps up on the femoral condyles

<110/min or >160/min

ABNORM: if no FHTs are heard by Doppler by *12 weeks,* verify fetal cardiac activity with US further investiage any FHTs that are ____________________ or are irregular

spine

ABNORM: if the dots form a slight S-shape when the person stands, a spinal curve is present limited ROM occurs with osteoarthritis and anklyosing spondylitis pain with motion

spleen

ABNORM: if you feel an enlarged _______________, refer the person but do not continue to palpate it; an enlarged spleen is friable and can rupture easily with overpalpation; describe the number of centimeters that it extends below the left fostal margin

mcmurray test

ABNORM: if you hear or feel a click, mcmurray test is positive for a torn meniscus; this must be referred to orthopedics for imaging and posssible surgical repair

Tinel Sign

ABNORM: in carpal tunnel syndrome percussion of the median nerve produces burning and tingling along its distribution, which is a positive ________________

ankle and foot

ABNORM: in hallux valgus the distal part of the great toe is directed awat form teh body midline hammertoes calluses ulcers swelling or inflammation ttenderness, occurs with arthirtis, trauma to ligaments plantar fascitis shows localized tenderness under where heel fascia is torn

leopold maneuvers

ABNORM: in patient who are obese, those with excessive anmnotic fluid, or an anteriorly implanted placenta, _________________ are difficult to perform and interpret correctly; malpresentations are confirmed by US

subulxation of the head of the radius

ABNORM: inability to supinate the hand while the arm is flexed, together with pain in the elbow, indicates __________________ pain or tenderness in extremities is usually cased by trauma or infection fractures caused by trauma show as an inability to use the area, a deformity, or an excess motion in the involved bone with pain and crepitation

mcBurney point tenderness

ABNORM: inflammation of the appendix usually produces RLQ pain to palpation, with maximal tenderness sometimes ocurring over ________________

knee

ABNORM: irregular bony margins occur with osteoarthritis pain at joint line pronounced crepitus is significant, and it occurs with degenerative diseases of hte knee

shoulder

ABNORM: limited ROM assymetry pain with motion crepitus with motion rotator cuff lesions may cause limited ROM, pain, and muscle spasm during abduction, whereas forward flexion stays fairly normal

ankle and foot

ABNORM: limited ROM pain with motion unable to hold flexion a

knee

ABNORM: limited ROM; contracture; pain with motion; limp; sudden locking- the person is unable to extend the knee fully; this usually occurs with a painful and audible pop or click; sudden bucling or giving way occurs with ligament injury which causes weakness and instability

preschool and school age children musculoskeletal system

ABNORM: lordosis is marked with muscular dystrophy and rickets severe bowing or unilateral bowing also occurs with rickets genu valgrum also occurs with rickets, poliomyelitis, and syphilis pronation byond 30 months

cervical infections or STIs

ABNORM: many _________________ are asymptomatic; any cervical secretions that are purulent or mucopurulent (chlamydia or gonorrhea); yellow or green frothy (Trichomoniasis); thin, white, gray, or milky, with a fishy odor (bactterial vaginosis); or thick, white and clumpty (candidiasis) should be treated appropateily during the pregnancy if you suspect cervicitis, obtain cultures

pulsations or movement

ABNORM: marked pulsation of aorta occurs with widened pulse pressure (e.g. hypertension, oartic insufficiency, thyrotoxosis) and aortic aneurysm marked visible peristalsis, together with a distended abdoemn indicates intestinal obstruction

general survey

ABNORM: monitor for signs of preeclampsia throughout pregnancy weight gain monitored throughout pregnancy; provide counseling on appropriate weight gain as needed; adequate nutrition is important throughout pregnancy

infant musculoskeletal system

ABNORM: more than 20 degrees of deviation or if lateral malleolus is anterior to meedial mallelous, it indicates tibial torsion i

light palpation

ABNORM: muscle guarding rigidity large masses tenderness

hyperthyroidism, thyroidis, and hypothyroidism

ABNORM: neck solitary nodules indicate neoplasm; multiple nodules usually indicate inflammation or a multinodular goiter; signifcant diffuse enlargement occurs with ___________________

ultrasound (US)

ABNORM: note any abnormal mass within the breast and refer for _________; ___________ of the breast(s) is used in lieu of mammograms during pregnancy and lactation

symmetry

ABNORM: note any localized bulging hernia or enlarged liver or spleen may show

prophylactic antiboitics

ABNORM: note any other murmur and refer; valvular disease may need _______________ at delivery; pregnancy places a large hemodynamic burden on the heart, and thet woman with cardiac disease is managed closely

vascular sounds

ABNORM: note location, pitch, and timing of a vascular sound a systolic bruit is a pulsatile blowing sound and occurs with stenosis, partial occlusion, or aneurysm of an artery venous hum and peritoneal friction rub are rare

dullness of sound

ABNORM: over a distended bladder, adipose tissue, fluid, or a mass

rebound tenderness test

ABNORM: pain on release of pressure confirms ______________, which is a reliabile sign of perionteal inflammation; peritoneal inflammation accompanies appendicitis; cough tenderness that is localized to a specific spot also signals peritoneal irritation _____________- occurring in the right lower quadrant when pressure is applied to the left lower quadrant (Blumberg sign) may indicate appendicitis; refer the person with suspected appendicitis for computed tomography scanning

hip

ABNORM: pain with palpation crepitation limited motion pain with motion flexion flattens the lumbar spine; if this reveals a flexion defmormity in the opposite hip, it is a postiive Thomas test

Get up and go test:

ABNORM: performance > 10 seconds together with history of falls and mobility problems increase risk for future falling

skin

ABNORM: prominent, dilated veins (caput meduase) occur with portal hypertension, cirrhosis, ascites, or vena caval obstruction veins are more visible with malnutrition as a result of thinned adipose tissue poor turgor occurs with dehydration, which often accompanies GI disease

skin

ABNORM: redness with localized inflammation jaundice (shows best in nautral daylight) skin glistening and taut with ascities striae also occur with ascites striae look purple-blue with Cushing syndrome (excess adrenocortical hormone causes the skin toe be fragile and easily broken from normal stretching)

shoulder

ABNORM: redness; inequality of bony landmarks occurs with scoliosis; atrophy shows as lack of fullness; can signal rotator cuff problem or disuse dislocated shoulder loses normal rounded shape and looks flattened laterally swelling from excess fluid is best seen anteriorly; considerable fluid must be present to cause a visible distention because the capsule normally is so loose

infant abdominal exam

ABNORM: refer any umbilical hernia larger than 2.5 cm continuing to grow after 1 month; or lasting for more than 2 years in a white child or more than 7 years in a black child refer diastasis recti lasting more than 6 years marked peristalsis with pyloric stenosis bruit venous hum

demeanor

ABNORM: restlessness and constant turning to find comfort occur with the colicky pain of gastroenteritis or bowel obstruction absolute stillness, resisting any movement, occurs with the pain of periontitis knees flexed up, facial grimacing, and rapid, uneven respirations also indicate pain

contour

ABNORM: scaphoid abdomen caves in; protuberant abdomen *indicates abdominal distension*

infant abdominal exam

ABNORM: scaphoid shape occurs with dehydration dilated veins the presence of only one artery in umbilical cored signals the risk for congenital defects inflammation drainage after cord falls off

costovertebral angle tenderness

ABNORM: sharp pain occurs with inflammation of hte kidney or paraphrenic area, as in pyelonephritis

knee

ABNORM: shiny and atrophic skin swelling or inflammation angulation deformity: Genu varum (bowlegs) genu valgum (knock-knees) flexion contracture

spine

ABNORM: spinal curvature; tenderness low back pain and spasm of paravertebral muscles chronic axial skeletal pain occurs with fibromyalgia syndrome

elbow (subcutaneous nodules)

ABNORM: subcutaneous nodules are raised, firm, and nontender, and overlying skin moves freely; common sites are i nthe olecranon bursa and along the extensor surface of hte ulna; thes nodules occur with RA after a fall or trauma, full extension of the elbow can usually rule out fracture

wrist and hand

ABNORM: subluxation (partial dislocation) of wrist ulnar deviation; fingers list to ulnar side anakylosis; wrist in extreme flexion dupuyyren contracture; flexion contracture of fingers swan-neck or boutonniere deformity in fingers atrophy of the thenar eminence with carpal tunnel syndrome

elbow

ABNORM: subluxation of hte elbow shows the forearm dislocated posteriorly swelling and redness of olecranon bursa are localized and easy to observe because of the close proximity of the bursa to skin effusion or synovial thicking shows first as a bulge or fullness in groove on either side of hte olecranon process and it occurs with gouty arthirits and bursitis

temporomandibular joint

ABNORM: swelling looks like a round bulge over the joint, although it must be moderate or marked to be visible crepitus and pain occur with ___________ dysfunction during movement or chewing; malocclusion of teeth also cause palpable crepitus or audible click decreased ROM occurs with ____________ inflammation and arthritis *lateral motion may be lost earlier and more significantly than vertical motion* ______________ causes tenderness with plapatiion

musculoskeletal exam inspection

ABNORM: swelling may be excess joint fluid (effusion), thicking of the synovial lining, inflammation of surrounding soft tissue (bursae, tendons), or bony enlargement deformities include fracture (a break in a bone), dislocation (compelte loss of contact between the two bones in a joint), subuluxation (two bones in a joint stay in contact, but their alignment is off), contracture (shortening of a muscle leading to limtied ROM of joint), or anklyosis (Stiffness or fixation of a joint)

shoulder

ABNORM: swelling of subacromial bursa is localized under deltoid muscle and may be accentuated when the person tries to adduct the arm swelling hard muscles with muscle spasm tenderness or pain

ankle and foot

ABNORM: swelling or inflammation, tenderness, occur wih tarthirits or trauma

bulge sign

ABNORM: the ___________ occurs with very small amounts of effusion, 4 to 8 mL, from fluid flowing across the joint

ascultation method

ABNORM: the _________________ can wrongly suggest taht the feeding tube is correctly placed in the stomach; serious harm or even fatality can result form administering tube-feeding material or medications into the lung

spleen

ABNORM: the ______________enlarges with mononucleosis, trauma, leukemia and lymphomas, portal hypertension, and HIV infection; consider malaria in persons with fever and splenomegaly returning form travel to areas where malaris is endemic;

liver span, splenic dullness, and bladder percussion

ABNORM: the upper liver border is overestimated if chronic obstructive lung disease is present, and both upper nad lower edges are obscured if obesity or ascites is present

shifting dullness ascities test

ABNORM: this test has less diagnostic value than the fluid wave test; shifting dullness is positive with a large volume of ascitic fluid; ti will not detect less than 500-1100 mL of fluid

tibial torsion

ABNORM: toeing in from forefoot adduction that if fixed or lasts beyond age 3 years toeing in from _____________ limp, usually caused by trauma, fatigue, or hip disease abnormal gait patterns

bowel sounds

ABNORM: two distinct patterns of abnorma lbowel sounds may occur: 1. hyperactive sounds are loud, high-pitched, rushing, tinkling sounds that signal increased motility 2. hypoactive/ absent sounds follow abdominal surgery or with inflammation of hte peirtoneum

infant musculoskeletal system

ABNORM: unequal gluteal folds may accompany hip dislocation after 2-3 months of age polydactyly is the presence of extra fingers or toes; syndactyly is webbing between adjacent fingers or toes a single transverse crease is a palmar crease that occurs with Down syndrome, accompanied by short broad fingers, incurving of little fingers, and low-set thumbs fractured clavicle: note irregularity at the fracture site, crepitus, and angulation; the site has rapid callus formation with a palpable lump within a few weeks; observe limited arm ROM and unilateral response to Moro reflex

measure leg length discrepancy

ABNORM: unequal leg lengths true leg lengths are equal, but apparent leg lengths unqual- this condition occurs with pelvic obliquity or adductio nor flexion deformity in the hip

skin

ABNORM: unusual color or change in shape of mole petechiae spider angiomas occur with portal hypertension or liver disease lesions, rashes underlying adhesions are inflammatory bands that connect opposite sides of serous surfaces after trauma or surgery

ottawa knee rules

ABNORM: use hte _____________ for any knee pain with injury for referral for imaging: 1. isolated pain of patella or head of fibula; 2. age > 55 years; 3. cannot flex knee to 90 degrees; 4. cannot bear weight for 4 steps

musculoskeletal exam palpation

ABNORM: warmth and tenderness signal inflammation palpable fluid is abnormal; because fluid is contained in an enclosed sac, if you push on one side of hte sac, the fluid will shift and cause a visible bulging on the other side

iliopsoas Muscle test

ABNORM: when the _______________ is inflamed (which occurs with an inflammed or perforated appendix), pain is felt in the RLQ and the test is positive

inspiratory arrest (murphy sign)

ABNORM: when the test is positive, as the descending liver pushes the inflammed gallbladder onto the examining hand, the person feels sharp pain and abruptly stops inspiration midway

aortic aneurysm

ABNORM: widened with abdominal ___________________ prominent lateral pulsation with _______________ pushes the examiner's two fingers apart; palpation may have poor accuracy detecting _____________ due to interference of the skin and adipose tissue, as well as the retroperitoneal location of the aorta

Ortolani maneuver

ABNORM: with a dislocated hip the head of hte femur is not cupped in the acetabulum but rests posterior to it hip instability feels like a clunk as the head of the femur pops back into place; this is a positive ____________- sign and warrants referral

asthma exacerbations

ABNORM: women with _______________ during pregnancy may have an expirationry( and possibly inspiratory) wheeze note any signs of respiratory infection: dyspnea, crackles, congested cough

sickle cell anemia

African American parents may pass ___________________ on to a child

enlarged gallbladder

An enlarged, tender gallbladder suggests acute cholecystitis. Feel it behind the liver border as a smooth and firm mass like a sausage, although it may be difficult to palpate because of involuntary rigidity of abdominal muscles. The area is exquisitely painful to fist percussion, and inspiratory arrest (Murphy sign) is present. An enlarged, nontender gallbladder also feels like a smooth, sausagelike mass. It occurs when the gallbladder is filled with stones, as with common bile duct obstruction.

phalen test

Ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand

enlarged spleen

Because any enlargement superiorly is stopped by the diaphragm, the spleen enlarges down and to the midline. When extreme, it can extend down to the left pelvis. It retains the splenic notch on the medial edge. When splenomegaly occurs with acute infections (mononucleosis), it is moderately enlarged and soft, with rounded edges. When the result of a chronic cause, the enlargement is firm or hard, with sharp edges. An enlarged spleen is usually not tender to palpation; it is tender only if the peritoneum is also inflamed.

electronic health recording

EHRs allow clinicans toe access a lifetime of data to treat patients more effectively; traditional medical records may be in a variety of locations, limiting availability; and poor penmanship can make older medical records illegibile

enlarged kidney

Enlarged with hydronephrosis, cyst, or neoplasm. May be difficult to distinguish an enlarged kidney from an enlarged spleen because they have a similar shape. Both extend forward and down. However, the spleen may have a sharp edge, whereas the kidney never does. The spleen retains the splenic notch, whereas the kidney has no palpable notch. Percussion over the spleen is dull, whereas over the kidney it is tympanitic because of the overriding bowel.

polydactyly

Extra digits are a congenital deformity, usually occurring at the 5th finger or the thumb. Surgical removal is considered for cosmetic appearance. The 6th finger shown here was not removed because it had full ROM and sensation and a normal appearance.

nutritional assessment (subjective data)

I would like to ask about your diet. Tell me all food you ate yesterday starting with breakfast which fresh food markets are located in your neighborhood

done by women

IADL instruments measure tasks historically ________________ (e.g. doing laundry, cooking, housework), and many do not address activities done primarily by men such as home repairs and yard work

costovertebral angle tenderness

Indirect fist percussion causes tissues to vibrate instead of producing a sound. To assess kidney, place one hand over 12th rib at costovertebral angle on back. Thump that hand with ulnar edge of your other fist. Person normally feels thud but no pain. Its usual sequence in complete examination is with thoracic assessment, when person is sitting up and you are standing behind

ovarian cyst (large)

Inspection. Curve in lower half of abdomen, midline. Everted umbilicus. Auscultation. Normal bowel sounds over upper abdomen where intestines pushed superiorly. Percussion. Top dull over fluid. Intestines pushed superiorly. Large cyst produces fluid wave and shifting dullness. Palpation. Transmits aortic pulsation, whereas ascites does not. oc

scoliosis

Lateral curvature of thoracic and lumbar segments of the spine, usually with some rotation of involved vertebral bodies.

aortic aneurysm

Most aortic aneurysms (>95%) are located below the renal arteries and extend to the umbilicus. A focal bulging >5 cm is palpable in about 80% of cases during routine physical examination and feels like a pulsating mass in the upper abdomen just to the left of midline. You will hear a bruit. Femoral pulses are present but decreased.

colles fracture

Nonarticular fracture of distal radius, with or without fracture of ulna at styloid process. Usually from a fall on an outstretched hand; occurs more often in older women. Wrist looks puffy with "silver fork" deformity, a characteristic hump when viewed from the side.

hallux valgus with bunion and hammertoes

Note the hammertoe deformities in the 2nd, 3rd, 4th, and 5th toes that include hyperextension of the metatarsophalangeal joint and flexion of the proximal interphalangeal joint. Corns (thickening of soft tissue) develop on the dorsum over the bony prominence from prolonged pressure from shoes.

mcmurray test

Perform this test when the person has reported a history of trauma followed by locking, giving way, or local pain in the knee. position the person supine as you stand on the affected side; hold the heel and flex the knee and hip; place your other hand on the knee with fingers on the medial side; rotate the leg in and out to loosen the joint; externally rotate the leg, and push a valgus (inward) stress on the knee; slowly extend the knee; normally the leg extends smoothly with no pain

rheumatoid arthritis (RA)

RA carries increased cardiovascular risk of heart attack and stroke

rheumatoid arthritis (RA)

RA is a chronic inflammatory painn condition that is possibly started by an autoimmune response, inflammatory event or infection; it occurs 2.5 times more in women than in men; its peak is ages 30-60 years although it can occur at any age; the inflammation of synovial tissues, hyperplasia, and swelling lead to fibrosis, ,cartilage and bone destruction, which limit motion and show as deformity

ankle and foot

Test ROM by: point toes toward floor (plantar flexion of 45 degrees) point toes toward the nose (dorsiflexion of 20 degrees) turn soles of feet out, then in; stabilize nakle with one hand and hold heel with other to test the subtalar joint (eversion of 20 degrees; inversion of 30 degrees) flex and straighten toes

muscle testing

Test strength of prime mover muscle groups for each joint; repeat motions for active ROM; Ask person to flex and hold as you apply opposing force; Muscle strength should be equal bilaterally and should fully resist opposing force; a wide variability of strength exists among people; use a grading system from no voluntary movment to full strength

Denver Developmental Screening Test

The ________________ was introduced in 1967 to identify young children, up to age six, with developmental problems

Trendelenburg sign

The _________________ is said to be positive if, when standing on one leg (the 'stance leg'), the pelvis drops on the side opposite to the stance leg. The muscle weakness is present on the side of the stance leg. If the patient compensates for this weakness (by tilting their trunk/thorax to the affected side), then the pelvis will be raised, rather than dropped, on the side opposite to the stance leg

Acute Care for Elders unit (ACE)

The _________________- is a continuous quality improvement model of care designed to prevent the patient's loss of independence from admission to discharge in the performance of activities of daily living (hospital-associated disability)

progesterone

__________________ maintains the endometrium around the fetus, increases alveoli the the breasts, and keep sthe uterus in a quiescent state

succussion splash

Unrelated to peristalsis, this is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach, as seen with *pyloric obstruction or large hiatus hernia. * ss

pica

_____________: although a toddler may attempt nonfodos at some time, he or she should recognize edibles by age 2 years

vitamin D

________________ rationale: is essential for maternal response to the calcium demands of the fetus for growth and bone development

nausea/vomiting (subjective data)

_________ rationale: nausea/vomiting is common with GI disease, many medications, pregnancy hematemesis occurs with stomach or duodenal ulcers and esophageal varices consider food poisoining or other types of bacterial or vital gastroenteritis nausea, vomiting, and diarrhea can occur when exposed to new local pathogens in developing countries; water supply may be contaminated

hallux valgus with bunion and hammertoes

__________ deviation of the great toe with medial prominence of the head of the 1st metatarsal. The bunion is the inflamed bursa that forms at the pressure point. The great toe loses power to push off while walking; this stresses the 2nd and 3rd metatarsal heads, and they develop calluses and pain. Chronic sequelae include corns, calluses, hammertoes, and joint subluxation. Note the ________________ deformities in the 2nd, 3rd, 4th, and 5th toes that include hyperextension of the metatarsophalangeal joint and flexion of the proximal interphalangeal joint. Corns (thickening of soft tissue) develop on the dorsum over the bony prominence from prolonged pressure from shoes.

epigastric

__________ is the area between the costal margins

striae

__________ look purple-blue with Cushing syndrome (excess adrenocortical hormone causes the skin toe be fragile and easily broken from normal stretching)

celiac disease

___________ is an autoimmune disorder that affects less than 1% of the population, although the incidence has been increaseing in recent years; affected persons are permanetly intolerant of gluten, a protein found in wheat, barley, rye, and some commerically produced oats; when gluten is ingested, immune-mediated inflammation results in damage to the small intestine and in malabsorption; onset can occur in childhood or adulthood with common symptoms of diarrhea, abdominal pain, and abdominal distention; other symptoms include anemia, osteoporosis, neuropathy, abnormal liver function, and skin lesions

variety

___________ is hte location of the fetal back to the anteiror, lateral, or posterior part of the maternal pelvis;

celiac disease

___________ is treated through a gluten -free diet; persons with wheat allergy and non_____________ gluten sensitivity shuold also follow a gluten-free diet; there is currently a trend for persons without these disease-specific indication to follow a gluten-free diet becuase of the perception that a gluten-free diet is healther or for hte treatmetn of other symptoms or dieroders, suc has irritable bowel syndrome, autism, and chronic fatigue syndrome; due to inadequate/and/or inconclusive research, there is controversy regarding the benefits of a gluten-free diet in persons without ____________________, gluten sensitivity, or wheat allergy

calf pain with walking, go away with rest (muscles subjective data)

___________ rationale: suggests intermittent claudication

bowel habits (subjective data)

____________ rationale: assess bowel habits black stools may be tarry due to occult blood (melena) from GI bleeding or nontarry from iron medications; gray stools occur with hepatitis red blood in stools occurs with GI bleeding or localized bleeding around the anus (e.g. hemorrhoids)

which medications do you take? (aging adult abdomen subjective data)

____________ rationale: consider GI side effects (e.g. nausea, upset stomach, anorexia, dry mouth

quality of joint pain (joints subjective data)

____________ rationale: exquisitely tender with acute inflammation

how often does toddler/child eat? (infant/children subjective data)

____________ rationale: irregular eating pattersn are common and a source of parental anxiet; as long as the child shows normal growth and development and only nutritious foods are offered, parents may be reassured pica: although a toddler may attempt nonfodos at some time, he or she should recognize edibles by age 2 years

myalgia

____________ rationale: is usually felt as cramping or aching

location: which joints/ both sides (joints subjective data)

____________ rationale: rheumatoid arthirits involves symmetric joints; other musculoskeletal illness involve isolated or unilateral joints

ascities

_____________ (free fluid in the peritoneal cavity) occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer

presentation

_____________ describes the part of the fetus that is entering the pelvis first (i.e., vertex [head], breech, foot)

hypogastric/suprapubic

_____________ is the are above the pelvic bone

umbilical

_____________ is the area around the umbilicus

polydactyly

_____________ is the presence of extra fingers or toes;

syndactyly

_____________ is webbing between adjacent fingers or toes

timing: time of day does pain occur (joints subjective data)

_____________ rationale: RA pain is worse in the morning when arising; osteoarthiris is worse later in the day; tendintiis is worse in the morning and improves during the day

haer a pop injury? can you stand on leg/ flex knee? (knee joint (if injury reported) (subjective data)

_____________ rationale: __________ may mean tear in ligament or fracture; with direct knee trauma, obtain x-ray if the patient is unable to flex knee to 90 degrees or unable to bear weight for 4 steps, if pain is experienced at fibula head or patella, or if patient is over age 55 years

diabetes

_____________ rationale: _____________ is carefully managed during pregnancy to avoid serious complications such as a macrosomic infant and cesarean delivery; consider early screening and nutritional interventions

persistent severe nausea and vomiting

_____________ rationale: breast tenderness, or fatigue is normal during pregnancy; nausea and vomiting usually begin between weeks 4 and 5, peak between weeks 8 and 12, and resolve; _________________ are hyperemesis and may require medical treatment

nutritional assessment (subjective data)

_____________ rationale: nutritional assessment via 24-hour recall; many inner-city neighborhoods are fresh food deserts, lacking produce markers but full of fast-food resturants

food and housing adequate

_____________ rationale: refer for state and federal programs to help with food, housing, or other needs

regular exercise program? which type? (medical history)

_____________ rationale: regular exercise in pregnancy may reduce risk for gestational HTN

scratch test

_____________: this traditional technique uses ausculation to detect the lower border of the liver; place the stethoscope over the xiphoid process while lightly stroking the skin with one finger up the MCL from the RLQ and parallel to the liver border; when you reach the liver edge, the sound is magnified in the stethoscope; however, there are many variations in the technique, and evidence is mixed as to its value; one study found moderate agreement between the results by scratch test and ultrasound; the researchers recommend the scratch test if the abdomen is distended, obese, or too tender for palpation or if muscles are rigid or guarded

pyrosis

______________ (heartburn), a burning sensation in esophagus and stomach from reflux of gastric acid

pigeon toes (i.e. toeing in)

______________ are demonstrated when the child tends to walk on the lateral side of the foot and the longitudinal arch looks higher than normal; it often starts as a forefoot adduction, which usually corrects sponatneously by 3 years of age as long as the foot is flexible

genetic disorders

______________ are diseases or defectst that hte baby inheris from the genes or chromosomes of one or both parents; the risk of having certain chromosomal disorders such as Down syndrome increases as a woman ages; parents may also be carriers of genetic defects: cystic fibrosis is an inherited disorder of respiratory and gastrointestinal sequelae; Jews of Eastern European descent may have the risk of having childrne with Tay-Sachs, a metabolic disorder; African American parents may pass sickle cell anemia on to a child

joint pain and loss of function (joints subjective data)

______________ are the most common musculoseletal concerns that prompt a person to seek care

activities of daily living

______________ are trasks necessary for self-care; typically ADLs include domains of eating/feeding, bathing, grooming (the individual tasks of washing face, combing hair, shaving, cleaning teath), dressing (lower body and upper body), toileting (bowel and bladder), walking (including propelling a wheelchair), using stairs (ascending and descending), and trasnferring (e.g. bed to chair); the ADL instruments are designed as either self-report, observation of tasks, or proxy/surrogate report

position

______________ designates the location of a fetal part ot the right or left of the maternal pelvis;

assisted living

______________ facilities are a popular choice for older adults and typically are considered for adults who can no longer reside at home yet do not need a skilled nursing facility; most facilities provide apartment-style living, although some single-family dwellings are licensed to provide care; facilities offer homelike environments where residents have the opportunity for social interaction through group dining and activities; some offer assistance with personal care, support with ADLs, and/or basic nursing care along with transportation and recreational activities as part of an overall package

age related GI system changes

______________ include: the indicende of gallstones increases with age, occurring in 10-20% of middle-age and older adults, being more common in females liver size decreases by 25% between the ages of 20-70 years, although msot liver functino remains normal; drug metabolism byy the liver is impaired, in part because blood flow through the liver and liver size are decreased; therefore the liver metabolism that is responsible for the enzymatic oxidation, reduction, and hydrolysis of drugs is substantially decreased with age; prolonged liver metabolism casues increased side effects (e.g. people taking benzodiazepines that have increased risk of falling and thus hip fracture)

fetal lie

______________ is the orientation of the fetal spine to hte materla spine and may be longitudinal, transverse, or oblique

neonatal abstinence syndrome (NAS)

______________ may include poor feeding, jitteriness, high-pitched crying, irritability, diarrhea, unstable temperature, and even seizures;________________ can be treated with medications and supportive therapy

joint injury

______________ occurs from trauma or repeated motion

teen pregnancies

______________ pose serious medical risks for both mother and fetus, such as toxemia and low-birth-weight infants; it is unclear whether these risks are the result of biologic or social factors, prolonged labor, or postpartum complications; unfortunately women who are under 20 years old at the time of conception are the least likely age-group to seek early prenatal care

delerium

______________ presents as an acute change in cognition, affecting the domain of attention; ____________ is usually attributable to an acute illness such as an infection or a medication side effect

job hazards

______________ rationale: ______________? possible teratogenic exposures? the woman who is rubella nonimmune may be advised not to continue working in a daycare center; suitability for pregnancy? the woman whose job requires long horus of standing or heavy lifting may be unable to work if signs of PTL occur

muscles look small (muscles subjective data)

______________ rationale: atrophy

experiencing edema? where and under what circumstances? (current pregnancy)

______________ rationale: in the 3rd trimester differentiate the norrmal weight-dependent edema of pregnacny from the edema of preeclampsia

how did you injure knee (knee joint (if injury reported) (subjective data)

______________ rationale: inside knee injury can strain or rupture medial ligament; outside injury can strain or rupture lateral ligament; abrupt twisting can injure anterior cruciate ligament

low back pain

______________ rationale: occurs with degenerative discs, osteoporosis, lumbar stenosis, or is nonspecific

muscle aches associated with fever, chills, flu (muscles subjective data)

______________ rationale: viral illness often includes myalgia

home care

______________- refers to a range of supportive social and health services provided in the home environment; services include nursing care, primary care, therapy (physical, occupational, and speech), social work, nutrition, case management, ADL assistance, and durable medical equipment;

spider angiomas

__________________ occur with portal hypertension or liver disease

hepatitis B and C

_______________ are spread through blood and body fluids, for example, by sharing contaminated needles or by sexual contact. Both hepatitis B and C can cause a brief period of illness, then either be cleared from the body entirely or go on to cause a long-term, or chronic, infection. Chronic infection is especially common with hepatitis C. Chronic hepatitis can eventually cause the liver to fail by causing liver scarring (Fibrosis and cirrhosis). Chronic hepatitis also increases your risk for liver cancer

dislocation

_______________ compelte loss of contact between the two bones in a joint

hypoactive/ absent sounds

_______________ follow abdominal surgery or with inflammation of the peirtoneum

esophagus pain/ gastroesophageal refulx disease (GERD)

_______________ is a complex of symptoms of esophagitis, including burning pain in midepigastrium or behind lower sternum that radiates upward, or heartburn; occurs 30-60 minutes after eating; aggravated by lying down or bending over e

cystic fibrosis

_______________ is an inherited disorder of respiratory and gastrointestinal sequelae;

lordosis

_______________ is marked with muscular dystrophy and rickets

tears in the menisci

_______________ occur with severe ligament injury and present with joint instability, swelling, and pain; suspected tears are referred to orthopedics due to future increased risk of osteoarthritis

adolescent musculoskeletal subjective data

_______________ rationale: assess safety of sport for child; note if child's height and weight are adequate for the particular sport (e.g. football) use of safety equipment and presence of adult supervision decrease risk for sports injuries students may not report injury or pain for fear of limiting participation in sports

aging adult musculoskeletal subjective data

_______________ rationale: encourage exercise to the best of the person's ability and safety a history of falls increases risk of future falling screening interval of 2 years is suggested to measure any change in BMD; recent evidence shows if baseline BMD is normal or osteopnia is mild, rescreening intervals of 15 years may suffice, and intervals of 5 yeras for women with moderate osteopenia

incest or other abuse

_______________ rationale: _______________ increases risk for dysfunctional labor and cesarean delivery

what do you eat at regular meals (adolescent subjective data)

_______________ rationale: adolescent takes control of eating and may reject family values (E.g. skipping breakfast, consuming junk foods and soda pop); the only control parents have is what food is in the home you probably cannot change adolescent eating pattenrs, but you can supply nutritional facts

chronic disability/ crippling illness effect on interactions with family/friends; way you view yourself (patient-centered care musculoskeltal)

_______________ rationale: assess for: self-esteem distrubance loss of independence body image disturbance role performance distrubance social isolation

occupational hazards (patient-centered care musculoskeltal)

_______________ rationale: assess risk for back pain or carpal tunnel syndrome

how do you acqurie groceries and prpare meals (aging adult abdomen subjective data)

_______________ rationale: assess risk for nutritiona ldeficit: limited access to grocery store, income, or cooking facilities; physical disability (impaired vision, decreased mobility, decreased strength, neurologic deficit)

do you share meals with others (aging adult abdomen subjective data)

_______________ rationale: assess risk for nutritional deficit if living alone; may not bother to prepare all meals; social isolation; depression

feelign worried or anxious? (bones susbjective data)

_______________ rationale: chronic pain can increase anxiety symptoms

pain relieved by food or worse after eating abdominal pain (subjective data)

_______________ rationale: chronic pain of gastric ulcers occurs usually on an empty stomach; pain of duodenal ulcers occurs 2-3 hours after a meal and is relieved by more food

does child have constipation/ how long (infnat/children subjective data)

_______________ rationale: constipation may affect from 0.7% to almost 30% of children; this is almost always funnctional constipation, meaning the bowel is otherwise healthy, but there may be inadequate fiber and fluids, inactivity, stress, medications, or other contributing diseases; children may also ignore the urge to defecate or whithhold to delay defecation, especially during toilet training

supplemental medications, calcium or vitamin D? dairy protucts eaten daily (patient-centered care musculoskeltal)

_______________ rationale: dietary calcium is better absorbed than supplements; sserum levels of vitamin D can be checked, and supplements recommended

fetal movements

_______________ rationale: fetal movement is an excellent indicator of fetal health; in the 3rd trimester clinicians assign women to count ____________________

bone pain? affected by movement? (bones susbjective data)

_______________ rationale: fracture causes sharp pain that increases with movement; other bone pain usually feels dull and deep and is unrelated to movement

poor dental hygiene

_______________ rationale: gums may be puffy or bleed easily in pregnancy, predispoing caries; _____________ can lead to PTD, low-birth-weight babies, adn neonatal death; dental care is an importnat part of prenatal care

obsetric history

_______________ rationale: helps guide prenatal care

do you feel safe in your relationship/ home environment? (review of systems)

_______________ rationale: intimate partner violence may escalate during pregnancy

pain associated with chills, fever, recent sore throat (joints subjective data)

_______________ rationale: joint pain 10-14 days after an untreated strept throat suggests rheumatic fever; joint injury occurs from trauma or repeated motion

general tympany

a resonant sound heard in percussion (as of the abdomen)

social networks

________________ consist of informational supports that are accessed by the older adult; informational support is partly based on cultural beliefs regarding who should be providing care, prior relationships, and the location and availability of caregivers; informational support includes family and friends and is usually provided free of charge; nearly 40 million people provide unpaid caregiving services to an adult over 50 years old in hte US; services provided include tasks such as ADLs, shopping, and paying bills; formal supports range from social services such as meal programs to health care services such as home health care

abdomen subjective data

________________ includes: appetite dysphagia food intolerance abdominal pain nausea/vomiting bowel habits past abdominal history medications nutritional assessment

preeclampsia

________________ is a condition specific to pregnancy that is rarely seen before 20 weeks' gestatio nexcept in the absnece of a molar (gestational trophoblastic) pregnacny; it occurs in 3% to 10% of pregnancies

Sister Mary Joseph nodule

________________ is a hard nodule in umbilicus that occurs with metastic cancer of stomach, large intestine, ovary, or pancreas

structural scoliosis

________________ is fixed; the curvature shows both on standing and on bending forward; note rib hum with forward flexion; when person is standing, not unequal shoulder elevation, unequal scapulae, obcious curvature, and unequal hip level

functional scolisosi

________________ is flexible; appears with standing and disappears with forward bending; it may compensate for other abnormalities (leg length discrepancy)

leopold's first maneuver

________________ is preformed by facing the gravida's head and placing your fingertips around hte top of the fundus; note its size, consitency, and shape; imagine which fetal part is in the fundus; the breech feels large and firm; because it is attached to the fetus at the waist, moving it between the thumb and fingers of the hand results in moving it slowly and with difficulty; on contrast, the fetal head feels large, round, and heard; when it is ballotted, it feels hard as you push it away and hard again as it bobs back against your fingers in an answer; note that the bobbing or ballotting sensation of the movment occurs because the head is attached at the neck and moves easily; there is no part in the fundus, the fetus is in the transverse lie

bone remodeling

________________ is the cyclic process of bone resorption and deposition responsible for skeletal maintenance at sites that need repair or replacement

lactase

________________ is the digestive enzyme necessary for absorption of hte carbohydrate lactose; in some racial groups __________ activity is high at birht but declines to low levels by adulthood

PPPP (pruritic urticarial papules nad placquest of pregnancy)

________________ is the most common pruritic skin rask during pregnancy, more common in white and nulliparous women; it has an intensely pruritic erythmatous eruption that appears late in pregnacny in the abdomen and thighs; the incidence is about 1 in 160 pregnancies; women who are primiparas or have multiple fetuses are at higher risk

dislocated shoulder (glenohumeral dislocation)

________________ is the most frequent type of joint dislocation; anterior dislocation (95) shows when hunching the shoulder forward and teh tip of hte clavicle dislocates; it occurs with trauma involving abduction, extension, and rotation (e.g. falling on an outstretched arm or viding into a pool), showing obvious deformity and severe pain; needs radiography; at risk for further dislocations due to injury to ligaments

black stools

________________ may be tarry due to occult blood (melena) from GI bleeding or nontarry from iron medications

gray stools

________________ occur with hepatitis

meniscal injuries

________________ present as a sharp acute pain at lateral or medial joint line together with catching, locking, or popping

food intolerance (subjective data)

________________ rationale: (e.g. lactase deficiency resulting in bloating or excessive gas after taking milk products) pyrosis (heartburn), a burning sensation in esophagus and stomach from reflux of gastric acid eructation (belching)

stiffness in your joints (joints subjective data)

________________ rationale: RA stiffness occurs in the morning and after rest periods

abdominal pain (subjective data)

________________ rationale: abdominal pain may be visceral form an internal organ (dull, general, poorly localized); parietal from inflammation of overlying peritoneum (sharp, precisely localized, aggrivated by movement); or referred from a disorder in another site; acute pain requiring urgent diagnosis occurs with appendicits, cholecystitis, bowel obstruction, or a perforated organ

had a mammogram, breast biopsy, breast surgery? (gynecologic history)

________________ rationale: as US women delay childbearing, incidence ob breast cancer may increase, posing difficult treatment options

do you smoke? how many? for how many years? ever tried to quit? drink alcohol? how many times per week? use any street drugs?

________________ rationale: explain dnager of these substances in pregnancy; smoking increases the risk for ectopic pregnancy, spontaneous abortion, low birth weight, prematurity, preterm premature rupture of membranes, HTN in pregnancy, placental abruption, and sudden infnat death syndrome; alcohol increases the risk to the fetus for fetal alcohol syndrome; cocain use is associated with congenital anomalies, a fourfold increase d risk for abruption placenae, and fetal addiction; narcotic-addicted infants may have developmental delays or behavioral disturbances; refer to a counseling/support program and periodic toxicology screening; refer to a smoking-cessation program

functional assessment (ADLs) (subjective data)

________________ rationale: functional assessment screens the safety of independent living, the need for home health services, and quality of life

depression or other mental disorders

________________ rationale: increases risk for pregnancy and postpartum _____________; some medications prescribed for _______________ negatively affect the fetus; help her to prepare a support network; counseling helps navigate the developmental challenges of becoming a mother

gluten-free diets

_________________ may result in deficiencites in fiber, vitamin D, vitamin B 12, folate, iron, zinc, magnesium, and calcium; persons following a _______________ also may have increased intake of saturated and hydrogenated fatty acids; regardless of the reason for adhering to a _________________, it is essential to refer patietns who adopt this diet to registered dietitans to prevent micronutrient deficiency and optimize quality of nutritional choices

progressive lordosis (an inward curvature of the lumbar spine)

_________________ occurs to compensate for the shifting center of balance caused by the anteriorly enlarging uterus, predisposing the woman to bachaches; slumping of the shoulders and anterior flexion of hte neck from the increasing weight of the breasts may cause aching and numbness of the arms and hands are s a result of compression of the median and ulnar nerves in the arm, commonly reffered to as carpal tunnel syndrome

engagement

_________________ occurs when the widest diameter of the presenting part has descended into the pelvic inlet-specifically to the imagined plane at the level of the ischial spines

red blood in stools

_________________ occurs with GI bleeding or localized bleeding around the anus (e.g. hemorrhoids)

poor turgor

_________________ occurs with dehydration, which often accompanies GI disease

positive signs

_________________ of pregnancy are those taht are direct evidence of the fetus, such as the auscultation of fetal heart tones (FHT) or positive cardiac activity on ultrasound

depression

_________________ persons often complain of memory impairment

assessment of cognition

_________________ provide continuing comparisons with the individual's baseline to detect any acute changes such as with delirium; the assessments are not diagnostic, but rather are for screening purposes and identify the need for a more comprehensive workup;

food inteolrence

_________________ rationale: a ____________, such as lactose intolerance limiting calcium intake, might affect the woman's and fetus's nutrition

special diet

_________________ rationale: a _______________ may have nutritional risk; help achieve adequate nutrition within the confines of her diet; refer to dietitian

your weight before pregnancy (calculate BMI) (review of systems)

_________________ rationale: baseline needed to evaluate changes

wear seatbelt when driving

_________________ rationale: for maternal and fetal safety, instruct the woman to place hte lap belt below the uterus and to use the shoulder strap

are you in a relationship with someone who phyically/ emotiaonlly abuses/ threatens you? (review of systems)

_________________ rationale: most women will not freely offer this information; you must ask these questions at the appropriate time and in a nonthreatnening manner

have allergies to medcatiosn or foods? if so which type of reaction? latex? (medical history)

_________________ rationale: prevents prescribing error

take prescribed, OTC or herbal medications (medical history)

_________________ rationale: screen all medications to esetablish safety during pregnancy

cesearean birth

_________________ rationale: the vertical, or classical, incision has increased risk for rupture and mandate that all future deliveries be by ________________; the low transverse or horizontal incision carriers a low risk, and subsequent deliveries may be vaginal; note that the direction of the skin scar does not necessarily tell how the uterus was incised

instrumental activities of daily living (IADL)

_________________ refer to functional abilities necessary for independent community living; typically ____________ tasks include shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, and using transportation; tasks such as yard work or home maintenance and leisure activities such as reading and other hobbies are included in some but not all IADL instruments; IADL instruments measure tasks historically done by women (e.g. doing laundry, cooking, housework), and many do not address activities done primarily by men such as home repairs and yard work

age related GI system changes

_________________-- occur but do not significantly affect function as long as no disease is present; salivation decreases, causing a dry mouth and a decreased sense of taste esophageal emptying is delayed; if an aging person is fed in the supine position, it increases risk for aspiration gastric acid secretion decreases with aging; this may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron deficiency anemia, and malabsorption of calcium

renal artery stenosis

_________________: murmur is midline or toward flank, soft, low-to-medium pitch ras

fractured clavicle

_________________: note irregularity at the fracture site, crepitus, and angulation; the site has rapid callus formation with a palpable lump within a few weeks; observe limited arm ROM and unilateral response to Moro reflex

hyperactive sounds

__________________ are loud, high-pitched, rushing, tinkling sounds that signal increased motility

exercise

__________________ can improve cardiovascular function, postural stability, range of motion, flexibility, and muscle mass in older adults; because of these positive effects, fall risk and fractures may be decreased; in addition, participation in physical ______________- has shown to reduce depressive symptoms and improve feelings of psychosocai lwell-being

primary prevention hepatitis

__________________ involves risk factor modification, which includes the provision of resources to make the necessary lifestyle modifications to reduce risk of exposure; for example, be prepared to provide referrals to drug treatment programs, information about condom use, and recommendations for vaccines; although there is no vaccination for HCV, there is a safe, effective vaccine against HBV; all infants should receive the hepatitis B vaccine, as well as people in high risk groups, and all health care workers

pregnancy

__________________ is divided into 3 trimesters, 1. the first 12 weeks, 2. form 13 to 27 weeks, and 3 from 28 weeks to delivery

SBAR

____________________ was first used by hte US military to standardize communication and prevent misunderstandings; in the hospital, communications errors contribute to sentinenl events and are responsible, in part, for 30% o malpractice claims; standardized hand-off tools such as SBAR improve verbal communication and reduce medical errors; SBAR is a standardized framework to transmit important in-the-moment information; using SBAR will keep your message concise and focused on the immediate problem yet give your colleague enough information to grasp the current situation and make a decision

leopold's second maneuver

____________________, move your hands in to hte side sof hte uterus; not wiether small parts or a long, firm surface is palpable on hte woman's left or right side; the long, firm surface is the back; note whether the back is anterior, lateral, or out of reach (psoterior); the small parts, or limbs, indicate a posterior position when they are palpable all over the abdomen

inspiratory arrest (murphy sign)

____________________: normally palpating the liver causes no pain; in a person with inflammation of the gallbladder (cholecystitis), pain occurs; hold your fingers under hte liver border; ask hte person to take a deep breath; a normal response is to complete the deep breath without pain (note: this sign is less accurate in patients older than 60 years; evidence shows that 25% of them do not have any abdominal tenderness)

three prenatal diagnositc tests

_____________________ options are chorionic villi sampling (CVS), performed between weeks 11 and 13; amniocentesis, performed between weeks 15 and 20; and percutaneous umbilical blood sampling, performed between weeks 18 and 22; all are associated with a small risk of complications and miscarriage

surgery of the cervix (colposcopy, biopsty, loop electrosurgical excision procedure)? uterus? fallopian tubes? (gynecologic history)

_____________________ reationale: cervical surgery may increase the risk for cervical insufficiency, preterm cervical dilation, and preterm delivery; uterine surgery increases the risk for uterine rupture during pregnancy and labor

leopold's third maneuver (Pawliki's maneuver)

_____________________, asks the woman to bend her knees up slightly for comfort; grasp the lwoer abdomen just above the symphysis pubis between the thumb and fingers of one hand to determine which part of the fetus is there; if the presenting part is beginnign to engage, it wil lfeel fixed; with this maneuver alone, it may be difficult to differentiate the shoulder from the vertex

advanced activities of daily living (AADL)

______________________ are activities that an older adult performs as a member of a family, society, and community, including occupational and recreational activities; various _____________ instruments commonly include self,care, mobility, work (either paid or volunteer), recreational activities/ hobbies, and socialization; occupational therapists often perform assessment of ____________; it is important to have the older adult set priorities for ___________ so that interventions can be individualized

functional status

______________________ is a person's ability to perform self-care, the ability to negotiate the social and physical environment, and functions needed to support independent living; for example, arthirits may affect individual's ability to dress themselves; a condition such as Alzhimer disease may affect problem solving, safety, and motivation, which in turn affects function; lack of social support or a safe physical setting is an environmental issue that affects functional status and possibly the ability to live independently; functional status is not static; older adults may move continuously through varying stages of independence and disability

spiritual assessment

______________________ is highly individual and should be addressed with each person; open-ended questions provide a foundation for future dialogue; a sample question posed during the inital assessment might be "Do you consider yourself to be a spiritual person?" If the person says yes, a follow up question could be "How does that spirituality relate to your health ot health care decisions?" Involving chaplains or clergy members when possible and appropriate can provide the older adult with support and serve as a resource to the clinican

prenatal screening

_________________________ in all women typically includes a fetal anatomy US during the second trimester and maternal blood tests; all screening and diagnostic tests should be an informed choice after pretest counseling; a positive result on any of the screening tests should be followe dby appropriate counseling so that the mother can make an informed decision about next steps, including the need for further diagnostic testing

swelling

_______________may be excess joint fluid (effusion), thicking of the synovial lining, inflammation of surrounding soft tissue (bursae, tendons), or bony enlargement

falls

___________in older adults have multiple contributing factors such as gait and balance problems, poor vision, syncope, diabetic neuropathy, home hazards (e.g. throw rugs, uneven steps), and dementia; most _________are caused by a combination of factors; health care providers can reduce the risk of ____________by assessing risk factors and taking corrective action as appropriate

sleep

________architecture changes with aging (e.g. more difficulty falling and staying asleep); however, significantly altered ___________ patterns are not a normal part of aging; most adults of all ages need about 8 hours of ____________ per night to feel alert and rested; the primary causes of altered ___________ in older adults are physiologic (e.g. cardiovascular disease, pulmonary disease) and psychiatric illnesses (e.g. depression), as well as side effects of the medications to treat the disorders (beta-blockers, corticosteroids, diuretics); detrimental consequences of poor ______________in older adults include poor health outcomes, falls, and impaired cognition

osteoporosis screening

a BMD measurement by DEXA is the best predictor of future hip fracture risk; the test is noninvasive, taakes very little time, and has a low level of radiation exposure; another assessment tool is hte FRAX, a computerized fracture risk algorithm developed by the WHO; the FRAX algorithm helps in the decision for treatment; if hte absolute risk of hip fracture in the next 10 years is 3% or more, or the risk of major osteoporotic fracutre is 20% or more, treatment can decrease the rate of possible fractures

systolic bruit

a _____________ is a pulsatile blowing sound and occurs with stenosis, partial occlusion, or aneurysm of an artery

complete histroy/ physical exam

a _____________ is performed at a patient's first entry into an outpatient setting or initial admission ot the hospital; perform all the steps listed here for a complete examination; with experience you will learn to stroke a balance between which steps you must retain to be thorough and which corners you may safely cut when time is pressing

bursa

a ________________ is an enclosed sac filled with viscous synovial fluid, much like a joint; _________________ are located in areas of potential friction (e.g. subcromial bursa of teh shoulder, prepatellar bursa of the knee) and help muscles and tendons glide smoothly over the bone

multigravidia

a _________________ is a woman who has previously beeen pregnant

arterial vascular sounds

a bruti indicates turbulent blood flow, as found in constricted, abnormally dilated, or tortuous vessels; listen with bell; occurs with: -aortic aneurysm: murmur is harsh, systolic, or continuous and accentuated with systole. note in person with hypertension -renal artery stenosis: murmur is midline or toward flank, soft, low-to-medium pitch -parietal occlusion of femoral arteries avs

incisional hernia

a bulge near an old operative scar that may not show when the person is supine but is apparent when the person increases intra-abdominal pressure by a sit-up by standing, or by the Valsalva maneuver ih

demeanor

a comfortable person is relaxed quietly on the examining table and has a benign facila expression and slow even respirations

musculoskeletal exam

a complete ___________________ is appropriate for people with articualr disease, a history of musculskeletal symptoms, or any problems with ADLS

measuring physical performance

a disadvantage of many of the ADL and IADL instruments is the self-report or proxy report of functional activities; incorporating an objective standardized measure of performance prevents overestimation or understimation of abilities; many physical performance measures also incorporate balance, gait, motor coordination, and endurance; although there are clear advantages to directly observing the older adult perform the activities, there are some disadvantages; the instruments can be very time consuming, require training and special equipment, and carry the risk that the indiviual might fall or sustain an injury during the testing

losing independent living or having a caregiver move into the home

a functional assessment can be intimidating for older adults; frustration or embarrassment may arise if some physical maneuvers cannot be preformed or questions cannot be answered during cognitive testing; older adults may also be fearful about the consequences of functional testing such as ___________________; try to provide reassurance that not everyone can complete all of the tasks or answer all of the questions and that, to the extent possible, confidentiality will be honored

care planning, goal setting, and discharge planning

a functional assessment is the basis for ________________; it is needed for eligibility to obtain durable medical equipment, home modifications, and inpatient or outpatient rehabilitation services; for the older adult and family, a functional assessment can identify areas for current and future planning such as the most appropriate living situation

function

a functional assessment typically includes self-care (Activities of daily living), self-maintenance (instrumental activities of daily living), and physical mobility; functional status is influenced by the health of the individual; it can be monitored to identify response to treatment, and it can be prognostic in identifying long-term needs; functional assessments should be compared in a systematic way;

vertebrae

a lateral view shows that the _______________ column has four curves (a double S shape); the cervical and lumbar curves are concave (inward/ anterior) and hte thoracic and sacrococcygeal curves are convex; the balanced or compensatory nature of these curves, together with the resilient intervertebral discs allows the spine to absorb a great deal of shock

diastasis recti

a middle, longitudinal rdige that is a separation of the abdominal rectus muscles; ridge is revealed when intra-abdominal pressure is increased by raising head while supine; occurs congenitally and as a result of pregnancy or marked obesity in which prolonged distension or a decrease in muscle tone has occurred; usually it is not clinically significant dr

ingrown toenail

a misnomer; the nail does not grow in, but soft tissue grows over the nail and obliterates the groove; it occurs almost always on the great toe on the medial or lateral side; it is caused by triming the nail too short or toe crowding in tight shoes; the area becomes infected when the nail grows and its corner penetrates the soft skin

noninvasive screening tests

a variety of ___________________________ are available; the noninvasive options are considered screening tests because none can definitively diagnose anomalies in the fetus; US nuchal translucency measures the clear space in the tissues of the back of the baby's neck; it is use din combination with maternal serum levels of pregnancy-associated plasma protein A and hCG; free-cell DNA testing can also be done; because a small amount of fetal DNA is found circulating in the maternal bloodstream, the test involves drawing the woman's blood and testing for a variety of fetal anomalies, including trisomy 21, trisomy 18, trisomy 13, and a variety of sex chromosome abnormalities

multipara

a woman is a __________________________ after delivering 2+ babies

primigravidia

a woman pregnant for the first time is called a __________________

primipara

a woman's first delivery is called the ________________________

calcium for osteoporosis

about 99% of calcium in the body is in bones and teeth, and calcium is lost every day through skin, nails, hair, sweat, urine, and feces; the body does not produce new calcium; we must get it through food, or the body takes it from our bones; sources include dairy products (milk, cheese, yogurt), juices, brekfast foods, soy milk; check the nutrition facts panel on food packaging for the percentage of daily value provided in 1 serving; your body needs vitamin D to absorb the calcium; women and men under 50 need 400-800 IU daily; those over 50 need 800 to 1000 IU daily

periontitis

absolute stillness, resisting any movement, occurs with the pain of ____________________

ectopic pregnancy or ovarian mass

adnexal enlargement and pain with palpation occur with _______________________

single commands never assume

adults with cognitive impairment may need questions or directions broken down into _______________, with ongoing verbal or physical cueing; using yes or no questions may prevent frustration; be relaxed and patient because a person with dementia may mirror your emotions; _______________ that he or she cannot respond to questions even when there is known cognitive impairment;

complete histroy/ physical exam

after genital exam; tell hte person that you are finished with the examination and that you will leave the room as they get dressed; return to discuss the examinatio nand further plans and to answer any questions; thank the person for their time for the hospitalized person, return the bed and any room equipment to their original position; make sure that hte call light and telephone are within easy reach

first trimester of pregnancy

after the blastocyst (developing fertilized ovum) impalnts in the uterus, the serum hCG becomes positive when it is first detectable in maternal serum at approximately 8-11 days after conception the ofllowing menstrual period is missed, and then hCG can be detected in the urine; breast tingling and tenderness begin as the rising estrogen levels promote mammary frowth and development of the ductal system; progesterone stimulates both the alveolar system and mammary growth; more than half of all pregnant women have nausea and vomiting; the cause is unclrear but may involve the hormonal changes of pragnancy, low blood sugar, gastric overloading, slowed peristalsis, adn an enlarging uterus; fatigue is common and may be related to the inital fall in metabolic rate that occurs in early pregnancy

blood pressure

after the examination take hte BP when the woman is most relaxed, in the semi-Fowler or upright position; recheck an elevated pressure

colostrum

after weeks 12 to 16, the nausea, vomiting, fatigue, and urinary frequency of hte first trimester improve; the woman recognizes fetal movement (quickening) at approximately 18-20 weeks (the multigravida earlier); breast enlargement continues, and ____________, the precursor of milk, may be expelled from the nipples; ____________ is yellow in color and contains more minerals and protein but less sugar and fat than mature milk; it also contains antibodies, which are protective for the newborn during the first few days of life until mature milk production begins

aging adult abdomen

aging alters the apperance of teh abdomina lwall; after middle age, some fat accumulates in the suprapubic area in females as a results of descreased estrogen levels; males also show some fat deposits in the abdominal area, which accentuates with a more sedentary lifestlye; with further aging adipose tissue is redistributed away from the face and extremities to the abdoemn and hips; the abdominal musculature relaxes

85+ years

aging or older adult is often defined as 65 years or older; however, it is importnat to remember that the older adults are heterogeneous, and differences exist among biological, social, physical, and emotional rates of aging; older age-groups are often categorized as young-old (65-74 years), middle-old (75 to 84 years), and old-old (_______________); although the nubmer of chronic diseases does increase with aging, remember that a substantial number of older adults enjoy aging and report good-to-excellent health

age related GI system changes

aging peopel frequently report consitpation; chronic constipation occurs more frquently in the aging than in the general population and aging women are affected 2-3 times more than their male counterparts; a higher incidence of constipation in the aging resutls in greater use of laxatives, with up to 74% of aging patients i nnursing homes using laxatives every day; because many adults are confused as to what defines constipation, the Rome III standardizes symptom criteria for functional constipation; these symptotms include reduced stool frequency (less than 3 bowel movements per week) and other common and troublign associated symptoms (i.e. straining, lumpy or hard stool, feeling of incomplete evacuation, feeling of anorectal blockage, use of manual naneuvers)

dementia, delerium, and depression

altered cognition in older adults is commonly attributed to three disorders- __________________- although other disorders such as normal pressure hydrocephalus may contribute; depressed persons often complain of memory impairment; delerium presents as an acute change in cognition, affecting the domain of attention; delerium is usually attributable to an acute illness such as an infection or a medication side effect, whereas people with dementia have alterations in word finding and naming objects in addition to memory problems; dementia, delerium, and depression may occur simultaneously with an acute illness and can complicate assessments; for example, people with dementia are at higher risk for delerium and in the early stages of demenitia, may also be depressed

electronic health recording

although no system is perfect, a well-designed EHR system can increase pateint safety when successfully integrated into the workflow of a clinic or hospital; unfortunately EHRs are not always developed with the end user in mind, which can lead to issues with patient safety; as EHR use becomes the standard of care, more research is needed to determine the specific factors that contribute to patient safety and increased quality of care

depression and function

although older adults with physical impairments are at greater risk for depression, depression is not an inevitable consequence of functional impairment; emotional experiences of sadness, grief, response to loss, and temporary blue moods are considered normal, but persistent depression that interferes significantly with ability to function is not; fortunately, mood disorders, including depression, are highly treatable

infant and children musculoskeletal

although the skeleton continues to linear growth, muscles and fat are signifcant for weight increase; individual muscle fibers grow throughout childhood, but growth is marked during the adolescent growth spurt; then muscles respond to increased secretion of growth hormone to adrenal androgens and in boys to further stimulation by testosterone; muscles vary in size and strength in different people; this is because of genetic programming, nutrition, and exercise; all through life muscles increase with use and atrophy with disuse

uterus changes of pregnancy

amenorrhea (missed periods); enlarging uterus rises in the abdomen beginning at 12th week

enlarged nodular liver

an enlarged and nodular liver occurs with late portal cirrhosis, metastic cancer, or tertiary syphilis; often with cirrhosis the liver is smaller, but the edge is firmer than normal, and the edge is easily palpable en

enlarged liver

an enlarged, smooth, nontender liver occurs wit hfatty infiltration, portal obstruction or cirrhosis, high obstruction of inferior vena cava, and lymphocytic leukemia the liver feels enlarged and smooth mut is tender to palpation with early heart failure, acute hepatitis, or hepatic abcesses el

L4

an imaginary line connecting the highest point on each iliac crest crosses _____________

sacrum

an imaginary line joining the two symmetric dimples that overlie the posterior superior iliac spines crosses the ________________

assessment of the caregiver characteristics and stress

an older person's need for institutionalization often is better predicted from ________________ than from the severity of the patient's illness; the health and well-being of the patient and caregiver are closely linked; for these reasons part of assessing an older adult involves paying attention to the well-being of the caregiver; a health care provider may help identify programs such as support groups, respite programs, adult daycare, or hired home health aides

recent ankle trauma

an x-ray image is needed only if there is pain near the malleoli/midfoot and inability to bear weight (4 steps) or bone tenderness

positioning

another strategy is to use ________________ to decrease pain; ask which position is most comfortable; providing comfort can help maximize the information gathered; it is paramount to remember that older adults with cognitive impairment do not experience less pain; older adults with cognitive impairment suffer from conditions typically associated with pain (e.g. arthiritis, osteoporosis, shingles) just as frequently as cognitively intact persons

fetal movement counting

antepartum fetal testing helps improve hte prenatal outcome by decreasing stilblrith and long-term neurologic impairments of the fetus; this testing consists of monitoring fetal growth, amniotic fluid volume, biophysical profiling, and other potential fetal/maternal markers usign ultrasonography; fetal testing (nonstress test [NST] or contraction stress test [CST]) using electronic fetal monitors to graph and audibly hear the fetal heart rate and determine uterine activity is indicated for some conditions; the mother begins ________________ at 28 weeks, which gives a good incation of fetal well-being

lordosis

anterior flexion of hte neck and slumping of the shoulder girdle are other postural changes that compensate for the lordosis; these upper-back changes may put pressure on the ulnar nad median nerves during the third trimester; nerve pressure creates aching, numbness, and weakness in the upper extremities of some women

abdominal pain (subjective data)

any ___________________? please point to it is the pain in one spot, or does it move around? how did it start? how long have you had it? constnat, or does it come and go? occur before or after meals? does it peak? when? how would you describe the cahracter: cramping, burning in pit of stomach, dull, stabbing, aching is pain relived by foro or worse after eating is pain associated with menstrual period or irregularities, stress, dietary indiscretion, fatigue, nausea and vomiting, gas, fever, rectal bleeding, frequent urination, vaginal or penile discharge what makes pain worse: food, position, stress, medication, activity? what have you tried to relieve pain: rest, heating pad, change in position, medication?

bones (subjective data)

any bone pain? pain affected by movement? any deformity of bone or joint? caused by injury/ trauma? any accidents or trauma ever affect bones or joints? when did this occur? any back pain? in which part of back? any numbness and tingling? limping? feeling worried or anxious?

appetite (subjective data)

any change in appetite/ loss of appetite any change in weight/ how much gain/ lost/ over what time period/ weight loss caused by diet

dysphagia (subjective data)

any difficulty swallowing/ when did you first notice it/ any associated pain/ any coughing or chocking when swallowing/ any worse with liquids versus soilds

past abdominal history (subjective data)

any history of GI problems: ulcer, gallbladder disease, hepatitis/jaundice, appendicits, colitis, hernia? ever had abdominal surgery operations? please describe? any problems after surgery? any abdominal x-ray studies? how were results?

nausea/vomiting (subjective data)

any nausea or vomiting? how often? how much comes up? what is the color? is there an odor? is it bloody? is the nausea or vomiting associated with colicky pain, diarrhea, fever, chills? what foods did you eat in the past 24 horus? where? at home, school, restaurant? is there anyone else in the family with same symptoms in past 24 hours? any recent travel? where to? drunk the local water or eat fruit? swimming in public beaches/ pools?

patient-centered care musculoskeltal

any occupational hazards that could affect muscles and joints; does work involve heavy lifting or repetivie motion or chronic stress to joints tell me about your exercise program; describe type of exercise, frequency, and warm-up any pain during exercise any recent weight gain? taking medications for musculosketal systeem supplemental medications, calcium or vitamin D? if person has chronic disability or crippling illness: how has illness affected interations with family/ friends/ way you view yourself: how about ciagarettes? how much do you smoke per day? how many drinks per day? per week?

gravidia

any pregnant woman might be called a _____________________

muscles subjective data

any problems in muscles such as pain or cramping, which? if in calf muscles, is it pain with walking? go away with rest? are your muscle aches associated with fever, chills, the flu? any weakness in muscles? location: where is the weakness? how long have you noticed it? do the muscles look smaller there?

joints (subjective data)

any problems with joints? any pain? location: which joints? on one or both sides? quality: what does the pain feel like: aching, stiff, sharp or dull, shooting? severity: how strong is it? onset: When did it start? timing: what time of day does the pain occur? How long does it last? how often does it occur is the pain aggrivated by movement, rest, position, weather? Is it relieved by rest, medications, application of heat or ice is the pain associated with chills, fever, recent sore thorat, trauma, repetitive exercise any stiffness in joints any swelling, heat, redness in the joints any tick bite any limitation of movemnet in any joint, which? which activities give you problems

methadone or bupreophine

appropriate prenatal care is imperative in mothers who are addicted to substances or who report drug use during pregnancy; the use of ____________________ in the pregnant woman addicted to heroin or opioid pain medications is prferred to medically supervised withdrawal; the use of methadone or buprenophine provides a steady state of the drug to the fetus, reduces risk-taking behavior by the woman (E.g. reusing needles), improves compliance with prenatal care, and improves neonatal outcomes; untreated addiction during pregnancy places the woman and fetus at risk

engagement (Also called lightening or dropping)

approximately 2 weeks before going into labor, the primigravidia experiences ________________, when the fetal head moves down into the pelvis; symptoms include a lower-apperang and smaller measuring fundus, urinary frequency, increased vaginal secretions from increased pelvic congestion, and increased lung capacity; in the multigravidia, the fetus may move down at any time in late pregnancy or often not until labor; in preparation for labor the cervix begins to thin (efface) and open (dilate); at hick mucus plug, formed in the cervix as a mechanical barrier during pregnancy, is expelled at variable times before or during labor

food intolerance (subjective data)

are there any foods you cannot eat? what happens if you eat them: allergic reaction, heartburn, belching, bloating, indigestion do you use antacids? how often?

caregiver

as a health care provider, it is imperative that you include ______________- in your assessment; caregivers providing care for older adults may experience increased stress, anxiety, and burnout due to overwhelming demands; the level of care that the older adult requires may exceed ________________ ability; ________________ burden is the perceived strain by the person who cares for an elderly, chronically ill, or disabled person

ankylosing spondylitis (AS)

as is chronic inflamed vertebrae (spondylitis) that in extreme form leads to bony fusion of vertebral joints (ankyloses); it affects the spine, pelvis, and thoracic cage, and is characterized by inflammatory back pain that is dull and deep in lower back or buttocks; it also has morning back stiffness that lasts >30 minutes and decreases with activity, nighttime awakening wiht pain, age at onset <45 years

voluntary guarding

as you circle the abdomen, disciminate between voluntary muscle guarding and involuntary rigidity; _____________ occurs when the person is cold, tense, or ticklish; it is bilateral, and you will feel the muscles relax slightly during exhalation; use hte relaxation measures to try to eliminate this type of guarding, or it will interfere with deep palpation; if hte rigidity persists, it is probably involuntary

examination order

as you identify an __________ that works for you, make sure to be consistent and always perform the assessment in the same order; this will minize the risk of forgetting an assessment

vascular sounds

as you listen to the abdomen, note the presence of any vascualr sounds or bruits; using firmer pressure, check over the aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension; usually no such sound is present; however about 4-20% of health people (usually younger than 40 years) may have a normal bruit originating from the celiac artery; it is systolic, medium to low in pitch, and heard between the xiphoid process and the umbilicus

range of motion

ask for active (voluntary) _____________ while modeling the movements yourself as appropriate; thus you can use you own movements as a control; you may stabilize the body area proximal to that being moved; familiarize youself with the type of each joint and its normal ROM so you can recognize limitations; if you see a limiation, gently attempt passive motion with hte person's muscles relaxed while you move the body part; anchor the joint with one hand while your oher hadn slowly moves it to its limit; the normal ranges of active nad passive motion should be the same

cervical spine

ask person to: touch chin to chest (flexion of 45 degrees) lift chin toward ceiling (hyperextension of 55 degrees) touch each ear toward the corresponding shoulder; do not lift the shoulder (lateral bending of 40 degrees turn the chin toward each shoulder (rotation of 70 degrees)

after neurologic

ask pesron to stand with gown on; stand close to the person neur

after measurement

ask the person to empty the bladder (Save specimen if needed), do disrobe except for the underwear and put on a gown; leave the room to provide privacy while the person changes; upon your retur, ask the person to site with the legs dangling off the side of hte bed or table; you stand in front of the person mes

after lower extremity exam

ask the person to sit up and dangle the legs off hte bed or table; keep hte gown on and drape over hte lap le

symmetry

ask the person to take a deep breath to further higlight any change; the abdomen should stay smooth and symmetric; or ask the person to peroform a sit up without pushing up with his or her hands

temporomandibular joint

ask the person to: open mouth maximally (vertical motion, you can measure hte space between upper nad lower incisiors; normal is 3-6 cm or t fingers inserted sideways) partially open mouth, protrude lower jaw and move it side to side (lateral motion; normal extent is 1 to 2 cm) stick out lower jaw (protude without deviation)

pregnant woman exam

ask the woman to empty her bladder before hte exam, reserving a clean-catch specimen for dipping for protein and glucose and for urinalysis, if required; before hte exam, weigh her on the office scale and compute the BMI; provide the woman with an escort or chaperone during examinations give hte woman a gown and drape; begin the examination with the woman sitting on the exam table, wearing the gown, her lap covered by a drape

hip

assess ROM by: raise each leg with knee extended (hip flexion of 90 degrees) bend each knee up to the while keeping the other leg strait (hip flexion of 120 degrees; the opposite thigh should remain on the table) flex knee and hip to 90 degrees; stabilize by holding the thigh with one hand and the ankle with the other hand; swing the foot outward; swing the foot inward (internal rotation of 40 degrees; external rotation of 45 degrees) swing leg laterally, then medially, with knee strait; stabilize pelvis by pushing down on the opposite anterior iliac spine (abduction of 40 to 45 degrees; adduction of 20-30 degrees) when standing (later in examination), swing straight leg back behind body; stabilize pelvis to eliminate exaggerated lumbar lordosis; the most efficent way is to ask person to bend over the table and support the trunk on table; or the person cal lie prone on the table (hyperextension of 15 degrees when stabilized)

rebound tenderness test

assess _________________ when the person reports abdominal pain or when you elicit tenderness during palpation; choose a site remote from the painful area; hold your hand 90 degrees or perpendicular to the abdomen; push down slowly and deeply; then lift up quickly; this makes structures that are indented by palpation rebond suddenly; a normal, or negative, response is no pain on release of pressure; perform this test at the end of examination because it can cause severe pain and muscle rigidity

ankle and foot

assess muscle strength by asking the person to maintain dorsiflexio nand plantar flexion against your resistance

more time consuming

assessment of the functional status of an older adult can be ________________ than for younger adults; for hospitalized or institutionalized older adults, consider assessing function during normal activities such as grooming, at mealtimes, or during toileting

female genitalia

assist hte female back to the exam table and help her assume the lithotomy position; drape her appropriatley; you sit on a stool at the foot of the table for the speculum examination and then stand for the bimanual examination

coxa plana (Legg Calve Perthes Syndrome)

avascualr necrosis of the femoral head, occurring primarily in males between 3-12 years of age, with peak age age 6 years; in initial inflammatory state interruption of blood supply to femoral epiphysis occurs, halting growth; revascularization and healing occur later, but significant residual deformity may be present

first trimester of pregnancy

at the end of 9 weeks the embryonic period ends, and the fetal period begins, at which time major structures are present; FHTs can be heared by Doppler US between 9 and 12 weeks; the uterus may be palpated just above the symphysis pubis by about 12 weeks

routine lab/ radiologic imaging studies

at the first prenatal visit order a routine prenatal panel: a complete blood cell count, serology, rubella antibodies, HIV and hepatitis B screening, blood type nad Rhesus factor, adn antibody screening; some providers screen for herpes simplex virus I and II, thyroid function, and vitamin D level; sickle-cell cystic fibrosis, or thalassemia screening may be indicated; for some populations, a PPD/tine test may be indicated to rule out active tuberculosis or exposure to the disease; obtain a pap test with HPV screen at the inital visit along with cervical STI cultures

percussion

at times you may suspect that a person has ascities (free fluid in the peritoneal cavity) because of a distended abdomen, bulging flanks, and an umbilicus that is protruding and displaced downward; you can differentiate ascites from gaseous distension by performign fluid wave and shiftting dullness tests

infant abdominal exam

auscultation: auscultation yields only bowel sounds, the metallic tinkling of peristalsis; no vascular sounds should be heard

infant musculoskeletal system

back: lift the infant and examin the back; note the normal single C-curve of the newborn's spine; by 2 months the infant can lift the head while prone on a flat surface; this builds the concave cervical spinal curve and indicates normal forearm strength; inspect the length of hte spine for any tuft of hair, dimple in midline, cyst, or mass; normally none are present

infant musculoskeletal system

back: observe ROM through spontaneous movement of extremities; test muscle strength by lifting the infant with your hands under the axillae; a baby with normal muscle strength wedges securely between your hands

preschool and school age children musculoskeletal system

back: while the child is standing, note the posture; form behind, you should note a plumb line form the back of the head, along the spine, to the middle of the sacrum; shoulders are level within 1 cm, and scapulae are symmetric; form the side lordosis is common throughout childhood, appearing more pronounced in children with a protuberant abdomen

electronic health recording

basic EHR adoption includes the use of the EHR in at least one clinical unit, whereas comprehensive adoption requires each function (e.g., clinical notes, medication records, consultation requests, nursing orders, and laboratory results) to be adopted by all clinical units; EHR adoption is more prevalent among larger community and academic medical centers; rural hospital use of EHR systems has increased significantly with at least 8 in 10 small, rural, and critical access hospitals adopting basic EHRs

developmental milestones

be familiar with the __________________; keep handy a concise chart of the usual sequence of motor development so you can refer to expected findings for hte age of each child you are examining; use the Denver II test to screen the fine nad gross motor skills for the child's age

older adults

becasue of difficulty in performing activities of daily iving, some older adults rely on caregivers; personal caregiving can be formal (hired, paid caregivers) or informal (family, friends); informal services accounted for approximately 37 billion hours of care and were valued at $470 billion in 2013

sleep

because medications to treat insomnia such as sedatives and hypnotics have many side effects for older adults, a nonpharmacoligc approach to managing ______________is recommended; in the home, the use of relaxing music, exposure to sunlight during the day, consistent bedtime routines, the limiting of food and drink after early evening, whole- body relaxation, and reduced, light, noise, and room temperature may improve _____________

home care

because of advances in health care technology, equipment is smaller and more portable; as a result, people who one were limited to hospitalization can now be treated or managed at home; in addition to cost advantages with _____________ versus hospitalization, *older adults have been shown to recover faster when at home* in familiar settings than when placed in institutions and also can avoid the risk for hospital-acquired infections

aging adult abdominal exam

because of the thinner, softer abdominal wall, the organs may be easier to palpate (in the absence of obesity); the liver is easier to palpate; normally you will feel the liver edge at or just below the costal margin; with distended lungs and a depressed diaphragm, the liver is palpated lower, descending 1-2 cm below the costal margin with inhalation; the kidneys are easier to palpate

placental abruption and preeclampsia

because the incidence of chronic diseases increase with age, women older than 35 years who are pregnant may have medical complications such as diabetes, obesity, and hypertension; the increased incidence of hypertension causes an increase in _________________; hypertension in turn increases intrauterine growth restrion; more women of advanced maternal age have placenta previa, placental abrutpion, uterine rupture, and cesearian delivries; they have more spontaneous abortions, in part because of the increase in genetically abnormal embryos

general survey

before beginning the exam, obtain vital signs and a current weight; weight should be measured at eahc prenatal visit to monitor for appropiate weight gain

HELLP syndrome

before the ________________ becomes clinically manifested, it is affecting the placenta through vasospasm and a series of small infarctions; the capacity of the placenta to deliver oxygen and ntureints may be seriously diminished, and fetal growth may be restrtricted

light palpation

begin with __________________; with the first four fingers close together, depress the skin about 1 cm; make a gentle rotary motion, sliding the fingers and skin teogether; then lift the fingers (do not drag them) and move clockwise to the next location around the abdomen; the objective here is not to search for organs to to form an overall impression of hte skin surface and superficial musculature; save the examination of any identified tender areas until last; this method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination

wrist and hand

bend hand up at wrist (hyperextension of 70 degrees) bend hand down at wrist (palmar flexion of 90 degrees) bend fingers up and down at metacarpophalngeal joints (flexion of 90 degrees; hyperextension of 30 degrees) with palms flat on table, turn them outward and in (unlar deviation of 50-60 degrees and radial deviation of 20 degrees) spread fingers apart; make a fist (abduction of 20 degrees; fist tight; the responses should be equal bilaterally) touch thumb to each finger and to base of little finger (the person is able to perform, and the responses are equal bilaterally)

flexion

bending a limb at a joint

45% greater than prepregnancy level

blood volume, shich increased rapidly during the 2nd trimester, peaks in the middle of the third trimester at approximately ______________________ and plateaus thereafter; this volume is greater in multiple gestations; erythrocyte mass increases by 20-30% (caused by an increase in erythropoiesis and mediated by progesterone, estrogen, and placental chorionic somatomammotropin); however, plasma volume increases slightly more, causing a slight hemodilution and a small drop in hematocrit; BP slowly rises again to approximately the prepregnancy level

cullen's sign

bluish periumbilcal color occurs (through rarely) with intraperitoneal bleding (_________________)

what is your exercise pattern (adolescent subjective data)

boys need an average 4000 cal/day to maintain weight; more calories if exercise is pursued; girls need 20% fewer calories and the same nutrients as boys; fast food is high in fat, calories, and salt and has low fiber

infants/ children abdominal assessment (subjective data)

breastfeeding or bottle feeding which table foods have you introduced how often does your toddler/child eat does child have constipation? how long? does child have abdominal pain? for the overweight child: how long has weight been a problem?

infant and children musculoskeletal

by 3 months gestation, the fetus has formed a scale model of teh skeleton that is made up of cartilage; during succeeding months in utero, the cartilage ossifies into true bon and starts to grow; bone growth continues after birth- rapidly during infancy and then steaduly durnig childhood- until adeolscence, when boys and girls undergo a rapid growth spurt

metabolic changes of pregnancy

calcium, iron, and folate are drawn from mother's stores for baby's bone sand blood

tear of rotator cuff

characteristic "hunched" position and limited abduction of arm; occurs from traumatic adduction while arm is held in abduction, or from fall on shoulder, throwing, or heavy lifting. positive drop arm test: if the arm is passively abducted at the shoulder; the person is unable to sustain the position and shrugs or hitches the shoulder forward to compensate with remaining intact muscles; needs ultrasound imaging, possibly MRI

spine

check ROM by: bend sideways (lateral bending of 35 degrees) bend backward (hyperextension of 30 degrees) twist shoulders to one side, then the other (rotation of 30 degrees, bilaterally)

spine

check ROM of the spine by asking hte person to bend forward and touch the toes; look for flexion of 75-90 degrees and smoothness and symmetry of movement; note that the concave lumbar cuve should disappaer with this motion and the back should have a single convex C-shaped curve

infant musculoskeletal system

check for tibial torsion, a twisting of hte tibia; place both feet flat on the table and push to flex up the knees; with the patella and the tibial tubercule in a straight line, place your fingers on the malleoli; in an infnat note that a line connecting the four maleoli is parallel to the table

knee

check knee ROM by: bend each knee (flexion of 130-150 degreees) extend each knee (a straight line of 0 degrees in some people; a hyperextension of 15 degrees in others) check each knee ROM during ambulation if able, squat and try a duck walk (duck walk shows intact ligaments nad no effusion or arthritis)

knee

check muscle strength by asking the person to maintain knee flexion while you oppose by trying to pull the leg forward; musxle extension is demonstrated by the person's success in rising form a seated position in a low chair or by raising form a squat without using hte hands for support

child's gait

check the ______________ while talking away form and returning to you; let him or her wear socks because a cold tile floor distorts the usual gait; form 1-2 years expect a broad-based gait, wit harms out for balance; weight-bearing falls on the inside of the foot; from 3 years the base narrows, and the arms are closer to the sides; inspect the shoes for spots of greatest wear to aid your judgement of the gait; normally the shoes wear more on the outside of the heel and the inside of the toe

exam frequency

check the policy within your facility to identify frequency of specalized assessments; in high-acuity units such as an intensive care unit, the assessment may be completed every 4 hours, whereas on a basic medical-surgical unit the frequency may be every 12 hours

gallbladder

cholecystitis is biliary colic, sudden pain in RUQ taht may radiate to right or left scapula and that builds over time, lasting 2 to 4 hours, after ingestion of fatty foods, alcohol, or caffeine; associated with nausea and vomiting and with positive murphy sign or sudden stop in inspiration with RUQ palpation g

epicondylitis-tennis elbow

chronic disabling pain at lateral epicondyle of humerus; radiates down extensor surface of forearm; pain can be located with one ifnger; resisting extension of the hand increases the pain; inflammation along flexor and extensor tendons of elbow joing with overuse; occurs with excessive pronation and supination of forearm with an extended wrist (e.g. racquet sports or usign a screwdriver)

dupuytren contracture

chronic hyperplasia of the palmar fascia causes flexion contractures of the digits, first in the 4th digit, then the 5th digit, and then the 3rd digit; note the bands that extend form the midpalm to the digits and the buckering of palmar skin; common in men older than 40 and is usually bilateral; it occurs with diabetes, epilepsy, and alcoholic liver disease and as an inherited trait; the contracture is painless but impairs hand function

fibromyalgia syndrome

chronic widespread musculoskseltal pain lasting >3 months, associated with fatigue, insomnia, and psychosocial distress; most (90%) are adult women; the pain is amplified centrally in the brain; because it is not a peripheral pain condition, medications for peripheral pain (NSAIDS) will not help

older adult firsthand being most alert

cognitive impairment poses unique challenges; the older adult may not be able to actively participate in the evaluation and/or provide consistent answers; gathering information from the __________________ is always the best method but is not always feasible; another is to arrange opportunities to assess the person when they identify as __________________; to ensure the collection of reliable information, one strategy is to interview the caregiver and/or family to obtain subjective assessment data

caregiver and/or family

cognitive impairment poses unique challenges; the older adult may not be able to actively participate in the evaluation and/or provide consistent answers; gathering information from the older adult firsthand is always the best method but is not always feasible; to ensure the collection of reliable information, one strategy is to interview the _________________ to obtain subjective assessment data; another is to arrange opportunities to assess the person when they identify as being most alert

assessment of cognition

cognitive impairment rsulting from disease may be ttributed by patients, families, and health care providesr to normal changes with aging and mild-to-moderate decline in short-term memory may be attibutable to aging; an older adult may need a system for reminders; cognition can be improved through cognitive training interventions; cognitive training interventions include brain teasers, video games, word games, and sudoku; domains of cognition included in most mental status assesssments are attention, memory, orientation, language, visuospatial skills, and higher cognitive functions such as the ability to plan and make decisions

knee

continue palpation and explore the tibiofemoral joint; note smooth joint margins and absence of pain; palpate the infrapatellar fat pad and the patella; check for creptius by holding your hand on the patella as the knee is flexed and extended; some crepitus in an otherwise asymptomatic knee may occur

routine lab/ radiologic imaging studies

collect a clean-catch urinalysis at the inital prenatal visit to rule out cystitis; at each prenatal visit check the urine for protein and glucose; a clean-catch speciment is ideal for this dip because a random specimen may include vaginal secretions, which contain rotein, skewing the results; for women with active substance abuse, check a urine toxicology screen

health history

collect the _________________, complete or limited as visit warrants; while obtaining the history and throughout the exam, note the person's general apperance

environmental assessment

common ______________ hazards include inadequate lighting, loose throw rugs, curled carpet edges, obstructed hallways, cords in walkways, lack of grab bars, and low or loose toilet seats; __________________ modification can promote mobility and reduce the likelihood of a fall

constipation

common causes of ______________ include decreased pyhsical activity, inadequate intake of water, a low-fiber diet, side effects of medications (opioids, tricyclic antidepressnats), irritable bowel syndrome, bowel obstruction, hypothyroidism, and inadequate toilet facilities (i.e. difficulty ambulating to the toilet may cause the person to deliberately retain the stool until it becomes hard and difficult to pass)

dupuytren contracture

common in men older than 40 and is usually bilateral; it occurs with diabetes, epilepsy, and alcoholic liver disease and as an inherited trait; the contracture is painless but impairs hand function

GTPAL

commonly used appreviations in pregnancy are: G-gravidia p- para t- term pt- preterm delivieries a- abortion- missed, therapeutic, voluntary l- living children

innaccuracy of dates (small/large for dates)

conception may have occurred later than originally thought; reconsider the woman's menstural history; sexual history; contraceptive use; early pregnancy testing; early sizing of the uterus; US resutls; timing of pregnancy symptoms, including the date of quickening; and the funal height measurements; if, after this review the expected date of delivery (EDD) is correct, further investigation is required

adolescent positioned supine

conduct the cardiac, abdomen, and lower extremity examination for the inguinal area, place a drape over the lower abdomen and ask the adolescent to unzip and lower the jeans under the drape; pant legs can be pulled up to examine the lower legs and feet

talipes Equinovarus (clubfoot)

congenital, rigid, and fixed malposition of foot, including 1. inversion, 2/ forefoot adduction, and 3/ foot pointing downward (equinus); a common health defect, with an incidence of 1: 1000 to 3: 1000 live births; males are affected twice as frequently as females

aging adult musculoskeletal system

contour changes include a decrease of fat in the body periphery and fat deposition over the abdomen and hips; the bony prominences become more marked for most older adults ROM testing proceeds as for the adult;; ROM and muscle strength are much the same as with the younger adult, provided no musculoskeletal illnesses or arthirtic changes are present

preterm labor (small for dates)

contractions causing cervical change at <37 weeks gestation; other than delivery, preterm labor is the leading cause of hospital admission during pregnancy; risk factors for preterm birth include vaginal bleeding in early pregnancy, cigarette smoking, low maternal weight gain, licit drug use, young or advanced maternal age, poverty, strenuous working conditions, psychological factors (depression, anxiety, chronic stress), prior preterm delivery, and intrauterine infection

gingivitis or epulis of pregnancy

cutaneous blood flow is augmented during pregnany, caused by decreased vascular resistance, presumably helping to dissipate heat generated by increased metabolism; gums may hypertrophy and bleed easily; this condition is called ___________________ because of growth of the capillaries of the gums; for the same reason nosebleeds may occur more frequently than usual

osteoporosis

decrease in skeletal bone mass leading to low bone mineral desnsity and impaired bone density; the weakened bone state increases risk for fractures, especially at wrist, hip, and vertebrae; occurs primarily in postmenopausal white women; osteoporosis risk is associated with smaller height and weight, younger age at menopause, lack of physical activity, and lack of estrogen in women

ascultate abdomen

depart from the usual examination sequence and ausculate the abdomen next; this is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds; use the diaphragm endpiece because bowel sounds are relatively high-pitched; hold the stethoscope lightly against the skin; pushing too hard may stimulate more bowel sounds; begin in the RLQ at the ileocecal vale area because bowel sounds normally are always present here

distended bladder

detection of a ________________ through percussion is also omitted due to unreliability; bedise bladder scanning with ultrasound is commonly used to estimate bladder volume

intestinal obstruction

diagnostic tests: laboratory: evidence of dehydration, loss of electrolytes, and possibly sepsis radiology: accumulation of fluid and gas in bowel proximal to (above) _______________ io

osteoarthritis (OA)

different from RA, OA is characterized by hard, nontender, noninflammatory nodules, 2-3 mm or more; these osteophytes (bony overgrowths) of the DIP joints are called *Heberden nodes*; those of the PIP joints are called *Bouchard nodes* and are less common

auscultating fetal heart tones

differentiate the FHTs from the slower rate of the maternal pulse and hte uterine souffle (the soft, swishing sound of the placenta receiving the pulse of maternal arterial blood) by palpating the mother's pulse while you listen; all the abdominal findings are of interest to the woman; share them with her; often she will want to listen to FHTs with her significant other

hypoactive bowel sounds

diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. *Also occurs with pneumonia.*

Tinel Sign

direct percussion of the median nerve at the wrist produces no symptosm in the normal hand

deep vein thrombosis (DVT)

edema and pain in one leg occur with __________________ and warrant doppler studies

background

do not recite the patient's full history since admission; do state the data pertinent ot this moment's problem: admitting diagnosis, when admitted, and appropriate immediate assessment data (E.g. vital signs, pulse ox, change in mental status, allergies, current medications, IV fluids, lab results)

what do you eat at regular meals (adolescent subjective data)

do you eat breakfast, what do you eat for snacks? how many calories do you figure you consume

nutritional history

do you follow a special diet? are you vegetarian? eat fish? what types? teach her to avoid sea fish (Swordfish, mackrel) because of mercury concentration; also teach her to avoid raw eggs, soft cheeses, and unpasturized dairy foods and sliced meats from delicatessens because of risk of Listeria, Salmonella, and toxoplasmosis any food intolerance? for food craving? taking prenatal vitamins, folic acid, iron?

medical history

do you take any presctibed, OTC, or herbal medicines? do you have allergies to medicines or foods? if so, which type of reaction? latex? ever had german measles (rubella)? ever had chickenbox? do you smoke? how many? for how many yeras? ever tried to quit? drink alcohol? how many times per week? use street drugs? have a regular exercise program? which type? ever had your vitamin D level checkedd?

functional assessment (ADLs) (subjective data)

do your joint problemse create any limits on ADLS, which ones? bathing toileting dressing grooming eating mobility communicating

how often does toddler/child eat? (infant/children subjective data)

does he or she eat regular meals? how do you feel about your child's eating problems? please describe all that your child had to eat yestarday starting with breakfast? which foods does child eat for snacks? does toddelr/child eat nonfoods: grass, dirt, paint chips?

mcBurney point tenderness

draw a straight line from the anteior superior spinous process of the ileum to the umbilicus; _______________ is located 1.5 to 2 inches from the ileum along this line

older-adult drivers

driving represents independece, freedom and control, and is often a necessary part of functioning in daily life, such as getting to work or shopping for groceries; it also facilitates remaining connected socially with family and friends; driving cessation has been linked to functional decline and depressio nin older adults; if driving must be limited or cease altogether, it is important to establish a plan of action to enhance independence nad maintain normal activity levels; this might mean accessing public transportation, carpooling, or increased involvement of family and friends for activities taht rquire motor transportation

duodenum

duodenal ulcer typically hsa dull, aching, gnawing pain; does not radiate; may be relieved by food; and may awaken the person from sleep d

gallstone formation

during the second trimester systolic BP may be 2-8 mmHg lower and diastolic BP 5-15 mmHg lower than pre-pregnancy levels; this drop is most pronounced at 20 weeks and may cause symptoms of dizziness and faintness, parciularly after rising quickly; stomach displacmeent from the enlarging uterus and altered esophageal sphincter and gastric heartburn; intestines are also dispalced by teh growing uterus and tone and motility are decreased because of the action of progesterone, often causing constipation; the gallbladder, possibly resulting from the action of progesterone o nits smooth muscle, empties slugglishly and may become distended; the stasis of bile, together with the increased cholesterol saturation of pregnancy, predisposes some women to _________________

environmental assessment

during your ________________-, inquire about the safety of the neighborhood and ask whether older persons have transportation and/or services available in geographic proximity to where they live; access to basic services such as food and clothing stores, pharmacies, financial institutions, health care facilities, and social service agencies is necessary; the community environment needs to provide safety conditions such as street lamps, sidewalks, and police and fire protection; these are especially important for community dwelling older adults who need help with IADLs

skeletal muscle

each _____________ is composed of bundles of muscle fibers or fasciculi; the skeletal muscle is attached to bone by a tendon- a strong fibrous cord; skeletal muscles produce movements

nucleus propulsus

each vertebral disc has a _________________ made of soft, semifluid, mucoid material that has the consistency of tooth paste in the young adult

falls

each year millions of older adult experience a ___________, and approximately 20% of ___________result in a serious injury, such as psychological consequences; the fear of falling again may lead to a reduction in physical activity, which will cause further decline and increase the risk of subsequent _____________;

first trimester of pregnancy

early first-trimester blood pressures reflect pre-pregnancy values; in the 7th gesetational week, BP begins to drop until midpregnacny as a result of falling peeripheral vascular resistance; systemic vascular resistance decreases from the vasodilatory effect of progesterone and prostaglandins and possibly because of the low resistance of the placental bed; the BP gradually returns to the nonpregnant baseline by term

venous congesion in the legs

edema of the lower extremities may occur as a result of the enlarging fetus impeding venous return and from lower colloid osmotic pressure; the edema worsens with dependency, such as prolonged standing; varicosities, which have a familial tendency, may form or enlarge form porgeterone induced vascular relaxation; also causing varicosities is the engorgement caused by teh weight of the full uterus compressing the inferior vena cava and the vessels of hte pelvic area, resulting in ___________________, vulva, and rectum hemorrhoids are varicostieis of the rectum that are worsened by constipation, which occurs from relaxataion of the lareg bowel by progesterone

gynecologic history

ever had surgery of the cervix? pap test: any history of abnormal? any history of genital herpes, gonorrhea, chlamydia, syphilis, pelvic, inflammatory disease? have you been tested for HIV? when? result? what is your sexual prefernece? have you had a mammogram, breast biopsy, breast surgery

knee

enhance palpation with the knee in the supine position with compleete relaxation of hte quadriceps muscle; start high on the anterior thigh, about 10 cm above teh patella; palpate with your left thumb and fingers in a grasping suprapatellar pouch; note the consistency of the tissues; the muscles and soft tissues should feel solid, and the joint should feel smooth with no warmth, tenderness, thickening, or nodularity

Osgood-Schlatter disease

enlargement of the tibial tubercule with tenderness suggests ____________________

high-gloss, shiny, slippery surfaces

ensure adequate space if doing tests of mobility; an aging adult may need room to maneuver an assistive device; when testing mobility, stand close to them to prevent a fall; the environment should be well lighted; avoid _________________; minimize extraneous noise such as those from intercoms, televisions, or high-traffic areas; warm rooms, access to fluids, proximity to a bathroom, and privacy are important

acute gout

episodes are characterized by redness, swelling, heat, and extreme pain such as a continuous throbbing; increased prevalence in obesity, metabolic syndrome, hypertension, hyperlipidemia

pregnant woman exam

equipment: stethoscope, BP cuff centimeter measuring tape doppler and fetal heart rate monitor and gel reflex hammer urine collection containers dipsticks for checking urine for glucose and protein equipment needed for pelvic examination

first trimester of pregnancy

estrogen adn possibly progesterone cause hypertrophy of the uterine muscle cells, and uteirne blood vessels nad lymphatics enlarge; the uterus becomes globular in shape and compresses the bladder, which results in urinary frequency

Get up and go test:

evidence shows that this timed test helps to identify older adults at increased risk of falling; watch the time it takes the person to rise from an armchair, walk 10 feet, turn, walk back, and sit down again; a healthy adult over 60 can manage this test in fewer than 10 seconds

infant musculoskeletal system

examine the _____________ fully undressed and lying on the back; take care to place the newborn on a warming table to maintain body temperature

infant musculoskeletal system

feet and legs: start with the feet and work your way up the extremities; note any positional deformities, a residual of fetal positioning; often the newborn's feet are not held straight but instead in a varus (apart) or valgus (together) position; it is important to distinguish whether this position is flexible (and thus usually self-correctable) or fixed

fetal macrosomia (large for dates)

fetal risks include birth trauma such as fractured clavicle and brachial plexus nerve damage from shoulder dystocia, depressed APGAR scores, extended hospitalizations, and possible fetal mortality

general tympany

first percuss lightly in all four quadrants to determine the prevailing amount of tympany and dullness; move clockwise; tympany should predominante because air in the intestines rises to hte surface when the person is supine

fluid wave ascities test

first test for ________________ by standing on the person's right side; place the ulnar edge of another examiner's hand or hte patient's own hand firmly on the abdomen in hte midline (this stops the transmission across the skin of the upcoming tap); place your left hand on the person's right flank; with your right hand reach across the abdomen and give the left flank a firm strike; if ascities is present, the blow will generate a fluid wave through the abdomen, and you wil lfeel a distinct tap on your left hand; if the abdomen is distended from gas or adispose tissue, you will feel no change

swan neck and boutonniere deformity

flexion contracture resembles curve of a swan's neck as in metacarpophalangeal joint; then hyperextension of the PIP joint, and flexion of the DIP joint; it occurs with chronic RA, often accompanied by ulnar drift of the fingers; in boutonniere deformity the knuckle looks as if being pushed through a buttonhole; it is a common deformity

WHO recommended levels of phyiscal activity

for additional health benefits, older adults should increase their moderate-intensity aerobic physical acitivity to 300 minutes per week or engage in 150 minutes of vigorous inteisty aerobic physical activity per week or an equivalent combination of moderate and vigorous-intensity activity older adults with poor mobility should perform physical activity on 3 or more days per week to enhance balance and prevent falls

secondary prevention hepatitis

for both HBV and HCV infected people, ____________________ includes antiviral treatment regiments to prevent the long term complications that can lead to significant liver disease and death

wrist and hand

for muscle resting, position the person's forearm supinated (palm up) and resteing on a table; stabilize by holding your hand at the person's midforearm; ask the person to flex the wrist against your resistnace at the palm

ascultate abdomen

for safe practice do not use asculatiton of the abdomen for hte correct placement of NG tubes; despite evidence showing that auscultation of an air bolus is not adequate to determine plecmcent in the stomach or lung, you may see some nurses still practicing this method; current evidence mandates confirming inital placement by chest x-ray and supports continuing assessment by measuring the external portion of the tube and testing the pH of stomach aspirats (pH less than 5.5 is acceptable); ongoing visualization of gastric aspirates is also important to ensure taht the tube has not migrated; fasting gastric secretions range form clear to green to brown

bulge sign

for swelling in the suprapatellar pouch, the ______________ confirms the presence of small amounts of fluid as you try to mov eteh fluid from one side of hte joint to the other; firmly stroke on the medial aspect of hte knee 2-3 times to displace any fluid; tap the lateral aspect; watch the medial side in the follow for a distinct bulge from a fluid wave; normally none is present

obturator test

for the _________________, lift the person's right leg, flexing the hip, and 90 degrees at the knee; hold his or her ankle, and rotate the leg internally and externally; there should be no pain; this test is less specific

after musculoskeletal

for the male patient, sit on a stool in front of him; the person stands mus

functional assessment:

for those with advanced aging changes, arthritic changes, or musculoskeletal disability, perform a _____________ for ADLs; this applies the ROM and muscle strength assessments to the accomplishment of specific activities; you need to determine adequate and safe performance of functions essential for independent home life

linea alba

four layers of large, flat muscles form the ventral abdominal wall; these are joined at the midline by a teindinous seam, the _______________

size large for dates

fundal height measures larger than expected for dates

size small for dates

fundal height measures smaller tha nexpected for dates

spleen peritoneal friction rub

friction rub over lower left rib cage in left naterior axillary line form abcess, infection, or tumor

live rperitoneal friction rub

friction rub over lower right rib cage from abcesses or meastic tumor

third trimester of pregnancy

from 37 0/7 weeks to 38 6/7 weeks a pregnancy is considered early term, 39 0/7 weeks to 40 6/7 weeks is considered full term, and 41 0/7 weeks to 41 6/7 weeks is considered late term; elective early-term delivery should be avoid unless medically indicated due to increased risk of neonatal complications such as respiratory distress, hypoglycemia, and neonatal mortality;

spine

from teh side note hte normal convex thoracic curve nad concave lumbar curve; and enhanced thoracic curve, or kyphosis is common in aging people; a pronounced lumbar curve, or lordosis, is common in obese people

common adaptations for ADLs in aging

functional assessment test: 1. walk (with shoes on)- shuffling pattern; swaying; arms out to help balance; broader base of support; person may watch feet 2. climb up stairs- person holds handrail; may haul body up with it; may lead with favored (Stronger) leg 3. walk down stairs- holds handrail, sometimes with both hands; if person is weak, he or she may descend sideways, lwering weaker leg first; if person is unsteady, he or she may watch feet 4. pick up object from floor- person often bends at waist instead of bending knees; holds furniture to support while bending and straightening 5. rise up from sitting in chair- person uses arms to push off chair arms, upper trunk leans forward before body straightens, feet planted wide in broad base of support 6. rise up from lying in bed- may roll to one side, push with arms to lift up torso, grab bedside table to increase leverage

evidence-based interventions for screening and detection

functional decline and a loss of independence *are not inevitable consequences of aging*; although the prevalence of chronic disease increases with age, most older people remain functionally independent; however, ___________________ of health conditions and disease are important given the prevalence of chronic disease in older adults; the Agency for Healthcare Research and Quality in partnership with AARP provides recommendations to promote good health, screening test, and medications for adults over 50 years

stomach

gastric ucler pain is dull, aching, gnawing epigastric pain, usually brought on by food and radiates to back or substernal area; pain of perforated ulcer is burning epigastric pain of sudden onset that refers to one or both shoulders s

small intestine

gastroenteritis has diffuse, generalized abdominal pain with nausea, diarrhea si

acute gout

gout is a painful inflammatory arthiritis characterized by excess uric acid in the blood and deposites of urate crystals in the joint space; acute episode sare triggered by surgery, trauma, diuretics, alcohol intake; episodes are characterized by redness, swelling, heat, and extreme pain such as a continuous throbbing; increased prevalence in obesity, metabolic syndrome, hypertension, hyperlipidemia

hormonal changes of pregnancy

hCG form developing placenta detected in mother's urine; extra fat is lad down in hips and thighs as energy source for breastfeeding

hormone abnormalities, chronic liver disease

hair distribution ABNORM: patterns alter with endocrine or ________________________-

Thomas test

hip flexion flattens the lumbar spine; if this reveals a flexion deformity in the opposite hip, it is a positive __________________

infant musculoskeletal system

hips: adduct the legs until your thumbs touch; then gently lift and abduct, moving the knees appart and down so their lateral aspectst touch the table; this normally feels smooth and has no sound

obesity

inspection: uniformly rounded; umbilicus sunken (it adheres to peritoneum, layers of fat are superifical to it) auscultation: normal bowel sounds percussion: tympany; scattered dullness over adipose tissue palpation: normal, may be hard to feel through thick abdominal wall

Ortolani maneuver

hips: check the hips for developmental dysplasia of the hip (DDH); the most reliable method is the _______________, which should be done at every professional visit until the infant is 1 year old; with the infant supine, flex the knees holding your thumbs on the inner midthighs and your fingers outside on the hips touching the greater trochanters

liver palpation

hooking technique: an alternative method of palpating the liver is to stand up at the person's shoulder and swivel your body to the right so that you face the person's feett; hook your fingers over the costal margin from above; ask the person to take a deep breath; try to feel the liver edge bump your fingertips

aging adult abdomen (subjective data)

how do you acquire groceries and prepare meals do you eat alone or share meals with others please tell me all you had to eat yesterday, starting with breakfast how often do your bowels move

knee joint (if injury reported) (subjective data)

how long did you injure your knee? hit inside of knee? outside? twisting or pivoting? overuse such as jumping or kneeling hear a pop at injury? cna you stand on that leg? can you flex the knee? point to where it hurts most

for overweight child (infant/children subjective data)

how long has weight been a problem? at what age did child first seem overweight? did any chagne in diet pattern occur then? describe the diet pattern now? do any others in the family have a similar problem? how does the child fele about their weight?

if weight less than body requirements (adolescent subjective data)

how much have you lost? by diet? exercise? how? how do you feel? tired, hungry? how do you think your body looks? what is your activity pattern? is the weight associated with any other body change, such as menstrual irregularity? what do your parents say about your eating? what do friends say?

bowel habits (subjective data)

how often do you have a bowel movement? what is the color? consistency? any diarrhea or constipation? How long? any recent change in bowel habits? use laxatives? which ones? how often do you use them?

basic assessment

hte _______________ applies to adults in medical, surgical, and step-down care areas; in the intensive care setting additional assessments are necessary based on patient acuity and additional lifesaving equipment that may be in use; each assessment must be individualized to each adult, and the findings must be integrated into your complete knowledge base regarding the patient; this includes what you read in the chart, what you hear in report, and the results of any laboratory tests and diagnositc imaging that are available

family member or caregiver

if a _________________ needs to provide collateral information, avoid doing this in front of the older adult

straight leg raising or laseguie test

if lifting the unaffected leg reproduces sciatic pain, it strongly suggests a herniated nucleus propulses

administer premedication

if the older adult is feeling pain or discomfort, the depth or knowledge gathered through assessments will suffer; alleviating pain should be the priority; it may be necessary to ____________________ before parts of the assessment, especially if the assessment requires movement;

shoulder

if the person reports any shoudler pain, ask them to point to the spot with the hand of the unaffected side; be aware that shoulder pain may be from local causes or it may be referred pain form a hiatal hernia or a cardiac or pleural condition, which could be potentially serious; pain from a local cause if reproduclbe during the examination by palpation or motion

anorexia nervosa

if weight less than body requirements (adolescent subjective data) rationale: screen any extremely thin teenager for ________________, a serious psychosocial disorder that includes loss of appetite, voluntary starvation, and grave weight loss; this person may augment weight loss by purging (Self-induced vomiting) and use of laxatives denial of these feelings is common, although thin, teen insists that she looks fat, disgusting; distorted body image the adolescent with anorexia may have healthy activity and exercise, but is often hyperactive amenorrhea is common with anorexia nervosa this is a family problem involving control issues; anyone at risk fwarrants immediate referral to a physicia nand mental health professional

mass

if you identify a ______________, first distinguish it from a normally palpable stcuture or enlarged organ; then note the following: 1. location 2. size 3. shape 4. consistency (soft, firm, hard) 5. surface (smooth, nodular) 6. mobility (including movement with respirations) 7. pulsatility 8. tenderness

spine

if you suspect a spinal curvature during inspection, this may be seen more clearly when the person touches the toes; while hte person is bending over, mark a dot on each spinous process; when the person resumes standing, the dots should form a straight verticle line

fibrous joints

in __________________, the bones are united by interjacent fibrous tissue or cartilage and are immovable (e.g. the sutures in the skull)

examinations

in a hospital setting, the patient requries a complete head-to-toe physical examination upon admission but does not require subsequent complete head-to-toe assessments very day of his or her stay; he or she does require a consistent specalized examination that focuses on certain parameters

older-adult drivers

in addition, the Americna Automobile Association provides an online driver-self assessment test, and local-departments of motor vehicles and area agencies on aginag can provide additiona lresources to help older adults and thier famitlies with ongoing assessment and planning; health care providers also have an obligation to discuss safe driving with older adults; in many states providers are required to report certain sensory or neurodegenrative conditions

cartilage

in synovial joints a layer of resilient ________________ covers teh surface of opposing bones; cartilage is avascular; it receives nourishment from synovial fluid that circulates during joint movement; it is a very stable connective tissue with a slow cell turnover; it has a tough, firm consistency yet is flexible; this cartilage cushions the bones and gives a smooth surface to facilitatie movement

leopold maneuvers

in the 3rd trimester perfrom _________________ to determine fetal lie, presentation, attitude, position, variety, and engagement; fetal lie is the orientation of the fetal spine to hte materla spine and may be longitudinal, transverse, or oblique; presentation describes the part of the fetus that is entering the pelvis first (i.e., vertex [head], breech, foot); attitude, the position of fetal parts in relation to one another, may be flexed, military (straight), or extended

infants and children abdomen

in the newborn, the umbilical cord shows predominantly on the abdomen; it contains two arteries and one vein; the liver takes up proportionately more space in the abdomen at birth than later in life; in a healthy term neonate the lower edge me be palbated .5-2.5 cm below the costal margin; the urinary bladder is located higher in the abdomen than the adult; it lies between the symphysis and the umbilicus; in addition, during early childhood the abdominal wall is less muscular, making the organs easier to palpate

establishes rapport and promotes self-esteem

including the older adult in decision making about how the interview or testing is to be done __________________; be aware of body language and behaviors, and be prepared to modify your approach; touch can also help in establishing rapport and can reduce anxiety; remember to slow down your approach and provide breaks as necessary

spina bifida

incomplete closure of posterior part of vertebrae results in a neural tube defect; seriousness varies from skin defect along the spine to protrusion of the sac containing meninges, spinal fluid, or malformed spinal cord; the most serious type is myelomeningocele, in which the meninges nad neural tissue protrude; in these cases the child is usually paralizd below the level of the lesion

urinary changes of pregnancy

increased frequency of urination as growing fetus presses on bladder

pregnant woman musculoskeletal

increased levels of circulating hormones (estrogen, relaxin from the corpus luteum, and corticosteroids) cause increased mobility in the joints; increased mobility in the sacroiliac, sacrococcygeal, and symphysis pubis joints in the pelvis contributes to the noticeable changes in maternal posture

osteoarthritis (OA) degenerative joint disease

increased risk occurs with older age, females, and Caucasians; obesity increases risk and progression of ___________, especially in the knee; asymmetric joint involvement commonly affects hands, knees, hips, and lubar and cervical segments of the spine; affected joints have stiffness; swelling with hard, bony protubernaces; pain with motion; and limitation of motion

vertex presentation

malpresentation: after 34 weeks, the _______________ is desirable thereafter because spontaneous turning becomes less likely as the fetus grows in proportion to the amount of space and fluid in the uterus and pelvis

achilles tenosynovitis

inflammation of a tendon sheath near the ankle produces a superficial linear swelling and a localized tenderness along the route of the sheath; movement of hte involved tendon usually causes pain

shoulder

inspect and compare both shoulders posteriorly nad anteriorly; check the size and contour of the joint and compare shoulders for equaliy of bony landmarks normally no redness, muscular atrophy, deformity, or swelling is present; check the anterior aspect of the joint capsule and the subacromial bursa for abnormal swelling

cervical spine

inspect hte alignment of hte head and neck; the spine should be straight, and the head erect; palpate the spinous processes and the sternomastoid, trapezius, and paravertebral muscles; they should feel firm, with no muscle spasm or tenderness

knee

inspect hte knee's shape and contour; normally distinct concavities ,r or hollows, are present on either side of hte patella, the patellar grives; check them for any sign of fullness or swelling; note other locations such as the prepatellar bursa and the suprapatellar pouch for any abnormal swelling check the quadriceps muscle in the anterior thigh for any atrophy; because it is the prime mover of knee extension, this muscle is important for joint stability during weight bearing

wrist and hand

inspect the hands and wrist on the dorsal and palmar sides, noting position, contour, adn shape; the normal functional position of hte hand shows the wrist in slight extension; this way the fingers can flex efficiently, and the thumb can oppose them for grip and manipulation; the fingers lie straight in the same axis as the forearm; normally no swelling or redness, deformity, or nodules are present

elbow

inspect the size nad contour of the elbow in both flexed and extended positions; look for any deformity, redness, or swelling; check the olecranong bursa and the normally present hollows on either side of hte olecranon process for abnormal swelling

infant abdominal exam

inspect the umbilical cord throughout the neonatal period; at birth it is white and contains two umbilical arteries and one vein surrounded by mucoid connective tissue, called *Wharton's jelly*; the umbilical stump dries within a week, hardens, and falls off by 10-14 days; skin covers the area by 3-4 weeks

ankle and foot

inspect while the person is in a sitting, non-weight-bearing position and when standing and walking; compare both feet, noting positio nof feet and toes, contour of joints, adn skin characteristics; the foot should align with the long axis of the lwoer leg; an imaginary line would fall from midpatella to between the first and second toes

infant abdominal exam

inspection: the contour of hte abdomen is protuberant because of the immature abdominal musculature; the skin contains a fine, superficial venous pattern; this may be visible in lightly pigmented children up to the age of puberty

feces

inspection: localized distension auscultation: normal bowel sounds percussion: tympany predominantes; scattered, dullness over fecal mass palpation: plastic-like or ropelike mass with feces in intestines f

tumor

inspection: localized distension ausucltation: normal bowel sounds percussion: dull over mass if reaches up to skin surface palpation: define borders; distinguish from enlarged organ or normally palpable structure t

pregnancy

inspection: single curve, umbilicus protruding; breasts engorged auscultation: fetal heart tones; bowel sounds diminished percussion: tympany over intestines; dull over enlarging uterus palpation: uterine fundugs; fetal parts; fetal movements p

ascites

inspection: single curve; elevated umbilicus; bulging flanks when supine; taut, glistening skin due to recent weight gain; increase in abdominal girth auscultation: normal bowel sounds over intestines; diminished over __________ fluid percussion: tympany at top where intestines float; dull over fluid; produces fluid wave and shifting dullness palpation: taut skin and increased intra-abdominal pressure limit palpation a

air or gas

inspection: single round curve auscultation: depends on cause of ________ (e.g. decreased or absent bowel sounds with ileus); hyperactive with early intestinal obstruction percussion: tympany over large area palpation: may have muscle spasm of abdominal wall

34 weeks

malpresentation: before __________________ gestation, any position is normal;

peritoneum

internal to the abdominal msuculature lies the _____________, a double envelope of serous membrane that lines the abdominal wall (parietal peritoneum) and covers the surface of most abdominal organs (visceral peritoneum)

restrict fluid

intervention: ________________ intake in the evening rationale: this reduces nighttime awakening resulting from a full bladder

regular schedule

intervention: adhere to a _______________ for meals and sleep, using an alarm, if necessary, to ensure rising at a regular time; limit naps to one 30-minute, early afternoon nap rationale: maintaing temporoal patterns of rest and activity enhances synchrony with circadian rhythms; excessive daytime napping weakens the homeostatic drive to sleep

heavy, spicy meals

intervention: avoid ________________ near bedtime rationale: this reduces nighttime awakening caused by heartburn

delirium (Sleep promotion)

intervention: frequently reorient hte patient by keeping a clock and calendar in the room and maintaing a regular shceudle and associated light and dark patterns rationale: thse measures decrease anxiety

light bedtime snack

intervention: have a ________________ of milk or cheese and crackers rationale: this promotes sleep by reducing hyypoglycemia

relaxing activities

intervention: keep to a relaxing bedtime ritual rationale: ______________ augment one's readiness for sleep; a warm bath enhances a drop in core temperature

2 caffeineted drinks per day

intervention: limit caffeine to _________________, none after lunch rationale: caffeine promotes wakefullness by blocking adenosine receptors in the brain

environment (sleep promotion)

intervention: maintai ndaytime light and nighttime dark; open drapes and blinds; increase the wattage in lamps; increase sunlight exposure by at least 1/2 hour per day; keep sleep environemnt dark rationale: circadian rhythms are established primarily by patterns of light and dark

activities (sleep promotion)

intervention: maintain an active physical and social daytime schedule; avoid passive activiteis such as watching television rationale: vigorous activity promotes daytime arousal, prevents napping, and lessens depression, which can disrupt sleep

limiting noise

intervention: promote unterrupted sleep rationale: _______________ minimizes sleep disruption

1 drink per day

intervention: restrict alcohol to __________________, none after dinner rationale: alcohol may shorten the time it takes ot fall asleep; but it is metablolized quickly, and withdrawal occurs in the last half of hte night, producing lighter sleep and aggravating obstructive sleep apnea, restless legs syndrome, sympatethic arousal, and sweating

work or watching television

intervention: use the bed only for sleep or sex, not for _________________; limit time in bed to the average time spent asleep; if not asleep after 30 minutes, get up and engage in a relaxing activity until the need to sleep is felt rationale: the bed becomes an environmental cue for sleep

adolescent musculoskeletal subjective data

involved in any sports at school or after school? how frequently? how does your sport fit with other school demands/ activities do you use any special equipment? training program exist for your sport? what do you do if you get hurt?

ankylosing spondylitis (AS)

it affects males by a 2:1 ratio, beginning in late adolescence or early 20s; spasm of paraspinal muscles pulls spine into forward flexion, obliterating cervical and lumbar curves; thoracic curve exaggerated into single kyphotic ronding; also includes flexion deformities of hips nad knees as they compensate for spinal flexion

Geriatric Depression Scale, Short Form

it is vital to screen and identify those older adults who have depressive symptoms; several short screening instruments have been developed and validated for depression screening in the older adult; one example is the ___________________; Depression tends to be long-lasting and can recur; therefore, early intervention is warranted

arthritis

joint effusio nor synovial thickening, seen first as bulge or fullness in grooves on either side of olecranon process; redness and heat can extend beyond area of synovial membrane; soft, boggy, or fluctuant fullness to palpation; limited extensio nof elbow; occurs with RA, gout, OA, trauama

rheumatoid arthritis (RA)

joint involvement is symmetric and bilateral, wit heat, redness, swelling, and painful motion of affected joints; _______________________ symptoms include: fatigue, weakness, anorexia, weight loss, low-grade fever, and lymphadenopathy; RA carries increased cardiovascular risk of heart attack and stroke

range of motion

joint motion normally causes no tenderness, pain, or crepitation; do not confuse crepattaion with the normal discrete crack heard as a tendon or ligament slips over bone during motion, such as when you do a knee bend

rheumatic fever

joint pain 10-14 days after an untreated strept throat suggests ___________________

subtalar joint

joints distal to the ankle give additional mobility to the foot; the _____________- permits inversion adn eversion of the foot; the foot has a longitudinal arch, with weight-bearing distributed between the parts that tough the ground, the heads of hte metatarsals and the calcaneus; muscles include hte gastrocnemius and the to flexors for plantar flexion and the anterior tibialis and toe extensors for dorsiflexion

kidney

kidney stones prompt a sudden onset of severe, colicky flank or lower abdominal pain

medial/ lateral malleolus

landmarks of hte ankle on either side are hte ____________________; strong, tight medial and laterla ligaments extend from each __________ onto the foot; these help hte lateral stability of hte ankle joint, although they may be torn in eversion or inversion sprains of hte ankle

quadriceps muscle

lardmarks of the knee start with the large ______________, which you can feel on your anterior and latera lthigh; the _____________ extends the knee, and its four heads merge into a common tendon that contues down to enclose the round bony patella

colon

large bowel obstruction has moderate, colicky pain of gradual onset in lower abdomen and bloating; irritable bowel syndrome has sharp or burning cramping pain over a wide area; does not radiate; brought on by meals, releabed by bowel movement c

olecranon bursitis

large, soft knob, or goose egg, and redness from local swelling and inflammation of olecranon bursa; localized and easy o see because bursa lies just under skin; *occurs with trauma, gout, or RA*

murmur requires no treatment

later in pregnancy, you can palpate the apical impulse left of the midclavicular line and up to the 4th intercostal space because of the growing fetus; the pregnant woman often has a functional, soft, blowing systolic murmur that occurs as a result of increased blood volume; the ________________ and will resolve after pregnancy

bowlegged stance (genu varum)

legs and feet: anteriorly note the leg position; a ______________ is a lateral bowing of the legs; it is present when you measure a persistent space of more than 2.5 cm between the knees when the medial malleoli are together; ______________- is normal for 1 year after the child begins walking; the child may walk with a waddling gait; this resolves with growth; no treatment is indicated

aging adult musculoskeletal

lifestyle affects musculoskeletal changes; a sedentary lifestyle hastens musculoskeletal changes of aging; however, physical exercise increases skeletal mass and helps prevent or delay osteoporosis; physical activity delays or prevents bone loss in postmenopausal women in a dose-dependent manner

infant neuromuscular exam

lift hte infnat under the axillae and hold him or her facing you at eye level 1. note shoulder muscle tone and the infant's ability to stay in your hands without slipping 2. rotate the neonate slowly sid eto side; note the doll's eye reflex 3. turn the infant around so that his or her back is to you; elicit the stepping reflex adn the placing reflex against the edge of the examination table

swelling of menisci

localized soft swelling from cyst in lateral meniscus shows at hte midpoint of the anterolateral joint line; smiflexion of the knee makes swelling more prominent; other meniscal injuries present as a sharp acute pain at lateral or medial joint line together with catching, locking, or popping; tears in the menisci occur with severe ligament injury and present with joint instability, swelling, and pain; suspected tears are referred to orthopedics due to future increased risk of osteoarthritis

prepatellar bursitis

localized swelling on anterior knee between patella and skin; a tender, fluctant mass indicates swelling; infection may spread to surrounding soft tissue; the condition is limited to hte bursa, and the knee joint itself is not involved; overlying skin may be red, shiny, atrophic, or coarse and thickened

infant and children musculoskeletal

long bones grow in two dimensions; they increase in width or diameter by deposition of new bony tissue around the shafts; lengthening occurs at the epiphyses or growth plates; these specialized growth centers are transverse discs located at the ends of long bone; any trauma or infection ad this location puts the grwoing child at risk for bone deformity; this longitudinal growth occurs until closure of the epiphyses,; the last closure occurs at about age 20

assessment of risk for functional decline during hospitalization

losing the abiliity to perform ADLs and IADLS as a result of acute illness, and hospitalization is common in older adults and can have significant negative consequences; functional decline is attributable to the imposition of acute illness on an aging body with diminished physiologic reserve and to limitited mobility commonly experienced during a hospital admission; ideally, all patients should be screened for functional decline while hospitalized; multiple instruments are available to assess risk for functional decline, each with similar applicability to a variety of cultures and a range of older populations; a person identified as being at high risk for functional decline can be referred to restorative services (e.g., physical/occupational therapy and inpatient rehabilitation services) and multidisciplinary discharge planning at hte beginning of the hospital stay

atrophy

loss of muscle mass is exhibed as a lack of fullness surrounding the deltoid muscle; atrophy also occurs from disuse, msucle tissue damage, or motor nerve damage

mild synovitis

loss of normal hollows on either side of hte patella, which are replaced by mild distension; occurs with synovial thickening or effusion (excess fluid) as in RA; also note mild distension of hte suprapatellar pouch

aging adult musculoskeletal

loss of subcutaneous fat leaves bony prominences more marked (e.g. tips of vertebrae, ribs, iliac crests) and body hollows deeper (e.g. cheeks, axillae); an absolute loss in mucle mass occurs; some muscles decrease in size, and some atrophy, producing weakness

intervertebral discs

the _____________ are elastic fibrocartilaginous plates that constitute one-fourth of hte length of the oclumn

depression

lowering a body part

health history

make direct eye contact, and do not allow yourself to be distracted by intravenous (IV) pumps or other equipment as you ask how he or she is feeling and how he or she spend the previous shift; refer to what you have herad from the previous shift in the process of your own questioning; this alleviates the patient's frustration at answering the same questions every time he or she encounters a new staff member; assess for pain: are you currently having any pain or discomfort? be sure to ask follow-up questions as appropriate

mecoium

make note of the newborn's first stool, a sticky greenish-black ______________ stool within 24 hours of birth

musculoskeletal exam

make the person comfortable before and throughout the exam; drape for full visualization of hte body part you are examining without nedlessly exposing the person; take an orderly approach-head to toe, proximal to distal

palpation abdomen

making sense of what you are feelign is more difficult than it looks; inexperienced examiners complain that the abdomen all feels the same, as if they are pushing their hand into a soft sofa cushion; it helps to memorize the anatomy nad visualize that is under each quadrant as you palpate

computer provider order entry (CPOE)

many health care organizations also require providers to enter their own orders instead of allowing nurses to accept verbal or telephone orders; ____________________ has decreased prescribing errors; well0designed EHR systems can notify providers of potenital medication interactions, dosage adjustements for renal patients or advanced age, and additional required testing (E.g. laboratory tests)

montreal cognitive assessment (MoCA)

many instruemtns are avaialbe to screen for cognitive impairments; two commonly use dinstruemnts are the Mini-Mental State Examination (MMSE) and __________________; both instruments can be completed in approximately 10 minutes and require only a pen and paper; while the MMSE has been use for decades, the _______________-is more sensitive in detecting mild cognitive impairment; both instruments assess multiple cogntiive domains, including immediate and delayed memory and visuospatial capability, but the ________________includes assessments of frontal executive function and spatial inattention; patients with low educational levels tend to score poorly on the MMSE regardless of cogntiive impairment

Mini-Mental State Examination (MMSE)

many instruments are available to screen for cognitive impairments; two commonly used instruments are the ________________ and the Montreal cognitive assessment; both instruments can be completed in approximately 10 minutes and require only a pen and paper; while the ______________-has been use for decades, the MoCA is more sensitive in detecting mild cognitive impairment; both instruments assess multiple cognitive domains, including immediate and delayed memory and visuospatial capability, but the MoCA includes assessments of frontal executive function and spatial inattention; patients with low educational levels tend to score poorly on the _______________ regardless of cognitive impairment

disabilities or have activity limitations

many older americans live with ______________, often because of multiple chronic conditions that may include sensory, physical, or mental impairments; approximately 30% of older adults report difficulty in performing at least one activity of daily living, while an additional 12% report difficulty with more instrumental activities of daily living

pregnant woman exam

many women are anxious during hte pelvic exam; verbally prepare the woman for what will happen during the exam before youching her; save the pelvic exam for last; by that time the woman will be more comfrtable with your gentle, informing manner; communicate all findings as you go along to demonstrate your respectful affirmation oof her control adn responsibility in her own health and health care and that of her child

pyloric stenosis

marked peristalsis together with projectile vomiting in the newborn suggests ________________, an obstruction of the pyloric valve of the stomach; _____________- is a congenital defects and appears in the 2nd or 3rd week; after feeding, pronounced peristaltic waves cross from left to right, leading to projective vomiting; then one can palpate an olive-size mass in the RUQ midway between the right costal margin and umbilicus; refer promptly because of risk for weight loss ps

intestinal obstruction

marked visible peristalsis, together with a distended abdomen indicates ___________________

teen pregnancies

medical risks for the pregant adolescent are generally related to poverty, inadequate nutrition, substance abuse, sometimes sexually transmitted infections (STIs), poor health before pregnancy, and emotional and physical abuse from partner, family, and peers

peptic ulcer disease

medications (subjective data) rationale: ____________________ occurs with frequent use of NSAIDS, alcohol, smoking, and Helicobacter pylori infection

viscera

mesenteries serve as supporting networks to suspend and stabilize abdominal organs, called _________________

umbilical hernia

more common in premature infants; most resolve spontaneously by 1 year; parents should avoid affixing a belt or coin at the hernia because this will not help closure and may cause contact dermatitis; in an adult it occurs with pregnancy, chronic ascites, or chrionic increased intreathoracic pressure (e.g. asthma, chronic bronchitis) uh

caregiver assessment

most older adults with functional impairment live in the community with the help of informal support (commonly a spouse or other family member); many spousal caregivers are as frail as the person for whom they are caring, and adult children may be older than 65 years with their own chronic illnesses; although many caregivers experience satisfaction from providing care, caregiving is linked to physical and emotional stress, which can lead to caregiver burnout, depression, and worsening health

after chest, posterior, and lateral

move around to face the patient; the patient remains sitting; for a female breats examination, let the patient know you are going to lift the gown and drape it on the shoulders, exposing the anterior chest; for a male, lower the gown to hte lap cpl

retraction

moving a body part backward and parallel to the ground

protraction

moving a body part foward and parallel to the ground

abduction

moving a limb away from the midline of the body

adduction

moving a limb toward the midline of hte body

circumduction

moving the arm in a circle around the shoulder

greater tubercle

moving the fingers down from the acromion process in a small circle outward, down, and around, the next bump is the ____________________ of the humerus a few centimeterse down and laterally from the the coracoid process of the scapula is just a few centimeters medially

rotation

moving the head around a central axis

inversion

moving the sole of hte foot inward at the ankle

eversion

moving the sole of hte foot outward at the ankle

mouth

mucous membranes should be dark pink and moist; gum hyertrophy (Surface looks smooth, and stippling disappears) may occur normally during pregnancy (pregnancy gingivitis); bleeding gums may be from estrogen stimulation, which causes increased vasculaity and fragility

older adults

multiple disciplines may participate in this assessment, including physicians; nurses; physical, occupational, and speech therapists; social workers; case managers; nutritionists; and pharmacists; early recognition of disabilities and treatable conditions is instrumetal in preserving function and quality of life for older adults

WHO recommended levels of phyiscal activity

muscle-strengthening activiites involving major muscle groups should be done on 2 or more days a week when older adults cannot do the recommended amonts of physical activity because of health conditiosn, they should be as physically active as their abiltiies and conditions allow

liver palpation

next palpate for specific organs, beginning with the liver in the RUQ; place your left hand under the person's back parallel to the 11th and 12th ribs nad lift up to support the abdominal contents; place your right hand on the RUQ, with fingers parallel to the midline; push deeply down and under the right costal margin; ask the person to breath slowly; with every exhalation, move your palpating hand up 1 or 2 cm; it is normal to feel the edge of the liver bump your fingertips as the diaphragm pushes it down during inhalation; if feels like a firm, regular ridge; often the liver is not palpable and you feel nothing firm;

osteoarthritis (OA) degenerative joint disease

noninflammatory, localized, progressive disorder involving deterioration of articular cartilages (cushion between the ends of bones) and subchondral bone remodeling, synovial inflammation, and formation of new bone (osteophytes) at joint surfaces

to identify an older adult's strengths and any limitations

normal aging changes and hte development of disease may precipitate transition from home to a variety of settings where nursing-focused assessments are performed; care may be provided in hospitals; skilled nursing, long-term care, assisted-living, and acute rehabilitation facilities; homes; and clinics; the setting where care is provided usually determines the types of assessment and the instruments used; however, the goal of the geriatric assessment remains the same: _________________ so that appropriate interventions can be used to promote independence and prevent functional decline

bowel sounds

note the character and frequency of bowel sounds; although the origin of bowel sounds is not fully understood, they mat originate from the movemnt of air and fluid within the stomach and large and small intestine; a wide range of normal sounds can occur; normal bowel sounds are high-pitched, gurgling, cascasding sounds, occurring irregularly anywhere from 5-30 times per minute; do not bother to count them ;in addition, because hte sound radiate widely over hte abdomen, the gurgle you hear in the RLQ may originate in the stomach; therefore listneing in all four quatrans is not necessary; just judge if they are present or are hypoactive or hyperactive

linea nigra

note the presnce of the ______________, a hyperpigmented line taht begins at the sternal notch and extends down the abdomen throgh the umbilicus to the pubis

infant musculoskeletal system

note the relationship of the forefoot to the hindfoot; commonly, the hindfoot is in alignment with the lower leg, and just the forefoot angles inward; this forefoot adduction is meatatarsus adductus; it is usually present at birth and usually resolves spontaneously by age 3 years

bimanual examination

note the size and consistency of the uterus; in a singleton pregnancy the 6-week gestation uterus may seem only slightly enlarged and softened; the 8-week gestation uterus is approximately the size of an avocado, approximately 7-8 cm across teh fundus; the 10-week gestation uterus is about the size of a grapefruit and may reach to the pelivic brim, but it is narrow and does not fill the pelvis from side to side; the 12-week gestation uterus will fill the pelvis; after 12 weeks, the uterus is sized from the abdomen; the multigravida uterus may be larger initally, and early sizing of this uterus may be less reliable for dating

musculoskeletal exam inspection

note the size and contour of every joint; inspect the skin and tissues over the joints for color, swelling, and any masses or deformity; presence of swelling is significant nad signalss joint irritation; use hte contralateral side for comparison

speculum examination

note whether the cervix appears open; note whether it is the smooth, round cervix with a dotlike external os of the nulliparous woman or hte irregular multiparous cervix with an external os that appears more like a crooked line, the result of cervical dilation in a previous pregnancy; a friable cervix bleeds easily when touched with a cotton swab, cytobrush, or speculum beacuse of increased vascularity; advise the woman what small spotting may occur

obsetric history

number of times pregnant? number of term or preterm deliveries? preterm labor? number of sponatenous miscarriages, elective abortions, or ectopic pregnancies? how were previous pregnancies nad deliveries for you? ever had a cesarean section? if so, what was the indication? what type of uterine incision was made? ever had vaginal birht after cesarean section (VBAC)?

brusa

numerous _____________ prevent friction; one, the prepatellar _______________, lies between the patella and the skin

electronic health recording

nurses can benefit from EHR use in medication administration trhough the use of bar-cone scanners, which identify both the patient and the medication; checklists built into EHR systems can help clinicans identify health care-associated infections or patients at risk for these infections; checklists are also used for depressio nand sucide screening

exercise and osteoporosis

obesity and osteoporosis have their origins in childhood, and both are affected by diet and exercise; fast walking is the best prevention for osteoporosis; the faster the pace, the higher hte preventive effect on the risk for hip fracture; physical activity also improves muscle strength to prevent falls and increase balance and posture control, decreases back pain, and increases quality of life

general survey

observe the woman's state of nourishment: a healthy BMI is 19 to 25; note her grooming, posture, mood, and affect, which reflect her mental state; throughout the examination observe her maturity and ability to attend and learn so you can plan your teaching of the informatio nthat she needs to successfully complete a healthy pregnancy

diastasis recti

obsesrve teh shape and contours of the abdomen to discern signs of fetal position; as the woman lifts her head, you may see the ___________, the separation of the abdominal muslces, which occurs during pregnancy, with the muscles returning together after pregnancy with abdominal exercise; when palpating, note the abdominal muscle tone, which grows more relaxed with each subsequent pregnancy; note any tenderness; the uterus is usually nontender

developmental dysplasia of the hip

occurrence is 1:500 to 1:1000 births; common in girls by 7:1 ratio; signs include limited abduction of flexed thigh, positive indications of *Ortolani sign*, asymmetric ski ncreases or gluteal folds, unequal knee elevation, limb length discrepancy, and positive indication of *Trendelenburg sign* in older children

venous hum

occurs rarely. Heard in periumbilical region. Originates from inferior vena cava. Medium pitch, continuous sound, pressure on bell may obliterate it. May have palpable thrill. Occurs with portal hypertension and cirrhotic liver. vh

radiocarpal joint

of the body's 206 bones, over half are in the hands and feet; the wrist, or __________________, is the articulation of the distal radius (on the thumb side) and a row of 8 carpal bones; its condyloid action permits movement in two planes at right angles: flexion and extension, and side-to-side deviation; you can feel the groove of this joint on hte dorsum of the wrist

health history

offer water as a courtsey (if appropriate), but also knote the physical data this gives you: the person's ability to hear, to follow directions, to cross the midline, and especially to swallow; complete you inital overview by verifying that the correct name band has been applied to the wrist, and ask the paitent to state his or her name and date of birth

preschool and school age children musculoskeletal system

often parents tell you that they are concerned about the child's foot development; the most common questions are about flat feet and pigeon toes; *flattfoot (pes planus)* is pronation, or turning in of the medial side of the foot; the young child may look flatfooted because the normal longitudinal arch is concealed by a fat pad until age 3 years; when standing begins, the child takes a broad-based stance, which causes pronation; thus pronation is common between 12 and 30 months; you can see it best from behind the child, where the medial side of the foot drops down and in

older-adult drivers

older adults often recognize that their driving abilties have changed and adjust their habits accordingly (E.g. limiting driving to daytime, good weather conditions, or only local driving); however, when this is not the case, family members, friends, or healthcare providers may be concerned enough about hte safety of hte older driver and others at the community that they need to intervene; one practical approahc is a checklist of warning signs for when to stop driving

contexts of care

older adults reside in and enter the health care system along multiple levels or _________________-, including acute-care hospitals, inpatient nursing facilities, the community, and at home; the location of the care setting affects the ability to perform a comprehensive functional assessment; during an acute illness, it may be more difficult to perform a thorough functional assessment; in addition, if a resident resides in the home environment, the parameters of assessment will be broader than if he or she is in an inpatient long-term living situation

environmental assessment

older persons often have challenges not easily detected during an office visit; a home visit can reveal difficulties in the living situation such as household and bathing hazards, social isolation, family/caregiver stress, and nutrition issues; for example, a walk through the kitchen can assess the food preferences of the older adult; an empty refrigerattor and/or kitchen cabinets may give clue sto previously unrecognized functional impairment such as dementia, mobility challenges, or a decline in ability to peroform IADLs, which would warrant further assessment; itnerventions such as home health assistance, transporattion services, and shopping services may support the older adult to maintain community living

aging adult abdominal exam

on inspection you may note increased deposits of subcutaneous fat on the abdomen and hips because it is redistributed away from the extremities; the abdominal musculature is thinner and has less tone than that of the younger adult; thus in the absence of obesity, you may not peristalsis

older pregnancies

on the other hand, many women are delaying childbearing, and since the advent of assisted fertility, more women older than 35 years are now becoming pregnant; women after age 35 years are often more prepared emotionally and financially to parent; however, they are more at risk for inertility and age-related anomalies; fertility declines with advancing maternal age because of a decrease in the number and health of eggs to be ovulated, a decrease in ovulation, endometriosis, and early-onset menopause

health history

on the way into the room, verify that any necessary markers or flags are in place at hte doorway regarding conditions such as isolation precautions, latex allergies, or fall precautions; once in the room introduce yourslef as the nurse, and let the patient know how long you will be the nurse

right lower quadrant (RLQ)

organs in the ____________- include: cecum appendix right overary and tube right ureter right spermatic cord

preschool and school age children musculoskeletal system

once hte infant learns to crawl and then walk, the waking hours show perpetual motion; this is convenient for your musculoskeltal assessment; you can observe the muscles and joints during spontaneous play before a table-top examination; most young children enjoy showing off their physical accomplishments

Acute Care for Elders unit (ACE)

one model of care is the __________________, which is a dedicated unit within a hospital setting focused toward preventing functional decline in older adults through the design of the physical environment (E.g. bright lights, flooring to help prevent falls), collaboration among interdisciplinary teams, patient-centered care, and nursing protocols for clinical care (E.g. indwelling urinary catheter removal, reduction of restraint use, early mobilization); acute care nurses equipped with specialized knowledge and skills have an impact on improving outcomes for the hospitalized older adult

community

one of the goals of ______________-based services is to help the older adult remain at home; assessment of functional status helps to determine the type of services that an older adult needs to maintain independent living at home; *a low or negative result on a screening tool during assessment does not necessarily lead to the need for institutionalization,* but instead may lead a health care provider to identify appropriate support services to help the older adult maintain independence

rectus abdominus

one set of abdominal muscles, the __________________, forms a strip extending the length of the midline, and its edge is often palpable; the muscles protect and hold the organs in place, and they flex the vertebral column

borborygmus

one type of hyperactive bowel sound is fairly common: hyperperistalsis, when you feel your stomach growling, termed _________________

bowel sounds

one type of hyperactive bowel sound is fairly common: hyperperistalsis, when you feel your stomach growling, termed borborygmus bowel sound interpretation is highly subjective and can vary widely among clinicans, and bowel sounds are likely not a reliable indicator of bowel function in many circumstances; for example, when assessing for hte return of GI function after abdominal surgery, bowel sounds ar eless reliable than the passage of flatus and stool, as well as tolerance of oral intake; a perfectly silent abdomen is uncommon; you must listen for 5 minutes by your watch before deciding bowel sounds ar ecompletely absent

chronic emphysema

one variation occurs in people with _______________, in which the liver is displaced dowanard by the hyperinflated lungs; although you palpate the lower edge well below the right costal margin, the overall size is still within normal limts

preeclampsia

onset and worsening symptoms may be sudden; subjective signs may include headaches and visual changes (spots, blurring, or flashing lights) caused by cerebral edema or right upper quadrant/epigastric pain from liver enlargement; liver enzyme levels become elevated; hematocrit usually increases, and the platelets drop; serum creatine and blood urea nitrogen elevate; hemolysis occurs at least in part as a result of vasospasm

teen pregnancies

other risks for hte pregnant adolescent are psychosocial; this young woman is at risk for the downward cycle of poverty, beginning with an incomplete education, failure to limit family size, and continuing with failure to establish avocation and become independent; she may be unprepared emotionally to be a mother; her socail situation may be stresssful; she may not have the support of her familiy, her partner, or his family;

carpal tunnel syndrome with atrophy of thenar eminence

pain along thumb and index and middle fingers and atrophy occur form interference with motor function from compression of the median nerve inside the carpal tunnel; caused by chronic repettive motion; occurs between 40-60 years and is more common in women; symptoms of carpal tunnel syndrome incldue pain, nighttime pain, burning and numbness, positive findings on Phalen test, positive tinel sign, and often atrophy of thenar muscles

acute rheumatoid arthritis

painful swelling and stiffness of joints, with fusiform or spindle-shaped swelling of the soft tissue of PIP joints; fusiform swelling is usually symmetric, the hands are warm, and the veins are engorged; the infalmmed joints have a limited range of motion

osgood-schlatter disease

painful swelling of the tibial tubercle just below the knee, from overuse injury that places traction and microtrauma on the bone; occurs most in puberty during rapid growth and before closure of the growth plate; pain increases with kicking, running, bike riding, volleyball, basketball, soccer; it is uaually self-limited, and symptoms resolve with rest

anemia

pale mucous membranes indicate ________________ poor dental hygiene during pregnancy may lead to PTD or low-birth-weight infants

medial and lateral epicondyles olecranon process

palpable landmarks of the elbow are the _________________ of hte humerus and the large _________________ of the ulna between them; the sensitive ulnar nerve ruls between the olecranon process and the medial epicondyle

wrist and hand

palpate each joint in the wrist and hands; facing the person, support the hadn with your fingers under it and palapte the wrist firmly with both of your thumbs on its dorsum; make sure that hte person's wrist is relaxed and in straight alignment; move your palpating thumbs side to side to identify the normal depressed areas that overlie the joint space; use gentle but firm pressure; normalyl the joint surfaces feel smooth, with no swelling, bogginess, nodules, or tenderness

musculoskeletal exam palpation

palpate eacha joint, including its skin for temperature, its muscles, bony articulations, and area of joint capusle; notice any heat, tenderness, swelling, or masses; joints normally are not tender to palpation; if any tenderness does occur, try to localize it to specific anatomic structures (e.g. skin, muscles, bursae, ligaments, tendons, fat pads, or joint capsule) the synovial membrane normally is not palpable; when thickened, it feels doughy or boggy; a small amount of fluid is present in the normal joint, but it is not palpable

elbow

palpate hte area of the olecranon bursa for heat, swelling, tenderness, consistency, or nodules ask the person to: bend and straighten the elbow (flexion of 150-160 degrees; extension at 0; some health people lack 5-10 degrees full extension; others have 5-10 degrees of hyeprextension) movement of 90 degrees in pronation and supination (hold the hand midway; then touch the front and back side sto hte table)

temporomandibular joint

palpate the contracted temporalis and masseter muscles as hte person clenches the teeth; compare right and left sides for size, firmness, and strength; ask the person to move the jaw foward and laterally against your resistance nad open mouth against resistance; this laso tests the integrity of cranial nerve V (Trigeminal)

wrist and hand

palpate the metacarpophalangeal joints with your thumbs, just distal to and on either side of the knuckle use your thumb and index finger i na pinching motion to palpate hte sides of the interphalangesl joints; normally no synovial thickening, tenderness, warmth, or nodules are present

spine

palpate the spinous processes; normally they are straight and not tender; palpate the paravertebral muscles; they should feel firm with no tenderness or spasm

dextrorotation

palpate the uterus between your internal and external hands; note its position; the pregnant uterus may be rotated toward the right side as it rises out of hte pelvis because of the presence of the descending colon on the left; this is called __________________;

elbow

palpate with the elbow flexed about 70 degrees and as relaxed as possible; use your left hand to support the person's left forearm adn palpate hte extensor surface of the elbow- the olecranon process and the medial and lateral epicondyles of the humerus0with your right thumb and fingers

infant abdominal exam

palpation: aid palpation by flexing the baby's knees with one hand while palpating with the other the live rfills the RUQ; it is normal to feel the liver edge at the right costal margin or 1-2 cm below; normally you may palpate the spleen tip and both kidneys and hte bladder; also easily palpated are the cecum in the RLQ and the sigmoid colon, which feels like a sausage in the left inguinal area

newborn stool

palpation: make note of the _______________, a sticky greenish-black mecoium stool within 24 hours of birth; by the 4th day, stools of breastfed babies are golden yellow, pasty, and smell like sour milk, whereas those of formula-fed babies are brown-yellow, firmer, and more fecal smelling

pancreas

pancreatitis has acute, boring midepigastric pain radiating to the back and sometimes to hte left scapula or flank, severe nausea, and vomiting p

intestinal obstruction

patient history/ symptoms: history of previous abdominal surgery with adhesions vomiting fever absence of stool or gas passage colicky pain from strong peristlasis above the ________________ io

aging adult musculoskeletal

peak bone mass or bone mineral density is reached in the early to late 20s for caucasians, with females reahcing their peaks significantly earlier than males; after that bone remodeling occurs, which is the cyclic process of bone resorption and deposition responsible for skeletal maintenance at sites that need repari or replacement; the standard pattern is for bone resorption to equal bone replacement; whe nbone resorption (loss of bone matrix) occurs more rapidly , the net effect is a gradual loss of bone density or osteoporosis

dementia

people with ______________ have alterations in word finding and naming objects in addition to memory problems

lactose intolerant

people with low lactase are ______________ and have abdominal pain, blating, and flatulence when milk products are consumed; millions of Americans have the potential for ________________ symptoms; although 70-80% of white Americans produce lactase adequately into adulthood, only 30% of Mexican Americans, 20% of African Americans, and no American Indians will maintain adequate ability to digest lactose without adverse symptoms; this is clinically significant because dairy foods meet crucial nutritional requirements, including calcium, magnesium, potassium, proteins, and vitamins A, D, B12, and riboflavin; if people perceive themselves ot be lactose inteolerant based on racial heritage, the lowered calcium intake may affect bone health; health care providers should encourage low-fat or fat-free dairy foods and monitor any symptoms; in addition, even in _________________ individuals, regualr lactose consumption may be treated when the colonic flora adapt to aid digestio nof lactose

infant abdominal exam

percussion: percussion finds tympany over the stomach (the infant swallows some air with feeding) and dullness over the liver; the abdomen sounds tympanitic, although it is normal to percuss dullness over the bladder; this dullness may extend up to the umbilicus

ascites

percussion: tympany at top where intestines float; dull over fluid; produces fluid wave and shifting dullness palpation: taut skin and increased intra-abdominal pressure limit palpationa

deep palpation

perform _________________ using the technique for light palpation but push down about *5-8 cm 2-3 inches*; moving clockwise, explore the entire abdomen

palpation abdomen

perform palpation to jduge the size, location, and consistency of certain organs and to screen for an abnormal mass or tenderness; because most people are natrually inclined to protect hte abdomen, you may need to use additional measures to enhance complete muscle relaxation

iliopsoas Muscle test

perform the _______________when the acute abdominal pain of apendicits is suspected; with the person supine, lift hte right leg straight up, fpexiting at thehip; then push down over the lower part of the right thigh as the person tries to hold the leg up; when the test is negative, the person feels no change

measure leg length discrepancy

perform this measurement if you need to determine whether one leg is shorter than the other; for true leg length, measure between fixed points, from the anterior iliac spine to hte medial malleolus, crossing the medial side of hte knee; normally these measurements are equal or within 1 cm, indicating no true bone discrepancy

celiac disease

persons with evidence of malabsorption or at increased risk for _______________ (family history, other autoimmune diseases) should undergo testing for ______________ through serology and small bowel biopsy

intestinal obstruction

physical exam findings: restlessness, ill-appearing patient distended abdomen hyperactive bowel sounds in early obstruction, hypoactive or silent in late ______________ tenderness to palpation hypovolemic shock due to dehydration and sepsis may occur (increased pulse, decrease BP, cool skin, dry mucous membranes) io

skin

pigmented nevi (moles)- circumstribed brown macular or papular areas- are common on the abdomen normally no lesiosn are present, although you may note well-healed surgical scars; if a scar is present, draw its location in the person's record, indicating the length in centimeters; a surgical scar alerts you to the possible presence of underlying adhesions and excess fibrous tissue

signs of depression

poor grooming, a slumped posture, and a flat affect may be _________________ and risk for postpartum depression; poor grooming may reflect a lack of resources and need for a social service referral

aging adult musculoskeletal

postural changes are evident with aging; long bones do nto shorten with age; decreased height of 3-5 cm occurs with shortening of the vertebral column, caused by loss of water content and thinning of the intervertebral discs and by a decrease in the height of individual vertebrae from osteoporosis; a progressive decrease in height is not significant until 60 years; a greater decrease occurs in the 70s and 80s as a result of osteoporotic collapse of the vertebrae; other postural changes are an increase in thoracic curve (kyphosis), a backward head tilt to compensate for hte kyphosis, and a slight flexion of hips and knees

aging adult musculoskeletal system

postural changes include a decrease in height, more apparent in the 70s and 80s; the expression lengtheninig of hte arm-trunk axis describes this shortening of hte trunk with comparatively long extremities; kyphosis is common, with a backward head tilt to compensate; this creates the outline of a figure 3 when you view the older adult from the left side; slight flexion of hips and knees is also common

preeclampsia

predisposing factors for _________________ include: ___________________ in a previous pregnancy, multifetal gestation, chronic hypertensison, obesity, age 35 years or older, and African American race

presumptive signs

pregnancy is diagnosed by three types of signs and symptoms; __________________ are those that the woman experiences such as amenorrhea, breast tenderness, nausea, fatigue, and increased urinary frequency

toxins

pregnant women may be exposed to __________________, such as alcohol or cigarette smoke that increase the risk of birth defects

lordosis

proceed through the regular adult examination; expected postural changes in pregnancy include progressive _________ and, toward the third trimester, anterior cervical flexion, kyphosis, and slumped shoulders; when pregnancy is at its term, the protuberant abdomen and relaxed mobility in the joints create the charactersitc waddling gait

adolescent positioned sitting up

proceed with the head, eyes, ears, neck, and thoracic exam with the adolescent upright at the edge of the exam table

adolescents musculoskeletal system

proceed with the musculoskeletal exam that you provide for the adult, except pay special note to spinal posture; kyphosis is common during adolescence because of chronic poor posture; be aware of the risk for sports- related injuries with the adolescent because sports participation and competition oftne peak with this age group

increasing tidal volume

progesterone, and to a lesser degree, estrogen cause increased respiratory effort during pregnancy by _______________; hemoglobin, and therefore oxygen-carrying capacity, also increases; _________________ causes a slight drop in partial pressure of arterial carbon dioxide, causing the woman to occasionally have dyspnea

epigastric hernia

protrusion of abdominal structures presents as a small, fatty nodule at epigastrium in midline, through the linea alba; usualyl one can feel it rather than observe it; may be palpable ony when standing ep

obesity

racial disparities in __________ are well documented, with nearly 75% of non-hispanic black women of childbearing age being classified as overweight or ____________; one study found that approximately 10% of the racial disparity in birth outcomes between non-Hispanic white and non-Hispanic black women can be explained by ____________; ______________-and excessive weight gain during pregnancy also increaes risk of cesearean delivery in all age groups

elevation

raising a body part

abdominal pain

rationale: common causes of ___________________ in early pregnancy are spontaneous abortion, ectopic pregnancy, urinary tract infection, and round ligament discomfort; late pregnancy causes are premature labor, placental abrutpion, and HELLP syndrome

threatened abortion, cervicits, or ectopic pregnancy

rationale: vaginal bleeding may indicate _______________________ in 1st trimester and must be investigated; however, a friable cervix may bleed harmlessly after sex and not hurt the fetus

exam frequency

remeber that many assessments must be done frequently throughout hte course of a shift; as you perform the intial exam, take not of anything that will need continuous monitoring, such as an abnormal blood pressure or pulse oximetry reading, or adventitious breath sounds; if there is no protocol in place for a particular assessment situation, then use your nursing judgement to determine how oftne you need to check on the person's status; it is very easy to be distracted by call lights and alarms as the shift progresses

cervical spine

repeat motions while applying opposing force; the person normally can maintain flexion against your full resistance; this also tests integrity of cranial nerve XI (spinal accessory)

cardiorespiratory changes of pragnancy

respiration more efficent, cardiac output increases, blood volume increase swith oxygen and nutrient needs of fetus

gastroenteritis or bowel obstruction

restlessness and constant turning to find comfort occur with the colicky pain of _____________________

fall prevention

review medicines with provider to see which ones hurt balance check vision and hearing every year- eyes and ears help keep patients on their feet safety proof house- increase lighting, make stairs safe, remove trip hazards such as throw rugs, and install grab bars wherever needed

young child exam

review the developmental considerations in preparing for an examination of the young child; the preschool hild displays developing inititative and take son tasks independently; this child is cooperative, helpful, and easy to involve; however, he or she fears body injury and may recoil form invasive procedues (e.g. tongue depressor, otoscope); the young schoolchild is developing industry; during the examination the child is cooperative and interested in learning about the body

infant musculoskeletal system

scratch the outside of the bottom of the foot; if the deformity is self-correctable, the foot assumes a normal right angle to the lower leg; or immobilize the heel with one hand and gently push the forefoot to the neutral position with the other hand; if you can move it to neutral position, it is flexible

fetal macrosomia (large for dates)

risk factors associated with ______________ include obesity, diabetes (gestational and type 2), postterm gestation, mutiparity, large size of parents, advanced maternal age, previous macrosomic baby, and racial/ethnic factors

ganglion cyst

round, cystic, nontender nodule overlying a tendon sheath or joint capsule, usually on dorsum of wrist; flexion makes it more prominent; the fluid0filled mass is more common in women ages 30-60 years; nonpainful ganglion cysts are a cosmetic concern; painful ones may compress the median or ulnar nerve, causing numbness and tingling or weakness

herniated intervertebral disc

sciatic pain, numbness, and paresthesia of involved dermatome; listing away from affected side; decreased mobility; low back tenderness; and decreased motor and sensory function in leg; straight leg raising tests reporduce sciatic pain

forward bend test

screen for scoliosis with the ________________; seat yourself behind the standing child and ask him or her to stand with the feet shoulder-width apart and bend forward slowly to touch the toes; expect a straight vertical spine while standing and also while bending forward; posterior ribs should be symmetric, with equal elevation of shoulders, scapulae, and iliac crests

tobacco, alcohol, or illicit drugs

screening for ___________________ is an essential part of the intial prenatal visit for all pregnant women; making screening a routine part of care reduces stigmatization and can improve maternal and neonatal outcomes; appropriate referrals are important to help the woman with an opioid use disorder during pregnancy; a nonjudgmental attitude is essential when treating a pregnant woman with an opioid use disorder; a multidiscipinary approach, without criminal sanctions, improves outcomes

kidneys

search for the right _____________ by placing your hands together in a duck bill position at the person's right flank; press your two hands together firmly (you need deeper palpation that used with the liver or spleen), and ask the person to take a deep breath; in most people you will feel no change; occasionally you may feel the lower pole of the right kidney as a round, smooth mass that slide sbetween your fingers; either condition is normal

rickets

severe bowing or unilateral bowing also occurs with _____________

infant and children musculoskeletal

skeletal contur changes are apparent at the vertebral column; at birth the spine has a single C-shaped curve; at 3-4 months, raising the baby's head from brone position develops the anterior curve in the cervical neck region; from 1 year to 18 months, standing erect develops the anterior curve in the lumbar region

smoking/ drinking (patient-centered care musculoskeltal)

smoking increases bone loss nad risk of fracture in older women; moderatet-to-heavy alcohol drinking increases fall risk

Goodell sign

softening of hte cervix is called _______________; when examining the ecrvix, note its position (anterior, midposition, or posterior), degree of effacement (or thinning, exprssed in percentages assuming a >2 cm-long cervix initally), dilation (opening, expressed in cemtimeters), consistency (soft or firm), and the station of the presenting part (centimeters above or below the ischal plane)

breasts

some nipples are flattened or inverted, which are common variations of normal; these can be corrected easily during pregnancy or with proper postpartum latching-on techniques; take this opportunity in the exam to assure the pregnant woman that her breasts are perfect breasts for breastfeeding

alternative therapies

some pregnant women may rely on prescription opioid therapy for the treatment of chronic pain; in the case of medically necessary pain management, it is importnat to help the woman minimize opioid use by considering ___________________ (E.g. pyhsical therapy, behavioral approaches) and using nonopioid pain medications

cholasma

some women have ________________, known as hte mask fo pregnancy, with is a putterfly-shaped pigmentation of hte face

measure leg length discrepancy

sometiems the true leg length is equal, but hte legs still look unequal; for apparaent leg length, measure from a nonfixed point (the umbilicus) to a fixed point (meial malleolus) on each leg

spiritual assessment

spirituality provides personal answers about the meaning and purpose of one's own life nad how to interpet life evens; spirtual health may improve with age, even as physical and mental health deteriorate; the engaging process is part of one's journey, with capability for growht; views on spirituality vary greatly from one adult to another and among people of the same faith or belief system; ist is important to acknowledge spirituality as a powerful coping mechanism during stressful life events adn during illness to the end of life

contour

stand on the person's right side and look down on the abdomen; then stoop or sit to gaze across the abdomen; your head should be slightly higher than the abdomen; determine the profile from the rib margin to hte pubic bone; the contour describes the nutritional state nad normally ranges from flat to rounded

osteoporosis diet

startign in childhood, a diet rich in dark green and deep yellow vegetables (spinach, romaine lettuce, broccoli, carrots, sweet potatoes) and low in fried foods helps lower fat mass and promotes bone mass accrual; increasing exposure to healthy food markets and butchers was associated with higher BMD at 4 and 6 years of age

extension

straightening a limb at a joint

tendon

strong fibrous cord connecting muscle to bone

bone mineral density

substantial racial/ethic differences exist in ________________ among women in the US and globally; a higher _______________ means a denser bone; a low ___________ value is a strong and consistent predictor of hip and vertebral fracture among postmenopausal women; evidence comparing _____________ in older women in four countries showed, in comparison with US caucasian women, that hte BMD hip site measurements were 21-31% higher in Afro-Caribbean women and 13-23% higher in African-American women, similar in Hong Kong Chinese women, and higher in South Korean women; the higher ________________ values confer a lower fracture risk among women of African Heritage; this may be due to reports of their parents and grandparents to be of African ancestry with little European mixture, higher weight-bearing activiy, and more sun exposure in Caribbean countries

musculoskeletal exam

support each joint at rest; muscles must be soft and relaxed to assess the joints under htem accurately; take care when exammining any inflamed area where rough manipulation could cause pain and muscle spasm; to avoid this, use firm support, gentle movement, and gentlre return to a relaxed state compare corresponding paired joints; expect symmetry of structure and function and normal parameters for that joint

ankle and foot

support the ankle by grasping the heel with your fingers while palpating with your thumbs; explore the joint spaces; they should feel smooth and depressed, with no fullness, swelling, or tenderness palpate the metatsrsalphalangela joints between your thumb on the dorsum and your fingers on the plantar surface using a pinching motion of your thumb and forefinger, palpate the interphalangeal joints on the medical and lateral sides of hte toes

joint effusion

swelling from excess fluid in the joint capsule, here from rheumatoid arthirits; best observed anteriorly; fluctuant to palpation; considerable fluid must be present to cause a visible distention because the capsule normally is so loose

breasts changes of pregnancy

swelling, tenderness, visible veins, prominent tubercles, aroela enlarged nad dark

electronic health recording

teh use of technology at the bedside extends far beyond standard equipment; most hospitals and clinics use an electronic health record system; EHRs replace the paper medical record, placing all relevant patient information in an easily accessible electronic system; EHRs do not include billing and scheduling systems, but focus instead on patient information

liver

the ____________ fills most of hte right upper quadrant (RUQ) and extends over to the left midclavicular line (MCL); the lower edge of the ____________ and the right kidney normally may be palpable only on bimanual examination during the pelvic exam

shoulder

test ROM by asking the person to perform four motions; cup one hand over the shoulder during ROM to note any crepitatiton; normally none is prsent

Apgar score

the 1 and 5 minute ____________ results will give important data on the neonate's immediate response to extrauterine life but should be combined with a thorough assessment immediately after birth

costovertebral angle

the 12th rib forms an angle with the vertebral column, the ________________; the left kidney lies here at the 11th and 12th ribs; because of the placement of hte liver ,the right kidney rests 1-2 cm lower than the left kidney and sometimes may be palpable

fibromyalgia syndrome

the 2010 revised criteria stopped the tender point on the body count and substituted interview criteria; these include a widespread pain index or 0-19 of the person's report of the number of painful body regions; the 2010 criteria also assess characteristic symptoms (fatigue, nonrefereshed sleep, cognitive problems, somatic symptoms) on a 0-3 severity scale

without the edema or proteinuria

the BP should be compared with the woman's 1st prenatal BP (first timester); hypertension is necessary for the diagnosis of preeclampsia, but preeclampsia may be seen ___________________

Aging adult BMD screening

the US government recommends screening owmen ages 65 and older for osteoporosis with a low-dose x-ray called a DXA. screening interval of 2 years is suggested to measure any change in BMD; recent evidence shows if baseline BMD is normal or osteopnia is mild, rescreening intervals of 15 years may suffice, and intervals of 5 yeras for women with moderate osteopenia

older adults

the US has a large and expanding population of _____________; by 2040, older adults will represent 20% of the populatio nand the number of americans over 65 years is expected to surpass 82 million; adults over the age of 65 are responsible for more hospital stays adn clinic visits than younger adults

adolescents musculoskeletal system

the US preventive servies taks force does not support the routine screenign of asymptomatic adolescents for idiopathic scoliosis; they found that most cases detecte through screening did not progress to clinically significant scoliosis; in addition, the harm of unnecessary imaging, follow-up visits, and psychological adverse effects of brace wear did nto offset any potential benefits of screening; however, when idiopathic scoliosis is discovered incidentally or when the teen or parent expresses concern, clinicans should be prepared to evaluate

lungs

the _________- are clear bilaterally to auscultation with no crackles or wheezing; shortness of breath is common in the 3rd trimester from pressure on the diaphragm from the enlarged uterus

home care

the __________- nurse is tending not only to the illness of the older adult but also to the home safety considerations, family dynamics, and functional ability

Allis test

the ___________ also is used to check for hip dislocation by comparing leg lengths; place the baby's feet flat on the table and flex the knees up; scan the tops of hte knees, normally they are at the same elevation note the gluteal folds; normally they are equal on both sides; however, some asymmetry may occur in healthy children

musculoskeletal systsem

the _____________ constists of the body's bones, joints, and muscles; humans need this system (1) for support to stand erect, and (2) for movement; the musculoskeletal system also functions to (3) encase nad protect the inner viral organs (e.g. brain, spinal cord, heart); (4) to produce the red blood cells, white blood cells, and platlets in the bone marrow (hematopoiesis); and (5) as a reservoir for storage of essential minerals such as calcium and phosphorus in the bones

vertebrae

the ______________ are 33 connecting bones stacked in a vertical column; you can feel their spinous processes in a furrow down the midline of the back; the furrow has paravertebral muscles mounded on either side down to the sacrum, where it flattens; humans have 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 or 4 coccygeal vertebrare

solid viscera

the ______________ are those that maintain a characteristic shape (liver, pancreas, spleen, adrenal galnds, kidneys, ovaries, and uterus)

lawton instrumental activities of daily living

the ______________ contains 8 items: use of telephone, shopping, meal preparation, housekeeping, laundry, transportation, self-medication, and management of finances

Katz index of independnece in ADL

the ______________ is based on the concept of physical diabilit and measures physical function in older adults and the chronicaly ill; it is widely used with bsic ADLs to measure performance, evaluate treatment outcomes, and predict the need for continuing supervised care; activities assessed are bathing, dressing, toileting, transferring from bed to chair, contience, and feeding; the Katz ADL is valuable for planning specific types of assistance that the older person may need; for example, a person may be unable to bathe independently on hospital discharge but is independent in other ADLs; in this case, plan for a home health aid to go twice a week to assist the older adult with bathing

knee joint

the ______________ is the articulation of three bones- the femur, the tibia, and the patella (kneecap)- in one common articular cavity; it is the largest joint in the body and is complex; it is a hinge joint, permitting flexion and extension of hte lower leg on a single plane; there is no overlying fat or muscle; only the ligaments hold the tibia and femur in place, making the knee vulnerable to injury

joint

the ______________ or articulation is hte place of union bof tow or more bones; ___________ are the functional units of the musculoskeletal system because they permit the mobility needed for activitiets of daily living

placenta

the _______________ functions as an endocrine organ and produces several hormones; these hormones help in the growth and maintenance of the fetus, and they direct changes in the woman's body to prepare for birth and lactation; the hCG stimulates the rise in progesterone during pregnancy, supports the copus luteum, supports deep implantation of the placenta into the uterine wall, and helps maintain viability of the fetus

abdomen

the _______________ is a large, oval cavity extending from the diaphragm down to the brim of the pelvis; it is bordered in back by the vertebral column and paravertebral muscles, and at the sides and front by the lower rib cage and abdominal muscles

infrapatellar fat pad

the _______________ is a small, triangular fat pad below the patella behind the patellar ligament

greater omentum

the _______________ is a specialized fatty mesentery that overlies the ventral abdomen

midcarpal joint

the _______________ is the articulation between the two parallel bones of carpal bones; it allows flexion, extension, and some rotation

elbow

the _______________ joint contains the three bony articulations of hte humerus, radius, and ulna of hte forearm; its hinge action moves the forearm on one plane, allowing flexion and extension; the muscles are the biceps, and brachioradialis for flexion, and the triceps and brachialis for extension; the olecranon bursa lies between the olecranon process and the skin

greater trochanter

the _______________ of the femur is normally the witdh of the person's palm below the iliac crest and halfwat between the anterior superior iliac spine and the ischial tuberosity; feel it when the person is standing, in a flat depression on the upper laterla side of the thigh

Leopold's fourth maneuver

the ________________ helps to determine engagement and, in the vertex presentation, to differentiate shoulder from vertex; teh woman's knees are still bent; facing her feet, place your palms, with fingers pointing toward the feet, on either side of hte lower abdomen; pressing your fingers firmly, move slowly down toward the pelvic inlet; if your fingers meet, the presenting part is not enggaed; if your fingers diverge at the pelvic rim, meeting a hard prominence on one side, this prominence is the occiput; this indicates that the vertex is presenting with a deflexed head (the face presenting); if your fingers meet hard prominences on both sides, the vertex is engaged in either a miliatary of flexed position; if your fingers come to the pelvic brim diverged but with no prominences palpable, the vertex is dipping into the pelvis or is engaged; in this case the firm object felt above the symphysis pubis in the rhid maneuber is the shoulder

activities of daily living

the ________________ instruments are designed as either self-report, observation of tasks, or proxy/surrogate report

spleen

the ________________ is a soft mass of lymphatic tissue on the left posterolateral wall of the abdominal cavity, immediately under hte diaphragm; it lies obliquely with its long axis behind and parallel to the 10th rib, lateral to the midaxillary line; its width extends from the 9 th to 11 th rib, about 7 cm; it is not palpable normally; if it becomes enlarged, its lower pole moves downward toward midline

hip joint

the ________________ is the articulation between teh cup-shaped acetabulum and the head of hte femur; as in the shoulder, ball-and-socket action permits a wide range of motio non many axes; the hip has somewhat less ROM than the shoulder, but it has more stability as befits its weight-bearing function; hip stability is the result of powerful muscles that spread over the joint, a strong fibrous articular capsule, and the very deep insertion of hte head of the femur; the muscles include teh anterior flexor (iliopsoas), the posterior extensior (gluteus maximus), adductor muscles that swing the thigh toward the midline, and abductor muscles that swing it away; three bursae facilitate movement

opioid epidemic and pregnancy

the _________________ in the US is of grave concern for the health of women and infants; infants born to pregnant woman who abuse opioid pain medications or illicit drugs (e.g. heroin) are at risk for neonatal abstinence syndrome (NAS); NAS increased fivefold between 2000 and 2012, which translate to an infant with NAS born every 25-30 minutes in the US; clinical characteristics of NAS may include poor feeding, jitteriness, high-pitched crying, irritability, diarrhea, unstable temperature, and even seizures; NAS can be treated with medications and supportive therapy

pancreas

the _________________ is a soft, lbulated gland located behind hte stomach; it stretches obliquely across the posterior abdominal wall to the left upper quadrant

aorta

the _________________ is just ot hte left of midline in the upper part of the abdomen; it descends behind the peritoneum, and at 2 cm below the umbilicus it bifuricates into the right nad left common iliac arteries opposite the 4th lumbar vertebra; you can palpate the ______________ pulsations easily in the upper anterior abdominal wall; the right and left iliac arteries become the femoral arteries in the groin area; thier puslations are easily palpated at a point halfway between the anterior superior iliac spine and the symphysis pubis

temporomandibular joint (TMJ)

the _________________ is the articulation of hte mandible nad hte temporal bone; you can feel it in the depression anterior to the tragus of the ear; the _____________ permits jaw function for speaking and chesing; the joint allows three motions: hinge action to open and close the jaws; cliding action for protrusion and reteraction; and gliding for side to side movement of hte lower jaw

ischial tuberosity

the _________________ lies under the gluteus maximus muscle and is palpable when the hip is flexed

cruciate ligaments

the __________________ crisscross within the knee; they give anterior and posterior stability and help contro lrotation

shoulder girdle

the ___________________ is a belt of three large bones (humerus, scapula and clavicle), joints, and muscles

lawton instrumental activities of daily living

the ___________________ scale was originally developed to determine the most suitable living situation for an older adult- that is, determining competence and maintenance of life skills such as shopping, cooking, and managing finances in a meaningful way; IADLs are a prerequisite for independent living; the ______________ contains 8 items: use of telephone, shopping, meal preparation, housekeeping, laundry, transportation, self-medication, and management of finances

intervertebral discs

the ____________________ cushion the spine like a shock absorber and help it move; as the spine moves, the elasticity of hte discs allows the compression on one side, with compensatory expansio non the other; cometimes compression can be too great; the disc can then rupture, and the nucleus propulsus can herniate out of the vertebral column, compressing on the spinal nerves and causing pain

lawton instrumental activities of daily living

the ____________________ instrument is a self-report measure of performance rather than ability; direct testing is often not feasible (e.g. demonstrating the ability to prepare food while a hospital inpatient); attention to the final score is less important than identifying a person's strengths and areas where assistance is needed; the instrument is useful for discharge planning in acute hospital settings and for ongoing measurement of function in outpatient settings; it would not be useful for those residing in istitutional settings because many of the tasks are already being managed for the resident; other IADL instruments are available, with some being direct observation versus self-report; however, some instruemnts take over 90 minutes to complete and are not feaislbe in many settings

timed up ang go test

the _____________________ is a reliable and valid test to quantify functional mobility; the test is quick, require slittle training and no special equipment, and is appropriate for use in many settings, including hospitals and clinics;

obesity

the ______________________ epidemic in the US affects maternal and fetal outcomes; women who are ____________(BMI>30) have reproductive challenges; _______________women have more difficulty becoming pregnant and sustaining pregnancy, and they are more likely than their normal-weight counterparts to suffer from a variety of cimplications, including gestational diabetes and gestational hypertension; _______________in pregnancy also leads to an increased risk for neonatal complciations;

metacarpophalangeal and interphalangeal joints

the ______________________ permit finger flexion and extension; the flexor tendons of the wrist and hand are enclosed in synovial sheaths

infant abdominal exam

the abdomen should be symmetric, although two pulges are common; you may note an umbilical hernia; it appears at 2 to 3 weeks and is especially prominent when the infant cries; the hernia reaches maximum size at 1 month (up to 2.5 cm or 1 inch) and usually disappears by 1 year; another common variation is diastasis recti, a sepsartion of hte rectus muscles with a visible bulge along hte midline; the condition is more common with black infants and it usually disappears by early childhood the abdoemn shows respiratory movement; the only other abdominal movment you should note is occasional peristalsis, which may be visible because of the thin musuclature

four quadrants

the abdominal wall is divided into _______________ by a vertical and horizontal line bisecting the umbilicus

tibiotalar joint

the ankle or __________________ is hte articulation of the tibia, fibula, and talus; it is a hinge joint, limited to flexion (dorsiflexion) and extension (plantar flexion) on one plane

urinary tract infection

the assessment of function is important to provide a baseline for continuing comparison, to predict prognosis, and to provide objective measures o nthe efficacy of treatments; knowing only the person's medical diagnosis is not sufficient to predict functional abilities; older adults may not experience the usual symptoms of an acute illness, and oftne a decline in functional status may herald the presence of another process; for example, a _________________ may present as acute confusion in the older adult

family or friends

the available of assistance from _____________ frequently determines whether a functionally dependent older adult remains at home or is institutionalized; knowing who is available to help the person if he or she becomes ill is important to document, even for healthy older adults; knowing the social support network is an important part of the discharge plan for older adults; several standardized assessment instruments are available to measure social support

280 days

the average length of pregnancy is ______________ from the first day of hte last menstrual period (LMP), which is equal to 40 weeks, 10 lunar months, or 9 calander months; note that this include shte 2 weeks when the follicle was mutring, but before conception actually occurred

kidneys

the bean-shaped _______________ are retroperitoneal or behind the peritoneal cavity along the posteriro abdominal wall; they are well protected by the posterior ribs adn the musculature

mammary souffle

the blood vessels of the breasts enlarge and may shine bule through a seemingly more translucent than usual chest wall; when auscultating, blood flow through these blood vessels can be heard and may be mistaken for a cardiac murmur; this sound is called the _________________

acromion progess

the bones of hte shoulder have plpable landmarks; you can feel the bump of hte scapula's ______________ at the very top of the shoulder

breasts

the breast tissue feels nodular as the mammary alveoli hypertrophy; take this opportunity to teaech or reinforce breast self-examination (BSE); the woman should expect changes in the breas tissue during the pregnancy; because of the lack of menses, instruct her to perform BSE periodically during her pregnancy

breasts

the breasts are enlarged, perhaps with resulting striae, and may be very tender; the areolae and nipples enlarge and darken in pigmentation, the nipples become more erect, and secondary areolae (mottling around the areolae) may develop; the blood vessels of the breasts enlarge and may shine bule through a seemingly more translucent than usual chest wall; when auscultating, blood flow through these blood vessels can be heard and may be mistaken for a cardiac murmur; this sound is called the mammary souffle; montgomery tubercles, located around the areolae and responsible for skin integrity of the areolae, enlarge; colostrum, a thick yellow fluid, may be expressed from the nipples

fasiculi

the bundles of muscle that compose skeletal muscle

preschool and school age children musculoskeletal system

the child may sit for the remainder of the examination; start wit hteh feet and hands of hte child from 2 to 6 years because he or she is happy to show these off and proceed through the examination particularly check the arm for full ROM and presence of pain; look for subulxation of hte elbow (head of hte radius); this occurs most often between 2 and 4 years as a result of forceful removal of clothing or dangling while adults suspend the child by the hands palpate the bones, joints, and muscles of hte extremities

complete histroy/ physical exam

the choreography of the __________________ is the art of arranging all the separate steps into a fluid whole; your first examination may seem awkward and contrived; you may have ot pause and think of what comes next rather than moving smoothly between assessments; you will come to hte point at which the procedure flows naturally; and even if you forget a step, you will be able to insert in gracefully into hte next logical place

systolic BP of >140 mmHg or a diastolic BP of >90 mmHg

the classic sympotoms of preeclampsia are hypertension and proteinuria; hypertension is a __________________ that occurs after 20 weeks' gestation in a woman with previously normal BP

older adults

the comprehensive assessment of an older adult requires knowledge of not only normal aging changes but also the consequences of chronic diseases, genetic makeup, and lifestyle; a comprehensive geriatric assessment is multidimensional and incorporates the physical exam and assessments of mental status, functional status, and economic status, pain, and examinnation of the physical environment for safety concerns

aging adult musculoskeletal

the distribution of subcutaneous fat changes through life; usually men and women gain weight in their 40s and 50s; they begin to lose fat in the face and deposit it in the abdomen and hips; in the 80s and 90s, fat further decreases in the periphery, especially noticeable in the forearms, and increases over the abdomen and hips

genetalia

the enlargement of hte labia minora is common in multiparous women; labial varicostities may be present; the perineum may be scarred fro ma previous episiotomy or from lacerations; note any hemorrhoids; note any lesions on the symphysis pubis, labia, or perianal area

pregnant women abdomen

the enlarging uterus displaces hte intestines upward and posteriorl;y bowel sounds are diminished; the appendix may be displaced upward and to the right, but any appendicitis related pain during pregnancy would still be feld in the RLQ; finally skin changes on the abdomen such as stria and linea nigra occur

nagele's rule

the expected date of delivery, or EDD, being 280 daysy from the first day of the LMP, may be calculated using ____________________; that is, determine the first day of hte last normal menstrual period (normal in timing, length, premenstrual symptoms, and amount of flow and cramping); using the efirst day of the LMP, add 7 days and subtract 3 months; this date is the EDD; this date can be then used with a pregnancy wheel on which the EDD arrow is set; the present date will be pointing to the present week's gestation; the number of weeks of gestation also is estimated by physical examination, by measurement of the hCG, and most accurately by ultrasound (US) +/- 2 to 3 days

electronic health recording

the federal government encourages the adoption and meaningful use of EHRs through the Health information Technology for Economic and Clincial Health Act of 2009; the use of EHRs has increased steadily since 2008, with a ninefold increase in basic EHR adoption

multiple fetuses (large for dates)

the frequency of multiple fetuses increases with advanced maternal age and is enhanced by the increasing use of fertility drugs; the uterus enlarges where the fundal hieght may be beyond the calculated/expected gestational age; US examination confirms the diagnosis

inspect and palpate abdomen

the fundus should be palpable abdominally from 12 weeks' gestation; use the side of your hand and beign palpating centrally on the abdomen higher than you expect the uterus to be; palpate down until you feel the fundus( the top of the uterus); alternatively stand at teh woman's right side facing her head; place the palm of your right hand on the curve of the uterus in the right lwoer quadrant; moving from hand to hand, allowing the curve of the uterus to guide you, "walk" your hands to where they meet centrally at the fundus

rotator cuff

the glenohumeral joint is enclosed by a group of four powerful muscles and tendons that support and stabilize it; together these ar ecalled the __________________; the four muscles are the SITS muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) these form a cover around the head of hte humerus; they rotate the arm laterally and stabilize the head of hte humerus against hte shallow glenoid fossa of the scapula

lordosis

the most characteristic change in the pregnant woman is ____________, which compensates for the enlarging fetus; otherwise the center of balance sould shift forward; ________________ compensates by shifting the wight farther back on the lower extremities; this shift in balance in turn creates strain on the low bakc muscles, which in some women is felt as low bakc pain during late pregnancy

multiple assessments

the need for _________________ of each patient highlights the need for efficiency in the hospital setting; your assessments muts be thorough and accurate, yet you must be able to complete them rapidly without seeming hurried

older adults

the normal challenges of aging predispose an older adult to a disability; older adults may present to clinics or hospitals not only with an acute illness such as pneumonia, urinary incontinence, fragile skin, confusion, problems with eating or feeding, falls, or sleep disorders; geriatric syndromes represent a heterogeneous group of syndromes experienced by older adults; these syndromes are multifactoral and may lead to functional decline and decreased quality of life

110 and 160 beats/min

the normal rate is between ___________________; spontaneous accelerations of FHTs indicate fetal well-being

T7 and T8

the inferior angle of hte scapula is normally at the level of teh interspace between ________________

ligaments

the joint is surrounded by a fibrous caplsule and supported by _________________; _________________ are fibrous bands running directly from one bone to another bone that strengthen the joint and help prevent movement in undesirable directions

suprapatellar pouch

the knee's synovial membrane is the largest in the body; it forms a sac at the suprior border of the patella, called the ________________ or bursa, which extends up as much as 6 cm behind the quadriceps muscle

subacromial bursa

the large _______________________ helps during abduction of the arm so that the greater tubercule of the humerus moves easily under the acromion process of the scapula

kidneys

the left __________________ sits 1 cm higher than the right kidney and is not palpable normally; search for it by reaching your left hand across hte abdomen and behind hte left flank for support; push your right hand deep into the abdomen and ask hte person to breathe edeply; you should feel no change

peripheral vascular

the legs may show diffuse, symmetric, bilateral pitting edema, particularly in the 3rd trimester and if the examination is occuring later in the day when the woman has been on her feet; varicose veins in the legs are common in the 3rd trimester

abdominal exam preparation

the lighting should include a strong overhead light and a secondary stand light; expose the abdomen so that it is fully visible; drape the genetalia and female breasts; the following measures enhance abdominal all exalation: person should ahve emptied bladder keep room warm position person supine, head on pillow, knees bent, arms at sides stethsocope endpiece must be warm, hand wars, and fingernails short inquire about painful areas learn to use distraction

child abdominal exam

the liver remains palable 1-2 cm below the right costla margin; the edge is well-defined and moves easily; on the left the spleen also is easily palpable with a well-defined movable edge; usualy you can feel 1-2 cm of hte right kidney and the tip of the left kidney

have at least one chronic condition

the majority of older adults do not experience major depression; current assessments of community dwelling older adults estimate that just 1-5% of them experience depression; however, approximately 13.5% of older adults who require home health care experience depression; depression risk increases in those older adults who _________________________

free fetal DNA testing

the maternal serum alpha-fetoprotein or quad screening is offered but optional; fetal nuchal transluceny screening is offered as well but is optional; women at high risk for genetic anomalies in the fetus may also be offered ____________________; regardless of the type of screening, women should be counseled on what to expect, what the results mean, and what follow-up testing may be recommended

patient safety

the meaninguful use of EHRs, which includ eprovider order entry and clinical decision support, may increase patient safety nad quality care; EHRs allow all providers, regardless of geographic location, to access hte health information, place orders, and receive timely patient status updates; no longer does a provider have to be on the clinical unit to retrieve test results, vital signs, or the most recent nurses' or provider's note; EHRs improve hte coordination of care. facilitate safe and effective care, and assure the use of evidence-based guidelines

herniated intervertebral disc

the nucleus pulposus (the center of the disc) ruptures into the spinal canal and puts pressure on the local spinal nerve root, causing pain and inflammation; usually occurs from strenuous activities (lifting, twisting, continuous flexion with lifting, fall on buttocks), mostly in men 20-45 yeras of age, more in smokers; lumbar herniations occur mainly in interspaces L4 to L5 and L5 to S1

teen pregnancies

the number of ___________________ in the US continues to decline; however, over 200,000 babies are born annually to ___________ ages 15-19 years; the majority (73%) of ______________ occur in ____________ who are 18-19 years of age; Afrincan American and Latina ___________ have the highest rate of pregnances, at nearly twice the rate of non-Hispanic white ____________ ; socioeconomic facotrs (e.g. low income and low educational level) appear to influence _____________ pregnancy rates, and _______________ in the child welfare system (e.g. foster children) are more than twice as likely to become pregnant

bimanual examination

the ovaries rise with the growing uterus; always examine the adnexa to rule out the presence of a mass such as an ectopic pregnancy to determine tone, ask the woman to squeeze your fingers as they rest in the vagina; take this opportunity to each the kegel exercise, the squeezing of hte vagina, which the woman can do to prepare for and recover from birth (the woman cal also identify hte exercise of these muscles by stopping the flow of urine midstream, although she should only do this once and should usually let urine flow freely); direct the woman to squeeze slowly to a peak at the count of eight and then release slowly to the count of eight; you can prescribe this exercise to be performed 50-100 times per day

examination order

the patient walks into the room, sits; the examinaer sits facing the patient; the patient remains in street clothes; allowing the patient to retain street clothes helps establilsh rapport during the interview

hair distribution

the pattern of pubic hair growth normally has diamond shape in adult males and inverted triangle shape in adult females

spine

the person should be standing, draped i na gown, open at the back; place yourself far enough back so you can see the entire back; inspect and not whether hte spine is straight 1. by following an imaginary vertical line form the head through the spinous processes and down through the gluteal cleft; and 2. by noting equal horizontal positions for the shoulders, scapulae, iliac crests, and gluteal folds and equal spaces between the arm and laterla thorax on the two sides; the person's knees and feet should be aligned with the turnk and pointing forward

after heart exam

the person should be supine with the bed or table flat; arrange drapes to expose the abdomen from teh chest to the pubis h

knee

the person should remain supine with legs extended, although some examiners prefer the knees to be flexed and dangling for inspection; the skin normally looks smooth, with even coloring and no lesions inspect lower leg alignment; the lower leg shoudl extend in the same axis as the thigh

plantar fasciitis

the plantar fascia is a band of connective tissue that extends lengthwise from the medial tubercle of the heel to the metatarsal heads and the five proximal phalanges of the toes; an inflammatory response to repetitive microtrauam to this fascia is the most frequent cause of heel pain; risk factors include obesity, high-arched foot, running, standing long periods on hard flooring, or recent activity changes; pain is unilateral, throbbing, searing, or piercing, and is localized to hte plantar medial part of ht eheel; it is worse in the morning or afteriods of long rest; ultrasound imaging often aids in diagnosis; it is self limiting; treatments include rest and oral pain medications or sterids, a 2-4 month stretching program, orthotics for shoes, or night splints

timed up ang go test

the practitioner observes and times the patient as he or she raises from a chair, walks 10 feet, turns, walks back to hte chair, and sits down; factors to note are sitting balance, transferring from sitting to standing (E.g. doe shte person need to push off hte armrest to rise), pace and stability of gait, ability to turn without staggering, and sitting back down in the chair; the person should be encourage to wear their usual footwear and to use any assistive device that is typically used; an elderly person who takes longer than 12 seconds to complete the test is at high risk for falling and may need further evaluation

young child exam sequence

the preschooler and young shcoolchild are willing to undress; leave shorts and underpants on until the genital examination; talk to the child and explain the steps in the examination; use games; have the child blow on the pinwheel as you listen to lung sounds; the young child usually feels comfotable on the exam table; with the school age child, talk about school, family, friends, music, sports; demonstrate equipment to this curious child; allow the child to sit on a caregiver's lap if they are uncofortable on the exam table

sleep

the primary causes of altered ___________ in older adults are physiologic (e.g. cardiovascular disease, pulmonary disease) and psychiatric illnesses (e.g. depression), as well as side effects of the medications to treat the disorders (beta-blockers, corticosteroids, diuretics); detrimental consequences of poor ______________in older adults include poor health outcomes, falls, and impaired cognition

musculoskeletal exam

the purposes of the _____________ are to assess function for ADLs and to screen for any abnormalities; you already will have considerable data regarding ADLs through the history; note additional ADL data as the person goes through the motions necessary for an exam: gait, posture, how the person sites in a chair, rises form chair, takes off jacket, manipulates small objects such as a pen, raises from supine

tibial tuberosity

the quadricpes tendon inserts down on the ________________, which you can feel as a bony prominence in the midline; move to the sides a bit superiorly and note the lateral and medial condyles of the tibia; superior to these on either side of the patella are the medial and lateral epicondyles of the femur; posteriorly, the hamstring muscles flex the knee

social domain

the quality of life that an older person experiences is closely linked to the success of social function; the _____________ focuses on relationships within family, social groups, and the community and comprises multiple dimensions, including the sources of formal and informal assistance available; knowledge of the day-to-day routines can give you baseline information and a reference point to detect functional decline during future encounters; a comprehensive social assessment is spread over several evaluation periods and assesses caregivers as well as older adults

radioulnar joints

the radius and ulna articulate with one another at two __________________, one at the elbow and one at the wrist; these move together to permit pronation and supination of the hand and forearm

older pregnancies

the risk for down syndrome increases to 1 in 1340 at age 25 to 1 in 940 at age 30, 1 in 353 ate age 35 1 in 85 at age 40, and 1 in 35 ate age 45; women ages 35 years and older or with a history of a genetic abnormality may be offered genetic counseling and a variety of prenatal diagnostic and screenign tests; three invasive prenatal diagnositc options are chorionic villi sampling (CVS), performed between weeks 11 and 13; amniocentesis, performed between weeks 15 and 20; and percutaneous umbilical blood sampling, performed between weeks 18 and 22; all are associated with a small risk of complications and miscarriage

child abdominal exam

the school-age child has a slim abdominal shape as he or she loses the potbelly; this slimming trend continues into adolescence; variation in body image means that some adolescents are comfortable within exposure to the abdomen and others may be emarrassed; be sensitive to this and use adequate draping or keep them in personal clothing; the physical findings are the same as the adult

shifting dullness ascities test

the second test for ___________- is percussing for ________________; in a supine position __________ fluid settles by gravity into the flanks, displacing the air filled bowel to the periumbilical space; you will hear a tympanic note as you percuss over the top of the abdomen because gas filled intestines float over the fluid; then percuss down the side of hte abdomen; if fluid is present, the note will change from tympany to dull you you reach its level; mark this spot

adolescent exam

the sequence for the examination is hte head to toe format as described in the adult section; recall taht the major task of adolescnce is to develop a self-identity; the adolescent is increasingly self-conscious and introspective; for a well-person exam, keep the adolescent in street clothes and work around them

hollow viscera

the shape of the ______________ (stomach, gallbaldder, small intestine, colon, and bladder) depends on the contents; they usually are not palpable, although you may feel a colon distended with feces or a bladder distended with urine; the stomach is just below the diaphragm, between the liver nad spleen; the gallbaldder rests under the posterior surface of the liver, just lateral to the right MCL; the small intestine is located in all four quadrants; it extends from the pyloric valve of the stomach to the ileocecal vale in the right lower quadrant

bone

the skeleton is the bony framework of the body; it has 206 bones, which support hte body like the posts and beams of a building; ___________ and cartilage are specialized forms of connective tissue; ___________ is hard, rigid, and very dense; its cells are continually turning over and remodeling

wrist and hand

the skin looks smooth with knuckle wrinkles present and no swelling or lesions; muscles are ful lwith the palm showing a rounded mound proximal to hte thumb (the thenar eminence) and a smaller rounded mount proximal to the little finegr

C7 and T1

the spinous process of _______________ are prominent at hte bas eof the neck

around 18-20 weeks of gestation

the standard of care for US examinations is to have an US for fetal anatomic survey __________________; the US is helpful in showing the age of the fetus, location of the placenta, fetal position, often the sex of the fetus, and the number of fetuses, and it may screen for certain birth defects; *a cervical length measurement is recommended at 18-22 weeks, which can be useful to predict preterm birth*

skin

the surface is smooth and even, with homogenous color; this is a good area to judge pigment because it is often protected from sun one common pigment change is striae (lineae albicantes)-silvery, white, linear, jagged marks about 1-6 cm long; they occur when elastic fibers in the reticular layer of hte ski nare broken after rapid or prolonged stretching as in pregnancy or excessive weight gain; recent striae are pink or blue then the turn silvery white

neck

the thyroid may be palpable and feel full but smooth during the normal pregnancy of a euthyroid woman; it is stimulated by hCG

continuing care retirement communities

the unique feature of ______________ is that all care needs for the older adult can be met in one community, supporting the concept of aging in place; these facilities feature independent living arrangements, assisted-living care, and skilled nursing care, along with a variety of social and recreational activities; in these communities residents can progress through the continuum of care while residing in the same community; an older adult can enter at the independent level of thriving and then, as illness and/or functional limitations occur, can move to a higher level of support; some older adults may never leave the independent living level, whereas other may progress to skilled nursing as the need for care arises

spine

the unique structure of the _____________ enables both upright posture and flexibility for motion; the motions of hte vertebral column are flexion (bending forward), extension (bending back), abduction (to eitehr side), and rotation

tobacco, alcohol, or illicit drugs

the use of ___________________ during pregnancy has significant consequences on the fetus because many of the drugs pass easily through the placenta; the use of drugs is associated with 2 to 3 times greater risk of still-birth, and regular use of drugs can lead to dependence in the newborn

community

the vast majority of older adults reside in the _____________, and fewer than 5% of older adults live in skilled nursing facilities; the percentage of older adults residing in skilled nursing facilities increases from 1% of those ages 65 to 74 years to about 9% of those older than 85

prenatal testing

there are many options for _________________ either before or after conception; it tis important that hte parents make an informed choice about whether to persue such testing, and their choice must be respected

function

there are two approaches to use for performing a functional assessment: (1) asking individuals about their abilities to perform the tasks (using self-reports), or (2) actually observing their ability to perform the tasks; for people with memory problems, the use of surrogate reporters, such as family members or caregivers may be necessary, but keep in mind that surrogates may overestimate or underestimate actual abilities

leiomyoma (myoma or fibroids) (large for dates)

these are preexisting benign tumors of hte uterine wall, which then are stimulated to enlarge by the estrogen levels of pregnancy; myomatata may be located anywhere in the uterine wall; when they grow in the outer uteirne wall, the myometrium, they may affect the cinican's judgement of where the fundus of the uterus should be measured; a myoma may grow just underneath the endometrial surface into the uterune cavity, displacing the fetus or preventing its descent into hte pelvis

straight leg raising or laseguie test

these maneuvers reproduce back and leg pain and help confirm the presence of sciatica nad a herniated nucleus pulposus; straight leg raising while keeping the knee extened normally produces no pain; raise hte affected leg just short of the poitn where it produces pain; then dosiflex the foot raise the inaffected leg while leaving the other leg flat; inquire about hte involved side

rheumatoid nodules

these raised form nodules are granulomatous lesions that grow along small blood vessels in people with RA; can be tender or nontender, movable or fixed; skin slides freely over nodules; develop over pressure points such as extensor surface of arm (ulna) and olecranon

fetal macrosomia (large for dates)

this is a condition in which the infant's weight is beyond 4000 g or 4500 g, regardless of the gestational age; less than 8% of all live-born in fants in the US weigh more than 4000 g

umbilical hernia

this is a soft, skin-covered mass, the protrusion of the omentum or intestine through a weakness or incomplete closure in the umbilical ring; it is accentuated by increased intra-abdominal pressure as with crying, coughing, vomiting, or straining; but the bowel rarely incarcerates or strangulates; more common in premature infants; most resolve spontaneously by 1 year; parents should avoid affixing a belt or coin at the hernia because this will not help closure and may cause contact dermatitis; in an adult it occurs with pregnancy, chronic ascites, or chrionic increased intreathoracic pressure (e.g. asthma, chronic bronchitis) uh

alvarado score/ Mantrels score

this scoring system combines findings to assist evaluation in patients with RLQ pain; also called the ______________-, form the mnemonic, a score of 4 or less significantly decreases the probably of appendicitis

ballottment of the patella

this test is reliable when larger amounts tof fluid are present; use your left hand to compress the suprapatellar pouch to move any fluid into the knee joint; with your right hand push the patella sharply against the femur; if no fluid is present, the patella is already snug against the femur

highest risk for HCV

those at ______________________ include people with a current or past history of injection drug use and people with additional risk factors: blood transfusion before 1992, birth year between 1945 and 1965, unregulated tattoos, birth to an HCV infected mother, and long term hemodialysis; high risk individuals should be screened at least once and at periodic intervals if the risk persists (e,g, if the person continues to use injection drugs)

infant musculoskeletal system

tibial torsion may originate form intrauterine positioning and then be exacerbated at a latter age by continuous sitting in a reverse tailor position, the TV squat (i.e. sitting with hte buttocks on the floor and the lower legs splayed back and out on each side)

exercise

to help with compliance, physical activities should be readily available and have minimal cost associated with participation; becuase pathology, both known and undiscovered, may be present in older adults (e.g. osteoporosis), the physical activity chosen should not put excessive stress on the skeletal system; walking is a popular mode of of exercise for cardiovascular endurance; water activiies or stationary cycling may be alternative mode sfor individuals when wlaking is not feasible; developing an activity plan, particularly for older adults with chronic health conditions, may warrant clearance and input from a health care provider or referral to a speciality program (e.g. cardiac rehabilitation)

WHO recommended levels of phyiscal activity

to improve cardiorespiratoy function, muscular fitness, bone, nad functional health and to reduce hte risk of noncommunicable disease,s depression, and cognitive decline: older adults should do at least 150 minutes of moderate-intensity areobic physical activity throughout the week (E.g. housework, dancing, brisk walking) at least 75 minutes of vigorous-intesnity aerobic physical activity throughout hte week (e.g. fast swimming, fast cycling, running) or an equivalent combination of moderat-e and vigorous intensity activity aerobic actiivty should be performed in bouts of at least 10 minutes' duration

infant eyes exam

to open the neonate's eyes, support the head and shoulders and gently lower the baby backward or ask the parent to hold the baby over his or her shoulder while you stand behind the parent

binamual palpation

to overcome the resistance of a very large abdomen, use a bimanual technique; place your two hands on top of one another the top hand does hte pushing; the bottom hand is relaxed and can concentrate on the sense of palpation; with either technique, note the size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses

child abdominal exam

to palpate the abdomen, position the young child on the parent's lap as you sit knee-to-knee with the parent; flex the knees up and elevate the head slightly; the child can pant like a dog to further relax abdominal muscles; hold your entire palm flat on the abdominal surface for a moment before starting palpation; this accustoms the child to being touched; if the child is very ticklish, hold their hand under your own as you palpate or apply the stethoscoe and palpate around it

liver span not recommended

traditionally the upper nad lower borders of hte liver were identified by percussion to estimate liver span; this technique of measuing liver span undersestimates hte true liver size because clinicans place the upper border too low and/or the lower border too high; percussion also yields highly varialbe results between examiners and frequently does not identify hepatomegaly even when present; therefore this examination technique is ______________________

infant spine and rectum exam

turn the infnat over and hold him or her prone in your hands, or place the infant prone on the exam table 1. inspect the length of the spine, trunk, incurvation reflex, and symmetry of gluteal folds 2. inspect intact skin; note any sinus openings, protrusions, or tufts of hair 3. note patent anal opening; check for passage of mecomium stool during the first 24-48 hours after birth

shifting dullness ascities test

turn the person onto the right side (roll him or her toward you); the fluid will gravitate to the dependent (in this case, right) side, displacing the lighter bowel upward; begin percussing the upper side of hte abdomen and move downward; the sound changse from tympany to a dull sound as you reach the fluid level; but this time the level of dullness is higher, upward toward the umbilicus; this shifting of dullness indicates hte presnce of fluid

pronation

turning the forearm so the palm is down

supination

turning the forearm so the palm is up

medial and lateral menisci

two wedge-shaped cartilages, called the __________________, cushion the tibia and femur; the joint is stabilized by two sets of ligaments

contribute to fatigue or affect attention span

understand that a person with multiple medical problems may tire early and easily and that many medications have side effects that ________________; provide directions in written format if necessary; have the older adult use sensory assisstive devices such as glasses if necessary, and have hearing amplifiers and page magnifiers available; face the person as much as possible, speak slowly in a lower-pitched voice, and enunciate words clearly

aging adult musculoskeletal subjective data

use functional assessment questions to elicit any loss of function, self-care deficit, or safety risk taht may occur as a process of aging or musculoskeletal illness any change in weakness over the past months or years? any increase in falls or stumbling over hte past months or yeras do you use any mobility aids to help you get around: cane, walker? the US government recommends screening owmen ages 65 and older for osteoporosis with a low-dose x-ray called a DXA. have you had that image, know results, have access to this test?

neurologic

use teh reflex hammer, check the biceps, patellar, and ankle deep teond reflexes (DTRs); normally these are 1+ or 2+ and equal bilateraelly

inspect and palpate abdomen

use the centimeter measuring tape to measure the height of hte fundus in centimeters from teh superior border of the symphysis to the fundus; after 20 weeks the number of centimeters should approximate the number of weeks of gestation in a woman whigh healthy body size and a singleton pregnancy; beginning at 20 weeks you may feel fetal movement

aorta

using your opposing thumb and fingers, palpate hte aortic pulsation in the upper abdomen slightly to the left of midline; normally it is *2.5 to 4 cm wide* in the adult and pulsates in an anteiror direction

functional systolic murmur

uterine enlargement causes the diaphragm to rise and the shape of the rib cage to widen at hte base; decreased space for lung expansion may cause a sense of shortness of breath; the rising diaphragm displaces the heart up and to hte left; cardiac output, stroke volume, and force of contraction are increased; the pulse rate rises 15-20 beats/ min; becasue of the increase in blood volume, a _____________________, grade 2/6 or less can be heard in more than 95% of women

plantar wart

vascular papillomatous growth is caused by human papillomavirus and occurs on the sole of hte foot, commonly at hte ball and has small dark spotes; althoguh it looks like a callus, it is extremely painful; the wart is tender if you pinch it side to side, whereas a callus is tender to direct pressure

skin

veins usually are not seen, but a fine venous network may be visible in thin persons good ski nturgor reflects adequate hydration; gently pinch a fold of skin; then release to note the immediate return of hte skin to original position

hip

wait to inspect hte hip joint together with the spine a bit later in the examiation as the person stands; at that time note symmetric levels of iliac crests, gluteal folds, and equally sized buttocks; a smooth, even gait reflects equal leg lengths and functional hip motion help the person into a supine position and palpate hte hip joints; the joints should feel stable and symmetric with no tenderness or creptius

current pregnancy

was the pregnancy planned? how do you feel about it? how does the baby's father or your partner eel about the pregnancy? other family members? experienced any vaginal bleeding? when? how much? what color? accompanied by any pain? occurs after sex? (affirm that sx is safe during uncomplicated pregnancy) how have you been feeling? experienced abdominal pain? when? where in your abdomen? accompanied by vaginal bleeding? experiencing any edema? where and under what circumstances? how does the baby move on a daily basis?

exam sequence

wash your hands immediately in front of hte patient upon entry to the room; if the person is not already in bed, help the person into bed; raise the bed to a level that is comfortable for you; remember proper body mechanics

ankle and foot

weight bearing should fall on the middle of the foot, from the heel, along the midfoot, to between the 2nd and 3rd toes; most feet have a longitudinal arch, although that can vary normally from flat feet to a high instep the toes point straight forward and lie flat; the ankles are smooth bony prominences; normally the skin is smooth, with even coloring and no lesions; note the locations of any calluses or bursal reactions because they reveal areas of abnormal friction; examining well-worn shoes helps assess areas of wear and accommodation

infant measurement

weight, length, and head circumference are measured and plotted on growth curves for the infant's age

infant/children musculoskeletal subjective data

were you told of any trauma to infant during labor and delivery? did baby's head come out first? was there need for forceps/ resuscitation? were the baby's motor milesetones achieved at about the same time as siblings has child ever broken any bones? dislocations? how treated? ever noticed bone deformity? spine curvature? unusual shape of tores/ feet

adolescent abdominal (subjective data)

what do you eat at regular meals? what is you exercise pattern if weight is less tha tbody requirements: how much weight have yo ulost? by diet, exercise, or how?

assessment

what do you think is happening in regard to the current problem? if you do not know at least state which body system you think is involved; how severe is the problem

recommendation

what do you want the provider to do to improve the paitent's situation? here you offer probable solutions. order more pain meds? come and assess the patient?

situation

what is happening right now? why are you calling? state your name, your unit, patient's name, room number, patient's problem, when it hapepned or started, how severe it is

environment/ hazards

what is your occupation? what are the physical demands of the work? are you exposed to any strong odors, chemicals, radiation, or other hamful substances? or potentially harmful physical contact? do you consider you food and housing adequate? how do you wear your seatbelt when driving?

medications (subjective data)

what medications are you taking currently? how about alcohol? how much do you drink a day? week? when was the last alcoholic drink? how about cigarettes? do you smoke? how many packs per day? for how long?

abdominal pain

when a person gives a history of _____________, the pain's location may not necessarily be over the involved organ because the human brain has no felt image for internal organs; rather, pain is referred to a site where the organ was located in fetal development; although the organ migrates during fetal development, its nerves persist in referring sensations from the former location ap

spleen

when enlarged, the _________________ slides out and bumps your fingertips; it can grow so large that it extends into the lower quadrants; when this condition is suspected, start low so that you will not miss it; an alternative position is to roll the person onto his or her right side to displace the spleen more forawrd and downward; then palpate

Chadwick sign

when examining the vagina, you may see ___________________, the bluish, purplish disoloration adn congested look of teh vaginal wall and cervix from increased vascularity and engorgement; note the vaginal discharge; vaginal dsicharge in pregnancy may be heavier in amount but should be similar in description to teh woman's nonpregnant discharge and should not be associated with itching, burning, or an unusual odor (except that occasionally chapping of the vaginal area ma ybe seen because of excessive moisture); perform a wet mount or culture of the discharge wheen you are uncertain of its normalcy

pronation

when standing begins, the child takes a broad-based stance, which causes ____________; thus ______________ is common between 12 and 30 months; you can see it best from behind the child, where the medial side of the foot drops down and in

knee

when swelling occurs, you need to distinguish whether it is caused by soft tissue swelling or increased fluid in the joint; comparison with the unaffected knee is importnat; the tests for bulge sign and ballottment of hte patella aid this assessment

blastocyst

when the fertalized ovum enters teh uterus, it is called the _________________ and continues to divide ,differentiate, and brow rapidly; speclialized cells in the _________________ produce human chorionic gonadotropin (hCG), which stimulates the corpus lutuem ti continue to make progesterone; the _______________ implants into hte wall of the uterus, which may cause a small amount of vaginal bleeding

menstural history

when was the first day of last menstrual period that was normal in timing, premenstrual symptoms, length, amount of flow, cramping? numer of days in cycle? certainty of LMP?

increased risk for functional decline

while hospitalization may be necessary to treat acute illness, it puts older adults at _______________, iatrogenic complications, and potential discharge to a skilled nursing facility; hospitals appreciate the _________________ and adverse outcomes in older adults; many hospitals use targeted interventions to prevent ________________ related to hospitalization in older adults

shoulder

while standing in front of the person, palpate both shoulders, noting any muscular spasm or atrophy, swelling, heat, or tenderness; start at the clavicle and methodoically explore the acromioclavvicular joint, scapula, greater tuberculeof the humerus, area of hte subaraomial bursa, teh biceps groove, and anterior aspect of hte glenohumeral oint; palpate the pyramid-shaped axilla; no adenopathy or masses should be present

elbow

while testing muscle strength, stabilize the person's arm wiht one hand; have him or her flex the elbow with one hand; have him or her flex the elbow against your resistance applied just proximal to the wrist; then ask the person to extend the elbow against your resistance

developmental dysplasia of the hip

with a dislocated hip the head of the femur is displaced out of the cup-shaped acetabulum; the degree varies; subuluxation may occur as stretched ligaments allow partial displacement of femoral head and acetabeular dysplasia may develop become of excessive laxity of hip joint capsule

recent ankle trauma

with a history of ______________________ or a fall, palpate the length of the lateral and medial __________ ligaments in the position; if no sprain, there will be no tenderness, swelling, or bruising; follow the Ottawa rule for possible _______ or midfoot fracture

shoulder

with arms at sides and elbows extended, move both arms forward and up in wide vertical arcs and then move them back (forward fleexion of 180 degrees; hyperextenson up to 50 degrees) rotate arms internally behind back; place back of hands as high as possible toward scapulae (internal rotation of 90 degrees)

shoulder

with arms at sides and elbows extended, raise both arms in wide arcs in the coronal plane; touch palms together above head (abduction of 180 degrees; adduction of 50 degrees) touch both hands behind the head with elbows flexed and rotated posteriorly (external rotation of 90 degrees) test strength of the shoulder muscles by askign the person to shrug the shoulders, flex forward and up, and abduct against your resistance; the shoulder shrug also tests the integrity of cranial nerve XI, the spinal accessory

temporomandibular joint

with hte person seated, inspect hte area just anterior to hte ear; place the tips of your first two fingers in front of each ear and ask the person to open and close the mouth; drop your fingers into the depressed area over the joint and note smooth motion of hte mandible; an audible and palpable snap or click occurs in many peaothy people as the mouth opens

thyroid-stimulating hormone (TSH)

with the rise in hCG in the frist trimester, there is a transient decrease in _________________ levels between 8 and 14 weeks' gestation; plasma iodine levels decrease, allowing a transient increase in thyroid gland size in approximately 15% of pregnant women

elbow

with your thumb in the lateral groove and your index and middle fingers in the medial groove, palpate either side of hte olecranon process using varying pressure; noramlyl present tissues and fat pads feel fairly solid; check for any synovial thickening, swelling, nodules, or tenderness

bone mineral density

women have been studied regarding age at attaining peak ______________; in the spine, women of all races gain _____________ up to 30-33 years of age; at the femoral neck in the hip joint, __________ peaked earlier amog white women (<16 years) than among african americans (21 years) and hispanics (20 years); an earlier peak ____________ and more rapid decline following a trend that may explain the increased practure risk for white women later in life; these data plus physical activity data discussed suggest that weight-bearing physical activity (e.g. fast walking) is imperative during the reproductive nad middle adult years to slow the process of decline in ________________-

ankylosis

wrist in extreme flexion, due to severe rheumatoid arthritis. this is a functionally useless hand because when the wrist is palmar flexed, a good deal of power is lost from the fingers and the thumb cannot oppose the fingers

anterior superior iliac spine

you can feel the entire iliac creste, form the _________________ to the posterior

Hegar sign

you may note _________________, when the enlarge uterus bends forward on its soften isthmus bewteen the 4th and 6th weeks of pregnancy

health history

you should know when the last pain medication was given and what is ordered for pain management; determine whether further dosing is needed or whether you need to contact the provider for additional orders; confirm IV solution and rate, patient-controlled analgesia pump settings (if applicable), or epidural setting (if applicable); assess the IV side, epidural site (if applicable) and any indwellign drains (if applicable); assessment of the epidural site and drains can be combined with the appropriate body system

child abdominal exam

younger than 4 years, the abdomen looks protuberant when the child is both supine and standing; after age 4 years, the potbelly remains when standing because of lumbar lordosis, but hte abdomen looks flat wheen supine; normal movment on the abdomen includes reespirations, which remain abdominal until 7 years of age

review of systems

your weight before pregnancy? when did you last see the dentist? need any dental work? have you had HTN or kidney disease? do you have diabetes? on oral hypoglycmics? insulin injection, or insulin pump? did you have diabetes during a pervious pregnancy? have you had UTIs? have you had depression or any other mental disorder? have you taken medications for mental health disorders? do you feel safe in your relationship or home environment? are you in a relationship with someone who physically or emotionally abuses or threatens you has anyone forced you to have sexual activities against your will?