Nur Sci 112LA Lecture 8
Psoas Sign
RLQ pain with extension of right thigh indicative of appendicitis
Abdominal Regions
RUQ, LUQ, RLQ, LLQ, Suprapubic, Epigastric
NGT Assessment
Review chest & abdominal X-ray Test pH of aspirates Skin integrity Aspiration precautions
Stoma Assessment
Should be pink to red and moist *Pallor, cyanosis or dusky color indicates poor blood supply *Black indicated necrosis -Initial edema
Facial Landmarks
Assessing facial symmetry: -Nasolabial folds -Palpebral fissures -Mouth and eyes
Otitis Media
Middle ear infection/inflammation *More common in children b/c smaller eustachian tubes, developing immune system
Costovertebral Angle Tenderness (CVAT)
-CVAT: no pain when kidneys pounded gently +CVAT: pain when kidneys pounded gently *Pyonephrosis or pyelonephritis
Bowel Sound Distinctions
5-30 sound/min = Normal > 30 sounds/min- Hyperactive None after ~ 5 minutes - Absent
Hydrocephaly
A buildup of cerebrospinal fluid within brain
Stoma
AKA ostomy Surgically-created opening on the abdomen which allows stool or urine to exit the body -Colostomy -Ileostomy -Urostomy
Melena
Black, tarry stool -Contains digested blood
CVA vs. TIA
CVA -Sudden death of brain cells due to ischemia from blockage or rupture of arteries -Permanent deficits TIA -Sx for up to 24 hours and then resolve -No deficit problems; does indicate CVA risk though -"mini stroke" **#1 Reason for both: HTN
HEENT Auscultation
Carotid arteries -Check for bruits *No percussion
Clay-like White Stools
Due to Calcium Antacids
Acromegaly
Enlargement of the extremities
Nasal Sinuses
FEMS
FAST
Face Arm Speech Time *Sooner treatment
Neck ROM
Flexion Extension Hyperextension Rotation Lateral Flexion
HEENT Inspection
General appearance/Head and neck position Head size and shape ROM of neck Skin integrity Facial symmetry of structures Observe facial movements - CN VII Eyes, ears, mouth, nose, trachea
Palpation of Abdomen
Gentle pressure then increase Avoid quick, sharp jabs
Assessment of Emesis
Green, bile-stained: intestinal obstruction Hematemesis or "coffee grounds: PUD, GI bleed, coagulopathy Projectile: GI infection, CNS, pyloric stenosis
Facial Symmetry Assessment
Have patient: -Crease up forehead (raise eyebrows) -Puff out cheeks -Smile
HEENT Palpation
Head and Scalp Temporal arteries ROM of TMJ and motion Frontal/maxillary sinuses Ear and mastoid processes Lymph nodes to neck Trachea Thyroid gland
Cushing's Syndrome
Hypersecretion of cortisol
Causes of Bowel Sounds
Hypoactive: inflammation, obstruction, peritonitis Hyperactive: gastroenteritis, diarrhea, hunger, powerful peristalsis Absent: Post-op, paralytic ileus, obstruction
Abdomen Assessment Order
Inspection *Auscultation Palpation
Murphy's Sign
Pain with palpation of the RUQ during inspiration, indicative of cholecystitis
Hematochezia
Passage of blood with bright red mixed or formed stool
Labs for Acute Abdominal Pain
Pregnancy test in females AST, ALT, bilirubin INR, PT, PTT Lipase-elevated in pancreatitis CBC-elevated WBC, blood loss in H&H CMP-calcium levels low in pancreas Lactic Acid-elevated in cirrhosis
Bell's Palsy
Temporary paralysis of CN VII -Causes paralysis only on the affected side of the face
Hematemesis
Vomiting (fresh) blood Bleeding may be from esophagus, stomach, or duodenum
Jaundice
Yellow staining of skin and slcerae caused by high levels of bilirubin in blood