Physical exam final
knock-knees (genu valgum)
_________________ also occurs with rickets, poliomyelitis, and syphilis
perforators
_________________ are connecting veins that join the superficial to deep veins; they also have one-way valves that route blood from the superficial veins into the deep veins and prevent reflux to the superficial veins
electrical events
___________________ slightly precede the mechanical events of the heart
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
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)
fourth heart sound
a physiologic S4 may occur in adults older than 40 or 50 years with no evidence of cardiovascular disease, especically after exercise
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
0.9-0.71
ankle-brachial index indicates mild PAD
.7-.41
ankle-brachial index indicates moderate PAD
<.3
ankle-brachial index ischemia, with impending loss of tissue
.4 to .3
ankle-brachial index severe PAD, usually with rest pain except in presence of diabetic neuropathy
loud S1
change in valve structure-calcification of valve; needs increasing ventricular pressure to close the valve against increased atrial pressure e.g. mitral stenosis with leaflets still mobile
infant cardiac assessment
congenital defects are associated with harsh murmur quality, location (right upper sternal border, left lower sternal border, apex), and timing (pansystolic, diastolic, or continuous)
cough (subjective data)
dou you have _______? duration? frequency? type? cough up mucus, color, odor, blood tinged? associated with activity? does activity make it better or worse? relieved by rest or medication
pericardial friction rub
inflammation of the pericardium gives rise to a friction rub; the sound is high pitched and scratchy, like sandpaper being rubbed; it is best heard with the diaphragm, with the person sitting up and leaning forward and the breath held in expiration
tricuspid stenosis
objective data: diminished arterial pulse, jugular venous puulse prominent
deep vein thrombophlebitis
objective data: increased warmth; swelling; redness; dependent cyanosis is mild or may be absent; tender to palpation
dementia
people with ______________ have alterations in word finding and naming objects in addition to memory problems
diabetes mellitus/ chronic kidney disease
people with ________________ may have calcified arteries that occasionally ar enoncompressible and give a falsely high (or negative) ankle pressure; thus the presnce or severity of PAD may be underestimated
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
loud S1
position of AV valve at start of systole- wide open and no time to drift together e.g. hyperkinetic states in which blood velocity is increased; exercise, fever, anemia, hyperthyroidism
a-wave
the ______________ reflects atrial contraction because some blood flows backward to the vena cava during right atrial contraction
genu valgum
(knock-knees)
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
small changes in life
1. heart healthy diet: foods to increase- vegetables/ fruits; foots to avoid- trans fats and too much salt 2. physical activity- 30 minutes for 5 days a week 3. keep weight in the healthy range
male breasts
1. inspect and palpate while palpating the anterior chest wall 2. supporting each arm, palpate hte axilla and regional nodes
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
kidneys
ABNORM: enlarged kidney kidney mass
ankle and foot
ABNORM: limited ROM pain with motion unable to hold flexion a
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
contour
ABNORM: scaphoid abdomen caves in; protuberant abdomen *indicates abdominal distension*
regular exercise program? which type? (medical history)
_____________ rationale: regular exercise in pregnancy may reduce risk for gestational HTN
history of vascular problems (peripheral vascular subjective data)
_______________ rationale: risk factors for PVD; diabetes and smoking are stronger risk factors for PVD than they are even for heart disease
claudication distance
_______________ rationale: the number of blocks walked or stairs climbed to produce pain
black stools
________________ may be tarry due to occult blood (melena) from GI bleeding or nontarry from iron medications
food inteolrence
_________________ rationale: a ____________, such as lactose intolerance limiting calcium intake, might affect the woman's and fetus's nutrition
swelling
_______________may be excess joint fluid (effusion), thicking of the synovial lining, inflammation of surrounding soft tissue (bursae, tendons), or bony enlargement
systolic bruit
a _____________ is a pulsatile blowing sound and occurs with stenosis, partial occlusion, or aneurysm of an artery
children cardiac assessment
a carotid bruit is a benign murmur heard jsut above the clavicles; it is slightly hars, early or midsystolic, often louder on the left, and will disappear completely by carotid artery compression c
diminished S2
a fall in systemic blood pressure causes a decrease in valve strength e.g. shock
ectopic pregnancy or ovarian mass
adnexal enlargement and pain with palpation occur with _______________________
venous (stasis) ulcer
after acute DVT or chronic incompetent valves in deep veins; venous ulcers account for 80% of leg ulcers
acute venous symptoms
aggrevating factors: pain may increase with palpation
uterus changes of pregnancy
amenorrhea (missed periods); enlarging uterus rises in the abdomen beginning at 12th week
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)
diastolic rumbles of AV valves
filling murmurs at low pressures, best heard with bell lightly touching skin mitral stenosis tricuspid stenosis
accentuated S2
higher closing pressure e.g. systmic hypertension, ringing or booming S2 exercise and excitement increase pressure in aorta
BP control
if you feel blood pressure increases, stop at the clinic every 3 months for a blood pressure check
posterior tibial artery
in back of the leg, the ________________ travels down behind the medial malleolus and forms the plantar arteries in the foot
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
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
kidney
kidney stones prompt a sudden onset of severe, colicky flank or lower abdominal pain
angina pectoris
location/radiation: generalize dsubsternal or retrosternal: can radiate to teeth, jaw, neck, one or both arms or shoulders; or there may be no pain and only associated symptoms
depression
lowering a body part
brusa
numerous _____________ prevent friction; one, the prepatellar _______________, lies between the patella and the skin
carotid pulse
pressure: no change with pressure position of persion: unaffected by position
posture (murmur)
some murmurs disappear or are enhaced by a change in position
V wave
the ____________ occurs with passive atrial filling because of the increasing volume in the right atria and increased pressure
temporal arteries
the ______________ can be palpated in front of the ear
heart
the ______________ extends from the 2nd to the 5th intercostal space and from the right border of the sternum to the leftmidclavicular line
great vessels
the ______________ lie bunched above the base of the heart
ventricle
the _______________ is the muscular pumping chamber
cruciate ligaments
the __________________ crisscross within the knee; they give anterior and posterior stability and help contro lrotation
inguinal nodes
the ____________________ in the groin drain most of the lymph of the lower extremity, the external genitalia, and the anterior abdominal wall
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
S1
the closure of the AV valves contributes to the first heart sound, ______________, and signals the beginning of systole
bicsupid/mitral
the left AV valve is the ____________
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
Tay-Sachs
Jews of Eastern European descent may have the risk of having childrne with _______________, a metabolic disorder;
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)
heart
1. ask person to lean forward and exhale briefly; auscultate cardiac base for any murmurs
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 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
inguinal area
1. palpate each groin for the femoral pulse nad inguinal nodes; lift hte drape to expose the legs
measurement
1. weight 2. height 3. wasit circumference 4. compute body mass index 5. vision using Snellen eye chart
tricuspid stenosis
Calcification of tricuspid valve impedes forward flow into RV during diastole
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.
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
tricuspid regurgitation
objective data: engorged pulsating neck veins, liver enlarged; lift at sternum if RV hypertrophy present; often thrill at left lower sternal border
ventricular septal defect
objective data: lout, harsh, holosytolic murmuc, best heard at left lwoer steranl border, may be accompanied by thrill; large defects also have soft diastolic murmur at apex caused by incrased blood flow through mitral valve
inguinal lymph nodes
palpate the __________________; it is not unusual to find palpable ndes that are small (1 cm or less), moveable, and nontender
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
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
heart sound characteristics
______________ include: 1. frequency (pitch)- heart sounds are described as high pitched or low pitched, although these terms are relative because all are low-frequency sounds, and you need a good stethoscope to hear them 2. intensity- loud or soft 3. duration- very short for heart sounds; silent periods are longer 4. timing- systole or diastole
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
low back pain
______________ rationale: occurs with degenerative discs, osteoporosis, lumbar stenosis, or is nonspecific
nocturia (subjective data)
______________ rationale: recumbency at night promotes fluid resorption and exertion; this occurs with heart failure in the person who is ambulatory during the day
dislocation
_______________ compelte loss of contact between the two bones in a joint
growth children (cardiac subjective data)
_______________ rationale: poor weight gain
occlusions
_________________ in arteries are caused by atherosclerosis, which is the chronic gradual buildup of (in order) fatty streaks, fibroid plaque, calcification of the vessel wall, and thrombus formation. This reduces blood flow with vital oxygen and nutrients.
tick bite (joints subjective data)
__________________ rationale: suggests lymes disease
cardiovascular assessment
____________________ includes hte survey of vascular structures in the neck-the carotid artery and jugular veins; these vessels reflect the efficiency of cardiac function
fourth heart sound (s4)
_____occurs at the end of diastole, at presystole, when the ventricle is resistant to filling; the atria contract and push blood into a noncompliant ventricle; this creates vibrations that are heard as ___________; ____________ occurs just before S1
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
S4
a pathologic _______, atrial gallop, occurs with CAD
exercise program (patient-centered care musculoskeltal)
a strict program of regular high-dose exercsies increases bone strength and reduces fracture risk
spina bifida
a tuft of hair over a dimple in the midline may indicate ______________
multipara
a woman is a __________________________ after delivering 2+ babies
ventricular septal defect
abnormal opening in septum between teh ventricles, usually subaortic area; the size and exact position vary considerably; if the VSD is large, the extra L-R volume can overload the right heart and lungs, causing right-sided heart failure
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
heart failure symptoms
anxiety, gasping form pulmonary congestion falling O2 saturation confusion, unconscious from decreased O2 saturation to brain jugular vein distensino from venous congestion infarct, may be cause of decreased cardiac output
second right intercostal space
aortic valve area
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
pulmonary hypertension/ secondary
associated symptoms: dyspnea, lower-extremity edema, fatigue
flexion
bending a limb at a joint
smoking cessation
biggeset thing you can do to protect your heart
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?
arterial (ischemic) ulcer
buildup of fatty plaques on intima (atherosclerosis) pluts hardening, calcification of atererial wall (arteriosclerosis)
metabolic changes of pregnancy
calcium, iron, and folate are drawn from mother's stores for baby's bone sand blood
faint S1
change in valve structure- extreme calcification, which limits mobility e.g. mitral insufficiency
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)
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)
angina pectoris
common description: pressure like pain (e.g. tightness, squeezing, burning, heaviness that lasts 3-5 minutes precipitated by activity and often resolves with rest and/or nitroglycerin
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
heart failure symptoms
decreased blood pressure stimulates sympathetic nervous system which acts on heart to increase rate and increase force of contraction nausea and vomiting as peristalsis slows and bile and fluids back up into stomach ascites, fluid in peritoneal cavity dependent, pitting edmea in sacrum, legs
QRS complex
depolarization of hte ventricles
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.*
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
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 _____________;
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 peripheral vascular system
expect diffuse bilateral pitting edema in the lower extremities, especially at the end of the day and into the third trimester; nearly 80% of pregnant women have some peripheral edema because of increased water retention; varicose veins in the legs are also common in the third trimester
heart failure symptoms
fatigue, weakness from decreased cardiac output S3 gallop, tachycardia enlarged spleen and liver form venous congestion, which causes pressure on breathing decreased urine output as kidneys compensate for decreased cardiac output by retaining sodium and H2O weak pulse cool,moist skin as peripheral vasoconstriction shunts blood to vital organs
carotid artery palpation
feel the contour and amplitude of the pulse; normally the contour is smooth with a brisk upstroke and slower downstroke, and the normal strength is moderate; your findings should be the same bilaterally
gastrocnemius
flex the person's knee and then ngently compress the length of ___________ muscle anteriorly against the tibia; no tenderness should be present
linea alba
four layers of large, flat muscles form the ventral abdominal wall; these are joined at the midline by a teindinous seam, the _______________
spleen peritoneal friction rub
friction rub over lower left rib cage in left naterior axillary line form abcess, infection, or 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
size large for dates
fundal height measures larger than expected for dates
cardiac sex and gender differences (culture and genetics)
gender differences infolve ethnicity, culture, and socioeconomci status, and these factors are closely involved in cardiac risk factors and cardiac risk lifestyle behaviors, e.g. obesity, smoking, physical activity, cardiac rehabilitatio nparticipation, delay in seeking treatment
serum cholesterol (culture and genetics)
high levels of low-density lipoprotein add to the lipid core of plaque formation in coronary and carotid arteries, which results in MI and stroke
Thomas test
hip flexion flattens the lumbar spine; if this reveals a flexion deformity in the opposite hip, it is a positive __________________
orthopnea (subjective data)
how many pillows do you use when sleeping or lying down
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
ulnar and radial artery
immediately below the elbow the brachial artery bifurcates into the ____________________; these run distally and form two arches supplying the hand; these are called the superficial and deep palmar arches; the radial pulse lies just medial to the radius at the wrist; the ulnar artery is in the same relation to the luna, but it is deeper and often difficult to feel
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
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
limiting noise
intervention: promote unterrupted sleep rationale: _______________ minimizes sleep disruption
opening snap
it sounds after S2 and is best heard with the diaphragm at the 3rd or 4th left interspace at the sternal border, less at teh apex; the opening snap usually is not an isolated sounds; as a sign of mitral stenosis, the oepning snap usually ushers in the low-pitched diastolic rumbling murmur of that condition os
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
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 ___________________
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
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
aortic dissection
location/radiation: anterior chest pain with radiation to the neck, jaw, or intrascapular region of hte back
chest wall muscle strain
location/radiation: area around strained muscle, sternum, or ribs
mitral valve prolapse
location/radiation: chest pain wihout radiation
carotid pulse
location: higher and medial to the sternomastoid muscle quality: birsk and localized; one wave per cycle
aging adult (peripheral circulation)
loss of lymphatic tissue leads to fewer numbers of lymph nodes in older people and to a decrease in the size of the remaining noedes
intestinal obstruction
marked visible peristalsis, together with a distended abdomen indicates ___________________
tricuspid stenosis
murmur: diastolic rumble; best heard at left lower sternal border; louder in inspiration
chronic venous symptoms
onset and duration: chronic pain, increases at end of day
pneumothorax
pain description: acute/sudden and sharp
peripheral arteries (legs)
palpate the _________________ in both legs; grade the force on a three point scale
second left intercostal space
pulmoic valve area
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
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
S2
the closure of the semilunar valves causes the second heart sound, _________, and signals the end of systole
tricuspid
the right AV valve is the ___________
left lower sterna lborder
tricuspid valve area
aging adult cardiac assessment
use caution in palpating and auscultating the carotid artery; avoid pressure in the carotid sinus area, which could cause a reflex slowing of hte heart rate; also, pressure on teh carotid artery could comporomise circulation if the artery has been narrowed by atherosclerosis a
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
culture/ genetics peripheral circulation
variables for African americans are smoking, blood pressure, total choleterol, BMI, glucose, healthy diet, and physical activity; researchers found hte prevalence in African Americans increased with the frequency of poor health indicators in these 7 categories; a poor score in 3 or more of the healt hindicators increased the risk for PAD; thus the health care team must provide comprehensive screenigns for Africna Americans, women, and all aging persons and tailor managment of the disease
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
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
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
mitral regurgitation
Stream of blood regurgitates back into LA during systole through incompetent mitral valve. In diastole, blood passes back into LV again along with new flow; results in LV dilation and hypertrophy
Genu varum
(bowlegs)
pregnant woman cardiac assessment
ABNORM: murmurs of aortic valve disease cannot be obliterated p
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 ___________________
inspect and palpate arms
ABNORM: needle trakcs in hands, arms, anterior cubiatl fossae occur with intravenous drug use; linear scars in wrists may signify past suicial behavior
inguinal lymph nodes
ABNORM: nodes that are enlarged, tender, or fixed in the area
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
S1 intensity
_________________ depends on three factors: 1. position of the atrioventricular valve at the start of systole, 2. structure of the valve leaflets 3. how quickly pressure raises in the ventricle
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
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?
inspect jugular venous pulse
look for pulsations of the internal jugular veins in the area of the suprasternal notch or around the origin of the sternomastoid muscle around the clavicle; distingusih internal jugular vein from the carotid artery, it is easy to confuse them because they lie close together
foot care
look for: red spots, sensitive areas, discoloration, cuts, blisters, and ingrown toenails; use a mirror to check bottoms of your feet; if diabetic, check feet daily wash feet regularly, especially between toes; dry feet carefully after a shower or bath keep toenails trimmed straight across, file at edges wear clean socks every day
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
anemia
pale mucous membranes indicate ________________ poor dental hygiene during pregnancy may lead to PTD or low-birth-weight infants
faint S1
position of AV valve- delayed conduction from atria to ventricles; mitral valve drifts shut before ventricular contraction closes it e.g. first-degree heart block (prolonged PR interval)
varying intensity of S1
position of AV varies before closing from beat to beat e.g. atrial fibrillation-irregularly irregualr rhythm
acute coronary snydrome (ACS)
possible associated symptoms: indigestion-like feeling, nausea, vomiting, dizziness, flushing, perspiration, palpitations, dyspnea, fatigue
angina pectoris
possible symptoms: diaphroesis, nausea, vomiting, dyspnea, fatigue
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
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
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
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
tonsils
the ________________ are located at the entrance to the respiratory and gastrointestinal tracts and respond to local inflammation
fasiculi
the bundles of muscle that compose skeletal muscle
myalgia
____________ rationale: is usually felt as cramping or aching
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
lymph nodes
______________ are small, oval clumps of lymphatic tissue located at intervals along the vessels; most nodes are arranged in groups, both deep and superficial, in the body; ______________ filter teh fluid before it is returned to the bloodstream and filter out microorganisms that could be harmful to the body; the pathogens are exposed to B and T lymphocytes in the lymph nodes, and these moutn an antigen-specific response to elminate pathogens; with local inflammation the _____________ in that area become swollen and tender
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
smoking history (peripheral vascular subjective data)
______________ do you smoke; packs per day; when started; how many years; tried to quit; what worked when quitting; what didn't help
ankle circumference
______________ is a more reliable mesure of edema, using a nonstretchable tape at a point 7 cm proximal to the midpoint of the medial malleolus; because peripheral edema is a common clinical sign in a great number of conditions, it is important to detect true changes in the most accurate way possible; check with institution to conform to a consistently used scale
lymph node enlargement (peripheral vascular subjective data)
______________: any swollen glands? where? how long? any recent change how do they feel to you are swollen glands associated with pain?
pain aggrevated by movement/ rest/ position/ weather (joints subjective data)
_______________ rationale: movement increases most joint pain except in RA, in which movement decreases pain
exercise
_______________- does not prevent the process of aging, but it increases functional ability, helping to maximize the older adult's independence
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
Sister Mary Joseph nodule
________________ is a hard nodule in umbilicus that occurs with metastic cancer of stomach, large intestine, ovary, or pancreas
bone remodeling
________________ is the cyclic process of bone resorption and deposition responsible for skeletal maintenance at sites that need repair or replacement
meniscal injuries
________________ present as a sharp acute pain at lateral or medial joint line together with catching, locking, or popping
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;
special diet
_________________ rationale: a _______________ may have nutritional risk; help achieve adequate nutrition within the confines of her diet; refer to dietitian
use support hose (peripheral vascular subjective data)
_________________ rationale: avoid compression stockings with PAD sinc etehy further impede blood flow; they are indicated to presecnt leg swelling in standing worksers or thrombus formation
your weight before pregnancy (calculate BMI) (review of systems)
_________________ rationale: baseline needed to evaluate changes
describe ype of pain/ come on gradually or suddenly (peripheral vascular subjective data)
_________________ rationale: peripheral vascular disease (PVD) includes PAD and venosu disease
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
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
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
screening for splenomegaly
__________________ through percussion of splenic dullness is omitted because detection through palpation is more reliable
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
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
pertibial edema
_____________________ has not been proven to be an objective, reliable, or sensitive measurement for edmea; pressure used is arbitrary as is judgmenet of depth and rate of pitting
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
fixed split
a __________________ is unaffected by respiration; the split is always there e.g. atrial septal defect, right ventricular failure
standing to squatting (ascultating heart sounds)
a screening measure to detect hypertrophic cardiomyopathy in children, adolescents, and young adults is to change position, which changes the venous return to hte heart; if the person has a systolic murmur, listen to the murmur while the person changes from standing to squatting, and then squatting to standing; note any change in loudness of the murmur
base pulsations
a thrill in the 2nd and 3rd right interspaces occurs with severe aortic stenosis and systemic hypertension; a thrill in the 2nd and 3rd left interspaces occurs with pulmonic stenosis and pulmonic hypertension
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
primigravidia
a woman pregnant for the first time is called a __________________
primipara
a woman's first delivery is called the ________________________
systole
after the venticle's contents are ejected, its pressure falls; when pressure falls below pressure in the aorta, some blood flows backward toward hte ventircle, causing the aotric valve to swing shut
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
hemodynamic changes of aging
although the _____________ alone do not seem severe or portentous, the fact remai nthat the incidence of CV disease increases with age; CVD is the leading risk of death in those ages 65 years and older; certainly, lifestlye habits (smoking, chronic alcohol use, obesity, lack of exercise, diet) play a significant role in the acquisition of heart disease; also increasing the level of activity of older adults0 even a mdoerat level- shows a reduced risk of death from CVD and respiratory illness
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?
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?
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
anxiety
associated symptoms: palpitations, dizziness, sweating, shaking, restlessness, fatigue, irritability
acute venous symptoms
associated symptoms: red, warm, swollen leg
herpes zoster
associated symptoms: tinrling, itching, burning
popliteal artery
at the lower thigh, the femoral artery courses posteriorly; then it is termed the __________________; below the knee the _____________ divides into the anterior tibial artery and the posterior tibial artery
culture/ genetics peripheral circulation
because family history of PAD is independently and strongly associated with PAD prevalence nad severity, it would follow what genetic factors have a role, but data here are limited; there is no ideal biomarker to screen for PAD, and genetic developments that would target therapeutic interventions are larging; for environmental factors, cigarette smoking is a particularly strong risk factor for all persons with PAD, as are diabetes and hypertension; other risk factors are elevated levels of total choelsterol and obesity
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
Prizmetal/variant angina
common pain description: pressurelike discomfort often occurring at rest, unrelated to physical or emotional stress
hemodynamic changes of aging
diastolic BP may decrease after the fifth decade; together with a rising systolic pressure, this increases the pulse pressure; no change in resting heart rate occurs with aging; cardiac output at rest is not changed with aging
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
systole
during the pumping phase, or ____________, the AV valves close to prevent regurgitation of blood back up into the atria; the papillary muscles contract at this time so the valve leaflets meet and unit to form a perfect seal without turning themselves inside out
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 _________________
venous return
efficient ___________ depends on contracting skeletal muscles, competent alves in the veins, and a patent lumen; problems with any of these three elements lead to venous stasis; at risk for venous disease are people who undergo prolonged standing, sitting, or bed rest because they do not benefit from the milking action that walking accomplishes
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
size small for dates
fundal height measures smaller tha nexpected for dates
cardiac output
in the resting adult, the heart normally pumps between 4 and 6 L of blood per minute throughout hte body; this _________________ equals the volume of blood in each systole (called the stroke volume) times the number of beats per minute (rate); CO=SV X R
heavy, spicy meals
intervention: avoid ________________ near bedtime rationale: this reduces nighttime awakening caused by heartburn
mitral stenosis
murmur: low-pitched diastolic rumble,e best heard at apex, with person in left lateral positon; does not radiate
mitral regurgitation
objective data: trhill in sytole at apex; lift at apex; apical impulse displaced down and to left; S1 diminished, S2 accentuated, S3 at apex often present
acute venous symptoms
onset and duration: sudden onset (within 1 hr) v
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
Y descent
the _____________ reflects passive ventricular filling when the tricuspid valve opens and blood flows from the RA to the RV
PR interval
the ______________ from the beginning of the p-wave to the beeginning of the QRS complex; time necessary for atrial depolarization plus time for the impulse to travel through the AV node to the ventricles
aortic valve
the ______________ is in the left side of the heart, connects to the aorta
pulmonary veins
the ________________ return the freshly oxygenated blood to the left side of the heart
collateral ligaments
the _________________ connect the joint at both sides; they give medial and laterla stability and prevent dislocation
extetrnal jugular
the _________________ is more superifial and lies lateral to the sternomastoid muscle above teh clavicle
shoulder girdle
the ___________________ is a belt of three large bones (humerus, scapula and clavicle), joints, and muscles
heart
the cardiovascular consists of the ____________, the muscular pump and the blood vessels
110 and 160 beats/min
the normal rate is between ___________________; spontaneous accelerations of FHTs indicate fetal well-being
cardiac cycle
the rhythmic movement of blood through the heart is the ________________; it has two phases, diastole, and systole
superficial veins (small saphenous)
the________________, outside the leg, starts on the lateral side of the dorsum of the foot and ascends behind the lateral malleolus, up the back of the leg, where it joints the popliteal vein; blood flows from the superficial veins into the deep veins
identify S1 and S2
this is important because S1 is the start of systole and thus serves as the reference point for hte timing of all other cardiac sounds; usually S1 is identified instantly because you hear a pair of sounds close together and S1 is the first of hte pair; this works except in cases of tachydysrhythmias; then the diastolic filling time is shortened and the beats are too close together to distinguish
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
ankle-brachial index
use of the doppler stethoscope is a highly specific, noninvasive, and readily available way to determine the extent of peripheral arterial disease
neurologic
use teh reflex hammer, check the biceps, patellar, and ankle deep teond reflexes (DTRs); normally these are 1+ or 2+ and equal bilateraelly
infant measurement
weight, length, and head circumference are measured and plotted on growth curves for the infant's age
capillary refill
with the person's hands near the level ofo his or her heart, check ________________; this is an index of peripheral perfusion and cardiac output; depress and blanch the nail beds; release and note the time of color return; usually the vessels refill within a fractiion of a second; consider it normal if cololr returns in less than 1-2 seconds
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
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
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
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
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
carotid artery palpation
ABNORM: diminished pulse feels small and weak (decreased stroke volume as in cardiogenic shock); increased pulse feels full and strong in hyperkinetic states
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
infant cardiac assessment
ABNORM: failure of shunts to close (e.g. patent ductus arteriosus [PDA], atrial septal defect [ASD]) cyanosis at or just after birht signals oxygen desturation of congential heart disease the most important signs of heart failure in an infant are persistent tachycardia, tachypnea, and liver enlargement; engorged veins, gallop rhyth, and pulsus alterans also are signs; respiratory crackles are an important sign in adults but not in infants i
infant cardiac assessment
ABNORM: failure to thrive occurs with cardiac disease the apex is displaced with: cardiac enlargment, shifts to hte left pneumothorax, shifsts away from affected side diaphragmatic hernia, shifts usually right because this hernia occurs more often on the left dextrocardia, a rare anomaly in which the heart is located on the right side of the chest i
Allis test
ABNORM: finding one knee significantly lower than the other is a positive indication of _________ sign and suggests hip dislocation
profile sign
ABNORM: flattening of angle and clubbing (diffuse enlargement of termian lphalanges) occur with congenital cyanotic heart disease and cor pulmonale
radial pulses
ABNORM: full, bounding pulse (3+) occurs with hyperkinetic states (exercise, anxiety, fever) anemia, and hyperhtyroidism weak , thready pulse (1+) occurs with shock and PAD
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
pregnant woman cardiac assessment
ABNORM: gestational hypertension is BP >140/90 mmHg on two separate measures without proteinuria, starting after 20th week of prengancy; this returns to baseline by 12 weeks after delivery p
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
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
mcBurney point tenderness
ABNORM: inflammation of the appendix usually produces RLQ pain to palpation, with maximal tenderness sometimes ocurring over ________________
pulmonic regurgitation
Backflow of blood through incompetent pulmonic valve, from pulmonary artery to RV
tricuspid regurgitation
Backflow of blood through incompetent tricuspid valve into RA
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.
neuropathic ulcer
Diabetes hastens changes described with arterial ischemic ulcer, with generalized dysfunction in all arterial areas: peripheral, coronary, cerebral, retinal, and renal. peripheral diabettic ulcer has its pathogenesis in sensory neuropathy with lsos of productive sensation, autonmic neropathy with decreased sweating and dry skin, adn motor neuropathy with foot deformity
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
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
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.
appropriate aspirin therapy
Men 45-79 may take a low-dose aspirin daily when the potential benefit of preventing a heart attack outweighs the potential harm of an increase in stomach bleeding; women 55-79 years may choose to take low-dose aspirin when the potential benefit of preventing a stroke due to blood clot outweighs potenital harm of increase in bleeding in stomach
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
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
occlusions
Risk factors for atherosclerosis include obesity, cigarette smoking, hypertension, diabetes mellitus, elevated serum cholesterol, sedentary lifestyle, and family history of hyperlipidemia.
atrial septal defect
Subjective data: defect is remarkably well tolerated; symptoms in infants are rare; growth and devlopment normal; children and young adults have mild fatigue and DOE
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
second heart sound S2
The S2 is associated with closure of the semilunar valves. You can hear it with the diaphragm over the entire precordium, although S2 is loudest at the base
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)
palpate across the precordium
Using palmar aspects of your four fingers, gently palpate apex, left sternal border, and base, searching for any other pulsations. Normally none occur. If any are present, note timing. Use carotid artery pulsation as a guide, or auscultate as you palpate.
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.
split S2
When the aortic valve closes significantly earlier than the pulmonic valve, you can hear the two components separately; this is a _________________
striae
__________ look purple-blue with Cushing syndrome (excess adrenocortical hormone causes the skin toe be fragile and easily broken from normal stretching)
pain wake you up at night (peripheral vascular subjective data)
__________ rationale: night leg pain is common in aging adults; it may indicate ischemic rest pain of PAD, severe night mucsle cramping, or restless leg syndrome
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
associated symptoms with chest pain (subjective data)
___________ rationale: diaphoresis, cold sweats, pallor, grayness palpitations, dyspnea, nausea, tachycardia, fatigue
activity children (cardiac subjective data)
___________ rationale: fatigue; record specific limitaitons cyanosis occurs in some congenital defects: tetraology of fallot or transpotion of the great arteries
calf pain with walking, go away with rest (muscles subjective data)
___________ rationale: suggests intermittent claudication
cardiovascular subjective data
____________ includes: 1. chest pain 2. dyspnea 3. orthopnea 4. cough 5. fatigue 6. cyanosis or pallor 7. edema 8. nocturia 9. past cardiac history 10. family cardiac history
venous flow
____________ is accomplished by: 1. contracting skeletal muscles that milk the blood proixmally back toward the heart; 2. the pressure gradient caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and 3. the intraluminal valves, which ensure unidirectional flow; each valve is a paried semilunar pocketthat opens toward the heart and closes tightly when filled to prevent backflow of blood
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)
chest pain (subjective data)
____________ rationale: angina, an important cardiac symptom, occurs when the heart's own blood supply cannot keep up with metabolic demand; chest pain also may have pulmonary, musculoskeletal or gastrointestinal origin; important to differentiate
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
orthopnea (subjective data)
____________ rationale: is the need to assume a more upright position to breathe; note the exact number of pillows used
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)
pwave
_____________ is depolization of the atria
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
neuropathic ulcer
_____________ occur with repetitive stress over at risk areas; over half of diabetic ulcers become infected and about 20% of infections lead to some level of amputation
Deep Vein Thrombosis
_____________ presents with unilateral swelling of the affected leg, tenderness to severe pain, possibly warmth and redness form accompanying inflammation, and possibly superficial venous dilation; evaluate these symproms considering patient's current history and medical conditions; for more accurate resutls use the wells criteria; note that the wells score has been validated in the outpaitent settings, but some evidnece finds it insufficeint to rule out DVT in the inpatient setting; doppler ultrasound imaging should be done
characteristics of chest pain (subjective data)
_____________ rataionale: a squeezing lenched fist sign is charactersitic of angina, but diaphorsis, palpatations, dyspnea, nausea, tachycardia may be aginal equivalents in the absence of chest pain
fatigue related to time of day (fatigue usbjective data)
_____________ ratioale: fatigue from decreased cardiac output is forse in the evening, whereas fatigue from anxiety or depression occurs all day or is worse in the morning
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
new change in exercise (peripheral vascular subjective data)
_____________ rationale: pain of musculoskeletal origin rather than vascular
food and housing adequate
_____________ rationale: refer for state and federal programs to help with food, housing, or other needs
pain made worse by moving arms/neck (subjective data)
_____________ rationale: try to differentiate pain of cardiac versus noncardiac origin
pica
_____________: although a toddler may attempt nonfodos at some time, he or she should recognize edibles by age 2 years
skin changes on arms/legs (peripheral vascular subjective data)
_____________: any skin changes on arms/ legs; what color any change in temperature do leg veins look bulging and crooked/ how treated do you use support hose any sores/ ulcers; where
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
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)
First heart sound S1
______________ is caused by closure of the AV valve; it signals the beginning of systole; you can hear it over the entire precordium although it is loudest at the apex you can hear S1 with the diaphragm with the person in any position and equally well in inspiration and expiration; a split S1 is normal, but it occurs rarely; a split S1 means you are hearing the mitral and tricuspid components separately; it is aduible in the tricuspid valve area, the left sternal border; it is very rapid with two components
afterload
______________ is pressure- it is the opposing pressure the ventricle must generate to open the aortic valve against the higher aortic pressure; it is the resistance against which the ventricle must pump its blood; once the ventricle is filled with blood, the ventricular end diastolic pressure is 5-10 mmHg, whereas that in the aorta is 70-80 mmHg; to overcome this difference, the ventricular muscle tenses (isovolumetric contraction); after the valve opens, rapid ejection occurs
preload
______________ is volume- it is the venous return that builds during diastole; it is the length to which the ventricular muscle is stretched at the end of diastole just before contraction
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
how much swelling/ both legs equally swollen? (edema subjective data)
______________ rationale: cardiac edema is bilateral; unilateral swelling has a local vein cause
dyspnea (subjective data)
______________ rationale: dyspnea on exertion- quantify exactly (e.g. DOE after walking two level blocks)
lymph node enlargement (peripheral vascular subjective data)
______________ rationale: enlarged lymph nodes occur with infection, malignancies, and immunologic diseases
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
edema (subjective data)
______________ rationale: is dependent when caused by heart failure
chest pain chldren (cardiac subjective data)
______________ rationale: serious causes of chest pain are not common; most causes are musculoskeltal pain and respiratory causes, including asthma; however you should refer any acute onset of chest pain, or refer and concern about a potenitally serious cardiac cause
smoking history (peripheral vascular subjective data)
______________ rationale: tobacco constricts arteries, increase coagulability, injures endothelium, and promotes inflammaiton; smoking is the strongest risk factor for PAD; starting at <16 years more than doubles future PAD risk
fatigue (subjective data)
______________ rationale: unsuual _____________ is a top prodromal MI symptom for women
muscle aches associated with fever, chills, flu (muscles subjective data)
______________ rationale: viral illness often includes myalgia
aneurysms
______________ types: thoracic aortic arch abdominal aorta femoral popliteal
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;
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
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
axillary nodes
_______________ drain the breast and upper arm
cervical nodes
_______________ drain the head and neck
hypoactive/ absent sounds
_______________ follow abdominal surgery or with inflammation of the peirtoneum
lymphatics
_______________ functions to: 1. conserve fluid and plasma proteins that leak out of the capillaries, 2. form a major part of the immune system that defends the body against disease, 3. absorb lipids from the small intestine
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
acute heart failure onset
_______________ occurs following a myocardial infarction when the heart's contracing ability has been directly dmaanged
chronic heart failure onset
_______________ occurs with hypertension, when the ventricles must pump against chronically increased pressure
cyanosis/ pallor (subjective data)
_______________ raitonale: occurs with MI or low cardiac output states as a result of decreased tissue perfusion
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
change in sexual function (peripheral vascular subjective data)
_______________ rationale: aortoiliac occlusion is associated with erectile dysfunction (Leriche syndrome)
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
claudication distance
_______________ rationale: not sudden decrease in claudication distance or pain not relieved by rest
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
cough up mucus, color, odor, blood tinged (cough subjective data)
_______________ rationale: sputum production, mucoid or purulent; hemoptysis is often a pulmonary disorder but also occurs with mitral stennosis
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
noted any cyanosis while nursing/ crying (infant cardiovascular history)
_______________ rationale: to screen for heart disease in infant, note fatigue during feeding; infant with heart failure takes fewer ounces each feeding; becomes dyspenicc with sucking; may be diaphoretic, then falls into exhausted sleep; awakens after a short time hungry again
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
leg veins look bulging (peripheral vascular subjective data)
_______________ rationale: varicose veins
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
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
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
cartilaginous joints
________________ are separated by fibrocartilaginous discs and are only slightly movable (E.g. the vertebrae)
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
lymphatic system organs
________________ include: spleen tonsils thymus
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
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
lymphedema
________________ is the accumulation of protein rich fluid in the interstitial spaces of the arm following breast surgery or treatment; it results from axillary lymph node removal, radiation therapy, fibrosis, or inflammation; once protein-rich lymph builds up in the interstitial spaces, it further raises local colloid osmotic pressure, which promotes more fluid leakage
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
lymphedema
________________ objective data include unilateral swelling, measurement of arm volume, nonpitting brawny edema, overlying skin indurated; early knowledge is important because there are treatments to prevent it: deep breathing and ball squeezing exercises, simple lympahtic drainage massage, elevation, compression garments, and strength training as long as no infection is present
gray stools
________________ occur with hepatitis
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
swelling in arms/ legs (peripheral vascular subjective data)
________________ rationale: edema is bilaterla when the cause is generalized (heart failure) or unilateral when it is the result of a local obstruction or inflammation
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
vitamin D
________________ rationale: is essential for maternal response to the calcium demands of the fetus for growth and bone development
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
peripheral artery disease (PAD)
_________________ affects noncoronary arteries and usually refers to arteries supplying the limbs; it is usually caused by atherosclerosis, and less commonly by embolism, hypercoagulabe states, or arterial dissection
mitral prosthetic valve sound
_________________ an iatrogenic sound, the opening of a ball-in-cage mitral protehsis gives an early diastolic sound: an opening click just after S2; it is loud, heard over the whole precordium, and loudest at the apex and left lower sternal border mpv
valves
_________________ are unidirectional; they can only open one way; they open and close passively in response to pressure gradients in the moving blood
lymphatics
_________________ form a completely separate vessel system that retrieves excess fluid and plasma proteins from the interstitial spaces and returns them to the bloodstream; fluid moves according to a pressure gradient (filtration); at the arterial end the hydrostatic pressure is caused by the pumping action of the heart and pushes somewhat more fluid out of the capillaries than the venules can absorb; this fluid is vacuumed out of the interstitial spaces by the lymph vessels; without lymphatic drainage, fluid would build up in the interstitial spaces and produce edema
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
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
what time of day does swelling occur (edema subjective data)
_________________ rationale: cardiac edema is worse at evening and better in morning after elevating legs all night
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
leg sores/ ulcers (peripheral vascular subjective data)
_________________ rationale: leg ulcers occur with chronic arterial and venous disease
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
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
aggrivated by activity/ walking (peripheral vascular subjective data)
_________________ rationale: with PAD, blood flow cannot match muscle demand during exercise; therefore people feel muscle fatigue or pain when walking (claudication); but only 10% of those with PAD have this symptom
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
medications (peripheral vascular subjective data)
_________________ which medications are you taking (e.g. oral ocntraceptives/ hormone replacment)
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
congental heart defects
_________________: patent ductus arteriosus atrial septal deect ventricular septal defect tetrology of fallot coracoration of the aorta
renal artery stenosis
_________________: murmur is midline or toward flank, soft, low-to-medium pitch ras
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
wells score for leg deep vein thrombosis
__________________ combined findings into a simple scoring system; these criteria separate patients into groups of low, moderate, or high risk probability of DVT
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
diastolic dysfunction
__________________ is a failure of the heart to relax fully between heartbeats; here the heart muscle wall is stiff and does nto fill properly; there is low cardiac output but a nromal ejection fraction; about 50% of paitents with heart failure have a preserved ejection fraction; it is normal at rest, but may ny increase appropriately with the stress of exercise, tachycardia, or hypertension
pregnancy
__________________ is divided into 3 trimesters, 1. the first 12 weeks, 2. form 13 to 27 weeks, and 3 from 28 weeks to delivery
progesterone
__________________ maintains the endometrium around the fetus, increases alveoli the the breasts, and keep sthe uterus in a quiescent state
spider angiomas
__________________ occur with portal hypertension or liver disease
heart failure decreased cardiac output
__________________ occurs when the heart fails as a pump and the circulation becomes backed up and congested
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
change in temperature (peripheral vascular subjective data)
__________________ rationale: coolness occurs with PAD
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
Third heart sound
___________________ also occurs with conditions of volume overload such as mitral regurgitation adn aortic or tricuspid regurigtation; the S3 is also found in high cardiac output sates in the absence of herat disease such as hyperthyroidism, anemia, and pregnancy; when the primary condition is conrrected, the gallop disappears
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
heart failure symptoms
___________________ come from two basic mechanisms: 1. the heart's inability to pump enough blood to meet the metabolic demands of the body 2. the kidney's compensatory mechanisms of abnormal retention of sodium and water to compensate for the decreased cardiac output; this increases blood volume and venous return, which causes further congestion
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
deep vein thrombophlebitis
___________________ requires emergency referral because of risk for pulmonary embolism; note that upper extremity DVT is increasingly common as a result of frequent use of invasaive lines such as central venous catheters
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
swelling in arms/ legs (peripheral vascular subjective data)
___________________: in one or both? when star? what time of daw is it worse? does it come and go/ constnat what brings it on what relieves it is it associated wit hpain, heat, redness, ulceration, hard skin
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;
*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
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
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 ______________
medications (peripheral vascular subjective data)
____________________ rationale: these may cause a hypercoagualbe state; also note low-dose aspirin or clopidogrel is used to prevent blodo clots in selected people
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
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
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
left sternal border pulsation
a *lift (heave)* occurs with right ventricualr hypertrophy as found in pulmonic valve disease, pulmonic hypertension, and chronic lung disease; you feel a diffuse lifting impulse during systole at the left lower sternal border; it may be associated with retraction at the apex because the left ventricle is rotated posteriorly by the enlarged right ventricle
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
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
pericardial friction rub
a ______________________ can be heard any place on the precordium but usually is best heard at the apex and left lower sternal border, places where the pericardium comes into close contact with the chest wall; timing may be systolic and diastolic; the friction rub of pericarditis is common during the 1st week after a myocardial infarctio nand may last only a few hours
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
pregnant woman cardiac assessment
a continuous murmur from breast vasculature is termed a mammary souffle, which occurs near term or whe nthe mother is lactating; it is caused by increased blood flow through the internal mammary artery; the murmur is heard in the 2nd 3rd, or 4th intercostal space; it is continuous, although it is accented in systole; you can obliterate it by pressure with the stethoscope or one finger lateral to the murmur; ABNORM: murmurs of aortic valve disease cannot be obliterated p the ECG has no changes except for a slight left-axis deviation caused by change in the heart's position p
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
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;
aging adult cardiac assessment
a gradual rise in the SBP is common with aging; the DBP stays fairly constant with a resutling widening of pulse pressure; some older adults experience orthostatic hypotension, a sudden drop in BP when rising to sit or stand a
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
fourth heart sound
a pathologic S4 is termed an atrial gallop or S4 gallop; it occurs with decreased compliance of the ventricle (e.g. coronary artery disease, cardiomyopathy) and systolic overload (afterload), including outflow obstruction to the ventricle (aortic stenosis) and systemic hypertension; a left sided S4 occurs with these conditions; it is heard best at the apex, in the left lateral position
S3
a pathologic ____________, ventricualr gallop, occurs with heart failure and volume overload
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
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
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
children cardiac assessment
a venous hum- caused by turbulence of blood flow in the jugular venous system- is common in healthy children and has no pathologic significance; it is a continuous, low-pitched, soft hum that is heard throughout the cycle although it is loudest in diastole; listen with the bell over the supraclavicular fossa at the medial third of the clavicle, especially on the right, or over the upper anteiror chest c
atrial septal defect
abnormal opening in the atrial septum, resulting usually in left-to-right shunt and causing large increase in pulmonary blood flow
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
lymphedema
acute ___________________ (within the first 18 months) is reversible with treatment if no tissue damage has occurred; chronic ____________ is more difficult, and can lead to pain, disfigurement, mobility dysfunctino, difficulty fitting into clothing, increased weight of arm making it hard to do daily activities, negative body image, and a constant emotional reminder of cancer
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;
change position (ascultating heart sounds)
after auscultating in the spine position, roll the person toward or her left side; listen with the bell at the apex for the presence of any diastolic filling sounds, i.e. S3 or S4
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
auscultation of the heart
after placing the stethoscope, close eyes briefly to tune out distractions; concentrate and listen to one sound at a time; soncider that 2-4 sounds may happen in less than 1second; begin with the diaphragm endpiece and use the following routine: note the rate and rhythm, identify S1 and S2, assess S1 and S2 separately, listen for extra heart sounds, and listen for murmurs
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
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
electrocardiograph
age related changes in the ____________ occur as a result of histologic changes in the conduction system these include: prolonged PR interval and prolonged QT interval, but QRS interval is unchaged left axis deviation from age-related mild LV hypertrophy and fibrosis in left bundle branch increased incidence of bundle branch block
chronic venous symptoms
aggrevating factors: prolonged standing, sitting
chronic arterial symptoms
aggrivating factors: activity; claudication distance is specific number of blocks/stairs it takes to produce pain elevation (rest pain indicates severe involvement)
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)
aging adult (peripheral circulation)
aging produces a progressive enlargement of the intramuscular calf veins; prolonged bed rest, prolonged immobilization, and heart failrue increase the risk for deep vein thrombosis and subsequent pulmonary embolism; these conditions are common in aging and also with malignancy and myocardial infarction; low-dose anticoagulatn medication reduces risk of venosu thromboembolism
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
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
midysytolic click
although it is systomic, this is not an ejection click; it is associated with mitral valve prolapse, in which the mitral valve leaflets not only close with contractio nbut balloon back up into the left atrium; during ballooning, the sudden tensing of the valve leaflets and chordae tendine creates the click mc
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
culture and cardiovascular disease
among people with a higher genetic risk, adopting favorable lifestyle is associated with 46% lower risk of CAD events than an unfavorable lifestyle; a favorable lifesyle includes four healthful factors- no current smoking, no obesity, physical activity at least once per week, and a healthy diet (i.e. fruits, nuts, vegetables, whole grains, fish, dairy products with lesser amounts of refined grains, processed meats, red meats, sugary drinks, trans fats, and sodium)
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 _____________
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
dorsalis pedis
anterior tibial artery travels down the front of the leg on to the dorsum of the foot, where it becomes the ___________________
chest pain (subjective data)
any __________ or tightness onset: when did it start? how long have you had it? location: where did the pain start? character: where di the pain start? any radiation? character? how would you decribe pain? pain brought on by: activity any associated asymptoms pain made worse by moving the arms or neck pain relieved by rest or nitroglycern
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
family cardiac history (subjective data)
any family history of: hypertension, obesity, diabetes, CAD, sudden death at younger age
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?
past cardiac history (subjective data)
any history of: hypertension, elevated cholesterol or triglycerides, heart murmur, congenital heart disease, rheumatic fever or unexplained joint pains as child or youth, recurrnet tolsilits, anemia ever had heart disease? when was this? treatment? last ECG, stress ECG, serum cholesterol measurement, other heart tests?
aging adult cardiac subjective data
any known heart or lung disease: hypertension, CAD, chronic emphysema, bronchitis (risk of CVD increases with age) take any medications for illness such as digitalis (noncompliance, may be related to risk of side effects or lack of finances) environment: does home have any stairs/ how often do you climb them
leg pain/ cramps (subjective data)
any leg pain/ cramps; where? describe the type of pain, is it burning, aching, cramping, stabbing aggrivated by activity/ walking how many blocks does it take to produce pain has amount changed recetly is the pain worse with elevation/ cool temperature does hte pain wake you up at night recent change in exercise what relives the pain: dangling, walking, rubbing is it associated with change in sexual function any history of vascular/ heart problems
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 _____________________
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
edema (subjective data)
any swelling of feet/ legs? onset? recent change? time of day swelling occurs? how much swelling would you say there is/ both legs equally swollen? does swelling go away with: rest, elevation, sleep? any associated symptoms, such as SOB?
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
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?
aportic prosthetic valve sound
as a sequela of modern technology for heart problems, some people have iatrogenically induced heart sounds; the opening of a mechanical ________________ produces an early systolic sound; this sound is less intense with a tilting disc prosthesis and is absent with a biologic tissue prosthesis
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
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
change position (ascultating heart sounds)
ask the person to sit up, lean forward slightly, and exhale; listen with the diaphragm pressed at the base, right, and left sides; check for the soft, high-pitched, early diastolic murmur of aortic or pulmonic regurgitation
varicose veins
ask the person to stand up so you can assess the venous system; note any visible, dilated, and tortuous veins; if ______________ are present, ask if they cause pain, swelling, fatigue, cramping
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
acute arterial symptoms
associated symptoms: 6 p's: pain, pallor, pulselessness, parasthesia, poikiliothermia, paralysis
pneumothorax
associated symptoms: acute dyspnea, cough
pulmonary embolism
associated symptoms: dyspnea, hemoptysis, cough
chronic venous symptoms
associated symptoms: edema, varicosities, weeping ulcers at ankles
mitral valve prolapse
associated symptoms: fatigue, light-eadedness, dyspnea, irregular heart beat, palpitations, exercise intolerance
depression
associated symptoms: fatigue, restlessness, withdrawal, weight gain or loss, depressed mood
chronic arterial symptoms
associated symptoms: low ankle-brachail index; cool, pale skin; diminished pulses, pallor on elevation
aortic dissection
associated symptoms: mental status changes, limb pain and weakness, dyspnea
chest wall muscle strain
associated symptoms: muscle spasm, crepititation, swelling, loss of strength
cholecystitis
associated symptoms: nausea, vomiting, anorexia, fever
pancreatitis
associated symptoms: nausea, vomiting, anorexia, sometimes diarrhea
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
varying intensity of S1
atria and ventricles beat independently e.g. complete heart block with chaniging PR interval
varying intensity of S1
atria and ventricles beat indepndently e.g. complete heart block with changing PR interval
pregnant woman cardiac assessment
auscultation of the hart sounds sows changes caused by the increased blood vulmue and workload; an exaggerated splitting of S1 and increased loudness of S1 are common, as is a loud, easily heard S3; an ejection systolic murmur is common; heard at left sternal border; grade 1-3 in intensity p
infant abdominal exam
auscultation: auscultation yields only bowel sounds, the metallic tinkling of peristalsis; no vascular sounds should be heard
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
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
pulsus paradoxus
beats have weaker amplitude with inspiration, stronger with expiration; best determined using blood pressure measurement; reading decreases during inspiration and increases with expiration associated with: common finding in cardiac tamponade (pericardial effusion in which high pressure compresses the heart and blocks cardiac output) and in severe bronchospasm of acute asthma
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)
venous flow
besides the presence of intralumanial valves, venous structure differs from arteria lstructure; because venous pressure is lower, walls of the veins are thinner than those of the arteries
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;
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
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
pulmonic stenosis
calcification of pulmonic valve restricts forward flow of blood
aortic stenosis
calcification of the aortic valve cusps restricts forward flow of blood during systole; LV hypertrophy develops
mitral stenosis
calcified mitral valve impedes forward flow of blood into left ventricle during diastole; results in LA enlarged and LA pressure increased
apex pulsation (volume overload)
cardiac enlargement displaces the apical impulse laterally and over a wider area when left ventricular hypertrophy and dilation are present; this is volume overload, as in heart failure, mitral regurgitation, aortic regurgitation, and left-to-right shunts
culture and cardiovascular disease
cardiovasular disease is the most common underlying cause of death in the world, causing 31.5% of all global deaths; inherited DNA variation and lifestyle factors each contribute independently to the development of cardiovascular disease or coronary artery disease
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
pansystolic regurgitation mumurs
caused by backward flow of blood from area of high pressure to one of lower pressure mitral reguritation tricuspid regurgitation
midsystolic ejection murmur
caused by forward flow through semilunar valves aortic stenosis pulmonic stenosis
early diastolic murmurs
caused by semilunar valve incompetence aortic regurigation pulmonic regurgitation
chronic venous symptoms
character: aching, tiredness, feeling of fullness
chronic arterial symptoms
character: intermittent claudication, feels like cramp, numbness and tingling, feeling of cold
acute venous symptoms
character: moderat eto intense, sharp; deep muscle tender to touch
acute arterial symptoms
character: throbbing
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
pertibial edema
check for _______________; firmly depress the skin over tie tibia or the medial maleolus for 5 secnds and release; normally, your finger should leave no indentation, although a pit is commonly seen if the person has been standing all day or is pregnant
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 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
epitrochlear lymph node
check the _________________ in the depression 2-3 cm above and behind the medial condyle of the humerus; do this by shaking hands with the person and reaching your other hand under the person's lebow to the groove between the biceps and triceps muscles, above the medial epicondyle; they are not normally palpable
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
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
auscultation of the heart
clean the endpieces with an alcohol wipe; you will use both; although all heart sounds are low frequency, the diaphragm detects relatively higher-pitched sounds, and the bell detects relatively lower-pitched ones; make sure the earpieces fit snugly and are aimed forward toward the nose to avoid air leak; heart sounds are soft, enhace success iwth a completely quiet room, no television, radio, or talking
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
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
risk factors for CAD
collect data regarding elevated cholesterol, elevated BP, blood sugar levels above 100mg or known DM, obesity, cigarette smoking, low activity level, and length of any hormone replacement therapy for postmenopausal women.
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
capillary refill
conditions can skew findings include: cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia
murmurs
conditions that can cause ______________ include: velocity of blood increases (flow murmur) (e.g. in exercise, thyrotoxicosis) viscosity of blood decreases (e.g., in anemia) structural defects in valves (a stenotic or narrowed valve, an incompetent or regurgitant vale) or unusual openings in the chambers (dilated chamber, septal defect)
paradoxical split
conditions that delay aortic valve closure cause the opposite of a normal split; in inspiration P2 is normally delayed; thus with a ___________________ the sounds fuse; in expiration you hear the split in order of P2 A2 e.g. aortic stenosis, left bundle branch block, patent ductus arteriosus
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
heart
consider the _____________ is two pumps; the right side of the ____________ pumps blood into the lungs, and the left side simultaneously pumps blood into the body; the two pumps are separated by an impermeable wall, the septum
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
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
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
loudness (murmurs)
describe the intensity in rerms of six grades: 1. barely audible, heard only in quiet room with difficulty 2. clearly audible but faint 3. moderately loud, easy to hear 4. loud, associated with thrill palpable on chest wall 5. very loud, heard with one corner of the stethoscope lifted off chest wall, associated thrill 6. loudest, heard with entire stehoscope lifted off chest wall, associated thrill
pitch (murmurs)
describe the pitch as high, medium, or low; the pitch depends on the pressure and rate of blood flow producing the murmur
acute coronary snydrome (ACS)
description: heaviness; viselike, squeezing, crushing, tightness; vague, burning, constricting, or pressure; poorly localized pain lasting 20-30 minutes to hours and does not resolve with rest or nitroglycerin
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
incompetent valves
dilated and tortuous veins create __________________, wherein the lumen is so wide that the valve cusps cannot appxoimate; this condition increase venous pressure, which further dilates the vein; some people have a genetic predisposition to _______________, but venous pooling also occurs in obese people and women following multiple pregnancies
heart failure symptoms
dilated pupils (Sympathetic nervous system response) skin pale, gray, or cyanotic dyspnea, SOBOE is early symptom from pulmonary congestion orthopnea, cannot breathe unless sitting up creackles, wheeze are adventitious breath sounds cough, frothy pink or white sputum
Tinel Sign
direct percussion of the median nerve at the wrist produces no symptosm in the normal hand
auscultation of the heart
do not limit ________________ to only four locations; sound prouced by the valves may be heard all over the precordium; thus learn to inch your stethoscope in a rough z pattern, from the base of the heart across adn down and over to the apex; or start at the apex and work your way up
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)
nocturia (subjective data)
do you awaken at night with urgent need to urinate? how long has it been occuring? any recent change?
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?
fatigue (subjective data)
do you seem to tire easily? able to keep up with family/ co-workers? onset: when did fatigue start? fatigue related to time of day?
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?
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
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
veins in the arm
each arm has two sets of veins: superifial and deep; the superfiical veins are in the subcutaneous tissue and are responsible for most of the venous return
pulse
each heartbeat creates a pressure wave, which makes the arteries expand and then recoil; it is teh recoil that propels blood through like a wave; all arteries have this pressure wave, or _______________, throughout their length, but you can feel it only at body sites where the artery lies close to the skin and over a bone
pulsus bisferiens
each pulse has two strong systolic peaks with a dip in between; best assessed at the carotid artery associated with: aortic valve stenosis plus regurgitation
nucleus propulsus
each vertebral disc has a _________________ made of soft, semifluid, mucoid material that has the consistency of tooth paste in the young adult
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
full, bounding pulse
easily palpable, pounds under your fingertips associated with: hyperkinetic states (exercise, anxiety, fever), anemia, hyperthyroidism
deep vein thrombosis (DVT)
edema and pain in one leg occur with __________________ and warrant doppler studies
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
men age 45-79/ women 55-79
encouage ________________ to use low-dose aspirin if the potential benefit of preventing MI outwieghs potential risk of GI bleeding; vitamin D replacement is importnat; vitamin D deficiency increases risk of CVD and is associated with hypertension
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
raynaud phenomenon
episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress; 1. white from sympathetic-mediated vasoconstriction and resulting deficit in supply; 2. blue from slight relaxation of spasm that allows a slow trickle of blood throug the capillaries and increased oxygen extraction of hemoglobin; 3. red (rubror) in heel of hand caused by return of blood into dilated capillary bed/ reactive hypemia
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
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
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
peripheral vascular exam preparatin
examin arms at beginning during vital signs and person is sitting examine legs after abominal exam have person stand to evaluate leg veins compare findings with opposite extremity equipment: paper tape measure, tourniquet/ BP cuff, stethoscope, doppler ultrasound
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
culture/ genetics peripheral circulation
examining risk factors by gender, data showed that depressio nwas the strongest risk factor in women for PAD; because PAD is underrecognized and undertreated in women, mental helath screening may target more women i nneed of care; across age ranges, African Americans have twice the burden of PAD than do Caucasians; traditional risk factors for African Americans are high, but adjusting these does not eliminate the high prevalence
infant cardiac assessment
expect the heart rhythm to have sinus arrhythmia, the phasic speeding up or slowing down of the respiratory cycle rapid rates make it more challenging to evaluate heart sounds; except sounds to be louder in infants than in aduults because of the infant's thinner chest wall; also S2 has a higher pitch adn is sharper than s1; splitting of S2 jsut after the height of inspriation is common, not at birth but beginning a few hours after birth i
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
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
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
ankle-brachial index
for _______________, the patient is lying flat with the head and heels fully supported; confirm no smoking within 2 hours and a 5-10 minute rest period supine before measurement; choose correct cuff width for arm and ankle; position the ankle cuff just above the malleoli with straight wrapping
apical impulse
for ________________ note: location- it should occupy only one interspace, the 4th or 5th, and be at or medialy to the midclavicular line size- normally 1-2 cm amplitude- normally a short, gentle tap duration- short; normally occupies only first half of systole
systole
for a very brief moment all four valves are closed; the ventricular walls contract; this contraction against a closed system works to build pressure inside the ventricles to a high level *(isometric contraction)*; when the pressure in the venitrcle finally exceeds pressure in the aorta, the aortic valve opens, and blood is ejected rapidly
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
auscultaitng carotid artery
for people middle age or odler who show signs of CVD ascsultate each carotid artery for the presence of a bruit; this is a blowing, swishing sound indicating blood flow turbulence; normally none is present
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
children cardiac assessment
for the child whose murmur has been shown to be innocent, it is very important that the parents undesetand thsi completely; they need to believe tha tthe murmur is just a noise and has no pathologic significance; otherwise the parents may become overprotective adn limit activity for the child which may result in the child developing a negative self-concept c
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
tetralogy of fallot
four defects: 1. pulmonic stenosis; 2. VSD; 3. compensatory right ventricular hypertrophy, and 4. overriding aorta that receives blood from both right and left ventricles; results: shunts a lot of venous blood directly into aorta away from pulmonary system, thus blood never gets oxygenated
cardiac sex and gender differences (culture and genetics)
four prodromal symptoms linked with ACS are discomfort in the jaw or teeth, unusual fatigue, arm pain, and shortness of breath; at the time of having ACS, women are more likely to report fatigue, nausea, neck pain, right arm pain, jaw pain, dizziness, and syncope than men women with ACS were less likely to list chest pain as their primary symptom and more likely to report nausea, shoulder pain, and upper back pain; further, women with ACS report more symptoms when compared with men
inspect jugular venous pulse
from the jugular veins you can assess the central venous pressure (CVP) and thus judge the heart's efficiency as a pump. Stand on the person's right side because the veins there have a direct route to the heart. You may use either hte external or internal jugular veins because measurements in both are similar; you can see the top of the external jugular vein distension overlying the sternomastoid muscle or the pulsation of hte internal jugular vein in the sternal notch; the latter is harder to see because of the deep postiion. Position the person supine anywhere from a 30- to a 45-degree angle, wherever you can best see the top of the vein or pulsations. in general the higher the venous pressure is, the higher hte position you need. remove the pillow to avoid flexing the neck; the head should be in the same plane as the trunk. Turn the person's head slightly away from the examined side, and direct a strong light tangentially onto the neck to highlight pulsations and shadows.
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
water hammer (corrigan) pulse
greater than normal force, then collapses suddenly associated with: aortic valve regurgitation, patent ductus arteriosus
children cardiovascular subjective data
growth: has child grown as expected by growth charts activity: is child able to keep up with siblings/ age mates has the child had any chest pain? does the child have frequent respiratory infections? family history: child have sibling with heart defect?
identify S1 and S2
guidelines to ____________ include: S1 is louder than S2 at hte apex; S2 is louder than S1 at the base S1 coincides with carotid artery pulse; feel the carotid gently as you ascultate the apex S1 coincides with the R wave is the person is on an ECG
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 ________________________-
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
weak, theady pulse
hard to palpate, need to search for it, may fade in and out, easily obliterated by pressure *associated with*: decreased cardiac output, peripheral arterial disease, aortic valve stenosis
pregnant woman cardiac subjective data
have ou had any high BP during this or eralier pregnancies? what was usual BP level before pregnancy; how has it been monitored during pregnancy if high BP, what treatment started? any associated symptoms: weight gain, protein in urine, swelling in feet any faintness or dizziness with pregnancy
leg color changes
have the person sit up with both legs over the side of the table; compare the color of both feet- the time it takes for color to return to the feet is 10 seconds or less; also note the time it takes for superficial veins around the feet to fill- normal is about 15 seconds; *this test is unreliable if the person has concomitant venous disease with incompetent valves*
systole
heart contraction is _________________; during ___________ blood is pumped from the ventricles and fills the pulmonary and systemic arteries; this is one-third of the cardiac cycle
systolic dysfunction
heart failure may involve __________________, inwhich the heart cannot contract properly, resulting i na low ejection fraction (the stroke volume divided by the end-diastolic volume, normalyl 60-80%)
children cardiac assessment
heart murmurs that are innocent/ functional in origin are very common throughout childhood (often termed Stills murmur); they ma have a 30% occurrence, although some authors say that nearly all children may demonstrate a murmur at some time; most innocent murmus have these characteristics: soft, relavively short, early or midsystolic ejection murmur; medium pitch; vibratory; best heard at the left lower sternal or midstarnal border, with no radiation to the apex, base, or back c
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
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
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
estimating jugular venous pressure
hold a vertical ruler on the sternal angle; align a straightedge on the ruler like a T-square and adjust the level of the horizontal starightedge to the level of pulsation; read the level of intersection on the vertical ruler; normal jugular venous pulsation is 2 cm or less above the sternal angle; also state the person's position (e.g. internal jugular vein pulsations 3 cm above sternal angle when elevated 30 degrees)
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
pregnant woman (peripheral circulation)
hormonal changes cause vasodilation adn the resulting drop i nblood pressure; the growing uterus obstructs drainage of the iliac veins and the inferior vena cava; this condition causes low blood flow and increases venous pressure; this in turn causes dependent edema, varicosities in the legs and vulva, and hemorrhoids
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?
infant cardiovascular history
how was mother's health during pregnancy? any unexplained fever, rubella first trimester, other infection, hypertension, drugs? have you noted any cyanosis while nursing, crying? is baby able to eat without tiring? growth: has baby grown as expected by growth charts about about same as siblings/ peers? activiy: were baby's motor milestones achieved as expected?
precordium auscultation
identify anatomic areas where you listen note rate and thythm of heartbeat identify S1 and S2 and note any variation listen in systole and diastole for any extra heart sounds listen in systole and diastole for murmurs repeat sequence with bell listen at apex with person in left lateral position listen at base with person in sitting position
auscultation of the heart
identify the ascultaory areas where you will listen; these include the four traditional valve areas; the valve areas are not over the actual anatomic locations of hte valves but are the sites on the chest wall where sounds produced by the valves are best heard; the sound radiates with the direction of blood flow
pertibial edema
if present, grade it on the following scale: 1+ mild pitting, slight indentation, no perceptable swelling of leg 2+ moderate pitting, indentation subsides rapidly 3+ deep pitting, indententation remains for a short time, leg looks swollen 4+ very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted
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
estimating jugular venous pressure
if venous pressure is elevated or if you suspect heart failure, perform the abdominojugular test; position the person comfortable supine and instruct him to to breathe quietly through an open mouth; hold your right hand over the midabdomen and watch the level of jugular pulsation as you push in with your hand; exert firm sustained pressure for 10 seconds; this displaced blood out of the splanchic vessels and adds its volume to the venous system; if the heart is able to pump the additiional volume, the jugular veins will rise for a few seconds and the nrecede back to the previous level
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
estimating jugular venous pressure
if you cannot find the internal jugular veins, use the external jugular veins and note the point where they look collapsed; be aware that the technique of estimating venous pressure is difficult and is not always a reliable predictor of CVP; consistency in grading amng examiners is difficult to achieve
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
leg color changes
if you suspect an arterial deficit, raise the legs about 30 cm off hte table and ask the person to wag the feet for 30 seconds to drai noff venous blood; the skin color now reflects onyl contribtuin of aterial blood; a lgiht-skinned person's feet normally look a little pale, but should still be pink; a dark-skinned person's feet are more difficult to evaluate, but the soles should reveal extreme color change
diastole
in ________________, the ventricles relax and fill with blood; this takes up 2/3 of the cardiac cycle
diastole
in _________________ the ventricles are relaxed, and the AV valves (i,e, triscupid and mitral) are open; opening of normal valve is acoustically silent; the pressure in the atria is higher than that in the ventricles; therefore blood pours rapidly into the ventricles; this first passive filling phase is called early/ protodiastolic filling
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
Third heart sound
in adults the S3 is usually abnormal; the pathologic S3 alsoc called a ventircualr gallop or an S3 gallop, and it persists when sitting up; the S3 indicates decreased compliance of the ventricles, as in heart failure; it may be the earliest sign of heart failure; the S3 may originate from either the left or right ventricle; a left-sided S3 is heard at the apex in the left lateral position, and a right-sided S3 is heard at the left lower sterna lborder wit hthe person supine and is louder on inspiration s3
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
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
calf pump/ peripheral heart (venous flow)
in the legs, this mechanism is called the _____________; when walking, the calf muscles alternately contract (systole) and relax (diastole); in the contraction phase the gastrocnemius and soleus muscles squeeze the veins and direct the bllod flow proximally; because of the valves, venous blood flows just one way-toward the heart
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
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
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
infants and children cardiovascular system
inflation and aeration of hte lungs at birth produces circulatory changes; now the blood is oxygenated through the lungs rather than through the placenta; the foramen ovale closes within the first hour because of the new lower pressure in the right side of the heart than the left side; the ductus arteriosus closes later, usually within 10-15 hours of birth; now the left ventricle has the greater workload of pumping into the systemic circulation; so by the time baby has reached one year of age, the mass of the left ventricle will increase to the adult ratio of 2:1 left to right ventricle
pregnant woman cardiac assessment
insepction fo the skin often shows a mild hyperemia in light skinned women becasue the increased cutaneous blood flow tries to eliminate the excess heat generated by the increased metabolism; palpation of the apical impulse is higher and lateral compared with the norrmal position because hte enlarging uterus elevates the diaphragm and ispalces the heart up and to he left and roates it on its long axis p
heart
inside the body the heart is rotated so its right side is anterior and its lseft side is mostly posterior; of the heart's four chambers, the right venticle is immediately behind the sternum and forms the greaterset area of anteiror cardiac surface; the left ventricle lies behind the right ventircle and forms the apex and slender area of the left border; the right atrium lies to the right and above the right ventricle and forms hte right border; the left atrium is located posteriorly, with only a small portion, the left atrial appendage, showing anteriorly
temperature of legs
inspect and palpate legs: palpate for tempereature along the lgs down to the feet, comparing symmetric spots; the skin should be warm and equal bilaterally; bilateral cool feet may be caused by environmental factors such as cool room temperature, apprehension, adn cigarette smoking; if any increase in temperature is present higher up the leg, not if it is gradual or abrupt
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
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
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
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
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
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
timing (murmurs)
it is crucial to define the murmur by its occurrence in systole or diastole; you must be able to identify S1 and S2 accurately to do this; try to further describe the murmur as being in early, mid, or late systole or diastole throughout the cardiac even (termed pansstolic, holosytiolic/ pandiastolic, or holodiastolic) t; and whether it abscures or muffles the heart sounds
aging adult cardiovascular system
it is difficult to isolate the aging process of the ________________ because it is so closely related with lifestly,e habits, and diseases; lifestyle modifies the development of CV disease; smoking, diet, alcohol use, exercise patters, and stress have an immense influence; lifestyle also affects the aging process; cardiac changes one thought to be caused by aging are partially the result of the sedentary lifestyle accompanying aging
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
auscultaitng carotid artery
keep the neck in neutrla psotiion; lightly apply the bell of the stethoscope over the carotid artery at three levels: 1. angle of jaw; 2. mid cervical area; 3. base of the neck; avoid compressing the artery because this could cause an artifial bruit, and it could copmromise circulation if the carotid artery is already narrowed by atherosclerosis; ask person to take a breath, exhale, and hold it priefly while you listen so tracheal breath sounds to not mask or mimic a bruit; sometimes you can hear normal heart sounds transmitted to the neck
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
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
inspect and palpate arms
lift both hte person's hads in your hands; inspect and then turn the persons hads over, noting color of skin and nail beds; temperature, texture, and turgor of skin; and the presence of any lesions, edema, or clubbing
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
modified allen test
limitations of the ________________ are that it is subjective nad requries patient cooperation that may not occur in emergency or ritical care situations- just the times when you need to cannulate the radial artery; doppler flow studies can ensure colateral flow that is quantifiable; a small, flat probe is taped to the palm at the end of the patient's index finger; a baseline value for blood flow is recorded and then compared for change when the two arteries are occluded
focus on systole, then diastole, then other heart sounds (ascultation of heart sounds)
listen with the diaphragm; then switch to the bell, covering all ausculatory areas; usually these are silent periods; when you do detect an extra heart sound, listen carefully to note its timing and characteristics; during systole the midsstolic clic is the most common extra sound; the third and fourth heart sounds occur in diastole; either may be normal or abnormal
apical impulse
localize the _________________ precisely by using one finger pad; asking the person to exhale and hold it helps the examiner locate the ________________; you may need to roll the person midway to the left to find it; note that this also displaces the apical impulse farther to the left; you feel it best at the end of expiration when the heart is closest to the chest wall; then it moves quickly away from the finger
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
carotid artery palpation
located central to the heart, the carotid artery yields important information on cardiac function; palpate each ______________ medial to the sternomastoid muscle in the neck; avoid excessive pressure on the carotid sinus area higher in the neck; excessive vagal stimulation here could slow down the heart rate, especially in older adults; take care to palpate gently; palpate only one _______________ at a time to avoid compromising arterial blood to the brain
pulmonary hypertension/ secondary
location/radiation: chest region
herpes zoster
location/radiation: chest region in dermatome distribution
cholecystitis
location/radiation: epigastrium or right upper abdomen that can radiate to right intrascapular region, shoulder, or back
pancreatitis
location/radiation: epigastrum of periumbilical pain radiating to back
acute coronary snydrome (ACS)
location/radiation: generalized substernal or retrosternal: can radiate to teeth, jaw, neck, one or both arms or shoulders; or there may be no pain and onyl associated symptoms
pneumonia
location/radiation: mostly generalized to one side of chest but can have upper abdominal pain
pulmonary embolism
location/radiation: pain can be experienced in chest, back, shoulder, or upper abdomen
gastroesophageal reflux
location/radiation: retrosternal region
Prizmetal/variant angina
location/radiation: retrosternal: can radiate to jaw, neck, left arm, or shoulder
esophageal spasm
location/radiation: substernal
pericarditis
location/radiation: substernal, which can radiate to trapezius muscle region
pneumothorax
location/radiaton: lateral region of the chest but can have referred pain to shoulder
acute venous symptoms
location: calf
chronic arterial symptoms
location: deep muscle pain, usually in calf, but may be lower leg or dorsum of foot
internal jugular pulse
location: lower, more lateral, under or behind the sternomastoid muscle quality: undulant and diffuse; two visible waves per cycle
acute arterial symptoms
location: varies, distal to occlusion, may involve entire leg
chronic venous symptoms
locoation: calf, lower leg
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
infants and children (peripheral circulation)
lymph nodes are relatively large in children, and the superficial ones often are plpable even when teh child is healthy; with infection, excessive swelling and hyperplasia occur; enlarged tonsils are familiar signs in respiraotry infections; the excessive lymphoid response also may account forthe common childhood symptom of abdominal pain with seemingly unrelated problems such as upper respiratory infection; possibly the inflammation of hte mesenteric lymph nodes produces abdominal pain
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
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
34 weeks
malpresentation: before __________________ gestation, any position is normal;
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
raynaud phenomenon
may have cold, numbness, or pain along with pallor cyanosis stage; then burning, throbbing pain, swelling along with rubror; avoidance of cold is the most effective therapy; when episodes do occur, rewarm hands by donning gloves, rubbing in warm water, or using chemical rewarmers; afeer rewarming, a typical attack lasts 15-20 minutes; avoid smoking, sympathomimetic drugs, certai ndrugs for migrain headaches and for ADHD
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
faint S1
more foreceful atrial contraction into noncompliant ventricle; delays or diminsihes ventiruclar contraction e.g. severe hypertension-systemic or pulmonary
abdominal aortic aneursym AAA
most common are fusiform in shape extending from below the renal arteries to invovle the entire intrarenal aorta and often involve the common iliac arteries; pressure causes lower abdominal pain and dull lower back pain
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
rotation
moving the head around a central axis
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
aortic stenosis
murmur: loud, harsh, midsystolic crescendo-decrescendo, loudest at second right interspace, radiates widely to side of neck, down left sternal border, or apex
mitral regurgitation
murmur: pansystolic, often loud, blowing, best heard at apex; radiates well to left axilla
tricuspid regurgitation
murmur: soft blowing pansystolic; best heard at left lower sternal border; increases with inspriation
aortic regurgitation
murmur: starts almost simultaneosly with S2; soft, high pitched, blowing diastolic, decrescendo, best heard at 3rd left interspace at base as person sits up and leans forward, radiates down
pulmonic stenosis
murmur: systolic, medium pitch, coarse, crescendo-decrescendo (diamond shape), best heard at 2nd left interspace, radiates to the left and neck
infant cardiac assessment
murmurs in the immediate newborn period do not necessarily indicate congenital heart disease; they are relaitevly common in the first 2-3 days; the murmur of PDA is a continusou machinery murmur, which disappears by 2-3 days; on the other hand, absence of a murmur in the immediate newborn period does not ensure a healthy heart; congential defects can be present that are not signaled by an early murmur i
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
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
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
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
opening snap
normally the opening of hte AV valves is silent; in the presence of stenosis, increasingly higher atrial pressure is required to open the valve; the deformed valve opens with a noise: the opening snap; it is sharp and high pitched with a snapping quality os
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
infant cardiac assessment
note any extracardiac signs that may reflect heart status (particularly in the skin), liver size, and respiratory status; the skin color should be pink to pinkish brown, depending on the infant's genetic heriage; if cyanosis occurs, determine its first appearance- at or shortly after birth versus after the neonatl period; normally the liver is not enlarged, and the respiratiosn are not labored; in addition, note the expected parameters of weight gain throughout infancy
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
children cardiac assessment
note nay extracardiac or cardiac signs that may indicate heart disease: poor weight gain, developmental delay, persistent tachydardia, tachypnea, DOE, cyanosis, and clubbing; note that clubbing of fingers and toes usually does not appear until late in the first year, even with severe cyanotic defects; the apical impulse is sometimes visible in children with thin chest walls; note any obvious bulge or any heave- these are not normal c
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
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
inspect jugular venous pulse
note the external jugular veins overlying the sternomastoid muscle; in some people the veins are not visible at all, whereas in others they are full in the supine position; as the person is raised to a sitting position, the external jugulars flatten and disappear, usually at 45 degrees
inspect and palpate arms
note the presence of any scars on hands and arms; many occur normally with usual childhood abrasions or occupations involving hand tools
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
listen to S1 and S2 separately
note whether each heart sound is normal, accentuated, diminished, or split; inch your diaphragm across the chest as you do this
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
systole
now so much blood has been pumped into the ventricles that eventricular pressure is finally higher than that in the atria; thus hte mitral and tricuspid valves swing shut; the AV valves close to prevent any regurgitation of blood back up into the atria during contraction
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)?
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
coarctation of the aorta
objective data: arm with hypertension over 20 mmHg higher than leg measures is a hallmark of coarctation; another important sign is absent or greatly diminished femoral pulses; a systolic murmur is heard best at the left sternal border, radiating to the baack
aortic regurgitation
objective data: bounding "water-hammer" pulse in carotid, brachial and femoral arteries; blood pressure has wide pulse pressure; pulsations in cervical and suprasternal area, apical impulse displaced to left and down, apical impulse feels brief
arterial (ischemic) ulcer
objective data: coolness in only one foot or leg, pallor, elevational pallor and dependent rubror; diminished pulses; systolic bruits; signs of malnutrition (thin shiny skin, thick-ridged nails, atrophy of muscles); distal gangrene
superficial varicose veins
objective data: dilated, tortuous veins; new varicosities sit on surface of muscle or bone; older ones are deep and feel spongy
mitral stenosis
objective data: diminished, often irregular arterial pulse; lift at apex, diastolic thrill common at apex; S1 accentuated; precordium followed by murmur
venous (stasis) ulcer
objective data: lower leg edema that does not resolve with diuretic therapy; firm, brawny edema; coarse, thickened skin; pulses normal; brown pigment discoloration; petechiae; dermatitis; venous stasis causes increased venous pressure, which then causes red blood cells to leak out of veins into skin; RBCs break down to hemosiderin (iron deposits), which are brown pigment deposits; borders are irregular; venous ulcers are shallow and may contain granulation tissue; a weepy, pruritic stasis dermatitis may be present
pulmonic stenosis
objective data: thrill in systole at 2nd and 3rd left interspaces, ejection click often present after S1, diminished S2 and usually with wide split, S4 common with RV hypertrophy
patent ductus arteriosus
objective: blood pressure has wide pulse pressure and bouding peripheral pulses from rapid runoff of blood into low-resistance pulmonary bed during diastole; thrill is often palpable at left upper sternal border; the continuous murmur heard in systole iand diastole is called a machinery murmur
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
aging adult cardiac assessment
occational premature ectopic beats are common and do not necessarily indicate underlying heart disease; when in doubt obtai nan ECG; however, consider that hte ECG records for only one isolated minute in time and may need to be supplemented by a test of 24-hour ambulatory monitoring a
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
heart conduction
of all organs, the heart has a unique ability- automaticity; the heart can contract by itself, independent of any signals or stimulation from the body; it contracts in response to an electrical current conveyed by a condcution system
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
respiration affect on heart sounds
on the left side, a greater amount of blood is sequestered in the lungs during inspiration; this momentarily decreases the amount returned to hte left side of the heart, decreasing left ventricular stroke volume; the decreased volume shortens lefet ventricular systole and allows the aortic valve to close a bit earlier
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
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
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
aging adult (peripheral circulation)
only about 10% of people with PAD have the classic symptom of intermittent claudication; about 40% do not state the symptom of leg pain, and the remaining 50% present with a mix of leg symptoms different from IC; IC is pain in a speciifc muscle group that is brought on by walking and is relieved by rest; IC impairs both walking distance and the person's quality of life; many older adults are disabled, suffer from arthiris or peripheral neuropathy, and cnanot or will not walk; this delays PAD diagnosis and accounts for so many undiagnosed by history alone
chronic arterial symptoms
onset and duration: chronic pain, onset gradual after exertion
acute arterial symptoms
onset and duration: sudden onset (within 1 hr) a
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
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
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
pulmonary hypertension/ secondary
pain description: cardiac-like chest pain with exertion
esophageal spasm
pain description: crushing chest pain
depression
pain description: heaviness location/ region: chest region
gastroesophageal reflux
pain description: may be angina-like; however, usually burning sensation with eating large meals reproduced by lying down and relieved by sitting up
pneumonia
pain description: sharp or stabbing pain associated with cough
anxiety
pain description: sharp pain location/radiation: chest region
mitral valve prolapse
pain description: sharp pain not associated with activity
chest wall muscle strain
pain description: sharp pain with moving, stretching, or pushing movements of the arms; palpation of area reproduces the pain
costochondritis
pain description: sharp, pleuritic-type pain worsens with deep breahting, palpation, or movement
pulmonary embolism
pain description: sharp, stabbing pain worsening with deep breaths
pancreatitis
pain description: sudden dull, boring, steady pain unrelieved by lying supine; leaning forward or the fetal position may ease pain
cholecystitis
pain description: sudden onset of bain taht crescendos and can last for up to 20 minutes, usually after eatting a fatty meal
aortic dissection
pain description: sudden severe pain with change in location and/or tearing sesnation lasting for hours
pericarditis
pain description: sudden sharp and stabbing pain relieved often by sitting or leaning forward and worsens by lying down or with inspiration
herpes zoster
pain description: unilateral, burning, borelike pain
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
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
infants and childrne peripheral vascular system
palpable lymph nodes occur often in healthy infants and children; they are small, firm (shotty), mobile, and nontender; they may be sequalae of infection such as inguainl nodes from a diaper rash or cervical nodes from a respiratory infection; vaccinations also can produce local lympadenopathy; note characteristics of any palpable nodes and whether they are local or generalized
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)
brachial pulses
palpate the ________________ if there is suspected arterial insufficiency, their force should be equal bilaterally
children cardiac assessment
palpate the apical impulse in the fourth interocstal space to the left of the midclavicular line until age 4 years; at the fourth interspace at the midclavicular line from ages 4-6 years, and in the fifth interspace to the right of the midclavicular line at age 7
infant cardiac assessment
palpate the apical pulse to determine the size and position of the heart; because the ifnat's heart has a more horizontal placement, expect to palpate hte apical impulse at the 4th intercostal space just lateral to hte midclavicular line; it may or may not be visible i
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
awakening from sleep at night (dyspnea subjetive data)
paroxysmal nocurnal dyspnea occurs with heart failure; lying down increase svolume of intrathoracic blood and the weakened heart cannot accommodate the increased load; typically, the person awakens after 2 hours of sleep with the perception of needing fresh air
machinery murmur
patent ductus arteriosus the continuous murmur heard in systole iand diastole is called a _______________
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
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
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
aging adult (peripheral circulation)
peripheral blood vessels grow more rigid with age, termed arteriosclerosis; this condition produces the rise in systolic blood pressure; do not confuse the process with atherosclerosis, or the deposition of fatty plaques on the intima of hte arteries; both processes are present with PAD in aging adults; PAD is underdiagnosed and undertreated, yet it is a large cause of morbidity and mortality in the US
patent ductus arteriosus
persistence of the fetal channel joining left pulmonary artery to aorta; this is normal in the fetus and normally closes spontaenously within hours of birth
cardiac assessment preparation
person sit up or supine with head/chest between 30-45 degrees stand on person's right side warm room order: 1. pulse/ BP; 2. extremities; 3. neck vessels; 4. precordium equipment: stethscope, alcohol wipe, small centimeter ruler
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
pericarditis
possible associated symptoms: dry cough, muscle and joint aches, fever
Prizmetal/variant angina
possible associated symptoms: palpitations, syncope, or feelings of syncope
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
toxins
pregnant women may be exposed to __________________, such as alcohol or cigarette smoke that increase the risk of birth defects
internal jugular pulse
pressure: light pressure at the base of the neck easily obliterates position of person: level of pulse drops and disappears as the person is brought to a sitting position
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
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
accentuated S2
pulmonary hypertension; e.g. mitral stenosis, heart failure semilunar valves calcified but still mobile; e.g. aortic or pulmonic stenosis
anterior chest inspection
pulsations: you may or may not see the apical impulse, the pulsation created as the left ventricle rotates against the chest wall during systole; when visible it occupies the 4th or 5th intercostal space, at or inside the midclavicular line; it is easier to see in children adn those with thinner chest walls
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
chronic venous symptoms
relieving factors: elevation, lying, walking
acute venous symptoms
relieving factors: pain medication
chronic arterial symptoms
relieving factors: rest (usually within 2 min) dangling (severe involvement)
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
t wave
repolarization of the ventricles
cardiorespiratory changes of pragnancy
respiration more efficent, cardiac output increases, blood volume increase swith oxygen and nutrient needs of fetus
internal jugular pulse
respiration: varies with respiration; its level descends during inspiration when intrathoracic pressure is decreased palpable: no
carotid pulse
respriation: does not vary with respirations palpable: yes
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
pulsus bigeminus
rhythm coupled, every other beat comes early, or normal beat followd by premature beat; force of premature beat decreased because of shortened cardiac filling time asosociated with: conduction disturbance (e.g. premature ventircular contraction, premature atrial contraction)
lymphedema
risk factors include age, obesity, extent of axillary surgery, axillary radiation, infection, surgery occurred on dominant or nondominant side, and failure to exercise or use other activiteis to prevent ______________
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
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
cholesterol control
screen every year for men beginning at age 35 and women at 45; an elevation in low-density lipoprotein can damage the blood vessels that feed the heart; if it becomes eleveated, medications called statins may be given
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
diminished S2
semilunar valves thickened and calcified, with decreased mobility e.g. aortic or pulmonic stenosis
rickets
severe bowing or unilateral bowing also occurs with _____________
coarctation of the aorta
severe narrowing of descending aorta, usually at the junction of the ductus arteriosus and the aortic arch, just distal to the origin of the left subclavian artery; results in increased workload on left ventricle and obstruction of distal blood flow; associated with defects of aortic valve in most cases, associated patent ductus arteriosus, and associated VSD
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
neuropathic ulcer
signs include decreased refelxes, loss of proprioception, loss of vibration sensation, small muscle wasting, loss of warm and col sensatio nadn pinprick, decreased refelxes, poor blod flow, adn cold feet; without careful vigilance of pressure points on feet, ulcers may go unnoticed
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 (culture and genetics)
smoking increases the risk of CVD by increasing the oxygen demand on the heart while causing a concominant decrease in oxygen supply, by an activation of platelets and fibrinogen, and by an adverse change in the lipid profile; since the US surgeon general's first report on teh health risks of smoking, rates ahve decreased; this sharp decrease in smoking is in great measure one reason for teh sharp decline in the CVD death rates during the same period; one problem is that smoking rates increase as family income declines
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)
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
heart conduction
specialized cells in the sinoatrial node near the superior vena cava initiate an electrical impulse; because the SA node has an intrinsic rhyhtm, it is the pacemaker; the current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum; there it is delayed slightly so the atria have sime to contract before the ventricles are stimulated; then the impulse travels to the bundle of His, the right and left bundle branches, and then through hte ventricles
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
extension
straightening a limb at a joint
aortic regurgitation
stream of blood regurgitates back through incompetent aortic valve into LV during diastole. LV dilation and hypertrophy caused by increased LV stroke volume. Rapid ejection of large stroke volume into poorly filled aorta, then rapid runoff in diastole as part of blood pushed back into LV
superficial varicose veins
subjective data: aching heaviness in calf, easy fatigability, restless legs, burning, throbbing, cramping
venous (stasis) ulcer
subjective data: aching in calf or lower leg, worse at end of day, worse with prolonged standing or sitting; pain lessens with leg elevation; itching with stasis dermatitis
arterial (ischemic) ulcer
subjective data: deep muscle pain in calf or foor, claudication (pain with walking); pain worsens with leg elevation; pain at rest indicates worsening of condition
mitral regurgitation
subjective data: fatigue, palpitation, orthopnea, PND
mitral stenosis
subjective data: fatigue, palpitations, DOE, orthopena, occasional PND or pulmonary edema
coarctation of the aorta
subjective data: in infants with associated lesions or symptoms, diagnosis occurs in the early months as heart failure develops; for asymptomatic children, growth and development are normal; diagnosis follows abnormal BP findings; adolescents may complain of vague lower-extremity cramping, worse with exercise
aortic regurgitation
subjective data: only minor symptoms for many years, the nrapid deterioration: DOE, PND, angina, dizziness
tetralogy of fallot
subjective data: severe cyanosis, not in first months of life but develops as infant grows and right ventricular outflow (i.e. pulmonic) stenosis getse worse; cyanosis with crying and exertion at first, then at rest; uses squatting posture after starts walking; DOE is common; development is sloweded
ventricular septal defect
subjective data: small defects are asymptomatic; infants with large defects have poor growth, slow weight gain; later they look pale, thin, delicate; may have feeding problems; DOE; frequent respiratory infections; ;adn, when teh condition is severe, heart failure
deep vein thrombophlebitis
subjective data: sudden onset of intesne, sharp, deep msucle pain
patent ductus arteriosus
subjective data: usually no symptoms in early childhood; growth and development are normal
lymphatics
substances pass around the microcirculation by a concentration gradient; most plasma proteins are too big to be pushed out of the arterioles; they remain and create teh force for colloid osmotic pressure that pulls interstitial fluid back into the venules; a few smaller plasma proteins do escape teh arterioles; they are captured by the lymph vessels and eventually returned to the bloodstream
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
neuropathic ulcer
symptoms include nubmness and tingling, pain, weakness, loss of balance, falling, allodynia
tachydysrhtmias
tachydysrhtmias may not be tolerated as well in older people; the myocardium is thicker and less compliant, and early diastolic filling is impaired at rest; thus it may not tolerate a tachycardia as well because of shortened diastole; also, tachydysrhythmias may further compromise a vital organ whose function has already been affected by aging or disease
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
diastole
the AV valves open during the heart's filling phase, or ____________, to allow the ventricles to fill with blood
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 peripheral vascular system
the DP and PT pulses may become more difficult to find; trophic changes associated with arterial insufficiency als occur normally with aging
Third heart sound
the S3 can be confused with a split S2; use these guidelines to distinguish the S3: location- the S3 is heard at hte apex or left lower sternal border; S2 is heard at the base respiratory vibration- the S3 does not vary in timing with respirations; the split S2 does pitch- the S3 is lower pitched; the pitch of the split S2 stays the same s3
Third heart sound
the S3 may be normal or abnormal; the normal S3 is heard frequently in children and young adults; it occasionally may persist after 40 years, especially in women; the normal S3 usually disappears when the pesron sits up s3
fourth heart sound
the S4 is a ventricular filling sound; it occurs when the atria contract late in diastole; it is heard immediately before S1; this is a very soft sound of very low pitch; you need a good bell, and you msut be listening for it; it is heard best at the apex with the person in left lateral position
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
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
apical impulse
the ___________ is palpable in supine position in 25-40% of adults and in the left lateral position in 50-73% of adults; it is not palpable in obese persons or in people with thick chest walls; whith high cardiac output states (anxiety, fever, hyperthyroidism, anemia) the _______________ increases in ampltude and duration
great vessels
the ____________ are the major arteries and veins connected to the heart
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
S1
the ____________ occurs with closure of the AV valves and thus signals the beginning of systole; the mitral component of the first sound (M1) slightly precedes the tricuspid component (T1), but you usually hear these two components fused as one sound; you can hear __________ over all the precordium, but usually it is loudest at the apex
intervertebral discs
the _____________ are elastic fibrocartilaginous plates that constitute one-fourth of hte length of the oclumn
aorta
the _____________ carries oxygenated blood out to hte bodyy; the ____________ ascends from the left ventricle, arches back at the level of the sternal angle, and descends behind the heart
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
heart wall
the _____________ has numerous (three) layers: the pericardium, myocardium, and endocardium
popliteal pulse
the _____________ is a more diffuse pulse and can be difficult to localize; with the leg extended but relaxed, anchor the thumbs on the knee and curl your fingers around into the poplitela fossa; press your fingers forward hard to compress the arter against the bone; often it is just lateral to the medial tendon
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
semilunar valves
the ______________ are set between the ventricles and the arteries; each valve has three cusps that look like half moons; the ______________ include the pulmonic valve and aortic valve; they open during pumping/systole, when blood ejects from the heart
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
right lymphatic duct
the ______________ empties into the right subclavian vein; it drains the right side of the head and neck, right arm, right side of the thorax, right lung and pleura, right side of the heart, and right upper section of hte liver
jugular veins
the ______________ empty unoxygenated blood directly into the superior vena cava; because no cardiac valve exists to separate the superior vena cava and the right atrum, the ________________ give information on the right side of the heart; specifically, they reflect filling pressure and volume changes; because volume and pressure increase when the right side of the heart fails to pump efficiently, the ______________ reveals this
atrium
the ______________ is a thin-walled reservoir for holding blood
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
epitrochlar node
the ______________ is in the antecubital ofssa and trains the hand and lower arm
pulmonic valve
the ______________ is in the right side of the heart, connects to the pulmonary artery
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
myocardium
the ______________ is the muscular wall of the heart, it does the pumping
pulmonary artery
the ______________ leaves the right ventricle, biurificatees, and carries venous blood to the lungs
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
carotid artery
the _______________ is a central artery; its timing closely coincides with ventricular systole; the _____________ is located in the groove between the trachea and the sternomastoid muscle, medial to and alongside the muscle; characteristics include, a smooth rapid upstroke, a summit that is rounded and smooth, and a downstroke that is more gradual and has a dicrotic notch caused by closure of the aortic valve
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
thymus
the _______________ is the flat, pink-gray gland located at the superior mediastinum behind the sternum and in front of hte aorta; it is relatively large in the fetus nad young child and atrophies after puberty; it is important in developing the T lymphocytes of hte immune system in children; the B lymphocytes originate in teh bone marrow and mature in the lymphoid tissue
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
deep veins (femoral and poplitela veins)
the _______________ run alongside the deep arteries and conduct most of the venous return from the legs; these are _____________________; as long as these veins remain intact, the superficial veins can be excised withotu harming the circuation
X descent
the _______________ shows atrial relaxation when the right ventricle contracts during systole and pulls the bottom of the atria downward
pregnant woman cardiovascular system
the ________________ adapts to ensure adequate blood supply to the uterus and placenta, to deliver oxygen and nturients to the fetus, and to allow the mother to function normally during this altered state; blood volume increases by 30-50% during pregnancy, with the most rapid expansion occuring during the second trimester; this creates an increase in stroke volume and cardiac output and an increased pulse rate of 10 to 20 beats/ min; the pulse rate rises in teh first trimester, peaks in the third trimester, and returns to baseline within the first 10 postpartum days; despite the increased cardiac output, aterial BP decreases in pregnancy as a result of peripheral vasodilation; BP drops to lowest point during the second trimester and rises after that
lymphatics
the ________________ have a unique structure; lymphatic capillaries start as microscopic open-ended tubes, which siphon interstitial fluid; the capillaries converge to form vessels and drain into larger ones; the vessels have valves; therefore flow is one way from the tissue spaces into the bloodstream; the many valves make the vessels look eaded; the flow of lymph is slow compared to blood; lymph flow is propelled by contraction of the skeletal muscles, by pressure changes secondary to breathing, and contraction of the vessel walls themselves
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
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
dorsalis pedis pulse
the ________________ pulse requires a very light touch; normally it is just lateral and parallel with the extensor tendon of the big toe; do not mistake the puse of your own fingertips for that of the person
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
vascular system
the _________________ consists of the vessels for transporting fluid such as the blood or lymph; any disease in the vascular system impairs the delivery of oxygen and nutreints to the affected cells and retards the elimination of carbon dioxide and waste products from cellular metabolism
thoracic duct
the _________________ drains the entirety of the body except the right arm, head, neck, right side of thorax, lung, pleura, heart, and upper section of liver
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)
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
Third heart sound
the _________________ is a ventricular filling sound; it occurs in early diastole during the rapid filling phase; your hearing quickly accommodates to the S3; thus it is best heard when you listen intiially; it sounds after S2 but later than an opening snap would be; it is a dull, soft sound; and it is low pitched, like a distant thunder; it is heard best in a quiet room, at the apex, with the bell held lightly, and with the person in the lateral position s3
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
spleen
the _________________ is located in the left upper quadrant of hte abdomen; if has four functions: 1. destroy old red blood cells; 2. produce antibodies; 3. store red blodo cells; and 4. filter microorganisms from the blood
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
femoral arteries
the _________________ just below the inguinal ligament halfway between the pubis and anterior superior iliac spines; to help exose the ____________________, particularly in obese people; as the person to bend his kness to the side in a froglike position; press firmly and the nslwoly release, noting the pulse tap under your fingertips; if weak or diminished, ascultate the site for a bruit
ischial tuberosity
the _________________ lies under the gluteus maximus muscle and is palpable when the hip is flexed
ejection click
the _________________ occurs early in systole at the start of ejection because it results from opening the semilunar valves; normally the SL valves open silently, but in the presence of stenosis, their opening makes a sound; it is short and high pitched, with a click quality and is heard better with the diaphragm ec
pericardium
the __________________ is a tough, fibrous, double-walled sac that surrounds and protects the heart; it has two layers that contain a few mililiters of serous pericardial fluid; this ensure ssmooth, friction-free movement of the heart muscle; the _______________ is adherent to the great vessels, esophagus, sternum, and pleurae and is anchored to the diaphragm
endocardium
the __________________ is the thin inner layer of endothelial tissue that lines the inner surface of the heart chambers and valves
C wave
the __________________ or ventircular contraction, is backflow from the bulging upward of the tricuspid valve when it closes at the beginning of venticular systole (not from the neighboring carotid artery pulsation)
superior/inferior vena cava
the __________________ return unoxygenated venous blood to the right side of the heart
immune system
the ___________________ is a complicated network of organs and cells taht work together to protect the body; it detects and eliminates foreign pathogens, both that come in from the environment and those arising from inside (Abnormal or mutant cells); it accomplishes this by phagocytosis of the substances by neutrophils and monocytes/macrophages and production of specific antibodies or specific immune responses by lymphocytes
carotid artery
the ___________________ is palpated in the groove between the steromastoid muscle and the trachea
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
superficial veins (great saphenous)
the ___________________, inside the leg starts at the medial side of the dorsum of the foot; you can see it ascent in front of the medial malleolus; then it crosses the tibia obliquely and ascends along the medial side of the thigh;
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;
modified allen test
the ______________________ is used to evaluate the adequacy of collateral circulation before cannulating the radial artery; A. formlmy occlude both hte ulnar and radial arteries of one hand while the person makes a fist several times; this causes hte hand to blanch; B, ask the person to open the hand without hyperextening it; then release pressure on the ulnar artery while maintaing pressure on the radial artery; adequate circulation is suggested by a palmar blush, a return to normal color in less than 7 seconds; although it is simple nad useful, it is relatively crude and subject to error (i.e. you must occlude both arteries uniformly with 11 pounds of pressure for the test to be accurate)
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
ejection click
the aortic ____________ is heard at the 2nd right interspace and apex and may be loudeste at the apex; its intensity does not change with respiration; the pulmonic _________________ is best heard in the 2nd left interspace and often grows softer with inspiration ec
apex pulsation (pressure overload)
the apixal impulse is increased in force and duration but not necessarily displaced to the left when the left ventricle hypertrophy occurs alone without dilation; this is pressure overload, as found in aortic stenosis or systemic hypertension
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
children cardiac assessment
the average heart rate slows as the child grows older, although it is still variable with rest or activity the heart rhythm remains characterized by sinus arryhtmia; physiolgoic S3 is common in childrne; it occurs in early diastole,just after S2 and is a soft dull sound that is best heard at the apex c
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
pulmonary and systemic circulation
the blood vessels are arranged in two continuous loops, the _________________; when the heart contracts, it pumps blood simultaneously into both loops
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 _________________
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
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
midysytolic click
the click and murmur move with postural change; when the person assumes a squatting position, the click may move closer to S2, and murmur may sound louder and delayed; the valsalva maneuver also moves the click closer to S2 mc
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
listen for murmurs
the contractile force of the heart is greater in children; this increase sblood flow velocity; the increased velocity plus a smaller chest measurement makes an audible murmur
veins
the course of the __________________ is parallel to the arteris, but the direction of flow is opposite; the ____________ absorb CO2 and waste products from the periphery and carry them back to the heart; the body has more veins, and they lie closer to the skin surface; ______________ accessible to examination are jugular, arm, and leg
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
heart conduction
the eletrical impulse stimulates the heart to do its work, which is to cotnract; a small amount of electricity spreads to the body surface, where it can be measured and recorded on the ECG; the ECG waves are arbitralily PQRST
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
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
infants and children cardiovascular system
the fetal heart functions early; it begins to beat around thet end of 3 weeks' gestation; the lungs are nonfunctional, but the fetal circulation compensates for this; oxygenatio ntakes place at the placenta, and teh arterial blood is returned to the right side of the fetal heart; there is no point in pumping all the freshly oxygenated blood through the lungs; therefore it is rerouted in two ways; first about 2/3 of it is shunted through an opening in the atrial septum, the *foramen ovale*, into hte left side of the heart where it is pumped out through the aorta; second the rest of the oxygenated blood is pumped by the right side of the hearet out through the pulmonary artery, but it is detoured through the *ductus arteriosus* to the aorta; because they are both pumping into systemic circulation, the right and left ventricles are equal in weight and muscle wall thickness
jugular venous pulse
the five components of the ____________ occur because of events in the right side of the heart; it includes the A wave, C wave, X descent, V wave, and Y descent
chambers
the four _________________ are separated by swingnig-door-like structures, called valves, whose main purpose is to prevent backflow of blood
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
iscchemia
the function of hte arteries is to supply oxygen adn essentia lnutrients to the cells; __________________ is a deficient supply of oxygenated arterial blood to a tissue caused by obstruction of a blood vessel; a complete blockage leads to death of the distal tissue; a partial blockage creates an insufficient supply and the ischemia may be apparent only at exercise when oxygen needs increase
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
mediastinum
the heart and great vessels are located between the lungs in hte middle third of the thoracic cage, called the _______________
cardiac output
the heart can alter its ____________________ to adapt to the metabolic needs of the body; preload and afterload affect the heart's ability to increase _________________
arteries
the heart pumps freshly oxygenated blood through the ________________ to all body tissues; the pumping heart meakes this a high-pressure system; the _____________ walls are strong, tough, and tense to withstand pressure demands; ________________ contain elastic fibers, which allow their walls to stretch with systole and recoil with diastole; they also contain muscle fibers, which control the amount of blood delivered to the tissues; the VSM contracts or dilates, which changes the diameter of the arteries to control the rate of blood flow
infant cardiac assessment
the heart rate is best auscultated because radial pulses are hard to count accurately; use the small pediatric diaphragm and bell; the heart rate ma range from 100-180 beats/min immediately after birth and stabilize to an average of 120-140 beats/min; infants normally have wide fluctuations with activity, from 170 beats/min or more with crying or being active to 70-90 beats/min with sleeping; varations are greatest at birth and are even more so with premature babies i
infants and children cardiovascular system
the heart's position in the chest is more horizontal in the infant than the adult; thus the apex is higher, located at the fourth intercostal space; it reaches the adult position when the child reaches 7 years of age
T7 and T8
the inferior angle of hte scapula is normally at the level of teh interspace between ________________
pattern (murmur)
the intensity may follow a _____________ during cardiac phase, growing louder, tapering off or increasing to a peak, and then decreasing; becasue the whole murmur is just miliseconds long, it takes practice to diagnose the ________________
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
internal jugular
the larger _________________ lies deep and medial to the sternomastoid muscle; it is usually not visible, although its diffuse pulsations amy be seen in the sternal notch when the person is supine
cardiac sex and gender differences (culture and genetics)
the leading cause of death in women is CVD, claiming more lives than cancer, chronci lower respiratory disease, and diabetes mellitus combined; _____________ are the biologic result of one chromosome difference between me nand women; e.g. women tend to have smaller coronary arteries than men
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
infants and children (peripheral circulation)
the lymphatic system has the same function in children as in adults; lymphoid tissue is well developed by birth and grows rapidly until age 10-11 years; by 6 years of age the lymphoid tissue reaches adult size; it surpasses adult size by puberty, and then it slowly atrophies; it is possible that the excessive antigen stimulation in children causes the early rapid growth
brachial artery
the major artery supplying the arm is the ______________, which runs in the biceps-triceps furrow of the upper arm and surfaces at the antecubital fossa in the elbow medial to the biceps tendon
femoral artery
the major artery to the leg is the ____________________, which passes under the inguinal ligament; the _________________ travels down the thigh
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
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
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
hemodynamic changes of aging
the overall size of the heart does not increase with age, but left ventricular wall thickness increses; this is an adaptive mechanism to accommodate the vascular stiffening that creates an increased workload on the heart
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
dysrhythmias
the presence of supraventricular and ventricualr ____________________ increases with age; ectopic beats are common in aging people; although these are usually asymptomatic in healthy older people, they may compromise cardiac output and BP when disease is present
high blood pressure (culture and genetics)
the prevalence of hypertension in Black Americans is among the highest in the tworld; compared with whites, African Americans develop __________ earlier in life, and their acerage BPs are much higher; this results in a greater rate of stroke, death from heart disease, and end-stage kidney disease for African americans
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
note rate and rhythm (ascultation)
the rate ranges normally from 50-95 beats per minute; the rhythm should be regular, although sinus arrhythmia occurs normally in young adults and hcildrne; with sinus arrhythmia, the rhythm varies with the person's breathing, increasing at the peak of inspiration and slowing with expiration; not any other irregualr rhythm; if one occurs check if it has a pattern or is total irregular
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
events in the heart
the same _______________________ are happening at hte same time in the right and left sides of the heart, but pressures in the right side are much lowe rthan the left because less energy is needed to pump blood to its destination, the pulmonary circulation; also events, occcur slightly later in the right side of hte heart because of the route of myocardial depolaization; as a result, two distinct components to each of ht heart sounds exist and sometimes you can hear them seprately; in S1, the mitral component closes just before the tricuspid component; and with S2, aortic closure occurs slightly before pulmonic closure
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
S2
the second heart sound, ________________ occurs with closure of the semilunar valves and signals the end of systole; the aortic component of the sound (A2) slightly precedes the pulmonic component (P2); although it is heard all over the precordium, ___________ is loudest at the base
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
midysytolic click
the sound occurs in mid-to-late systole and is short and high pitched with a click quality; it is best heard with the diaphragm, at at the apex, but also may be heard at hte left lower sternal border; the click usually is followed by a systolic murmur mc
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*
lymph nodes
the superficial groups of ________________ are accessible to inspection and palpation and give clues to the status of the lymphatic system
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
infant cardiac assessment
the transition from fetal to pulmonic circulation occurs in the immediate newborn period; fetal shunts normally close within 10-15 hours but may take up to 48 hours; thus you should assess teh CV system during the first 24 hours and again in 2-3 days i
atrioventricular valves
the two _____________ separate the atria and ventficles
inspect and palpate arms
the two arms should be symmetric in size ABNORM: edema of upper extremities occur when lymphatic drainage is obstructed after breast surgery or radiation
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
chordae tendineae
the valves' thin leaflets are anchored by collagenous fibers, _________________, to papilalry muscles embedded in the ventricle floor
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
children cardiac assessment
the venous hum is usually not affected by respiration, but may sound louder when the hcild stands, and is easily obiterated by occlusing the jugular veins in the neck with your fingers ABNORM: this helps differentiate the venous hum from other cardiac murmurs c
pregnant woman cardiac assessment
the vital signs usually yield an increase in resting pulse rate of 10-20 beats/min and a drop in BP from the normal prepregnancy level; the BP decreases to its lowest point during the second trimester and then slowly rises during the thrid trimester; it varies with position; it is usually lowest in the left lateral recumbent position, a bit higher when supine, and highest when standing p
respiration affect on heart sounds
the volume of the right and left ventricular systole is just about equal, but this can be affected by __________________ during inspiration, intrathoracic pressure is decreased; this pushes more blood into the vena cava, increasing venous return to the right side of the heart, which increases right ventricular stroke volume; the increased volume prolongs right ventricular systole and delays pulmonic valve closure
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
valves
there are no ___________ between the vena cava and the right atrium or between the pulmonary veins and the left atrium; for this reason, abnormalyl high pressure in hte left side of the heart gives a person symptoms of pulmonary congestion, and abnormally high pressure in the right side of the heart shows in the distended neck veins and abdomen
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
hemodynamic changes of aging
there is a decreased ability of the heart to augment cardiac output with exercise; this is shown by a decreased maximum heart rate with exercise and diminished sympathetic response; noncardiac factors also cause a decrease in maximum work performace with aging: decrease in skeletal muscle performance, increase in muscle fatigue, increased sense of dyspnea; however, aerobic exercise conditioning modifies many of the aging changes in CV function
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
heart
think of the __________________ as an upside-down triangle in teh chest; the top of the heart is teh broader base, and the bottom is the apex, which points down and to the left; during contraction, the apex beats against the chest wall, normally at the fifth intercostal space 7-9 cm from the midsternal line
estimating jugular venous pressure
think of the jugular veins as a CVP monitor attached directly to the right atrium; you can read the CVP at the highest level of pulsations; use the angle of louis (sternal angle) as an arbitrary refernce point, and compare it with the highest level of hte distended vein or venous pulsation
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)
chronic venous symptoms
those at risk: job with prolonged standing or sitting; obesity; multiple pregnancies; prolonged bed rest; history of heart failure, varicosities, or thrombophlebitis; veins crushed by trauma or surgery
chronic arterial symptoms
those at risk: older and middle age adults; african americans 2x more likely; smoking is strongest risk, also hypertension, diabetes, hypercholesterolemia, obesity, vascular disease
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
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
diastole
toward the end of _______________-, the atria contract and push the last amount of blood into the ventricles; this active filling phase is called presystole or atrial systole, or sometimes the atrial kick; it causes a small rise in left ventricular pressure; atrial systole occurs during ventricular diastole
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 ______________________
infants and childrne peripheral vascular system
transient acrocyanosis and skin mottling at birth; pulse force should be normal and symmetric; it also should be the same as in the upper and lower extremities
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
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
arterial (ischemic) ulcer
ulcers at toes, metatarsal heads, heels, and lateral ankle and are characterized by pale ischemic base, well defiend edges, and no bleeding; they look dry and punched out; arterial ulcers are more common in those with smoking, diabetes, hyperlipidemia, and hypertension
venous (stasis) ulcer
ulcers occuur at medial malleolus and tibia; characterized by bleeding, uneven edges
inspect and palpate legs
uncover the legs while keeping the genitalia draped; inspect both legs together, noting skin cololr, hair distribution, venosu pattern, size, and any skin lesions or ulcers normally hair covers the legs; even if leg hair is shaved, you will not hair on the dorsa of the toes
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
high blood pressure (culture and genetics)
untreated hypertension causes direct damage to the arterial system; further _______________ contributes to CAD because it accelerates the process of atherosclerosis; it increases workload o nthe heart, and it increases the oxygen demand on the heart already compromised by atherosclerosis; more men than women have _____________ up to age 64 years; those >65 years show a higher percentage of wome nthan men with hypertension
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?
ankle-brachial index
use hte doppler probe for bot hmeasurements; in all sides locate the pulse with the doppler and inflate teh cuff 20 mmHg above the disapperance of flow signal; then deflate slowly to detect reappearance of flow signal; moving counterclockwise, measure: right arm, right posterirtibial, right dorsalis pedis, left PT, left DP, left arm
keep skin on feet soft and smooth
use mild soap/ skin lotion avoid adding oils or bubble bath to the bath, it makes the feet and tube slippery
profile sign
use the ________________, viewing the finger from the side, to detect early clubbing; the norma lnail-bed angle is 160 degrees
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
doppler ultasonic probe
use this device to detect a weka peripheral pulse, to monitor blood pressure in infants or children, or to measure a low blood pressure or blood pressure in a lower extremity; the _________________ magnifies the pulsatile sounds from the heart and blood vessels; position the person supine, with the legs externally rotated so you can reach the medial ankles easily; place a drop of coupling gel on the transducer; palce the transducer over a pulse site at a 90 degree angle; apply light pressure; locate pulse by the swishing, whooshing sound
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
venous flow
veins drain the deoxygenated blood with its waste products from teh tissues and return it to hte heart; unlike the arteries, veins are a low-pressure system; because tehy do not have a pump to generate their flow, they need a mechanism to keep blood moving
capacitance vessels
veins have a larger diameter and are more distensible; they can expand and hold more blood whel blood volume increases; this is a compensatory mechanism to reduce stress (preload) on the heart; because of this ability to stretch, veins are called _________________
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
shoes
wear shoes that fit and are comfortable, when when outside always measure feet toward end of day when feet may be largest if one foot is larger than the other, buy shoes that fit the larger one chose shoes so that the ball of the foot fits comfortably into the widest part of the shoe and toes are not crowded low-heeled shoes are safer nad less damaging to toes
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
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?
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
isometric/isovolumetric relaxation
when all four valves are closed, and the ventricles relax, called ___________________; meanwhile the atria have been filling with blood delivered from the lungs; atrial pressure is now higher than the relaxed ventricular pressure; the mitral valve drifts open, and diastolic filling begins again
summaiton sound
when both pathologic S3 and S4 are present, a quadruple rhythm is heard; often in cases of cardiac stress, one response is tachycardia; during rapid rates the diastolic filing times shortens, and the S3 and S4 move closer together; they sound superimposed in mid-diasotlle, and you hear one loud, prolonged _____________, often louder than S1 or S2
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
wide split
when the right ventricle has delayed electrical activation, the split is very wide on inspiration and is still there on expiration; e.g. right bundle branch block (which delays P2)
preload
when the volume of blood returned to the ventricles (as when exercise stimulates skeletal muscles to contract and force more blood back to the heart), the muscle bundles are stretched beyond their normal resting state to accommodate; the force of this stretch is the ________________; according to the Frank-Starling law, the greater the stretch, the stronger the contraction of the heart; this increased contractility increases the volume of blood ejected (increased stroke volume)
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?
splitting of S2
when you first hear the ______________; do not ask the person to hold their breath; breaht holding only equalizes ejection times causing the split to go away; instead concentrate on the split as you watch the person's chest rise up and down with bbreahting; the ____________ occurs about every 4th heartbeat, fading in wiht inhalation and out with exhalation
note rate and rhythm (ascultation)
when you notice any irregularity, check for a pulse deficit by auscultating the apical beat while simultaneuosly palpating rhe radial pulse; count a serial measurement of apical beat nad radial pulse ; normally ever beat you hear at the apex should perfuse to the periphery and be palpable; the two counts should be identital; when different, subtract hte radial rate from the apical, and recrod the remainder as the pulse deficit
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
hemodynamic changes of aging
with aging ther is an increase in systolic BP, termed isolated systolic hypertension; this is caused by thickening and stiffening of the large arteries, which in turn are caused by collagen and calcium deposits in vessel walls and loss of elastic fibers; this stiffening (arteriosclerosis) creates an increase in pulse wave velocity because the less compliant arteries cannot store the volume ejected
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
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
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
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?
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
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 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
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
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
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
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
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
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
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
peripheral circulation subjective data
1. leg pain/ cramps 2. skin changes on arms/ legs 3. swelling in arms/ legs 4. lymph node enlargement 5. medications 6. smoking history
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
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
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
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 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
deep vein thrombophlebitis
A deep vein is occluded by a thrombus, causing inflammation, blocked venous return, cyanosis, and edema. virchow triad is the classic 3 factors that promote thrombogenesis: stasis, hypercoagulability, and endothelial dysfunction; cause may be prolonged bed rest, history of varicose veins, trauma, infection, cancer, obesity, immobility, heart failure, or use of estrogen hormones
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
bilteral pitting edema
ABNORM: __________________ calls for an examination of the neck veins; if the neck veins are abnormally distended, the peripheral edema may be related to heart disease or pulmonary hypertension; if neck veins are normal, something else may cause the edema, (e.g. liver disease, nephrosis, chronic venous insufficiency, antihypertensive or hormonal medications
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
pulse deficit
ABNORM: a ____________ signals a weak contraction of the ventircles; it occurs with atrial fibrillation, premature beats, and heart failure
auscultaitng carotid artery
ABNORM: a carrotid bruit is audible when the lumen is occluded by 1/2 to 2/3; bruit loudness increass as the atherosclerosis worsens until the lumen is occluded by 2/3; after that, bruit loudness decreases; when the lumen is completely occluded, the bruit disappears; the absence of a bruit does not ensure absence of carotid lesion
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 __________________
splitting of S2
ABNORM: a fixed split is unaffected by respiration; the split is awlays there a paradoxical split is the opposite of what you would expect; the sounds fuse on inspiration and split on expiration
anterior chest inspection
ABNORM: a heave or lift is sustained forceful thrusting of the ventricle during systole; it occurs with ventricular hypertrophy as a result of increaesd workload; a right ventricular heave is seen at the sternal border; a left ventricular heave is seen at the apex
auscultaitng carotid artery
ABNORM: a murmur sounds much the same but is caused by a cardiac disorder; some aortic valve murmurs (aortic stenosis) radiate to the neck and must be distinguished from a local bruit
fluid wave ascities test
ABNORM: a positive ________________ test occurs with large amounts of ascitic fluid; also note edema in the legs
children cardiac assessment
ABNORM: a precordial bulge to the left of hte sternum with a hyperdynamic precodium signals cardiac enlargemnt; the bulge occurs because of the cartilaginous rib cage is more compliant a substernal heave occrs with right ventricular enlargement; an apical heave occurs with left ventricular hypertrophy c
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
timing (murmurs)
ABNORM: a systolic murmur may occur with a healthy heart or with heart disease, a diastolic murmur always indicates heart disease
palpate across the precordium
ABNORM: a thrill is a palpable vibration; if feel slike the throat of a purring cat; the thrill signifies turbulent blood flow and directs you to locate the origin of loud murmus; however, absence of a thrill does not rule out the presence of a murmur accentuated first and second heart sounds and extra heart sounds may cause abnormal pulsations
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
temperature of legs
ABNORM: a unilateral cool foot or leg or a sudden temperature drop as you move down the leg occurs with arterial ischemia
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
ankle-brachial index
ABNORM: an ABI between .91 and 1 is borderline cariovascualr risk an ABI of 0.9 or lower indicates PAD
alvarado score/ Mantrels score
ABNORM: an ______________- of >7 increases the probability of appendicitis
epitrochlear lymph node
ABNORM: an enlarged ________________ occurs with infection on the hand or forearm; ______________ occurs in conditions of generalized lymphadenopathy; lymphoma; chronic leukemia; infectious mononuclerosis; HIV infection
obturator test
ABNORM: an inflamed appendix irritates the _______________-, and this leg movement produces pain in a positive finding
note rate and rhythm (ascultation)
ABNORM: an isolated beat is early, or a patterne occurs in which every third or fourth beat sounds early; irregularly irregular- no pattern to the sounds; beats come rapidly and at random intervals as in atrial fibrillation
inspect and palpate legs
ABNORM: asymmetry of 1-3 cm occurs with mild lymphedema; 3-5 cm with moderate lymphedema; and more than 5 cm with severe lymphedema asymmetric calf swelling of >2 cm occurs with DVT, but betware of diagnosing DVT with one finding
pertibial edema
ABNORM: bilateral, dependent pitting edema occurs with heart failrue, diabetic neuropathy, and hepatic cirrhosis
First heart sound S1
ABNORM: both heart sounds are dminished with conditions that place an increased amount of tissue between the heart and your stethoscope; emphysema (hyperinflated lungs), obesity, and pericardial fluid
preeclampsia
ABNORM: brisk or greater than 2+ DTRs and clonus may be associated with elevated BP and cerebral edema in the ________________ woman
skin discoloration
ABNORM: brown discoloration occurs with chronic venous stasis caused by hemosiderin deposits from red blood cell degradation venous ulcers occur usually at medial malleolus becaus eof bacterial invasion of poorly drained tissues with arterial deficit, ulcers occur on tips of toes, metatarsal heads, and lateral malleoli
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
gastrocnemius
ABNORM: calf pain is not specific for DVT because it occurs also with superficial phlebitis, Achilles tendinitis, gastrocnemius and plantar muscle injury, and lumbosacral disorders
apical impulse
ABNORM: cardiac enalrgement left ventricular dilation displaces impulse down and to the left and increases size more than one space; a diameter >4 cm is likely a dilated heart; this occurs with heart failure and cardiomyopathy a sustained impulse with increased force and duration but no change in location occurs with left ventricular hypertrophy and no dilation
carotid artery palpation
ABNORM: carotid sinus hypersnsitivity is the condition in which pressure over the carotid sinus leads to a decreased heart rate, decreased BP, and cerebral ischemia with syncope; this may occur in older adults with hypertension of occlusion of the carotid artery
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
leg color changes
ABNORM: dependent rubor (deep blue-red color) occurs with severe arterial insufficiency; chronic hypoxia produces loss of vasomotor tone and pooling of blood in veins delayed venous filling occurs with arterial insufficiency
inspect and palpate legs
ABNORM: diffuse bilateral edema occurs with systemic illnesses acute unilateral painful swellign and asymmetry of calves of 1 cm or more is abnormal; refer the person to determine whether DVT is present
infants and childrne peripheral vascular system
ABNORM: diminished or absent femoral pulses but normal upper-extremity pulses suggest corctation of aorta enlarged, warm, tender nodes indicate current infection; look for source of infection
children cardiac assessment
ABNORM: distinguish innocent murmurs from pathological ones; this may involve referral to another examiner or performing diagnostic tests (e.g ECG or echocardiography) c
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
estimating jugular venous pressure
ABNORM: elevated pressure is a level of pulsation that is >3 cm above the starnal angle while at 45 degrees; this occurs with heart failure, cardiac tamponade, and constrictive pericarditis also, try to estimate a CVP for the patient with ascites or edema: when elevated, it suggest heart or lung disease; if normal, the problem may be something else, such as live rdisease
leg color changes
ABNORM: elevational pallor (marked) indicates arterial insufficiency
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)
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
estimating jugular venous pressure
ABNORM: if heart failure is present, the jugular veins will elevate more tha n4 cm and stay elevated as long as you push
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
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
infant cardiac assessment
ABNORM: investigte any irregularity except sinus arrhythmia fixed split S2 indicates atrial septal defect i
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
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
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
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
sensation/ strength lower extremities
ABNORM: motor loss occurs with severe arterial deficit; sensory loss occurs with arterial defect, especially diabetes
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
modified allen test
ABNORM: pallor that persists or a sluggish return to color suggests occlusion of hte collateral arterial flow; an equivocal result is 8 to 14 seconds; equal to or greater than 15 seconds is a negative result; avoid radial artery cannulation until adequate circulation is shown
inspect and palpate legs
ABNORM: pallor with vasoconstriction; erythema with vasodilation; cyanosis malnutrition: thin, shiny, atrophic skin; thick-riged nails; loss of hair; ulcers; gangrene; malnutrition, pallor, and coolness occur with arterial insufficiency
infant cardiac assessment
ABNORM: persistent tachycaria is >200 beats in newborns or >150 beats in infants bradycardia is <90 beats/ min in newborns or <60 beats/ min in older infants or children; this causes a serious drop in cardiac output becacuse of the small muscle mass of their hearts cannot increase stroke volume significantly i
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
capillary refill
ABNORM: refill lasting more than 1-2 seconds signifies vasoconstriction or decreased cardiac output (hypovolemia, heart failure, shock) the hands are cold, clammy, and pale
pregnant woman peripheral vascular system
ABNORM: remain alert for generalized edema plut hypertension, which suggests pre-eclampsia, a dangerous obstetric condition
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
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
wells score for leg deep vein thrombosis
ABNORM: score of 1-2= moderate brobability 3 or more= high probability of DVT
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
aging adult cardiac assessment
ABNORM: the S3 is associated with heart failure and is always abnormal over age 35 years a
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;
children cardiac assessment
ABNORM: the apical impulse moves laterally with cardiac enlargement thrill (palpable vibration) c
standing to squatting (ascultating heart sounds)
ABNORM: the murmur of hypertrophic cardiomyopathy grows softer with standing to squatting, and it grows louder with squatting to standing; HCM is an inherited thickening of the myocardium, affecting 1 in 500, men and women equally
change position (ascultating heart sounds)
ABNORM: the soft diastolic murmur of aortic regurgitation may be heard only when the person is leaning forward in the sitting position
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
inspect jugular venous pulse
ABNORM: unilateral distension of external jugular veins is caused by local cause i.e. kinking or aneurysm full distended jugular veins above 45 degrees signify increased CVP as with heart failure
pertibial edema
ABNORM: unilateral edema occurs with occlusion of a deep vein; unilateral or bilateral edema occurs with lymphatic obstructinn; with these factors it is brawny or nonpitting and feels hard to thte touch
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
varicose veins
ABNORM: varicosities occur in the saphenous veins; exaimation techniques to assess valve incompetency within varicose veisn are not reliable because valve incompetence can be widely distributed throughout the leg; imaging by doppler ultrasound is an objective, noninvaisve measure of valvular incompetency
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
infants and childrne peripheral vascular system
ABNORM: weak pulses occur with vasoconstriction of diminsihed cardiac output full, bounding pulses occur with patent ductus arteriosus from the large left-to-right shunt
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
allodynia
Allodynia is an unusual symptom that can result from several nerve-related conditions. When you're experiencing it, you feel pain from stimuli that don't normally cause pain
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.
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
third heart sound (s3)
- Normally diastole is a silent event. However, in some conditions ventricular filling creates vibrations that can be heard over the chest. These vibrations are ___________. - ____________ occurs when the ventricles are resistant to filling during the early rapid filling phase (protodiastole). - This occurs immediately after S2, when the AV valves open and atrial blood first pours into the ventricles.
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
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
infant nose exam
1. determine the patnecy of the nares 2. note the nasal discharge, sneezing, and any flaring with respirations
direction of blood flow
1. from liver to right atrium (RA) through inferior vena cava; superior vena cava drains venous blood from the head and upper extremeties; from RA, venous blood travels through tricuspic valve to right ventricle (RV) 2. from RV, venous blood flows through pulmonic valve to pulmonary arter; pulmonary artery delivers unoxygenated blood to lungs 3. lungs oxygenate blood; pulmonary veins return fresh blood to the left atrium (LA) 4. from LA arterial blood travels through mitral valve to left ventricle (LV); LV ejects blood through aortic valve into aorta 5. aorta delivers oxygenated blood to body
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 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
young child genetalia examination
1. inspect the external genetalia 2. on males palpate the scrotum for testes; if masses are present, transilluminate
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
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
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
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
femoral arteries
ABNORM: a bruit occurs with turbulent blood flow, indicating partial occlusion
lagging fundal height
ABNORM: a __________________ >2cm may indicate intrauterine growth restriction (IUGR), transverse lie, or oblique presentation of the fetus
<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
auscultaitng carotid artery
ABNORM: a bruit indicates turbulence from a local vascular cause and is a marker for atherosclerotic disease; this increrases the risk of trnasient ischemic attack and ischemic stroke; however, a bruit also occurs in 5% of those age 45-80 who have no significant carotid disease
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
change position (ascultating heart sounds)
ABNORM: S3 and S4 and the murmur of mitral stenosis sometimes may be heard only when on the left side
listen for murmurs
ABNORM: ___________ may be caused by congenital and acquired valvular defects
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
ankle and foot
ABNORM: swelling or inflammation, tenderness, occur wih tarthirits or trauma
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
aneurysms
An _______________ is a sac formed by dilation in the artery wall. Atherosclerosis weakens the middle layer (media) of the vessel wall. This stretches the inner and outer layers (intima and adventitia), and the effect of blood pressure creates the balloon enlargement. The most common site is the aorta, and the most common cause is atherosclerosis. The incidence increases rapidly in men older than 55 years and women older than 70 years; the overall occurrence is four to five times more frequent in men.
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
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
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
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.
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
scoliosis
Lateral curvature of thoracic and lumbar segments of the spine, usually with some rotation of involved vertebral bodies.
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.
radial pulses
Palpate both radial pulses, noting rate, rhythm, elasticity of vessel wall, and equal force Grade force (amplitude) on a three-point scale 3+, increased, full, bounding 2+, normal 1+, weak 0, absent
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
precordium
The ____________ is the area on the anterior chest directly overlying the heart and great vessels
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
fetal lie
______________ is the orientation of the fetal spine to hte materla spine and may be longitudinal, transverse, or oblique
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.
innocent murmurs
__________ indicates no valvular or other pathologic cause; the _______________ is generally soft, middiastolic, short, crescendo-decrescendo, and with a vibratory or muscial quality; it is heard at the 2nd or 3rd left intercostal space and disppears when sitting, and the young person has no associated signs of cardiac dysfunction; it is important to distinguish _______________ from pathologic ones; diagnostic tests, such as ECG and echocardiogram will establish an accurate diagnosis
epigastric
__________ is the area between the costal margins
physical activity (culture and genetics)
____________ has beneficial effects on high density lipoprotein, vitamin D, apolipoprotein B, and hemoglobin A1c; the ______ guidelines for adults show that about 150 min/week of moderate-intensity activity, compared with none, can reduce the risk of CVD
which medications do you take? (aging adult abdomen subjective data)
____________ rationale: consider GI side effects (e.g. nausea, upset stomach, anorexia, dry mouth
anklyosis
________________ Stiffness or fixation of a joint
popliteal aneurysm
________________ relatively uncommon; occurs in 5-20% of people with AAA
functional murmur
a _______________ is cuased by increased blood flow in the heart, e.g. anemia, fever, pregnancy, hyperthyroidism
multigravidia
a _________________ is a woman who has previously beeen pregnant
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
listen for murmurs
a murmur is a blowing, swooshing sound that occurs with turbulent blood flow in the heart or great vessels; except for the innocent murmurs described, murmurs are abnormal; if you hear a murmur, describe it by indicating its: timing loudness pitch pattern quality location radiation posture
general tympany
a resonant sound heard in percussion (as of the abdomen)
fourth heart sound
a right sided S4 is less common; it is heard at the left lower sternal border and may increase with inspriation; it occurs with pulmonary stenosis or pulmonary hypertension
splitting of S2
a split S2 is a normal phenomeonon that occurs toward the end of inspiration in some people; closure of the aortic and pulmonic valves is naerly synchronous; because of the effects of respiration on the heart, inspiration separates the timing of the two valves closure, and the aortic valve closes before the pulmonic valve; instead of one dup you haer a split sound; during expiration, synchrony returns and the aortic and pulmonic components fuse together; ______________ is only heard in the pulmonic valve area, the second left interspace
sacrum
an imaginary line joining the two symmetric dimples that overlie the posterior superior iliac spines crosses the ________________
periontitis
absolute stillness, resisting any movement, occurs with the pain of ____________________
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
arterial pulse
although an _______________- is caused by a forward propulsion of blood, the jugular venous pulse is different; the jugular pulse results from a backwash, a waveform moving backward caused by events upstream
dyspnea (subjective data)
any shortness of breath which type of activity/ how much brings on SOB? onset? duration? seem to be affected by position? awaken you from sleep at night? does it interfere with activities of daily living
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
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
costochondritis
associated symptoms: chest tightness, warmth at area of pain
pneumonia
associated symptoms: cough, fever, dsypnea, chills, sputum, myalgia, malaise
gastroesophageal reflux
associated symptoms: cough, regurgitation of food, abdominal pain
esophageal spasm
associated symptoms: dysphagia, sensation of object in throat or esophagus
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 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
murmurs
blood circulating through normal cardiac chmbers and valves usually makes no nosie; however, soem conditions create turbulent blood flow and collision currents; these result in a ____________________, much like a pile of stones or a sharp turn in a stream creates a noisy water flow a ______________ is a gentle, blowing, swooshing sound that can be hear on the chest wall
neck
carotid pulse-observe and plapate observe jugular venous pulse estimate jugular venous pulse
precordium inspect
describe location of apical impulse note any heave lift or thrill
quality (murmur)
describe the ______________ as musical, blowing, harsh, or rumbling ABNORM: the murmur of mitral stenosis is low pitch and rumbling, whereas aortic stenosis is harsh
location (murmur)
describe the area of maximum intensity of the murmur by noting the valve area or intercostal spaces
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
cyanosis/ pallor (subjective data)
ever noticed facial skin turning blue or ashen
posterior tibial pulse
for the _______________________, curve your fingers around the medial malleolus; press softly; you will feel the tapping right behind it in the groove between the malleolus and the Achilles tendon; if you cannot, try passive torsiflexion of the foot to make the pulse more accessible
after musculoskeletal
for the male patient, sit on a stool in front of him; the person stands mus
live rperitoneal friction rub
friction rub over lower right rib cage from abcesses or meastic tumor
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
venous disease
hypercoagulable states and vein wall trauma are other factors that increase risk for _________________
popliteal pulse
if there is difficulty feeling the ___________, turn the person prone and lift up the lower leg; let the leg relax against your arm and press in deeply with your two thumbs; often a norma lpoplitela pulse is impossible to palpate
skin discoloration
inspect and palpate legs: in the presence of _____________________, skin ulcers, or gangrene, note the size and exact location
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
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
ulnar pulses
it usually is not necessary to palpate the _______________; if indicated, reach the hand under hte person's arm and palpate along the medial side of th eforearm, although the ______________ often are not palpable in a healthy person
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
costochondritis
location/radiation: area from 2nd through 5th intercostal spaces; can radiate to arm, depending on where initial inflammation occurs
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
split S1
mitral and tricuspid components are heard separately e.g. normal, but uncommon
fifth intercostal space, left midclavicular line
mitral valve area
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
inversion
moving the sole of hte foot inward at the ankle
eversion
moving the sole of hte foot outward at the ankle
pulmonic regurgitation
murmur: has same timing and characteristics as that of aortic regurgitation, and is hard to distinguish on physical exam
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
superficial varicose veins
normal leg veins have dilated as a result of chronic increased venous pressure and incompetent valves that permit reflux of blood back toward leg instead of forward toward heart; varicose veins are 3 times more common in women than men; older age increases risk as a result of thinning of elastic lamina of veins and degeneration of vascular smooth muscle; size ranges from 1 mm to 1 cm in diameter; color ranges from red to blue or purple
infant vital signs
note pulse, respirations, and temperautre
aortic stenosis
objective data: pallor, slow diminished radial pulse, low BP, and ausculatory gap are common; apical impulse sustained and displaced to left; thrill in systole over 2nd adn 3rd right interspaces and right sid eof neck; S1 normal, often ejection click, often paradoxical split S2, S4 present with LV hypertrophy
atrial septal defect
objective data: sternal lift is often present; S2 has fixed split, with P2 often louder than A2; murmur is systolic, ejection, medium pitch, best heard at base in 2nd left interspace; murmur is caused not by shunt itself but by increased blood flow through pulmonic valuve
tetralogy of fallot
objective data: thirll palpable at left lower sternal border; S1 normal; S2 has A2 loud and P2 diminished or absent; murmur is systolic, loud, crescendo-decrescendo
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
right lower quadrant (RLQ)
organs in the ____________- include: cecum appendix right overary and tube right ureter right spermatic cord
cardiac sex and gender differences (culture and genetics)
one reason women tend to delay seeking care for CVD is that thier symptom cluster is different from men's; women may not experience the crushing chest pain of heart disease; women are more likely to experience prodromal symptoms for weeks or months before an acute cardiac syndrome; prodromal symptoms are those that are intermittent and resolve spontaneously; the most common prodromal symptom linked with ACS is fatigue
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
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
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
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)
pulsus alterans
rhythm regular, but vorce varies, with alternating beates of large and small amplitude associated with: when heart rate is normal, pulses alterans occurs with severe left ventricular failure, caused by ischemic herat disease, valvular heart disease, chronic hypertension, or cardiomyopathy
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
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
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
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
tendon
strong fibrous cord connecting muscle to bone
aortic stenosis
subjective data: fatigue, DOE, palpitation, dizziness, fainting, anginal pain
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
sensation/ strength lower extremities
test lower legs for ____________________ for those with history of diabetes, PAD, or HIV, test for sensation on the sole of the foot using a monofilament
lymphatics
the _________________ vessels converge and drain into two main trunks which enter into the venous system at the subclivian veins
aging adult cardiac assessment
the chest often increases in anteroposterior diameter with aging; this makes it more difficult to palpate the apical impulse and hear the splitting of S2 the S4 often occurs in older people with no known cardiac disease; systolic murmurs are common, occuring in over 50% of aging people a
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
radiation (murmur)
the murmur may be transmitted downstream in the direction of blood flow and may be heard in another place on the precordium, the neck, the back, or the axilla
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
inspect and palpate legs
the venous pattern normally is flat nad barely visible; note varicosities, although these are best assessed while standing; both legs should be symmetric in size without any swelling or atrophy; if the lower legs look asymmetric or if DVT is suspected, measure the calf circumference with a nonstretchable tape measure; measure at the widest point, takign care to measure the other leg in exactly the same place; if lymphedema is suspected, measure also the ankle, distal calf, knee, and thigh
valves
there are four ____________ in hte heart
acute arterial symptoms
those at risk: history of vascular surgery; arterial invasive procedure; abdominal aneurysm (emboli); trauma, including injured arteries; chronic atrial fibrillation
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
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
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
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
blood flowing to feet
walking sit down and rotate ankles in one then other direction but feet up when sitting, lying down, stretching, wiggling toes if sitting a long time, stand up and move every half hour to hour uncross legs often when sitting
anterior superior iliac spine
you can feel the entire iliac creste, form the _________________ to the posterior