Indirect inguinal hernia
inguinal ring (most common) Pain SwellingIncreased abdominal pressure
sac herniates thru internal inguinal ring; can remain in canal or pass into scrotum. Pain with straining; Congenital or acquired
Direct inguinal hernia
(weak point in fascia of abdominal wall)
Always acquired
Increased abdominal pressure
directly behind and through external inguinal ring, above inguinal ligament; rarely enters scrotum. Painless, swelling. Brought on by heavy lifting, muscle atrophy, obesity, chronic cough, or ascites
Femoral hernia
Anatomical defect
Usual in females
Can be strangulated
Through femoral ring and canal, below inguinal ligament, more on right side. Pain severe, strangulated. Acquired; increased abdominal pressure, muscle weakness, frequent stooping.
Incisional hernia
Through scar
Poor wound healing
Umbilical hernia
Congenital: age of 2. May disappear by 3-4. They do surgery
obese/ascites
Hernia
very common/ can’t feel it sometimes.
Born with it
Pain or no pain
painful→ strangulated→ no blood supply→ ER→ OR
Incarcerated: urgent but not so much. Cannot be reduced. Don’t force
Reducing hernias: reducible
Gonorrhea
Purulent discharge. Needs culture
Herpes
Vesicles (fluid filled pustules) in clusters. They rupture in 1-2 days and leave an ulcer.
Chlamydia
Urinary urgency/painful discharge or no symptoms.
Vaginal warts
firm, cauliflower
Syphilis:
papules (>1 cm)
Stools by 4th day of breastfed
golden yellow, pasty and smell like sour milk.
Formula fed
brown yellow firmer and smell fecal.
S&S of intestinal obstruction
Abdominal surgery Dehydration and loss of electrolytes Accumulation of fluid and gas in bowel above obstruction Colicky pain from peristalsis Fever Leaking fluid into peritoneum Hypovolemic shock.
in small bowel
crampy pain, bile projectile vomit, constipation and diarrhea.
Head of bed up
NPO, IV, NG tube, decompress, ileostomy
Postop: risk of DVT and PE (do leg exercises, electrical stockings, fluids)
In large bowel
deep pain/long/dull, Feces/constipation/diarrhea. Vomit smells like feces/ BP down, RR up, fever up
blood cross match/surgery/colostomy
Postop: risk of DVT and PE (do leg exercises, electrical stockings, fluids)
Cerebral cortex:
highest function, thought, reasoning, sensation, and voluntary movement
Frontal:
personality, behavior, emotions, and intellectual functions.
Parietal
sensation. movement/orientation
Temporal:
hearing, taste and smell.
memory/speech
Wernicke’s area
language comprehension.
Receptive aphasia: sound has no
meaning like a foreign language
Broca’s area
motor speech
Expressive aphasia: the person can’t talk.
Basal ganglia
help to initiate and coordinate movement and control automatic associated movements.
Thalamus
synapses occur here.
Hypothalamus
Respiratory center, temp, HR, BP, sleep, stress, autonomic nervous system activity,
Cerebellum
motor coordination, equilibrium, and muscle tone.
COMPLETE NEURO ASSESSMENT
CN Muscle strength Sensory systems Cerebellar functioning (posture, equilibrium) Reflexes
QUICK ASSESSMENT
LOC: alert, verbal stimuli, painful stimuli
oriented to person, place, time.
Motor function: squeeze my hands, raise arms.
Pupillary response
Glasgow coma scale: eye opening, motor response and verbal response.
Brains stem
midbrain pons medulla: BP, HR, RR.
dysphagia sign
drooling
dysarthria
pt cannot formulate their words
Screen symptoms of stroke:
sudden vision change, fleeting blindness, weakness, loss of consc.
mental status
LOC/orientation
Cerebellum testing
coordinated voluntary movements
balance
Sensory cortex (parietal lobe)
-stereognosis test
Graphesthesia: ability to read a number by having it traced on the skin.
-2-point discrimination
Extinction
Reflexes
+2 is normal
Rooting
(CN 5)
Moro reflex
(CN 8) flex side
Neurologic recheck
- LOC– Change is important!!!
- Motor function
- Pupillary response
- Vital signs
Decorticate
flexion of arm, wrist, and fingers; adduction of arm/extension of legs, internal rotation, plantar flexion. Lesion in cerebral cortex
Decerebrate
arms extremely extended, internally rotated, palms pronation. Legs swiftly extended.
Lesion in brainstem.
Increased Intracranial pressure
-LOC changes early sign
-Pupils (ipsilateral at first. becomes larger and doest react) dilated and fixed (CN 3)
-Deteriorating motor function (bilateral or unilateral)
-Decorticate position. Arms curl up
-Decerebrate position.
-Headache
-Presses on medulla (vomiting)
late changes —> VS
-BP systolic up diastolic down (widening) then drops
-pulses will be fast and then all of a sudden it goes down and stop
-Resp: fast, then slow
-temp: rises
-Pupil edema (optic disk swelling)
Tx for ICP
call others (rapid response team) increase HOB to 30 degrees no trandelenberg no suctioning no pressure on the neck check temp seizure control diuretics (mannitol) pain management
CVA tx
aspirin with no coating
r/o hypoglycemia
start IV, electrolytes, PT/PTT, CBC, BS, EKG, blood work
CAT scan (hemorrhagic)
tPA (manage BP—> less than 180 systolic) VS q 15 minutes watch for changes in LOC!!!
hypothermia treatment after it happened
Risk factors for CVA
smoking DM atherosclerosis oral contraceptives HTN
Tetralogy of Fallot
Right Ventricular outflow stenosis
VSD
Right ventricular hypertrophy
Overriding aorta
Result: shunts a lot of venous blood into aorta away from pulmonary system; blood never gets oxygenated
Severe cyanosis (as infant grows) with crying and exertion, then at rest.
DOE.
Development slowed.
Thrill at left lower sternal border
Murmur is systolic, loud, crescendo-decrescendo.
Patent Ductus Arteriosus (PDA)
Pulmonary artery and aorta connected. BP wide pulse pressure Bounding peripheral pulses Thrill palpable at left upper sternal border Machinery murmur (systole and diastole)
Atrial Septal defect (ASD)
Abnormal opening in atrial septum. Left to right shunt. Increase in pulmonary blood flow
Young adults: mild fatigue and DOE
Sternal lift. S2 fixed split
Murmur is systolic, ejection, medium pitch, best heard at base in 2nd left interspace.
Ventricular Septal Defect (VSD)
Abnormal opening between the ventricles (subaortic area). Large defects: infants have Poor growth Slow weight gain Pale, thin, delicate. Feeding problems DOE Frequent respiratory infections HF if severe Loud, harsh holosystolic murmur (left lower sternal border) Thrill Large: soft diastolic murmur at apex (mitral flow murmur) by increased blood flow through mitral valve.
Coarctation of the Aorta
Severe narrowing of descending aorta. Increased workload on left ventricle.
Associated with PDA or VSD.
HF develops
Teens: lower-extremity cramping, worse with exercise
Arm HTN over 20 mm Hg.
Absent/diminished femoral pulses
Systolic murmur at the left sternal border.