Where do we expect to hear DULLNESS on percussion in abdominal assessment
liver, spleen, adipose tissue, over feces
Hyperresonance in abdomen can indicate:
gaseous distension
Costovertebral angle tenderness in abdomen can indicate:
kidney inflammation
What does the person’s abodomen look like if they have distention from ASCITES
o Inspection-Single curve & everted umbilicus; bulging flanks; taut skin; increased abdominal girth
o Auscultation-Normoactive, diminished over fluid
o Percussion-Tympany over bowels but dull over fluid
o Palpation-Taut skin and increased pressure
What is the greatest risk factor for cervical cancer?
human papilloma virus (HPV)
79 million have HPV in US
what is a priapism
a long and painful erection (not from sexual excitation). This can occur in PTs w/ leukemia or hemoglobinopathies (e.g. sickle cell)
What qualifies as binge drinking
Binge drinking= 4 drinks in 2 hours for women, 5 drinks in 2 hours for men
How much alcohol is safe for a pregnant woman to drink?
NONE!
What are 4 general steps for alcohol screening and brief intervention?
■ Step 1: Ask about alcohol use
■ Step 2: Assess for alcohol use disorders
■ Step 3: Advise and assist
■ Step 4: Follow-up and continued support
What are the signs of UNCOMPLICATED alcohol withdrawal?
peaks at 2nd day, improves by 4th/5th day. Most s/s are GI or neuro
o Tremors of hands, tongue, eyes
o Anorexia, malaise, nausea, vomiting
o Autonomic hyperactivity – tachycardia, sweating, elevated BP
o Headache, insomnia, anxiety/depression, irritability, hallucinations
What are the signs of severe alcohol withdrawal?
Withdrawal delirium = delirium tremors - occurs within 1 week of cessation
■ Coarse, irregular tremor
■ Extreme autonomic hyperactivity (tachycardia, sweating)
■ Vivid hallucinations and elusions, agitated behavior
■ Fever
What scale can be used to assess alcohol withdrawal?
○ CIWA scale (Clinical Institute Withdrawal Assessment) for Alcohol
Max score: 67
● Mild withdrawal
What scale can be used to assess opiate withdrawal?
Clinical Opiate Withdrawal Scale (COWS)
Max score: 48
○ Mild withdrawal 36
Hypoactive bowel sounds are common in patients with what conditions?
constipation and paralytic ileus (paralysis of the intestinal muscles)
Hyperactive bowel sounds are common in patients with what conditions?
gastroenteritis (An intestinal infection marked by diarrhea, cramps, nausea, vomiting, and fever) and diarrhea
What are venous hums found during abdominal assessment?
continuous sounds found in the epigastric region and around the umbilicus and caused by portal hypertension.
What % of GI diseases can be diagnoses by obtaining a thorough health history?
80-90%
What is the 2nd leading cause of US cancer deaths
colorectal cancer
What is the most common blood-borne U.S. viral infection?
Hepatitis C
The RUQ includes:
liver galbladder head of pancreas right adrenal gland hepatic fixture of colon duodenum part of ascending and transverse colon
LUQ includes
body of pancreas stomach spleen left lobe of liver left adrenal gland splenic fixture of colon left kidney left adrenal part of transverse and descending colon
RLQ includes
cecum appendix right ureter right ovary right spermatic cord
LLQ includes
sigmoid colon part of descending colon left ovary and tube left ureter left spermatic cord
after middle age, where does fat accumulate in females?
in the suprapubic area due to decreased estrogen levels
what are age related changes in abdomen?
- salivation decreasess, there is decreased taste
- esophageal emptying is delayed
- gastric acid secretion decreases with aging, leading to pernicious anemia (decreased B12 absorption)
- Incidence of gallstones increases
- liver size decreases with age, although most liver function remains normal. prolonged drug metabolism leads to increased side effects.
common causes of constipation include:
decrease physical activity inadequate water intake low fiber diet side effects of meds IBS hypothyroidism
how do you avoid abdominal tensing?
don't place arms above head warm stethescope short nails examine painful areas LAST to avoid muscle guarding have PT bend at knees while supine
what is a scaphoid abdomen?
when it is sucked inwards
mainly seen in sever malnutritional status, marasmus, cachexia, acute diffusive peritonitis due to muscle rigidity.
the umbilicus may be everted with
pregnancy
ascites
underlying mass
umbilical hernia
bluish periumbilical color occurs with
intraabdominal bleeding (cullen sign)
Striae
linear stretch marks (recent striae are pink or blue, then they turn silvery white)
normally, veins shouldn’t be visible. they appear dilated and prominent with
portal hypertension, cirrhosis, ascites, malnutrition
poor turgor occurs with
dehydration
marked visible peristalsis, with a distended abdomen, indicate
intestinal obstruction
absolute stillness on the examination table occurs with
pain of peritonitis
restlessness and constant turning indicates
colicky pain of gastroenteritis or bowel obstruction
what endpiece of the stethescope do you use when auscultating the abdomen?
diaphragm because bowel sounds are high pitched
what quadrant do you begin in for ab assessment?
RLQ at the ileocecal valve area because bowel sounds are always present
what are causes of abdominal distention?
Fat Fetus Feces Flatus Fluid Fatal Tumor Fibroid
normal bowel sounds occur:
5-30 times per minute
they are high pitched, gurgling, cascading, occuring irregularly
hyperactive sounds are:
over 30 times per minute
they are loud, high pitched, rushing, tinkling sounds that signal increased motility
hypoactive sounds occur
less than 4 per minute. they follow abdominal surgery, or with inflammation of peritoneum
how long must you listen to decide that bowel sounds are absent?
5 minutes
what is a borborygmus?
a hyperactive bowel sound termed stomach growling
indicates diarrhea, hyperperistalsis, or an early indication of intestinal obstruction
where do you listen for bruits at the abdomen?
aorta
renal artery
iliac
femoral
do this especially in hypertensives. usually no sound is present.
a systolic bruit occurs with
stenosis or occlusion of an artery
when percussing over the abdomen, what should predominate?
tympany
when is hyperresonance present during abdominal percussion?
gaseous distention
emphysema
pneumothorax
when does dullness occur during abdominal percussion?
distended bladder
adipose tissue
fluid
mass (liver, spleen)
When would you suspect someone has ascites?
a distended abdomen, bulging flank, and a protruding umbilicus that is protruding
when does ascites occur?
HF, portal hypertension, cirrhosis, hepatitis, pancreatitis, cancer
what is the definitive tool for ascites?
ultrasound.
what do you do enhance muscle relaxation when palpating?
bend person’s kees
keep palpating hand low and parallel to abdomen
with a ticklish person: keep person’s hand under your own wiht your fingers curled over their fingers.
what is the objective of light palpation?
to form an overall impression of the skin surface and superficial musculature.
save the examination of any identified tender areas until last
how do you do light palpation?
with first FOUR fingers depress skin 1 cm and make gentle rotary motion, sliding fingers and skin together. LIFT fingers when moving to next location, and go clockwise.
what changes occur in the elderly that are evident during an abdominal assessment?
organs are easier to palpate because of the thinner abdominal wall.
- liver is easier to palpate
- liver is palpated lower, descending 1 to 2 cm below costal margin with inhalation
- kidneys are easier to palpate.
- abdominal rigidity with acute conditions is less common in the old.
- Fewer complaints with acute abdominal pain because of decrease nerve impulses.
an enlarged and TENDER liver occurs with
HF
acute hepatitis
hepatic abscess
what is the problem with 24 hour recall for food?
daily pattern may vary. attempt week long diary of intake.
what is cullen’s sign?
bluish periumbilical color that occurs with intraabdominal bleeding
Inadequate intake of ___________ during pregnancy is linked to neural tube defects in newborns.
folic acid
How is BMI calculated?
• BMI is calculated as weight in kilograms divided by height 2 in meters squared (m ). BMI of 18.5 to 24.9 is healthy, less than 18.5 is underweight, 25 to 29.9 is overweight, and 30 or greater represents obesity.
Lab values r/t nutrition include
serum albumin, pre-albumin, transferrin, total protein, creatinine, sodium, potassium, hemoglobin, hematocrit, total lymphocyte count, and hypersensitivity reaction.
Nursing diagnoses related to nutrition include:
Imbalanced nutrition: less than body requirements
Imbalanced nutrition: more than body requirements
Excess fluid volume
Deficient fluid volume.
food intake: food frequency questionnaire
how many times per day/week/month a particular food is eaten
All _____soluble vitamins have the potential for_____due to their ability to be stored in the body for long periods of time
fat-soluble, toxicity
clients with what diseases will cause a risk for nutritional deficiency
crohn’s disease, cystic fibrosis, celiac disease, intestinal bypass
Vitamin A contributes to
vision health, tissue strength and growth, embryonic development
Vitamin deficiency results in
vision changes, xerophthalmia ( dryness and thickening of the conjunctiva), and changes in the epithelial cells (especially in the mouth and vaginal mucosa
food sources of Vitamin A are
fish liver oils, egg yolks, butter, cream, and dark yellow/orange fruits and vegetables (carrots, yams, apricots, squash, cantaloupe)
Vitamin D contributes to
utilization of calcium and phosphorus, and aids in skin repair
Vitamin D deficiency results in
bone demineralization, extreme deficiency results in rickets
sunlight enables the body to:
synthesize vitamin D
the vitamin that essential to the synthesis of blood clotting factors is
vitamin K
which of the food groups would be the best sources of carotene
apricots, cantaloupe, squash, carrots, dark leafy greens
- When performing an abdominal assessment, what is the correct sequence?
Inspection, auscultation, percussion, palpation
Rationale: For the abdomen, auscultation must be performed before percussion and palpation to prevent minimizing bowel sounds.
A patient reports a long history of changes in bowel pattern. Which is the best question to determine normal bowel habits?
A. How often do you have a bowel movement? B. What was your bowel pattern before you noticed the change? C. Is there a family history of irritable bowel syndrome? D. Have any of your parents or siblings had cancer of the colon?
B. what was your bowel pattern before you noticed the change?
- When palpating the abdomen, the nurse notices a mass at the anterior right costal margin in the MCL. Which organ is most likely involved?
A. Liver B. Spleen C. Sigmoid colon D. Kidney
A. Liver
5. A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea with vomiting. What assessment technique will illicit kidney pain? A. Rovsing sign B. Psoas sign C. Percussion for CVA tenderness D. Blumberg sign
C. Percussion for CVA tenderness
Rationale: Fist percussion over the costovertebral angle (CVA) is the only technique listed that reflects a technique for assessing the kidney. The remaining techniques are used to assess peritoneal inflammation.
Psoas sign
place hand below PT’s R knee. Ask PT to raise thigh against hand and turn to L side. Extend R leg at the hip to stretch the iliopsoas muscle. A positive sign is ipain in the RLQ, suggesting appendicitis or peritoneal inflammation
Rovsing sign
Press deeply in LLQ and quickly withdraw fingers. The PT reports pain in RLQ during LLQ pressure, indicating appendicitis
Obturator sign
can indicate inflamed appendix or peritoneal inflammation
Murphy sign
hook thumb under R costal margin at edge of the rectus abdominis muscle; have PT take deep breath. Sharp tenderness and sudden stop in inspiratory effort constitutes positive Murphy sign, indicating CHOLECYSTITIS.
When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as a bruit of which of the following? A. Right renal artery B. Right femoral artery C. Right iliac artery D. Abdominal aorta
C. Right iliac artery
Rationale: The iliac arteries are located to the left and right of the midline of the abdomen, below the umbilicus. The aorta is midline, the renal artery is above the umbilicus, and the femoral artery is located in the groin.
- A patient with a history of cirrhosis tells the nurse that his abdomen seems to be getting larger and that he has gained 9.7 kg (20 lb) in the last 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain?
By percussing the abdomen for shifting dullness
Rationale: Percussing elicits a change from tympany to dullness when the abdomen is in its most dependent position. Fat remains static.
- A patient with a tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive?
A. Murphy sign
B. Psoas sign
C. Rovsing sign
D. Obturator sign
Murphy sign
Rationale: The Murphy sign tests for gallbladder pain. The other signs test for peritoneal irritation in the lower quadrants.
Which assessment technique would best confirm splenic enlargement?
A. Deep palpation under the left costal margin B. Fist percussion of the spleen with the patient in a sitting position C. Deep palpation over the RUQ with the patient lying on the right side D. Percussion along the left MAL spleen and gentle palpation
D. Percussion along the left MAL spleen and gentle palpation
Percussion is the best technique to estimate the size of the spleen; gentle palpation is necessary to reduce the risk of splenic rupture.
When documenting a finding in the region over the stomach and centered above the umbilicus, the nurse most accurately identifies the region as: A. epigastric. B. hypogastric. C. RUQ. D. LUQ.
epigastric
The epigastric region is located above the umbilicus and straddles the midline between the right and left upper quadrants.
- The patient has serum values that are abnormal for sodium and potassium. The nurse recognizes that these values are important to maintain in normal range for proper:
fluid and electrolyte function
Rationale: Water and sodium levels are indicators of fluid balance. Potassium levels must be maintained within a narrow range for proper electrolyte function.
Examples of fat-soluble vitamins
Vitamins A, D, E, and K
Name 3 important minerals
iron, zinc, and calcium
Folate, vitamin B12 and iron are necessary for:
Folate, vitamin B12, and iron are necessary for oxygenation and optimal hemoglobin and hematocrit counts.
Primary nutrients essential for optimal body function include:
carbohydrates, proteins, and fats.
A patient reports taking St. John’s wort along with a medication prescribed for heart disease. Which of the following is the most appropriate response from the nurse?
A. Never take supplements in addition to prescribed medications.
B. Supplements act in a very different way from prescribed medications.
C. Some supplements may interact with your medications.
D. It is known that St. John’s wort interacts with medications for heart disease.
C. Some supplements may interact with your medications.
St John’s wort may reduce the effectiveness of what medications?
St. John’s wort reduces the effectiveness of oral contraceptives and medications prescribed for heart disease, depression, seizures, some cancers, and organ transplant rejection.
A woman who is pregnant is being screened for adequate intake of calcium and vitamin D. Which of the following tools is most appropriate for the nurse to administer? A. 24-hour recall B. 3-day diet history C. Food frequency questionnaire D. Comprehensive nutrition assessment
C. Food frequency questionnaire
From the list below, select the older adult at greatest risk for malnutrition.
A. A 67-year-old married man with poor dentition
B. A 73-year-old woman in a nursing home
C. An 80-year-old widow who lives alone
D. A 78-year-old widower who receives food from Meals on Wheels
C. An 80-year-old widow who lives alone (this patient has 2 risk factors)
A patient is admitted to the hospital with multiple trauma from an automobile accident 5 days ago. Which of the following is the best indicator of current nutritional status? A. Transferrin B. Totalprotein C. Albumin D. Prealbumin
D. Prealbumin (has a shorter half life (2 days) compared to albumin (18-21 days))
The nurse assesses for alcohol or substance abuse using the _______tool.
CAGE tool
The nurse assesses spirituality and sense of meaning using the _____tool.
HOPE tool
Depression may be assessed using the _______ tool
SAD PERSONAS tool
Assessment of mental status includes (think ABCT)
Appearance (posture, movement, hygiene, and dress), Behavior (level of consciousness, eye contact, facial expressions, speech), Cognitive function (orientation, attention span, memory, judgment), and Thought processes (ABCT).
The MMSE tool measures
cognitive function and includes orientation, registration, attention and calculation, recall, and language to determine mental status
“Do you have any thoughts of wanting to kill or harm yourself?” is a common question to assess for suicidal ideation because it
will cover both suicidal and parasuicidal thoughts
Normal movements are
voluntary, deliberate, coordinated, smooth, and even.
Uncoordinated movements include
akathisia (agitation/distress/restlessness), akinesia (loss of voluntary movement), dystonia (involuntary muscle contractions that cause repetitive or twisting movements), parkinsonism, tardive dyskinesia (neuro disorder characterized by involuntary movements of face & jaw), and neuroleptic malignant syndrome.
Normal speech is audible. This is a normal finding describing which quality of speech? A. Fluency B. Quality C. Loudness D. Articulation
C. Loudness
A 90-year-old patient has a drooped body position, appears sad, and says that she has seasonal affective disorder. What tool would the nurse use to assess her?
A. MMSE B. CAGE C. HOPE D. Geriatric Depression Scale
D. Geriatric Depression Scale
the patient who perseverates will:
repeat content
Patients may laugh spontaneously, provide inappropriate responses, ask the nurse personal questions, or insult the nurse. These are examples of:
A. perseveration. B. auditory hallucinations. C. divergent tactics. D. altered mood.
C. divergent tactics.
When questioning a patient about violence, it is best to:
move from general to specific questions
The correct position in which to place a healthy adult male client to examine the rectum and prostate is:
leaning over the examination table with chest and shoulders resting on the table.
Rationale: Standing is preferred because it allows for visualization of the anus and palpation of the rectum. If the patient cannot stand, the Sims position is used.
What is the Sims position
PT is on left side with R leg flexed and the left leg semiextended (used for rectal exam if PT cannot stand)
Hemorrhoids are usually caused by:
constant or excessive straining upon defecation
During a physical assessment, using the handle of the reflex hammer, you gently stroke the inner left thigh of the patient, which causes the ipsilateral testicle to rise. What superficial reflex is demonstrated?
Cremasteric reflex (abnormal finding would be no movement)
what is Cryptorchidism
undescended testicle at birth
A 20-year-old Caucasian man complains of a mass in his left testicle. In addition to his age and race, what else is a risk factor for testicular cancer? A.Colon cancer in his mother B. Personal history of cryptorchidism C. Urinary tract infection last month D. Congenital hydrocele
B. Personal history of cryptorchidism
Testicular torsion requires immediate surgical intervention to prevent
strangulation of the testicle.
Testicular torsion
the sudden twisting of the spermatic cord, typically occuring on the L side bc L cord is longer. Blood supply is impaired–>ischemia–>venous engorgement–>gangrene. Requires IMMEDIATE ATTENTION
Most common in late childhood or early adolescence.
what is smegma
Smegma is a thin, white, cheesy substance that may normally be present under the foreskin.
Which of the following would you recognize as an unexpected finding while examining the male genitalia?
A. Smegma is present on the uncircumcised patient.
B. Testes are palpable and firm within the scrotal sac.
C. You note an impulse at the tip of your finger during hernia examination.
D. The urethral meatus has a slit like opening central to the distal tip of the glans.
C. You note an impulse at the tip of your finger during hernia examination.
When examining the scrotum of an adult Hispanic male, a normal finding is:
A. symmetrical scrotal sac with two movable testes.
B. smooth, rubbery, saclike surface that is sensitive to gentle compression.
C. asymmetrical sac with left side lower than right side.
D. reddish colored skin that is darker than general body skin and has sebaceous cysts.
C. asymmetrical sac with left side lower than right side.
A young male presents for a sports physical exam. In addition to examining for hernias, it would be appropriate for you to do which of the following?
A. Teach testicular self-examination.
B. Evaluate for urinary retention.
C. Examine for prostate cancer. D. Draw blood to measure prostatic surface antigen.
A. Teach testicular self-examination
Rationale: This age group is at high risk for testicular cancer; prostate cancer usually occurs later in life.
What is varicocele?
a condition caused by abnormal dilation and tortuosity of the veins along the spermatic cord, often on the left side. Upon palpation, the varicocele feels like a bag of worms.
A patient complains of a soft, irregular mass on the left side of the scrotum he noticed while walking. The nurse palpates a mass that feels like “a bag of worms.” These findings are consistent with which condition?
varicocele
hydrocele
the accumulation of serous fluid in a body sac
spermatocele
painless, movable cystic mass above the testis
Epididymitis
an inflammation of the coiled tube (epididymis) at the back of the testicle that stores and carries sperm.
A 70-year-old man presents with the following symptoms: straining to void, nocturia, dribbling, and hesitancy when voiding. These signs are consistent with what condition?
Benign prostatic hypertrophy (BPH)
phimosis
a congenital narrowing of the opening of the foreskin so that it cannot be retracted.
Pediculosis
infestation with lice
Hypospadias
when the urethral meatus is on the ventral side of the penis
Which sexually transmitted infection presents with painful red superficial vesicles along the penis or on the glans?
A. Gonorrhea B. Chlamydia C. Syphilis D. Herpes simplex virus 2 (HSV-2)
D. Herpes simplex virus 2 (HSV-2)
what is encompassed in the females “vestibule”
Within the vestibule lies the urethra at the upper middle area and the bilateral paraurethral Skene glands are at the seven- and five-o’clock positions, respectively.
An annual Pap smear is recommended to screen for what condition?
Cervical cancer
After completing a history on a 45-year-old patient, the nurse suspects the patient may have uterine fibroids. What information might have led her to this conclusion?
Heavier than usual menstrual periods
Uterine fibroids (non cancerous growths on the uterus) are suspected when
when a patient presents with heavy menstrual flow, irregular bleeding, pelvic pressure, or all of these symptoms
The practitioner has decided to place the patient on isotretinoin for her acne problems. The nurse is preparing to counsel the patient. What is the most important information she needs to tell the patient?
She needs to use 2 forms of BC or abstain from sex 1 month before, during, & 1 month after taking this medication.
Rationale: Because of the severe teratogenic effects of this medication, anyone of childbearing age must either abstain from sex or use at least two forms of birth control during treatment and for 1 month before and 1 month after treatment.
what is salpingitis
inflammation of the fallopian tubes (most common cause of fallopian disease)
Which organisms associated with salpingitis?
The most common organisms that cause salpingitis are Chlamydia trachomatis and Neisseria gonorrhoeae.
What is the greatest killer of women
heart disease
The nurse practitioner is assessing a patient with frequent candidiasis. The test that the nurse will order for this patient is:
a blood test for glucose
Frequent vaginal candidiasis can be a symptom of abnormal blood glucose levels. Need to rule out DM.
Condyloma acuminatum infection
warts. Condyloma present as fleshy white to gray appearing lesions (can be individual or may be clustered)
what does TSE stand for?
testicular self exam
Also:
timing. ..once a month
shower. ..warm water relaxes scrotal shaft
examine. ..check for changes
most common cancer of young men between ages of 14-40
testicular cancer
Abrupt onset of testicular pain and diagnosed with ultrasound
Testicular torsion
How often should a colonoscopy be done?
Every 10 years after age 50
venous hums are
soft-pitched humming noise with systolic and diastolic components. They indicate partial obstruction of an artery and reduced blood flow to the organ.
Friction rubs are
grating sounds that increase w/ inspiration. May indicate liver tumor, splenic infarction, or peritoneal inflammation.
Tenderness over the symphysis pubis may indicate
a UTI or pelvic inflammatory disease (PID)
Two ways to assess for ascites:
shifting dullness or fluid wave
1 concern for men’s reproductive health
BPH
Which ethnic group are at an increased risk for prostate cancer
african americans
Common problems in older men’s reproductive health
difficulty urinating, leaky urine, nocturia
What is the recommended age to start screening for colorectal cancer
age 50 (if you have fam history, start at 40)
What is the gold standard for screening for colon cancer
colonoscopy
Who is drinking these days?
52% of those age 12 and older reported drinking
The passage of fresh blood through the anus, usually in or with stools is called
hematochezia
