NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide
HEALTH ASSESSMENT MIDTERM
1-5 questions
Building A Complete Health History (Week 1) Chapters 1 & 26
• Communication techniques used to obtain a patient’s health history Chapter 1
– Open ended questions: gives the patient discretion about the extent of the answer
– Direct question: seeks specific information
– Leading question: most risky, may limit information
– Courtesy, comfort, connection, confirmation
– CAGE questionnaire screening: designed to help diagnose alcoholism
– CRAFT screening: ETOH and substance abuse in adolescents (Car, Relax, Forgot, Friends, Trouble)
– TACE screening: drinks does it take to feel high, people Annoyed you about your drinking, Cut back drinking, Eye opener drink in the AM
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– Partner violence screen (PVS): hit kicked or punched, feel unsafe…
– Domestic Violence (HITS): Hurt you physical, Insult you, Threaten you, Scream at you?
– Spirituality (FICA): Faith, Importance, Community, Address
– Types of histories: Complete, inventory (touches up on major points), Problem (focused, acute life-threatening problem), Interim (designed to chronicle events that have occurred since last meeting)
• Recording and documenting patient information Chapter 26
– Write out abbreviations Copy and paste or carry forward (CPCF)
– International Classification of Disease (ICD): diagnostic coding system that classifies diseases and injuries and u used to track mortality and morbidity NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide
– Geriatric screening tool: Katz Index consists of six items (bathing, dressing, toileting, transferring, continence and feeding
– Geriatric screening tool: Lawton Instrumental ADL-scale consists of eight items in women (ability to use the telephone, shopping, cooking, housekeeping, doing laundry, taking own medication, making transports, and ability to handle finances)
§ Functional impairment was defined as dependency on at least one domain of ADL (score <6) or IADL (a score <8 from women or <5 for men). Functional decline was defined as deterioration on at least one domain of ADL or IADL compared to baseline (decline ≥1 point). NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide. – Sullivan Book: § CPTP is a listening of descriptive terms and identifying code for reporting medical services and procedures SOAP note documentation – S: subjective (what patient tells you) – O: objective (observations) – A: assessment (interpretation and conclusions) – P: plan (diagnostic testing, rationale for decisions) • Subjective vs objective information when documenting – S: pain (use pain score) – O: relate findings to the process of inspection, palpation, auscultation, percussion. “no masses on palpation” “tympanic membranes are pearly gray” – O: Use anatomic landmarks to add precision – O: Findings that vary by degrees are customarily graded or recorded in an incremental scale format (pulse amplitude, heart murmur intensity, muscle strength, DTR NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide. – Illustrations useful in describing the origin of pain and where it radiates and the size, shape and location of a lesion – HX of present illness: OLDCARTS: onset, location, duration, character, aggravating factors, relieving factors, temporal factors, severity of symptoms Ethical decision making and beneficence – Beneficence: doing good Diversity and Health Assessment – Bullets 6, 7, 8 Cultural Awareness and Diversity Achieving cultural competence is a learning process that requires self-awareness, reflective practice, and knowledge of core cultural issues A culturally competent health care provider adapts to the unique needs of patients of backgrounds and cultures that differ from his or her own Culture , in its broadest sense, reflects the whole of human behavior, including ideas and attitudes; ways of relating to one another; manners of speaking; and the material products of physical effort, ingenuity, and imagination. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide The stereotype, a fixed image of any group that denies the potential of originality or individuality within the group Multiple studies have shown that health care providers activate these implicit stereotypes, or non-conscious bias, when communicating with and providing care to minority patients Members of racial and ethnic groups are not uniform. Each group is highly heterogeneous and includes a diverse mix of immigrants, refugees, and multigenerational Americans who have vastly different histories, languages, spiritual practices, demographic patterns, and cultures Culturally competent care requires that health care providers be sensitive to patients’ heritage, sexual orientation, socioeconomic situation, ethnicity, and cultural background When cultural differences exist, be certain that you grasp exactly what the patient means and know exactly what the patient thinks you mean in words and actions The definition of “ill” or “sick” is based on the individual’s belief system and is determined in large part by his or her enculturation. Socioeconomic, spiritual, and lifestyle factors affecting diverse populations Age, gender, race, ethnic group and, with these variables, cultural attitudes, regional differences, and socioeconomic status influence the way patients seek medical care and the way clinicians provide care A patient who knows the English language, however well, cannot be assumed to know the culture. Poverty and inadequate education disproportionately affect various cultural groups (e.g., ethnic minorities and women); socioeconomic disparities negatively affect the health and medical care of individuals belonging to these groups Age, gender, race, ethnic group and, with these variables, cultural attitudes, regional differences, and socioeconomic status influence the way patients seek medical care and the way clinicians provide care. Black and Latino children in the United States also experience health disparities, including lower overall health status and lower receipt of routine medical care and dental care compared to white children NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide Functional Assessments Functional Assessment for All Patients Quite simply, functional assessment is an attempt to understand a patient’s ability to achieve the basic activities of daily living. This assessment should be made for all older adults and for any person limited by disease or disability, acute or chronic. A well-taken history and a meticulous physical examination can bring out subtle influences, such as tobacco and alcohol use, sedentary habits, poor food selection, overuse of medications (prescribed and nonprescribed), and less than obvious emotional distress. Even some physical limitations may not be readily apparent (e.g., limitations of cognitive ability or of the senses). NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide. Keep in mind that patients tend to overstate their abilities and, quite often, to obscure reality. When performing a functional assessment consider a variety of disabilities: physical, cognitive, psychologic, social, and sexual. An individual’s social and spiritual support system must be as clearly understood as the physical disabilities. There are a variety of physical disabilities, including: Mobility Difficulty walking standard distances: ½ mile, 2 to 3 blocks, 1/3 block, across a room Difficulty climbing stairs, up and down Problems with balance Upper extremity function Difficulty grasping small objects, opening jars Difficulty reaching out or up overhead, such as taking something off a shelf Housework Heavy (vacuuming, scrubbing floors) Light (dusting) Meal preparation Shopping Medication use Money management Instrumental activities of daily living Bathing Dressing Toileting Moving from bed to chair, chair to standing Eating Walking in home Any limitations, even mild, in any of these areas will affect a patient’s independence and autonomy and, to the extent of the limitation, increase reliance on other people and on assistive devices. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide. These limitations indicate the loss of physical reserve and the potential loss of physical function and independence that indicate the onset of frailty. The patient’s social support system and material resources are then integral to the development of reasonable management plans. #9 Growth and Development Ch 6 of text book Growth Hormone-Releasing Hormone stimulates the pituitary to release the growth hormone. 70% of secretion of the growth hormone occurs during sleep Critical brain growth between conception and 3 yrs old. P uberty- Dependent on the GH and androgens (Sex Steroids). They stimulate and increase in the growth Hormone. Lymphatic tissues reach adult size by 6 yrs old and double by 10-12 yrs old. Pregnancy Weight Child- 6-8lbs of wt blood-3-4lbs Maternal Fat/protein 4-6lbs Uterus 2lbs breast 1-2 lbs Fluid 2-3lb Amniotic fluid 2lbs Older Adults Physical Stature decrease at 50 yrs 60 yrs – decrease HT, WT, BMI Increase Body Fat Children and Adolescence Sexual Maturation Girls Early < 7 yrs Delayed > 13 yrs
Sexual Maturation Boys
Early <9 Delayed > 14
BMI
Malnourished < 18 Normal 18.5-24.9 Overweight 25-29.9 Obese 30-39.9 Extreme >40
Measuring babies
Weight- Infants should be weight in Gm or KG to the nearest 10 gm
Normal newborn wt 2500-4000 gm * 5lbs 8oz – 8lbs 13 oz)
Lose 10 % of wt at birth and regain in 2 wks.
Birth weight doubles at 6 months and triples by 12 months
Head Circumference
Wrap measuring tape at occipital protuberance and supraorbital prominence.
Measure to the nearest 0.4cm
Place on the growth curve and compare with the standard.
Chest Circumference
Compare to head size
Wrap at nipple line
5 months – the head is = or exceeds the chest size
5 months – 2yrs head = chest
2 yrs chest is > head.
#10, #11, #12 #13
Nutritional assessment, Macronutrients, Food Diary, BMI
Macronutrients
• *Macronutrient is required in significant amounts of the diet. Macronutrient includes proteins, carbohydrates, and lipids.
*Macronutrients are so named because they are required in LARGE AMOUNTS.
Micronutrients
The nutrient which is required in smaller amounts in the body is called micronutrients. Two categories of micronutrients are vitamins and minerals.
• Which of the following assessment findings might lead the examiner to suspect vitamin D deficiency?
Ans. Rickets, a disease manifested by spinal curvature and bowed legs NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
Nutrition
• *The nutrients that are deficient in vegetarian diet are protein, Calcium, Iron, Vitamin B12, and vitamin D.
*Carbohydrates and proteins supply 4 calories per gram while fats supply 9 calories. Alcohol provides 7 calories per gram.
Carbohydrate
The body handles excess carbohydrate by storing as fat.
Protein
*Mrs. Webb is a 38-year-old patient who has been changing her lifestyle to eat in a healthy way and lose weight. During your health promotion education regarding her nutritional status, you explain the function of dietary protein as:
a. providing an energy source for the brain.
b. building and maintaining tissues.
c. participating in specific detoxifying metabolic pathways.
d. synthesizing and regulating hormones.
The correct Ans is b
*Which of the following are major functions of dietary protein?
Building and maintain tissues;
Regulating water and acid-base balance;
Working as a precursor for enzymes, antibodies, and several hormones
*The recommended minimum daily protein requirement for the normal adult is? Ans. 14%-20% of total calorie or 45 grams for adults.
Fat
*The recommended dietary fat intake for the normal adult is? About 20 to 35 grams per day.
*Advising a person to reduce which macronutrient will produce the greatest caloric reduction per gram of reduction?
o Ans. Fat
Which age group requires the highest percentage of dietary fat intake?
Ans. Before 2 years of age, fat intake may reach 35% 40% of calories.
Water
*Which one of the following would be assessed first in the patient with sustained respiration?
Ans. Hydration/ water
Rationale: A person can exist without food or vitamins for several weeks but without water for only a few days.
2-2.5 L water loss occurs daily by the body in a healthy person under normal circumstances.
Food Diary
• *The food diary is recorded as it happens, making this method the most accurate reflection of an individual’s food intake NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
#13 BMI
BMI is calculated by the weight in pounds multiplied by 703 divided by the height in inches squared.
*Monitoring a patient’s waist to hip ratio provides data concerning patient’s disease risk in cardiovascular term.
*When obesity occurs mostly in lifetime?
Obesity occurs during adolescents 70% of the time. Obesity occurs before skeletal growth or sexual maturation is complete.
*A scale is used to assess patient’s weight need to be calibrated every time before using.
*When monitoring serial measures, such as head circumference or abdominal girth, which procedure is best to ensure that the tape measure is placed in the same position each time?
Ans. Mark the borders of the tape at several intervals on the skin with a pen.
*You are using rule of thumb for advising a 150-pound person decrease calorie intake for weight loss. How many calorie intakes is appropriate per day?
ANS. 150 pounds/2.2 = 68 kg
68×25= 1700 calories.
Rule of thumb for weight loss equals 25 multiply each kg body weight.
*What medication may cause weight gain?
Steroids, oral contraceptives, antidepressants, and insulin
In a pregnant woman, 5-10 pounds of the total gained weight is considered fetus weight in a normal pregnancy. The remainder results from placenta, blood and fluid volume, amniotic fluid, uterus, breasts, and fat. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
A college student comes to the student health center complaining of difficulty in concentrating during class and while studying. The diet that would contribute to this problem is one that contains mostly:
a.fruit and vegetables.
b.lean meat and fish.
c.sandwiches and diet drinks.
d.pasta and chicken.
Correct ANS: B
Carbohydrates are the only source of fuel for the brain and central nervous system. A diet low in carbohydrates, such as a diet mostly of meat and fish, could affect brain function. Fruits and vegetables, sandwiches and diet drinks, and pasta and chicken have moderate levels of needed carbohydrates.
When using “rule of thumb” estimates of energy needs of healthy adults, how many kcal/kg are required to maintain the individual’s current weight?
30 kcal/kg is required for weight maintenance. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
#14 Pernicious anemia:
-B12 deficiency is usually the result of impaired B12 uptake caused by a lack of intrinsic factor that is caused by a loss of parietal cells in the stomach lining. The loss of these cells can be caused by partial or full gastrectomy, Crohn’s disease, autoimmune disorders such as DM1 and immunocompromised diseases such as HIV
-A smooth red tongue with a slick appearance may indicate NIACIN or Vit. B12 deficiency.
Pernicious Anemia can result in Vitamin B12 deficiency!!! (image attached in group)
Examination techniques and equipment #15
Student Laboratory Manual
Seidel’s Guide to physical Examination 8
th
edition Page 10, 11 and 168.
Tape measure
– use to examine multiple raised lesions.
Transilluminate
– An appropriate examination technique to assess vesicle in the skin. It also a source of light with a narrow beam.
Otoscope
– use to visualize the lower and middle turbines of the nose.
Inspection –
is applied throughout the entire examination and interview process.
Auscultation
– is carried out last except when examining kidney or abdomen . it is also used to listen for sounds produced by the body
Fist
– use for indirect finger percussion involves striking the middle finger of the nondominant hand
Deep abdominal palpation of the kidney
is used to assess tenderness over the kidney.
Ulnar surface of the hand
is used to palpate Mass in the skin
Diaphragm
– pressed lightly against skin to detect high frequency.
Scoliometer- measures the degree of rotation of the spine to screen for scoliosis. Pg. 49 8
th
edition.
Pneumatic attachment of an otoscope
– use to evaluate the cone of light reflex in adult and kids.
Red – free light
-seen through the ophthalmoscope to estimate the size and location of lesion. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
Dorsal surface of the hand
– sensitive to vibration
Amsler grid
– use to screen patient at risk for macular degeration
Pederson speculum
– use for women with small vaginal opening
Near-vision (Rosenbaum
) or
Jaeger chart
– Use for screening near vision
Dermatoscope
– is a skin surface microscope used to inspect the surface of pigmented skin lesions
Bell of stethoscope
– detects low frequency sound.
Wood lamp-
black light used to detect fungal infection.
Pan-optic ophthalmoscope
– larger field of view in eye examination.
Palpation-
gathering information through touch.
Monofilament
– help identify a patient with decreased sensation and increased risk for injury
Percussion Tone Expected
Stomach-
Tympanic
Sternum
-flat
Liver
-Dull
Lung with patient with Pneumonia
-Dull
Abdomen with lung tumor
-Dull
Diagnostic Assessment tools and tests to include tuning forks, BP monitoring, use of stethoscope, otoscope, ophthalmoscope
Tuning Fork
i. Weber Testà Place base of tuning fork on top of the head and see if the patient hears it equally in both ears. If not, this is considered conductive hearing loss and they will hear the sound in the impaired ear.
ii. Rinne Test à Base of the tuning fork is placed on the mastoid bone, count how long they hear it. Then move it in front of the ear and count how long they hear that. Normally the sound is heard longer through air than through bone. In conductive hearing loss, sound is heard through bone as long as or longer than it is through air (BC>AC). In sensorineural hearing loss, sound is heard longer through air (AC>BC). NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
b. Ophthalmoscope
i. Examine patient right eye with your right eye
ii. Visualize the RED reflex (caused by light illuminating the retina, opacities will stand out)
c. Otoscope
i. External auditory canal and tympanic membrane (should be translucent, pearly gray color) (middle ear)
1. Adult: pull ear up and back
2. Child: pull ear down and back
#17
Covers skin, pharmacology,GI, Nervous system, and MUCH MORE
information located in the files of this group. A large table.
Skin lesion characteristics
Maculeà flat discoloration, usual <1 cm in diameter (freckle/ measles) b. Patchà flat area of skin discoloration, larger than a macule (vitiligo) c. Papuleà raised lesion, <1 cm same or different color than surrounding skin (raised nevus) d. Vesicleà fluid filled, <1 cm (varicella/ chicken pox) e. Plaqueà raised lesion, >1 cm may be same or different color from surrounding skin (Psoriasis)
f. Purpuraà lesions caused by RBCs leaving circulation and becoming trapped in skin (Petechiae, ecchymosis)
g. Pustuleà vesicle like lesion with purulent content (impetigo, acne)
h. Whealàcircumscribed area of skin edema (Hive)
i. Noduleà raised lesion, >1 cm usually mobile (epidermal cyst)
j. Bullaà fluid-filled, >1 cm (blister with 2nd degree burn)
k. Excoriationà marks from scratches (pruritic skin disease)
l. Lichenificationà skin thickening resembling callus formation (chronic dermatitis)
m. Fissureà narrow linear crack into epidermis (split lip, athletes’ foot)
n. Erosionà partial focal loss of epidermis, heals without scarring (areas exposed after bullous lesion opens)
o. Ulcerà loss of epidermis and dermis, heals with scarring (pressure sore)
p. Scaleà raised, flaking lesion (dandruff, psoriasis)
q. Atrophyà loss of skin markings and full skin thickness (area tx excessively with higher potency corticosteroids) NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
#18- ABCD assessment of skin lesions:
A -asymmetry of lesion.
B- border (regular or irregular)
C- Color (is it uniform or varying colors)
D- Diameter (anything larger than 6mm)
Images posted in group
#19 Anatomy and physiology of skin layers
Epidermis
i. Outermost portion (stratum corneum & cellular stratum)
ii. Avascular
iii. Stratum Corneum: packed dead squamous cells, contain keratin, keratin cells formed in stratum germinativum (where melanocytes synthesize melanin)
iv. Cellular stratum: in thicker layers of palms and soles
b. Dermis
i. Very vascular connective tissue layer (supports and separates epidermis from adipose)
ii. Elastin, collagen and reticulum fibers, sensory nerve fibers NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide
c. Hypodermis
i. Loose connective tissue filled with fatty cells (generates heat/insulation/ shock absorption)
ii. Connected to underlying organs
d. Appendages
i. Eccrine sweat glandsà regulate body temp through water secretion
ii. Apocrine sweat glandsà found in axilla, nipple, areolae, genital, eyes and external ears
iii. Sebaceous glandsà lipid rich substance, stimulated by sex hormones (testosterone)
The skin is the largest organ of the body, with a total area of about 20 square feet. The skin protects us from microbes and the elements, helps regulate body temperature, and permits the sensations of touch, heat, and cold.
Skin has three layers:
Epidermis
Your skin’s top layer, the epidermis, is super thin on some parts of your body (your eyelids) and thicker on others (the bottoms of your feet). The epidermis is the layer of skin in charge of:
• Making new skin cells: This happens at the bottom of the epidermis. The skin cells travel up to the top layer and flake off, about a month after they form.
• Giving skin its color: The epidermis makes melanin, which is what gives your skin its color (find out more about this in What gives skin its color?).
• Protecting your body: The epidermis has special cells that are part of your immune system and help you stay healthy.
Dermis
A lot happens in the next layer, the dermis. The jobs of the dermis include:
• Making sweat: There are little pockets called sweat glands in the dermis. They make sweat, which goes through little tubes and comes out of holes called pores. Sweating keeps you cool and helps you get rid of bad stuff your body doesn’t need.
• Helping you feel things: Nerve endings in the dermis help you feel things. They send signals to your brain, so you know how something feels if it hurts (meaning you should stop touching it), is itchy or feels nice when you touch it.
• Growing hair: The dermis is where you’ll find the root of each tiny little hair on your skin. Each root attaches to a tiny little muscle that tightens and gives you goose bumps when you are cold or are scared.
• Making oil: Another type of little pocket, or gland, in your skin makes oil. The oil keeps your skin soft, smooth and waterproof. Sometimes the glands make too much oil and give you pimples. (See Acne: Pimples and Zits.
• Bringing blood to your skin: Blood feeds your skin and takes away bad stuff through little tubes called blood vessels.
Subcutaneous fat
The bottom layer of skin is the subcutaneous fat layer. This layer plays an important role in your body by:
• Attaching the dermis to your muscles and bones: This layer has a special connecting tissue that attaches the dermis to your muscles and bones.
• Helping the blood vessels and nerve cells: Blood vessels and nerve cells that start in the dermis get bigger and go to the rest of your body from here.
• Controlling your body temperature: The subcutaneous fat is the layer that helps keep your body from getting too warm or too cold.
• Storing your fat: This fat pads your muscles and bones and protects them from bumps and falls.
#20 Abnormal nail findings in older adults
Nail changes associated with aging are common in the elderly and include characteristic modifications of color, contour, growth, surface, thickness, and histology. The calcium content of the aging nail increases and iron decreases.
keratinocytes of the nail plate are increased in size with an increased number of ‘pertinax bodies’ (remnants of keratinocyte nuclei)
• nail bed dermis also shows thickening of the blood vessels and elastic tissue, especially beneath the pink part of the nail.
• Nail growth decreases by approximately 0.5% per year between 20 and 100 years of age.
• Prominent longitudinal ridges were the most common change
• Brittleness of the nail is a common condition related to aging.
• Onychauxis which is an age-associated thickening of the nail plate
• changes in nail contour, increased transverse curvature
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2965930/
White banding (Terry Nails) is a nail disorder that is specifically linked to age – p. 158.
Pathophysiology: associated with cirrhosis, CHF, adult-onset diabetes mellitus, and age.
Appearance: transverse white bands cover the nail except for narrow zone at the distal tip
Onychomycosis is a fungal infection that causes the nail plate to crumble – p. 156.
Pathophysiology: this is not specifically related to older adults but is associated with loss of manual dexterity (interfere with exercise or walking).
Appearance: distal nail plate turns yellow or white as hyperkeratotic debris accumulates, causing the nail to separate from the nail bed
#21 PSORIATIC SKIN LESIONS
Psoriasis is a common skin condition that speeds up the life cycle of skin cells. It causes cells to build up rapidly on the surface of the skin. The extra skin cells form scales and red patches that are itchy and sometimes painful.
Psoriasis is a chronic disease that often comes and goes. The main goal of treatment is to stop the skin cells from growing so quickly.
There is no cure for psoriasis, but you can manage symptoms. Lifestyle measures, such as moisturizing, quitting smoking and managing stress, may help
here are several types of psoriasis. These include:
• Plaque psoriasis. The most common form, plaque psoriasis causes dry, raised, red skin lesions (plaques) covered with silvery scales. The plaques might be itchy or painful and there may be few or many. They can occur anywhere on your body, including your genitals and the soft tissue inside your mouth.
• Nail psoriasis. Psoriasis can affect fingernails and toenails, causing pitting, abnormal nail growth and discoloration. Psoriatic nails might loosen and separate from the nail bed (onycholysis). Severe cases may cause the nail to crumble.
• Guttate psoriasis. This type primarily affects young adults and children. It’s usually triggered by a bacterial infection such as strep throat. It’s marked by small, water-drop-shaped, scaling lesions on your trunk, arms, legs and scalp.
The lesions are covered by a fine scale and aren’t as thick as typical plaques are. You may have a single outbreak that goes away on its own, or you may have repeated episodes.
• Inverse psoriasis. This mainly affects the skin in the armpits, in the groin, under the breasts and around the genitals. Inverse psoriasis causes smooth patches of red, inflamed skin that worsen with friction and sweating. Fungal infections may trigger this type of psoriasis.
• Pustular psoriasis. This uncommon form of psoriasis can occur in widespread patches (generalized pustular psoriasis) or in smaller areas on your hands, feet or fingertips.
It generally develops quickly, with pus-filled blisters appearing just hours after your skin becomes red and tender. The blisters may come and go frequently. Generalized pustular psoriasis can also cause fever, chills, severe itching and diarrhea.
• Erythrodermic psoriasis. The least common type of psoriasis, erythrodermic psoriasis can cover your entire body with a red, peeling rash that can itch or burn intensely.
• Psoriatic arthritis. In addition to inflamed, scaly skin, psoriatic arthritis causes swollen, painful joints that are typical of arthritis. Sometimes the joint symptoms are the first or only manifestation of psoriasis or at times only nail changes are seen. Symptoms range from mild to severe, and psoriatic arthritis can affect any joint. Although the disease usually isn’t as crippling as other forms of arthritis, it can cause stiffness and progressive joint damage that in the most serious cases may lead to permanent deformity.
Causes
The cause of psoriasis isn’t fully understood, but it’s thought to be related to an immune system problem with T cells and other white blood cells, called neutrophils, in your body.
T cells normally travel through the body to defend against foreign substances, such as viruses or bacteria.
But if you have psoriasis, the T cells attack healthy skin cells by mistake, as if to heal a wound or to fight an infection.
Overactive T cells also trigger increased production of healthy skin cells, more T cells and other white blood cells, especially neutrophils. These travel into the skin causing redness and sometimes pus in pustular lesions. Dilated blood vessels in psoriasis-affected areas create warmth and redness in the skin lesions.
The process becomes an ongoing cycle in which new skin cells move to the outermost layer of skin too quickly — in days rather than weeks. Skin cells build up in thick, scaly patches on the skin’s surface, continuing until treatment stops the cycle.
Just what causes T cells to malfunction in people with psoriasis isn’t entirely clear. Researchers believe both genetics and environmental factors play a role.
Psoriasis triggers
Psoriasis typically starts or worsens because of a trigger that you may be able to identify and avoid. Factors that may trigger psoriasis include:
• Infections, such as strep throat or skin infections
• Injury to the skin, such as a cut or scrape, a bug bite, or a severe sunburn
• Stress
• Smoking
• Heavy alcohol consumption
• Vitamin D deficiency
• Certain medications — including lithium, which is prescribed for bipolar disorder, high blood pressure medications such as beta blockers, antimalarial drugs, and iodides
Risk factors
Anyone can develop psoriasis, but these factors can increase your risk of developing the disease:
• Family history. This is one of the most significant risk factors. Having one parent with psoriasis increases your risk of getting the disease, and having two parents with psoriasis increases your risk even more.
• Viral and bacterial infections. People with HIV are more likely to develop psoriasis than people with healthy immune systems are. Children and young adults with recurring infections, particularly strep throat, also may be at increased risk.
• Stress. Because stress can impact your immune system, high stress levels may increase your risk of psoriasis.
• Obesity. Excess weight increases the risk of psoriasis. Lesions (plaques) associated with all types of psoriasis often develop in skin creases and folds.
• Smoking. Smoking tobacco not only increases your risk of psoriasis but also may increase the severity of the disease. Smoking may also play a role in the initial development of the disease.
Complications
If you have psoriasis, you’re at greater risk of developing certain diseases. These include:
• Psoriatic arthritis. This complication of psoriasis can cause joint damage and a loss of function in some joints, which can be debilitating.
• Eye conditions. Certain eye disorders — such as conjunctivitis, blepharitis and uveitis — are more common in people with psoriasis.
• Obesity. People with psoriasis, especially those with more severe disease, are more likely to be obese. It’s not clear how these diseases are linked, however. The inflammation linked to obesity may play a role in the development of psoriasis. Or it may be that people with psoriasis are more likely to gain weight, possibly because they’re less active because of their psoriasis.
• Type 2 diabetes. The risk of type 2 diabetes rises in people with psoriasis. The more severe the psoriasis, the greater the likelihood of type 2 diabetes.
• High blood pressure. The odds of having high blood pressure are higher for people with psoriasis.
• Cardiovascular disease. For people with psoriasis, the risk of cardiovascular disease is twice as high as it is for those without the disease. Psoriasis and some treatments also increase the risk of irregular heartbeat, stroke, high cholesterol and atherosclerosis.
• Metabolic syndrome. This cluster of conditions — including high blood pressure, elevated insulin levels and abnormal cholesterol levels — increases your risk of heart disease.
• Other autoimmune diseases. Celiac disease, sclerosis and the inflammatory bowel disease called Crohn’s disease are more likely to strike people with psoriasis.
• Parkinson’s disease. This chronic neurological condition is more likely to occur in people with psoriasis.
• Kidney disease. Moderate to severe psoriasis has been linked to a higher risk of kidney disease.
• Emotional problems. Psoriasis can also affect your quality of life. Psoriasis is associated with low self-esteem and depression. You may also withdraw socially.
#22 Vesicular Skin Characteristics
o Vesicles are small, clear, fluid-filled blisters. (page 127)
o A vesicle is elevated, superficial and less than 1cm. The vesicle does not go into the dermis. (page 127)
o Examples of a vesicle are varicella (chickenpox) and herpes zoster (shingles) viruses. (page 127)
o A bulla is a vesicle (blister) that is greater than 1cm. (page 128).
23 hair loss
youtube video
#24 Characteristics of Hair Distribution
Quantity and distribution of hair vary according to individual genetic makeup
Hair is commonly on the scalp, lower face, neck, nares, ears, chest, axillae, back and shoulders, arms, legs, toes, pubic area, and around the nipples
Hair loss is generalized or localized
Hair loss on toes may indicate poor circulation or nutritional deficit
Diffuse hair loss usually occurs without inflammation and scarring
Note if the hair shafts are broken off or completely absent
Scarring is helpful in diagnosis
During adulthood men who are genetically predisposed often display gradual symmetric hair loss on the scalp as a response to androgens
Asymmetric hair loss may indicate pathologic condition
Women in their 20s and 30s can also develop adrenal androgenic female pattern alopecia (hair loss), gradual hair loss from the central scalp
Fine vellus hair covers the body
Coarse terminal hair occurs on the scalp, pubic, axillary area, arms, legs (to some extent), and a man’s beard
Male pubic hair configuration is upright triangle with the hair extending midline to umbilicus
Female pubic hair configuration is an inverted triangle; hair may extend midline to the umbilicus
Assess for hirsutism in women- the growth of terminal hair in a male distribution pattern on the face, body, and pubic area. Hirsutism, alone or with other signs of virilization, may indicate an endocrine disorder
Ball et al., 2015, p. 133-134
Hair loss on lateral eyebrows and scalp may indicate a thyroid dysfunction
Dains et al., 2016, p. 251
Evaluate hair loss that is diffuse or localized and compare areas such as temporal and crown region to the occiput
Hair pull test will reveal any increased hairs shed with a gentle pull
Dains et al., 2016, p. 335
Hair disorders
Alopecia Areata
o Sudden, rapid, patchy loss of hair, usually from face or scalp
o Unknown cause may be triggered by genetic-environmental interactions
o Any hair may be affected
o Regrowth begins in 1-3 months
o Subjective data: sudden, rapid, patchy hair loss, may report nail pitting, may have family history
o Objective data: hair loss sharply defined round areas, hair shaft is poorly formed and break off at skin surface
Ball et al., 2015, p. 154
Scarring Alopecia
o Replacement of hair follicles with scar tissue
o Skin disorders of the scalp or follicles resulting in scarring and destruction of hair follicles and permanent hair loss
o Subjective data: may have other concurrent skin or systemic disorders
o Objective data: patchy hair loss, scalp may be inflamed, hair follicles may be pustular or plugged
Ball et al., 2015, p. 155
Traction Alopecia
o Hair loss that is the result of prolonged tightly pulled hairstyles
o Prolonged tension of the hair from traction breaks the hair shaft
o Follicle is not damaged, loss is reversible
o Subjective data: history of wearing certain hairstyles: braids, hair rollers, or hot combs
o Objective data: patchy hair loss that corresponds directly to the area of stress
o Scalp may or may not be inflamed
Ball et al., 2015, p. 155
Hirsutism
o Caused by high androgen levels (from ovaries or adrenal glands) or by hair follicles that are more sensitive to normal androgen levels, free testosterone causes hair growth
o Causes: genetic, physiologic, endocrine, drug-related, and systemic disorders
o Subjective data: excessive hair growth on face or body; onset, severity, and rate depend on underlying cause
o Objective data: thick dark terminal hairs in androgen-sensitive sites: face, chest, areola, external genitalia, upper and lower back, buttocks, inner thigh, and linea able; may or may not be accompanied by other signs of virilization
Ball et al., 2015, p.155
Hair-Pulling (Trichotillomania)
o Loss of scalp hair caused by physical manipulation
o Hair is twisted around the finger and pulled or rubbed until it breaks off; the act of manipulation is usually an unconscious habit
o Subjective data: may report tension, anxiety, emotional stressors
o Objective data: affected area has an irregular border, and hair density is greatly reduced, but the site is not bald
Ball et al., 2015, p. 163
Tinea capitits- the triad of hair loss, scaling, and lymphadenopathy in children
Dains et al., 2016, p. 334
#25 Cranial Nerves associated with HEENT exam
CN1: Olfactoryà sniff testà Sensory* O
• CN2: Opticà Vision (Snellen eye chart)àSensory* O
• CN3: Oculomotorà 6 cardinal gazes, pupils constrict, opening/closing of eyesà Motor O
• CN4: Trochlearà 6 cardinal gazes, downward/lateral of eye movementà Motor To
• CN5: Trigeminalà facial sensation- temp, pain, tactile (Tri/3), taste, mastication, corneal reflex à Both Touch
• CN6: Abducensà 6 cardinal gazes, lateral movement of eyesà Motor And
• CN7: Facial à dysfunction (Bell’s palsy) puffing out cheeks, smile/frown, facial symmetry* Both Feel
• CN8: Vestibulocochlear/ Auditoryà whisper test, weber, Rinne’s testà Sensory* Very
• CN9: Glossopharyngeal à tongue (glosso) throat (pharynx) gag reflex, swallowàBoth Good
• CN10: Vagus à aortic pressure, regulating BP, slowing HR, taste and digestionà Both Vagina
• CN11: Accessory/Spinalà shoulder shrug/ lateral neck movementà Motor* A
• CN12: Hypoglossal à tongue movement/strengthà Motor*
God gave you 1 nose (Olfactory) and 2 eyes (Optic). Nerves 3,4, and 6 make your eyes do tricks (3 Occularmotar, 4 Trochlear, and 6 Abducens). FIVE rhymes with TRI (5 Trigeminal). 7 is like an “F” backwards (F for Facial). 8 looks like earrings (8 Vestibulocochlear (Auditory)). “9 and10, under my chin” (IX Glossopharyngeal (Swallowing, saliva, taste), X Vagus (Control of PNS e.g. smooth muscles of GI tract) (just check gag reflex), 12 for swallowing (XII Hypoglossal (Tongue muscles – speech & swallowing)), and the number 11 looks like the neck (XI Accessory (Moving head & shoulders).
In the pic of the face attached, each part of the number 5 the crosses the face (3 lines) corresponds with the first, second, and third segments of the Trigeminal nerve (Forhead, maxila and mandible).
Here is a quick, meat and potatoes crainial nerve assessment video that is to point:
As the video suggests, the 1st crainial nerve is not tested during routine exam, but you could blindfold the patient and hold coffee, alchohol, etc under the nose and test like you would a taste for sugar and salt.
Now, to remember the order, a “clean” acronym for remembering the crainial nerve order would be,
“Oh Oh Oh To Touch And Feel Very Good Velvet, Such Heaven.” Take the first letter of this acronym for the order of the nerves. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
There is another acronym that helps you determine whether the nerve is sensory, motor, or both. This acronym is, “Some Say Marry Money But My Brother Says Big Brains Matter Most.”
Where S=Sensory, M=Motor, and B=Both.
Olfactory
Smell, sensory
Optic
Vision, sensory
III. Oculomotor
Pupil, motor
Trochlear
Lateral/inferior eye movement, motor
Trigeminal
Face feeling, chewing, sensory/motor
Abducent
Lateral eye movement, motor
VII. Facial
Expressions (motor), taste (sensory)
VIII. Vestibulocochlear
Hearing and balance, sensory
Glossopharyngeal
Swallowing (motor), taste (posterior/sensory)
Vagus
Heart, dig, respiratory (motor) / respiratory, voice, dig, (sensory)
Spinal Accessory
Sternocleidomastoid, trapezius (motor)
XII. Hypoglossal
Muscle of tongue (motor)
#26: Normal assessment findings of adolescent’s nose and throat
Nose:
Midline columella with width less than the diameter of a naris
-Nares oval and symmetrically positioned
-Deep pink and glistening nasal mucosa
-Hairs in vestibula
-Nasal septum midline and straight
Throat:
Pink and smooth posterior wall
Tonsils pink and smooth, no discharge, normal size
Positive gag reflex
Uvula is midline that rises when patient says ‘ah’
No swelling, exudate, or lesions
#27 Normal exam findings of an infants fontanelles
expected findings: anterior fontanel diamond shaped 2-3 – 3-4 cms
posterior fontanel triangular 0.5 – 1cm
fontanels soft, firm, and flat
sutures palpable with small separation between each.
Common variations: Caput succedaneum: swelling of the soft tissue in the scalp caused by pressure of the fetal head on a cervix that is not fully dilated. Swelling crosses suture line and decreases rapidly in a few days.
Examination findings of a patient with hypothyroid and hyperthyroid
Hyperthyroidism (FAST)
i. Overactive throid
1. Subjective data: weight loss, tachycardia, diarrhea, heat sensitivity (prefers cool temp), nervous, fidgety, amenorrhea/scant flow
2. Objective data: normal size thyroid, goiter, nodules, fine hair with loss, thin nails that break, peripheral tremors, palmar erythema
b. Hypothyroidism (SLOW)
i. Insufficient amount of thyroid hormone (primary)/ insufficient secretion (TSH/ TRH) (secondary)
1. Subjective data: weight gain, constipation, fatigue, cold intolerance (prefers warm temp), menorrhagia, good muscular strength NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide
2. Objective data: normal size thyroid, goiter, nodules, coarse hair, dry scaling skin, thick fingernails, puffiness in periorbital
Bullet 29: Techniques for Examining the HEENT
Chapters 10, 11, 12 Seidel’s Guide to Physical Examination
HEAD 189:
Observe position. Should be upright and still, no tilts or tremor
Skull/Scalp 189-192
: Front to back
Symmetry by parting the hair -assess size, shape and for lesions during the above
Palpate for indents/depressions (should be smooth/fontanels undetectable p 6mo)
Palpate over sinuses (no tenderness)
Scalp should move freely over skull
Special attention at hair line, crown and behind the ears
Palpate hair, noting texture, color, distribution (smooth, even, no split ends)
IF
appropriate- auscultate & palpate temp arteries for thickness/hardness/tenderness
Facial Features 189:
Includes eyelids/brows, palpebral fissures (under eye) nasolabial folds, mouth
Check Symmetry at rest (slight difference common w movement/expression)
Note unusual features (edema, bruising, bulging eyes, abn hair growth)
Tics (spasmodic movement)
Do features appear syndrome like? (characteristic facies)
Variation in skin color
Salivary Glands 192:
inspect/palpate for asymmetry, size, flexibility, firmness
Transillumination of Infant skull 196
: to check for fluid/decreased brain tissue
Neck 192-193:
Inspect symmetry- slight hyperextension as patient swallows (obs muscle movement)
Observe trachea alignment and fullness
Palpate lower trachea w thumbs at each side to eval space between trachea and sternocleidomastoid muscles on each side (uneven indicates displacement) NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
Palpate movement with swallowing (smooth and nontender) movement of cartilages should be felt under finger
ROM 193/516/578: Flex, extend, rotation without pain, resistance or dizziness
Palpation for tenderness in the paravertebral musculature and spinous processes (upper/lower back) coupled with ROM of neck for eval of stiff neck
Take note of any mass, webbing, skin folds (excessive posterior cervical skin)
Thyroid 194:
inspection, palpation, and auscultation for bruit if enlarged
Gently extend neck, use water for swallowing, gentle touch
Can be done from front or behind (learn and be consistent with your method)
Palpation for size, shape, configuration, pain, nodules
Lymph nodes 174-175:
Palpation (so much info pictures, I wasn’t sure how to break it down)
Eyes 208-209:
Near vision- Rosenbaum pocket vision screen (14 inch from face)
Distant Vision- Snellen eye chart/Pin hole (no glasses first) NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
Peripheral Vision- Confrontation test (bringing fingers in from the side)
Eyebrows 210:
Inspect texture, size, extension to temporal canthus
Eyelids 210-211:
Open and closes completely?
Eyelash position (should curve away)
Ptosis (drooping eyelid)
Fasciculation (twitching/tremor)
Flakey, redness, swelling?
Palpate for nodules -closed lids w gentle push into orbit (should be no discomfort)
Pull lower lid down to assess for color, discharge, lacrimal gland punctum, pterygium
Orbits 210:
Inspect for edema, puffiness, excess tissue
External Eye 212-214:
Corneal clarity using a pen light
Corneal sensitivity using a cotton wisp (slight touch across the cornea)
Corneal arcus: circle around the cornea
Color of irises should be the same
Pupils should be round, regular, equal size, and reactive to light
Pupillary defect with swing flashlight test (checks optic nerve)
Nystagmus- have patient follow your finger to check for involuntary movement
Muscle balance & movement 214-216:
Corneal light reflex 215: light source (used to check strabismus) Cover-uncover test 215, Six cardinal fields of gaze: assess extraocular muscles and cranial nerves, Nasal- straight, up, and down, Temporal- straight, up, and down
Opthalmic examination 216-218:
Give rest periods between tests using bright light, Dim the lights, Ophthalmoscope in the hand with corresponding eye (right hand-right eye), Instill dilating medications as necessary
Ears 239:
Inspect for size, shape, symmetry, landmarks, color, abnormalities.
Position- pull ear up and back
Palpate auricles and mastoid area for pain, swelling or nodules
Auditory canal 240: otoscope 1-1.5 cm depth- color, cerumen, abnormalities
Tympanic membrane 240-241: otoscope- movement (w positive pressure), color, landmarks, abnormalities
Hearing 240-242:
Response to questions during history, whispered voice, and tuning forks (top of head and mastoid area) NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
Nose and Sinuses 242-244:
Inspect external nose
Palpate bridge and soft tissues of nose
Nares -nasal speculum and light source
Palpate maxillary and frontal sinuses for swelling or pain
Transillumination 244: of sinuses if tender or infection is present
Mouth 245-249:
Inspect lips, teeth, and oral cavity for abnormalities
Palpate and inspect gingivae and buccal mucosa for color, lesions, and pain
Inspect and palpate the tongue
Elicit a gag reflex
Inspect tonsils and pharynx
#30 Examination findings for a patient with sinus symptoms
Seidel page 231, 243-244
Inspect the external nose, noting the shape, size, color, and nares.
Palpate the bridge and soft tissues of the nose, noting tenderness, displacement, and masses.
Evaluate the patency of the nares
Inspect the nasal mucosa and nasal septum for the following: color, alignment, discharge, selling of turbinates, or perforation.
Inspect the frontal and maxillary sinus area for swelling
Palpate the frontal and maxillary sinuses for any tenderness, pain, or swelling
Signs and Symptoms
Sinus infections often follow a cold and cause pain and pressure in your head and face. Palpating over the infected sinus will cause tenderness.
Sinusitis can be either acute or chronic. With chronic sinusitis, the infection or inflammation does not completely go away for 12 weeks or more.
Sinusitis can be caused by three things: viruses, bacteria, fungi. The same viruses that cause the common cold cause most cases of sinusitis. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
-Viral Sinusitis: When the lining of the sinus cavities gets inflamed from a viral infection like a cold, it swells. The swelling can block the normal drainage of fluid from the sinuses into the nose and throat.
-If the fluid cannot drain and builds up over time, bacteria or fungi (plural of fungus) may start to grow in it. These bacterial or fungal infections can cause more swelling and pain.
-Nasal allergies or other problems that block the nasal passages and allow fluid to build up in the sinuses can also lead to sinusitis.
Other common symptoms of sinusitis may include: headache, bad breath, cough that produces mucus, fever, pain in your teeth and a reduced sense of taste or smell.
Viral infections normally resolve without antibiotics within 14 days. Bacterial infections may require antibiotics. OTC medications can be obtained to relieve discomforts and sinus symptoms. Fungal infections (less common) require anti-fungals, these infections can require additional interventions (surigal).
Transillumination of the sinuses:
A transilluminator or small, bright light can be used.
Darken the room.
Maxillary sinuses: place the light source lateral to the nose, just beneath the medial aspect of the eye. Look through the patients open mouth for immunination of the hard palate.
Frontal sinuses: place the light source against the medial aspect of each supraorbital rim. Look for a dim red glow just above the eyebrow. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
The sinuses may differ in degree of illumination
-Opaque: no transillumination
-Dull: reduced transillumination
-Glow (expected): transillumination.
-An opaque response may indicate the sinus is filled with secretions or never developed.
-Asymmetry of transillumination is a significant finding.
#31 appropriate tuning fork frequencies to approximate vocal frequencies
Seidel page 241-242
Weber test: helps assess unilateral hearing loss. Place the base of the vibrating tuning fork on the midline of the patients head. Ask the patient if the sound is heard equally in both ears or is better in one ear. If the sounds is heard better in one ear, have the patient identify which ear.
-To test reliability have the patient occlude one ear. Repeat the test, the sound should be heard better in the occluded ear.
Rinne test: helps to distinguish if the patient hears better by air or bone conduction. Place the base of the vibrating tuning fork against the patients mastoid bone and ask the patient to tell you when the sound is no longer heard. Time this interval of bone conduction, noting the number of seconds. Quickly position the still vibrating tines 1-2 cm from the ear, and again ask the patient to tell you when the sound in no longer heard. Time the interval of sound conduction as well. Compare the seconds recorded for both bone and air conduction.
-Air conduction should be heard twice as long as bone conduction. (see figure 12-16 on page 242 in Seidel)
*Placing the base of a vibrating tuning fork on the midline vertex of the patient’s head is a test for? Lateralization of sound
*To approximate vocal frequencies, which tuning fork should be used to assess hearing?
Ans. 500 to 1000 Hz
32 Examining the oral mucosa (Reference Ball & Daines, page 246-248)
The oral cavity is the first component of the digestive tract, which is delimited by the lips anteriorly and the oropharynx posteriorly. The oral cavity functions as a protective barrier and is an essential component for speech and swallowing, mastication, digestion, and taste sensation. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
To exam of the oral cavity:
Inspect the dorsum of the tongue: Note any swelling or variation in size or color
Ask the patient to extend the tongue while you inspect for limited movement: test CN XII
Tongue should maintain at midline
Normal tongue: dull red, moist, and glistening; smooth surface with papillae with small fissures is visualized on the anterior surface; Posterior tongue: should have rugae
ABNORMAL: smooth red tongue with slick appearance may indicate B12 deficiency; hairy tongue with yellow-brown or black elongated papillae may follow ABT therapy NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
Ask the patient to touch the tip of the tongue to the palate area behind the upper incisor
Inspect the roof of the mouth
Inspect the ventral surface of the tongue
A ranula (mucocele) may be seen on the floor of the mouth when an obstruction of the sublingual salivary gland duct
Wrap the tongue in a piece of gauze and gently pull it to each side while inspecting the lateral border
Scrape and white or red margins to distinguish between food particles and leukoplakia
Palpate the tongue and the floor of the mouth for lumps, nodules or ulcerations
Ask the patient to tilt the head back for inspection of the palate and uvula NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
Normal: The whitish hard palate should be domed shaped with transverse rugae
Assess the movement of the soft palate by asking the patient to say “ahh” – as the patient vocalizes, observe the soft palate rise symmetrically with the uvula remaining midline – this test CN IX and X
ABNORMAL: A bifid uvula can be associated with Loey-Dietz syndrome
Oral Manifestations with HIV:
Oral hairy leukoplakia: white irregular lesion on lateral side of tongue or buccal
Angular cheilitis: red, unilateral, or bilateral fissures at the corner of the mouth
Candidiasis: creamy white plaque on oral mucosa that bleed when scraped
Herpes Simplex: recurrent vesicular crusting lesions on the lips
Herpes Zoster: Vesicular lesions distributed on the trigeminal nerve
Human papillomavirus: sessile or pedunculated nodules in the oral cavity
Aphthous ulcer: recurrent circumscribed ulcers with erythematous margins
Periodontal disease: gingivitis with bone and soft tissue degeneration with pain
Kaposi sarcoma: incomplete formed blood vessels proliferate, forming lesions
#33 hearing loss findings when examining the elderly patient
Textbook chapter 12 pg. 236
Findings include:
~Conductive hearing loss in older adults may result from an excess deposition(amount) of bone cells along the ossicle (bone in the middle ear)
~ a fixation of the stapes in the oval window(stapes are bones in the middle ear that focuses on conduction of sound vibrations in the inner ear) NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
Elaborating on what I read on the fixation of stables…. when doing the test with the tuning fork these patients may have abnormal results bc the vibrations are diminished
~cerumen (earwax) impaction
~sclerotic tympanic membrane (sclerotic= becoming rigid, unresponsive, or losing the ability to adapt)
#34 Thyroid Exam
Physical exam:
-inspection of neck
-palpation of paratracheal area
-palpation of lateral neck
-pulse rate
Looking for: exophthalmos, hoarseness of voice, distant mass
Examination techniques used to examine the trachea and thyroid
Trachea: hyoid bone, thyroid cartilage (adams apple), cricoid cartilage
b. Inspect then Palpate trachea with thumb along each side (sternocleidomastoid muscle on each side)
i. A tugging sensation, synchronous with the pulse is evidence of tracheal tug sign (Cardarelli sign or Oliver sign) suggesting an aortic aneurysm
c. Thyroid: extend neck, have the patient take a sip of water
i. *The estimation of thyroid size by lateral inspection is the most sensitive test for determining the presence of a goiter
ii. FRONT: place thumb over trachea 3 cm beneath thyroid cartilage, to examine RIGTH lobe use left thumb and press trachea towards patients left with your left thumb. Place first 3 fingers of your right hand in the right thyroid bed- leave fingers still while the patient swallows. To examine LEFT lobe, move your fingers o the reverse positions NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide
iii. BEHIND: 2 fingers on each sides of the trachea- swallow (feeling for movement of the isthmus) displace trachea to left (with fingers from right hand) with fingers from left hand palpate left lobe as patient swallows.
#35 Organs involved in the alimentary tract
The alimentary tract is 27 feet long and runs from the mouth to the anus including:
Esophagus
• collapsible 10 inches’ longs connecting the pharynx to the stomach
Stomach
• three sections fundus, body, and pylorus
• secretes hydrochloric acid and digestive enzymes that break down fats and proteins
• Pepsin digests proteins
• Gastric lipase emulsifies fat
• Little absorption takes place here
Small intestines
• 21 feet long
• coiled in the abdominal cavity
• first 12 inches’ duodenum forms a C shaped curve around the head of the pancreas
• Next 8 feet is the jejunum that gradually becomes larger and thicker
• Last 12 feet are the ileum
• Ileocecal valve lies between the ileum and the large intestines to prevent backflow
• Nutrients are absorbed through the mucosa of the small intestines
Large intestines
• Begins with the cecum, a blind pouch about 2-3 inches long that hold ileal contents
• vermiform appendix extends from the cecum
• Ascending colon extends from the cecum along the right posterior abdominal wall- under surface of the liver
• Transverse colon crosses the abdominal cavity toward the spleen and down toward the splenic flexure
• Descending colon runs along the left abdominal wall to the rim of the pelvis turning medially and inferiorly
• Sigmoid colon is the S shaped that connects to the rectum extending from the sigmoid to the pelvic floor through the anal canal and terminates at the anus NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide
The alimentary tract functions to digest food; absorb nutrients, electrolytes, and water; and excrete waste products
# 36
Correct assessment order for the abdomen
Patient remains supine. Cover chest with the patients gown. Arrange draping to expose the abdomen from the pubis to the epigastrium.
• Inspect skin characteristics, contour, pulsations, and movement
• Auscultate all quadrants for bowel sounds
• Auscultate the aorta and renal, iliac, and femoral arteries for bruits or venous hums
• Percuss all quadrants for tones
• Percuss liver borders and estimate span
• Percuss left midaxillary line for splenic dullness
• Lightly palpate all quadrants
• Deeply palpate all quadrants
• Palpate right costal margin for liver borders
• Palpate left costal margin for spleen
• Palpate laterally at the flanks or right and left kidneys
• Palpate midline for aortic pulsation
• Test abdominal reflexes
• Have your patient raise their head as you inspect the abdominal muscles
#37 Examination of the Liver pg. 385-386
Assessment YouTube Video:
Liver palpation
The lower edge of the liver can be palpable on inspiration about 3 cm below the right rib cage. The liver palpation can be performed with one hand or bimanually, and in the case of obese patients, the so-called “hooking” technique might be helpful as well.
One-hand liver palpation
Place your right hand on patient’s abdomen, lateral to the rectus muscle, well below the level of percussed border of liver dullness.
Orient your fingers towards the patient’s head or slightly diagonally towards the midline. Press your fingers firmly in and up (towards the patient’s head).
Ask the patient to take a deep breath. On inspiration, the liver descends, and its edge meets the fingertips of the palpating hand.
Continue palpating, moving your hand toward the coastal margin until you feel the liver edge (usually a few cm below right costal margin). Note liver edge texture and regularity. Slight tenderness on palpation is normal. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide
When your fingers meet the liver edge, slightly reduce the pressure on the abdominal wall while the patient is still taking a deep breath in. This maneuver allows the examiner to feel the anterior liver surface as it slips under the finger pads. Make a note of the consistency of the liver surface-nodes, granularity, etc. (Figure 2)
Bimanual liver palpation
Place your left hand posteriorly at the level of the patient’s two lower ribs, and gently press upward to elevate the liver into a more accessible position.
Ask the patient to take a deep breath and perform palpation with your right hand as described above.
The “hooking” technique
This can be helpful when the liver is not palpable by the standard techniques.
Stand on the right of the patient, facing the patient’s feet.
Place your flexed fingers over the edge of costal margin.
Ask the patient to take a deep breath and try to feel the liver edge as you press downward and upward (towards the patient’s head).
Signs and symptoms of liver disease include:
Skin and eyes that appear yellowish (jaundice)
Abdominal pain and swelling
Swelling in the legs and ankles
Itchy skin
Dark urine color
Pale stool color, or bloody or tar-colored stool
Chronic fatigue
Nausea or vomiting
Loss of appetite
Tendency to bruise easy
Question # 38 – Examination findings associated with appendicitis
Appendicitis
The incidence of appendicitis peaks at age 10 to 20 years, although it can occur at any age.
The patient reports sudden onset of colicky pain that progresses to a constant pain.
The pain can begin in the epigastrium or periumbilicus and later localize to the RLQ.
The pain worsens with movement or coughing.
Vomiting after the onset of pain sometimes occurs.
On physical examination, the patient will be lying still and demonstrate involuntary guarding.
Classically, tenderness occurs in the RLQ.
The other tests for peritoneal irritation will be positive.
Rebound tenderness may be present. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide
Variation in presentation is common, particularly with infants, children, and the elderly.
Diagnostic testing includes complete blood count (CBC) with differential to confirm or rule out infection and the use of either ultrasonography, CT scan, or laparoscopy.
Psoas sign, McBurney point pain, rebound tenderness, and periumbilical pain that migrates to the right lower quadrant are signs of appendicitis.
Conditions that cause irritation of the obturator muscle are late findings usually associated with a ruptured appendix or pelvic abscess.
An accurate diagnosis based on history and physical examination can facilitate immediate surgical evaluation and definitive treatment and prevent unnecessary use of radiologic imaging.
In adults, historical symptoms that increase the likelihood of appendicitis are right lower quadrant (RLQ) pain, initial periumbilical pain with migration to the RLQ, and the presence of pain before vomiting.
The presence of rigidity, a positive psoas sign, fever, and/or rebound tenderness are physical examination findings that increase the likelihood of appendicitis.
EVIDENCE-BASED PRACTICE
Clinical Diagnosis of Appendicitis
In a review of clinical decision rules to assist in diagnosing appendicitis, the authors concluded that decision models that score combinations of findings from the history and clinical examination are more powerful than any single finding.
They point to the Alvarado model as one that balances accuracy with ease of use and familiarity to clinicians.
It combines the results for eight findings; a score of 7 or more out of a potential 10 indicates the need for surgical intervention. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide
The Alvarado model has a sensitivity of 81% and a specificity of 74%.
ALVARADO SCORE FOR EARLY DIAGNOSIS OF ACUTE APPENDICITIS
VARIABLE
SCORE
Migration of pain
1
Anorexia-acetone
1
Nausea/vomiting
1
Tenderness in RLQ
2
Rebound pain
1
Elevation of temperature
1
Leukocytosis
2
Shift to the left on differential (neutrophils >75%)
1
Maximum total score
10
Positive score
≥7
*
*A score of 7 or more indicates the need for surgical intervention
#39
Examining Mc Burney’s sign:
McBurney’s Point:
– Lies 2 inches from anterior superior point of ileum along a line drawn to the umbilicus.
– Localized tenderness at/around area is indicative of appendicitis. (youtube video attached in group)
a. Find umbilicus, find ASIS (Anterior superior iliac spine/hip bone)
b. Draw imaginary line from umbilicus to ASIS- go 2/3 up line from ASIS!
a. Localized tenderness at/around area is indicative of appendicitis.
#40 Assessment of abdominal pain in women
*Key Points
Auscultation should be done last when examining the abdomen
Example question found through Elsevier online: Your patient is complaining of acute, intense sharp epigastric pain that radiates to the back and left scapula with nausea and vomiting. Based on this history, your prioritized physical examination should be to: inspect for ecchymosis of the flank.
When assessing abdominal pain in college-aged women always ask when the first day of their last menstrual period was!!! NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide
Before performing an abdominal exam have the patient empty their bladder!
After abdominal inspection then AUSCULTATE
Inspection of the abdomen should begin with the patient SUPINE
Advanced Health Assessment and Clinical Diagnosis in Primary Care (Dains, Baumann, & Scheibel: Chapter 3 pg. 11
Pg. 20: Perform a pelvic exam in women to rule out STI, PID, ovarian pain, ectopic pregnancy, and uterine fibroids. Cervical motion tenderness (CMT) is the hallmark of PID.
Pg. 28-32 table with common causes of acute abdominal pain
Examples for women:
Ectopic Pregnancy:
women of childbearing age, sudden onset of spotting and persistent cramping in lower quadrant that begins shortly after missed period.
Physical findings:
hemorrhage, shock, and lower abdominal peritoneal irritation, enlarged uterus, CMT, tender adnexal mass. (SURGICAL EMERGENCY) (Dains pg. 28) (Seidel pg. .391- Table 17.2)
Dysmenorrhea:
typical premenstrual pain onset soon after menarche, gradually diminishes with age. Gynecology consult is needed with pelvic ultrasound. (pg. 30)
Uterine Fibroids:
pain related to menses or intercourse. (
Physical Findings:
Palpable myomas. Pelvic ultrasound is needed with gynecology consult (pg. 27, 31)
Ovarian Cyst:
common with younger women. (pg. 27, 31)
Physical Findings:
adnexal pain and palpable ovarian cysts especially later in cycle
Cholecystitis:
more common in women. Pain located in RUQ and radiates to right scapular area, dark urine, N/V, light stools, and may be aggravated by certain foods. (pg. 29)
Pelvic Inflammatory Disease (PID):
common in women younger than 35 who are sexually active usually with more than one partner. Often caused by chlamydia trachomatis and Neisseria gonorrhoeae with onset occurring after menses. Patients present with lower abdominal pain that progressively becomes severe. Upon examination: tender abdomen, CMT, and adnexal tenderness. Patients may guard and have rebound tenderness, fever, irregular bleeding, vaginal discharge, and vomiting, WBC and ESR are usually elevated. (pg. 25) NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide
Causes of lower abdominal or pelvic pain
Lower abdominal or pelvic pain, refers to discomfort that occurs at or below your belly button. Most women will experience pain in the
lower abdomen
from time to time. More often than not this is due to menstruation.
The bladder and reproductive organs are often where pelvic pain occurs. In many cases it is difficult to diagnose the exact cause of the pain, but noting certain symptoms will help come to a diagnosis.
The most common lower abdominal pain causes are:
A urinary disorder, such as bladder or kidney problems.
A bowel problem.
A problem with the reproductive system – the uterus, fallopian tubes and ovaries.
Abdominal pain arising from the urinary system
Urine infections
are common and present symptoms, such as burning when you pass urine and going to the toilet more often.
Infection can spread to the kidneys (pyelonephritis) and can make you feel unwell with a high temperature and back pain.
If you have pain that spreads from your back down to your groin and is severe – your doctor may be more concerned that you have
kidney stones
. The doctor will test your urine if you have any of the above symptoms.
Abdominal pain arising from the digestive system
Pain arising from the large intestine is a particularly common cause of lower abdominal pain in both men and women. Features suggesting your pain may be to do with the bowel are:
Pain associated with bowel movement
A change in bowel habit
Blood with bowel movement
Bloating
Both
constipation
and
diarrhea
can give you pain. The pain they are often associated with is described as crampy or ‘colicky.’ This means that it comes and goes in waves. Large bowel pain is characteristically relieved on opening the bowels.
Potential causes of pain arising from the bowel include
irritable bowel syndrome
(IBS), which can give you alternating diarrhea, constipation and bloating.
Other conditions include diverticular disease and its complications which are more frequent in older patients. Inflammatory bowel disease (ulcerative colitis or Crohn’s). A rare but important diagnosis is colorectal cancer.
Bloating and swelling is also a common symptom that people report and can be due to a problem affecting the bowels. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
Abdominal pain arising from the reproductive organs
Pain can originate from your uterus (womb), fallopian tubes or ovaries. It’s usually felt in the middle of the lower abdomen.
Pain that is felt more to the side can be more typical of a pain coming from the ovary.
Pain coming from the uterus is often worse during your period and is called dysmenorrhea.
Some conditions affecting the reproductive system can also cause pain during intercourse. This is called
dyspareunia
and it is important to let your doctor know if you are concerned.
Examples of conditions of the reproductive organs include:
Endometriosis
Fibroids
Pelvic inflammatory disease
Ovarian cysts
Problems related to the early stage of pregnancy, such as a miscarriage or ectopic pregnancy.
*Seek immediate medical assistance if your symptoms include a fever, vomiting blood, passing dark or bloody stools or acute and worsening pain.
Questions about a person’s emotional life-family, home, work and sex life are appropriate.
Further abdominal pain investigations
Depending on the exact symptoms and duration, referral to the appropriate specialist is often required. These may include:
Gynecological causes may require vaginal swabs, cervical smears or pelvic ultrasound examination. Ultrasound may also be performed from within the vagina. Specialized blood test for ovarian cancer, CA-125, are usually performed. More invasive tests will depend upon the doctor’s suspicion of the cause of the pain.
Urinary causes can be investigated by urine culture, ultrasound or CT scan.
Colonic causes may require internal endoscopic examination of the bowel by Flexible Sigmoidoscopy or Colonoscopy. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
A CT (Computerized Tomography Scan) may be appropriate for all three major sites of pain.
#41
Landmarks for Abdominal Examination
Have the patient void before performing abdominal examination because a full bladder may interfere with an accurate examination of organs and makes the exam uncomfortable. Approach patient from the right side.
• Four Quadrants of the abdomen: RUQ, LUQ, RLQ, LLQ
• Refer to the nine regions of the abdomen. Figure 17-4 in Ball et al., 2015 p. 378. 1: Epigastric; 2: Umbilical; 3: Hypogastric; 4 & 5: right and left hypochondriac;6 & 7: right and left lumbar; 8 & 9: right and left inguinal.
• Refer to Box 17-1 in Ball et al., p. 379 for landmarks of abdominal exam
o Right Upper Quadrant (RUQ)
• Liver & Gallbladder NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide
• Pylorus
• Duodenum
• Head of Pancreas
• Right Adrenal Gland
• Portion of the Right Kidney
• Hepatic Flexure of Colon
• Portions of ascending and transverse colon
o Left Upper Quadrant (LUQ)
• Left lobe of liver
• Spleen
• Stomach
• Body of Pancreas
• Left Adrenal Gland
• Portion of the Left Kidney
• Splenic flexure of colon
• Portions of transverse and descending colon
o Right Lower Quadrant (RLQ)
• Lower pole of right kidney
• Cecum and appendix
• Portion of ascending colon
• Bladder (if distended)
• Ovary and Salpinx
• Uterus (if enlarged)
• Right Spermatic cord
• Right ureter
o Left Lower Quadrant (LLQ)
• Lower pole of left kidney
• Sigmoid Colon
• Portion of descending colon
• Bladder (if distended)
• Ovary and Salpinx
• Uterus (if enlarged)
• Left Spermatic Cord
• Left Ureter
• Refer to Box 17-1 on page 379 of Ball et al., 2015 to refer to the anatomic correlates of the nine regions of the abdomen.
#42 Characteristics of bowel sounds heard on auscultation
Always perform auscultation of the abdomen prior to percussion and palpitation as these maneuvers can change the frequency and intensity of the bowel sounds NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide
• Listen for bowel sounds and note frequency and character
• Usually heard as clicks and gurgle that occur irregularly and range from 5-35 sounds per minute.
• They are generalized so often can just be assessed by listening in one area.
• Borborygmi- loud prolonged gurgles (stomach growling)
• Increased bowel sounds can happen with gastroenteritis, early obstruction, or hunger
• High-pitched tinkling sounds can be indicative intestinal fluid and air under pressure, ie early obstruction.
• Decreased bowel sounds occur with peritonitis and paralytic ileus (auscultate in all 4 quads, if there is a concern) NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.
• Absent bowel sounds- inability to hear bowel sounds after 5 minutes of continuous listening-associated with abdominal pain/rigidity and is considered a surgical emergency. (Seidle’s Guide to Physical Examination, pg 381)
• You should listen over all 4 quadrants and be able to recognize what is in what quad. (RUQ-lower margin of the liver, gallbladder, part of the large intestine, few loops of the small intestine), (RLQ- appendix, connection between the large and small intestine and loops of bowel), (LUQ- lower margin of the spleen, part of the pancreas and some of the stomach and duodenum), (LLQ- bowel loops and descending colon)
• Important to chart location, quality, intensity, and frequency of bowel sounds. NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning Midterm exam study guide.