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NR 304 Exam 2 Study Guide ( Well Explained)
Chapter 21 Abdomen Structure and Function Abdominal Organs ▪ Solid Viscera-doesn’t change shape, liver, spleen, ovary ▪ Hollow Viscera-changes shape, stomach, intestine, bladder ▪ Abdominal Muscles ▪ Peritoneal Cavity-lines the abdomen Visceral Peritoneum-lines organs, stressed and inflamed with appendicitis andcholeycistytis Parietal Peritoneum-entire wall Structure and Function Abdominal Vasculature ▪ Abdominal Aorta-listen for bruit for aortic aneurysm. Caused by pressure ▪ Renal Arteries-stenosis from plaque Subjective Data ▪ Appetite/wt. change ▪ Dysphagia ▪ Abdominal Pain ▪ Nausea/Vomiting ▪ Indigestion ▪ Bowel Habits ▪ Stool Assessment ▪ Meds ▪ Nutrition ▪ Social Hx/Alcohol ▪ Past Abdominal Hx ▪ Stress ▪ Family Hx Lifespan Considerations ▪ Infants & Children : Feeding & eating habits, GI function & nervous system maturation r/t toilet training ▪ Pregnant Female : Nausea, constipation, heartburn (pyrosis), Linea Nigra ▪ Older Adult : Muscle tone, constipation, decreased peristaltic activity Objective Data Abdomen Inspection: Contour, symmetry, umbilicus, skin, pulsation Auscultation: Bowel sounds (4 quadrants), vascular sounds (bruit) Percussion: Tone (4 quadrants), *Ascites(fluid in the abdomen, becomes protuberant) flip pt to left-have tympana on right dull on left and vice versa assessment (p. 553). –want tympana due to gas
Palpation: Light and deep palpation. Special procedures: Rebound tenderness (Blumberg at McBurney’s point) and Iliopsoas Sign-appendix, Murphy’s Sign-gallbladder Illeocecal valve RLQ –watery Terms toknow… ▪ Rectus Diastasis-separation of the rectusmuscles midline. keep abdominal contents in place, pregnant women, body builders, abd. Surgery. ▪ Cullen’s Sign-blue ring around umbilicus, internal bleeding ▪ Borborygmi-really loud bowl sounds, hungry, negative sound when auscultating ▪ Paralytic Ileus-and not walking. Bowel obstruction. ▪ Melena-Blood in stool, oxidized blood. Black tarry thick stools ▪ Shifting Dullness- ascites patients ▪ Distended/Distention-gas, ascites ▪ Guarding of the Abdomen-Involuntary and voluntary ▪ What is involved in the ongoing assessment of a client with an NG tube to suction.. .? WHY.. .? –Drainage, aspirate gastric contents every time before you insert anything, turn off suction container when listening to bowel sounds Nursing Diagnoses ▪ Ineffective Nutrition: less than body requirements r/t nausea and vomiting ▪ Constipation r/t decreased fluid & fiber intake, bed rest, medications ▪ Risk for ineffective health maintenance r/t lack of knowledge of need for recommended colon screenings ▪ Pain, acute r/t inflammatory process What Predicts What?? ▪ Hemoglobin 6. ▪ Burning Sensation in epigastric region ▪ No Appetite ▪ Nausea/Vomiting Test yourknowledge A client reports abd. pain. How should the nurse proceed with the assessment?
- Deep palpation
- Assessing the painful area first 3. Assessing the painful area last with light palpation
- Checking for warmth at the painful area When auscultating a clients abd. the nurse detects gurgles over the RLQ. What should the nurse suspect?
- Decreased bowel motility
- Intrarenal- Direct damage to the kidneys by inflammation, toxins, drugs, infection or reduced blood supply
- Postrenal- Sudden obstruction of urineflow duetoenlarged prostate, kidney stones, bladder tumor, or injury Lifespan Considerations Infants & Children
- Nocturnal enuresis-bed wetting at night
- Hydration- Pregnant Female
- Frequency & incomplete emptying of bladder Older Adult
- Glomerular degeneration & loss of filtration
- Voiding difficulty & pattern changes Subjective Data -How frequently do you urinate? -When do you urinate the most? -Do you feel completely empty or does it feel like there is still urine there? -What color is it? -Does it burn or have pain? -How much fluids do you take in a day? -Have you ever had kidney stones? Surgery? UTIs? Objective data Inspection: Skin color, skin hydration,bladderdistention Auscultation: Right and left renal artery for vascular sounds Percussion : For Pain Costovertebral angle, bladder Palpation: Costovertebral angle, bladder ( when distended) What percussion tone should the nurse elicit over a full bladder? Objective Data Assessment of Urine
- **Color
- Clarity**
- **Amount
- Pain with voiding** What’s “normal”??? Urinary Incontinence
- **Stress-cough sneezed laugh to hard. Normal for aging
- Urge-When you gotta go you gotta go Why are Kegal exercises taught? –to strengthen the bladder muscles. Men can also do KegalsIand it involves the prostate Treatablefactors contributing to Incontinence – DIAPPERS** ❑ D elirium ❑ I nfection– Urinary, Symptomatic ❑ A trophic Urethritisand Vaginitis ❑ P harmaceuticals ❑ P sychologic Disorders ❑ E xcessive Urine Output e.g. from Heart Failure or Hyperglycemia ❑ R estricted Mobility ❑ S tool Impaction Terms toknow ▪ Polyuria-too much urine ▪ Oliguria-little amount urine less than 30mls/hr ▪ Anuria-no urinary output (Dialysis pts) ▪ Dysuria-Painful urination ▪ Retention-Post surgical patients, labor and delivery, spinal cord injuries ▪ Hematuria-blood in urine ▪ Enuresis-bedwetting ▪ Nocturia-excessive night time urination Kidney Stones=Renal Calculi What should the nurse include when teaching this client on prevention of further calculi...?
- Reflex A urine filled bladder is to percussion, while an empty bladder is. 1. Dull, unavailable to percussion 2. Resonant, flat 3. Tympanic, dull Match the conditions listed with the appropriate description Diminished urine output B Excessive voiding at night D Increased frequency & amount of voiding A Visible blood in urine C a. Polyuria b. Oliguria c. Gross Hematuria d. Nocturia Breast and Regional Lymphatics Chapter 17 Developmental Stages and Transitions ▪ Infant: breast buds ▪ Adolescent:
Male gynecomastia Breastdevelopment ▪ Pregnant woman: Colostrum Vascular pattern, increased size , straie ▪ Aging woman: sagging of breast tissue Subjective Data ▪ Breast changes: pain, lump, discharge, rash, swelling ▪ Trauma or Injury? ▪ Hx of breast disease and/or surgery? ▪ Family hx of breast cancer? ▪ Performance of BSE? ▪ Have you ever had a mammogram? ▪ Medications? Objective Data Inspection & palpation ▪ General Appearance – symmetry of size and shape. ▪ Skin – smooth, even color ▪ Axillary and supraclavicular regions – no bulging, discoloration or edema ▪ Nipple – symmetrically placed (supernumerary nipple) ▪ Retractionmaneuversand systematic palpation Male breast examination is done during the thorax assessment Health promotion/disease prevention teaching pg 400-401 breast examination ▪ Ideal time of month ▪ Palpation ▪ Patient positioning ▪ Systematic Alterations in Body system ▪ Edema (Peau d’Orange) ▪ Dimpling, moles ▪ Nipples (Paget’s) Red, itchy crusty nipple bloody d/c? ▪ Unilateraldilated superficial veins (non-pregnant female) ▪ Lumps, discharge from nipple Vocabulary ▪ Tail of Spence-almost where all breast cancers come from ▪ Retraction maneuvers pg. 395 ▪ Mastitis ▪ Tanner’s stagingpg. 388-
Vocabulary ▪ Prehn Sign-Torsion, orepididymitis. Lifttesticule and pain isbetter, probably epididymitis. If it doesn’t relieve pain than torsion which is positive sign ▪ Cryptorchidism-a condition in which one or both of the testes fail to descend from the abdomen into the scrotum. ▪ Transillumination (p. 703) pass strong light through (an organ or part of the body) in order to detect disease or abnormality. ▪ Phimosis-A condition in which tight foreskin can't be pulled back over the head of the penis. ▪ Paraphimosis-urologic emergency in which the retracted foreskin of an uncircumcised male cannot be returned to its normal anatomic position. It is important for clinicians to recognize this condition promptly, as it can result in gangrene and amputation of the glans penis Anus, Rectum, & Prostate Chapter 25 Developmental Stages and Transitions Benign Prostatic Hypertrophy or Hyperplasia (BPH) ▪ Present in 1 our of 10 males > 40 ▪ Rectal exam (DRE) ▪ Sxs: nocturia, dysuria, hesitancy, decreased urine stream ▪ PSA at age 50 & earlier for those w/ family hx & African-American men 45 years of age Subjective Data ▪ Usual bowel routine ▪ Change in bowel habits ▪ Rectal bleeding, blood in the stool ▪ Medications ▪ Rectal conditions ▪ Family History ▪ Self-Care screenings & care Objective Data Inspection & Palpation ▪ Inspection of peri-anal area ▪ Palpationof rectum: tone of sphincter, rectal wall ▪ Palpationofprostate: size, shape, surface, consistency, mobility, sensitivity (p. 728) Health Promotion/Disease Prevention Teaching ▪ Colorectal Cancer Screening pg. 730 ▪ Fecal occult blood testing ▪ PSA-screening for prostate cancer Alterations in Body system ▪ Inflammation, hemorrhoids ▪ Fissure, prolapsed rectum ▪ Stool: Color (pg. 729): black, gray ortan, pale yellow, greasy, occult blood), consistency, constipation, fecal impaction Vocabulary
▪ Pruritus ani-for children; from worms, come at night. Adult; usually from hemorrhoids ▪ Hemorrhoids ▪ Steatorrhea ▪ Melena-dark black stool The Female Genitourinary System Chapter 26 Developmental Stages and Transitions Infants –genitalla Adolescents ▪ Puberty & menarche ▪ Tanner stages (p.739) Pregnant Woman ▪ Goodell’s-whenfemale isprego, cervix changesand becomes softer, whenpalpate it would be soft. & Chadwick’s sign-cervix turns blue Aging Woman ▪ Menopause Subjective Data ▪ Menstrual hx (LMP) ▪ Obstetric hx: Grava-how many pregnancy thewomen has had& Para-how many births ▪ Menopause ▪ Urinary symptoms ▪ Vaginal discharge ▪ Past history ▪ Sexual Activity & Contraception use ▪ STI contact ▪ Self-carebehaviors Objective Data Inspection & Palpation ▪ External genitalia ▪ Internal genitalia ▪ Perineum ▪ Anus & Rectum Health Promotion/Disease Prevention Teaching ▪ Routinepelvicexams/PAP smears ▪ STI risk reduction ▪ HPV Vaccine Alterations in Body System Abnormal Findings 764- ▪ Herpes simplex virus: type 2 ▪ Red rash - contact dermatitis ▪ HPV: Genital warts Vocabulary ▪ LMP (last menstrual period) ▪ Nulliparous-never beendelivered baby
- Priapism 3. Hypospadias
- Phimosis What could this assessment finding mean? A 68-year-old male presents to clinic for a routine examination. The following is the documentation of theprostate examination. Which assessment findingupon palpation would be of concern to the advanced practice nurse? (Select all): 1. Nodular 2. Rubbery 3. Tender 4. Smooth
