NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A, Exams of Nursing

Download NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A and more Exams Nursing in PDF only on Docsity! NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Behavior/Mental Health Assessment and Modification for Age • Unexplained conditions lasting >6weeks should prompt screening for depression, anxiety, or both • PRIME-MD (Primary Care Evaluation of Mental Disorders). 26 questions and take 10 minutes to complete. Used for the 5 most common=anxiety, depression, alcohol, somatoform, and eating disorders. • Patient indications for Mental Health Screening: 1.Medically unexplained physical symptoms-more than half have depression and anxiety disorders 2. Multiple physical or somatic symptoms or high symptom count 3.High severity of the presenting somatic symptoms, chronic pain 4.Symptoms for more than 6 weeks 5. Physician rating as a “difficult encounter” 6. Recent stress 7.Low-self rating of overall health 8.Frequent use of health care services 9.Substance abuse. CAGE=substance-related and addictive disorders Modification for Age Elderly: • -Complain of memory problems but usually is due to benign forgetfulness • -Retrieve and process data more slowly and take longer to learn new information NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A • -Slower motor responses and their ability to perform complex task may diminish • -Important to distinguish age-related changes from manifestations of mental disorders • More susceptible to delirium which can be the first sign of infection, problems with medications, or impending dementia Infant: • Assess mental status of a newborn=observing newborn activities • 1.Look at human faces and turn to parents voice • 2.Ability to shout out repetitive stimuli • 3. Bond with caregiver • 4.Self-soothe Normal VS. Abnormal Findings and Interpretation • Mood disorders: compulsions, obsessions, phobias, and anxieties • -Lethargic: drowsy, but open their eyes and look at you, respond to questions, and then fall asleep. • -Obtunded: open their eyes and look at you but respond slowly and are somewhat confused. • -Agitated depression: crying, pacing, and handwringing NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A 10.Clanging: Speech with choice of words based on sound, rather than meaning, as in rhyming and punning. Example: “look at my eyes and nose, wise eyes and rosy nose. To to one, the ayes have it!” -Schizo and manic episodes Abnormalities of Perception 1. Illusions: misinterpretations of real external stimuli, such as mistaking rustling leaves for the sounds of voices -Grief, delirium, PTSD, Schizo 2.Hallucinations: Perception-like experiences that seem real but, unlike illusions, lack actual external stimulation. The person may or may not recognize the experiences as false. May be auditory, visual, olfactory, gustatory, tactile, or somatic. -PTSD, Schizo, delirium, dementia, alcoholism Abnormalities of Thought Content 1.Compulsions -repetitive behaviors feel driven to perform in response to an obsession (anxiety disorders) 2.Obessions -Recurrent persistent thoughts, images, or urges 3.Phobias -Persistent irrational thoughts, compelling desire to avoid provoking stimulus 4. Anxieties 5. Feelings of unreality 6.Feelings of Depersonalization 7.Delusions Erotomanic: the belief that another person is in love with the individual NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Somatic: involves body functions Unspecified: includes delusions of reference without a prominent persecutory or grandiose component Speech Patterns -Slow speech: depression -Accelerated speech: mania -Articulation: are the words clear and distinct: does the speech have a nasal quality -Dysarthria: defective articulation “slurred speech” -Dysphonia: results from impaired volume, quality, or pitch of voice. Difficulty speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords. -Aphasia: the loss of ability to understand (receptive/Wernicke) or express speech (expressive/Broco aphasia) -Brocas aphasia: patients articulate very slowly and with a great deal of effort. Nouns, verbs, important adjectives are usually present and only small grammatical words are dropped from speech "Well…..cat and…..up .................................................................................................................. um, well, um…forget it" -Wernicke's aphasia the patient can speak effortlessly and fluently, but his words often make no sense “the coffee cat looks crazy still” -Cerebrovascular infarction NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A -Fluency: fluency reflects the rate, flow, and melody of speech and the content and use of words. Abnormalities -Hesitancies and gaps in the flow and rhythm of words -Disturbed inflections, such as monotone -Circumlocutions: phrases or sentences are substituted for a word the person cannot think of. Example “what you write with for “pen” -Paraphasia: malformed, wrong, or invented Testing for Aphasia -Word comprehension: ask the patient to follow one-stage commands such as “Point to your nose” -Repetition -Naming -Reading comprehension -Writing Mental Status Examination Brief test used to screen for cognitive dysfunction or dementia and follow the patients course over time. • Orientation • Short-term memory-retention/recall • Language • Attention • Calculation • Constructive Praxis • Example of findings that suggest dementia: “The patient appears sad and fatigued; clothes are wrinkled. Speech is slow and words are mumbled. Thought processes are coherent, but insight into current life reverses is limited. The patient is oriented to person, place, and time. Digit span, serial 7s, and calculations accurate, but NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A screening tests warrant full diagnostic interviews. Failure to diagnose depression can have fatal consequences— the presence of an affective disorder is associated with an 11-fold increased risk for suicide. Depression screening • Over the past 2 weeks, have you felt down, depressed, or hopeless? • Over the past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)? Depression tends to be long-lasting and can recur. Because of these two factors, a wait-and-see approach to treatment is not desirable and timely treatment is necessary. Schizophrenia • Grooming and personal hygiene may deteriorate flat affect and remoteness • Hallucinations: lack actual external stimulation • Derailment: Tangential, speech with shifting from topics that are loosely connected or unrelated. The patient is unaware of the lack of association. • Neologisms: invented or distorted words, or words with new and highly idiosyncratic meaning. • Incoherence: Speech that is incomprehensible and illogical, with lack of meaningful connections, abrupt changes in topic, or disordered grammar or word use. • Flight of ideas, when severe, may produce incoherence NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A • Blocking: Sudden interruption of speech in midsentence or before the idea is completed “losing the thought” • Clanging: speech with choice of words based on sound, not meaning • Echolalia: repetition of the words and phrases • Illusions: misinterpretations of real external stimuli (mistaking rustling leaves for the sound of voices) • Usually occurs in late teens, early 20s (college students, common psych break) • Commonly seen in other family members Suicide Risk and Prevention Protective factors buffer individuals from suicidal thoughts and behavior. To date, protective factors have not been studied as extensively or rigorously as risk factors. Identifying and understanding protective factors are, however, equally as important as researching risk factors. Protective Factors ● Effective clinical care for mental, physical, and substance abuse disorders ● Easy access to a variety of clinical interventions and support for help seeking ● Family and community support (connectedness) ● Support from ongoing medical and mental health care relationships ● Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes • Cultural and religious beliefs that discourage suicide and support instincts for self-preservation • Suicide is the second leading cause of death among 15- to 24- NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A year olds. • Suicide rates are highest among those ages 45 to 54 years, followed by elderly adults ≥age 85 years. • Men have suicide rates nearly four times higher than women, though women are three times more likely to attempt suicide. • Men are most likely to use firearms to commit suicide, while women are most likely to use poison. • Overall, suicides in non-Hispanic whites account for about 90% of all suicides. • American Indian/Alaska Native women ages 15 to 24 years have the highest suicide rates of any racial/ethnic group. • Substance Use Disorders, Including Alcohol and Prescription Drugs. • The harmful interactions between mental disorders and substance use disorders also present a major public health problem. Rates of drug-induced deaths continue to increase and are highest among whites and American Indian/Alaska Natives. The Centers for Disease Control and Prevention reports that prescription drugs have replaced illicit drugs as a leading cause of drug- induced deaths. Every patient should be asked about alcohol use, substance abuse, and misuse of prescription drugs Suicide Risk and Prevention Risk Factors ● Family history of suicide ● Family history of child maltreatment ● Previous suicide attempt(s) NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A • S1 & S2=vibrations emanating from the leaflets, the adjacent cardiac structures, and the flow of blood. • S1=Closure of the mitral valve • s2=Aortic valve closure • S2 split= Closure of aortic valve and then pulmonic valves, best heard over the pulmonic area with the bell of the stethoscope • S3 & S4= Heart failure or acute myocardial ischemia • S3=caused by rapid deceleration of blood against the ventricular wall • S4= increased left ventricular end diastolic stiffness which decreases compliance • Systolic blood pressure=maximal left ventricular pressure • Diastole= left ventricular pressure continues to drop and falls below left atrial pressure. The mitral valve opens, event usually silent but may be audible if valve leaflet motion to restricted (mitral stenosis) • Right ventricle is the chamber that you can assess by palpation since it occupies most of the anterior surface of the heart. Events in the Cardiac Cycle • Systole= Ventricular contraction 5mm HG to 120 mm HG. Blood ejected into Aorta. Aorta valve open and mitral closed. • Diastole= Ventricular relaxation blood flows from atrium to ventricular. Aorta valve closed, and mitral valve open. Normal JVP: 3 cm above the sternal angle, in patients with obstructive lung disease, JVP can appear elevated on expiration but veins collapse on inspiration. • Jugular venous pressure-reflect right atrial pressure which in NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A turn equals central venous pressure and right ventricular end-diastolic pressure. Lies deep in SCM muscles. Abnormal JVP: falls with loss of blood or decreased venous vascular tone and increases with right or left heart failure, HTN, tricuspid stenosis, AV dissociation, increased vascular tone, and pericardial compression or tamponade. Jugular Venous Pulsations • A-atrial contraction, C-carotid transmission, V-venous filling • Abnormally prominent waves occur: increased resistance to right atrial contraction, tricuspid stenosis, 1st/2nd/3rd degree AVB, SVT, junctional tachycardia, pulmonary HTN, pulmonic stenosis. • Absent a wave=A FIB • Systolic phenomenon is the X descent • Increased V waves=occur in tricuspid regurgitation, atrial defects, and constrictive pericarditis. • Abnormal: >3 cm above sternal angle (NOT NOTCH) or > 8 cm above right atrium, best measured at the end of expiration • The vertical height of the blood column in centimeters, plus 5 cm, is the JVP Carotids Characteristics: amplitude, contour, timing of upstroke in relation to S1 and S2 NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Normal: 2+, no bruits or thrills Abnormal: small, thready or weak in cardiogenic shock, and bounding in aortic regurgitation • Carotid upstroke is delayed in aortic stenosis • Carotid pulse mall, thready, or weak= cardiogenic shock • The pulse pounding= aortic regurgitation • Bruit-murmur like sound arising from turbulent arterial blood flow. Caused by- atherosclerotic luminal stenosis • Carotid vs. Jugular: carotid is palpable Dextrocardia-a rare congenital transposition of the heart, the heart is situated in the right chest cavity and generates a right-sided apical impulse. Pulsus alternans : a bigeminal pulse that varies from beat to beat, almost always indicates LV dysfunctions Paradoxical pulse : varies with respiration, greater than normal drop in BP during inspiration, suspected with cardiac tamponade. Cardiovascular Risk Factors Screening • Heart Disease: long asymptomatic latent period. Assess lifetime risk in asymptomatic patients starting at age 20 since many deaths occurs from lack of prior warning signs or cardiac diagnosis. • AHA guidelines recommend screening every 2 years in patients over 20 for blood pressure, body mass index, waist circumference, and pulse. • The physical examination criteria for identifying metabolic syndrome include a waist of 40 inches or greater for males, a waist of 35 inches or greater for females, and a blood pressure of 130/85 or greater (in both males and females). NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A overload from aortic or mitral regurgitation, and left-to- right shunts. o Left-side S3; heard at apex with pt on left lateral position o Right-sided S3: heard at lower left sternal border or below xiphoid with pt supine; louder on inspiration - Fourth heart sound, S4, o not often heard in normal adults, and marks atrial contraction. o It immediately precedes S1 of the next beat and can also reflect a pathologic change in ventricular compliance. o Causes of a left-sided S4 include hypertensive heart disease, aortic stenosis, and ischemic and hypertrophic cardiomyopathy. o Left-sided S4 best heard at apex in left lateral decubitus position. o Right-sided S4 heard along lower left sternal border or below xiphoid. Louder with inspiration. - The fact that diastole usually lasts longer than systole is helpful in distinguishing the two sounds. o The aortic and pulmonic valves are closed, and the mitral and tricuspid valves are open, as seen in diastole o Systole: period of ventricular contraction o Diastole: period of ventricular relaxation. o Cardiac cycle: During systole · Aortic valve is open, allowing ejection of blood from the left ventricle into the aorta. · The mitral valve is closed, preventing blood from regurgitating back into the left atrium. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A · During systole the pulmonic valve opens and the tricuspid valve closes as blood is ejected from the RV into the pulmonary artery During diastole · The aortic valve is closed, preventing regurgitation of blood from the aorta back into the left ventricle. · The mitral valve is open, allowing blood to flow from the left atrium into the relaxed left ventricle. · During diastole, the pulmonic valve closes and the tricuspid valve opens as blood flows into the right atrium A second-degree A-V block can result in a pulse rate less than 60 Auscultation of Heart Sounds - Diaphragm is better for detecting higher pitched sounds such as S1 or S2, the murmurs of aortic and mitral regurgitation, and pericardial friction rubs. - The bell is more sensitive to low-pitched sounds such as S3 or S4 and the murmur of mitral stenosis. - Correlate heart sounds with the patient’s jugular venous pressure and carotid pulse. For example, if there is a diffuse PMI and an S3 suggesting congestive heart failure, look for an elevated JVP. - You will listen for S1 and S2 in each of the six listening areas: in the aortic area in the right 2nd interspace close to the sternum, in the pulmonic area in the left 2nd interspace close to the sternum, in the left 3rd interspace, in the tricuspid area in the left 4th and left 5th interspaces, and in the mitral area at the apex. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A - Note the cardiac rate and rhythm. Normally the rate is 60–100 beats per minute, and the rhythm is regular. - Identify S1 and S2, in the aortic area, S2 is usually louder than S1. - S2 is also usually louder than S1 in the pulmonic area. - Listening in the pulmonic area, identify the inspiratory splitting of S2 into its two components. o Its first component, A2, is from aortic valve closure. § A2 louder than P2 § A2 heard over precordium § P2 heard over 2nd and 3rd left interspace close to sternum. Here you search for splitting of S2. o Its second component, P2, comes from pulmonic valve closure. o This “physiologic split” of S2A (aortic) and S2P (pulnomic) normally occurs during inspiration. Use the bell with light pressure over the 2nd left intercostal space to hear the s2 split best. o During expiration, however, these two components are fused into a single sound, S2. - S2 usually diminishes in intensity while S1 becomes louder as you proceed down through the 3rd interspace and into the tricuspid and mitral areas. - If patient has emphysema, listen to heart sounds in the epigastrium area. - Use bell of the stethoscope and listen along the lower left sternal border in the left 4th and 5th interspaces. Then listen at the apex. - To hear S3, S4, and the murmur of mitral stenosis, place patient in left lateral decubitus position . NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A causes turbulent blood flow across the valve, and increased LV afterload. CAUSE: VALVE CALCIFICATION in older adults. Second most common cause: CONGENITAL BICUSPID AORTIC VALVE. • Hypertrophic Cardiomyopathy: 3rd and 4th IS. Medium pitch. Harsha quality. Intensity decreases with squatting and Valsalva release phase (increased venous return), increases with standing and valsalva strain phase. The carotid upstroke rises quickly, unlike aortic stenosis.The apical pulse is sustained. S2 may be single. S4 is usually present at the apex, unlike mitral stenosis. Usually benign, but can progress to syncope, ischemia, AFIB, dilated cardiomyopathy and heart failure, and increase stroke, and sudden death. Unexplained diffuse or focal ventricular hypertrophy with myocyte disarray and fibrosis associated with unusually rapid ejection of blood from the left ventricle during systole. lus and from leaflet, papillary muscle, or chordae tendineae dysfunction. • Tricuspid Regurgitation: Lower left sternal border, if RV pressure is high=murmur is loud a the apex and confused for mitral regurgitation. Blowing, holosystolic quality. Precordial Rock. JVP elevated. Pulsatile liver, ascites, edema. When the tricuspid valve fails to close fully in systole, blood regurgitates from RV to right atrium, producing a murmur. Common causes: RV failure and dilatation, with resulting enlargement of the tricuspid orifice, often induced by pulmonary HTN or LV failure; and endocarditis. • Ventricular Septal Defect: 3rd, 4th, 5th. Radiation often wide. Very loud with thrill. S2 obscured by loud sound. Larger defects cause, left to right shunts, pulmonary HTN, RV overload. Congenital abnormality. • Mitral valve prolapse: short, high-pitched sound in systole, followed by a murmur which increases in intensity until S2, NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A best heard over the apex. A great test would be having pt squat, the noise will move later in systole along with the murmur Diastolic Murmurs • Aortic Regurgitation: use diaphragm for high pitch. Heard better when patient is upright leaning forward. Blowing decrescendo quality. Diastolic pressure drops to as low as 50 mm Hg; pulse pressure can widen to > 80. Apical pulse becomes diffuse. Corrigan pulse. Duroziez sign. Quincke pulses. The aortic valve leaflets fail to close completely during diastole, causing regurgitation from the aorta back into the left ventricle and left ventricle overload. Austin Flint. Causes: leaflet abnormalities, marfan syndrome, subvalvular abnormalities such as subaortic stenosis or an atrial septal defect • Aortic insufficiency: usually associated with a bounding carotid pulse • Mitral insufficiency: produces a murmur of equal intensity throughout systole • Mitral Stenosis: Apex. Little to no vibration. Low pitched rumble with presystolic accentuation. USE BELL. A FIB occurs in about a third of symptomatic patients, increasing the risk of blood clots. The stiffened mitral valve leaflets move into the left atrium in mid systole and narrow the valve openings, causing turbulence. Common causes: Rheumatic fever, which causes fibrosis, calcification, and thickening of the leaflets and commissures, and chordal fusion. • Pulmonic Stenosis: Left 2 & 3 IS. If radiation loud, toward the left shoulder and neck. Intensity is soft to loud, if loud associated with thrill. JVP prominent a NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A wave. The RV is often sustained. An early pulmonic ejection sound is present in mild to moderate. Severe, s2 is widely split and P2 softens. May hear a right-sided s4 over the left sternal border. Congenital disorder with valvular, supravalvular, or subvalvular stenosis. Pansystolic (Holosystolic) Murmurs • Mitral regurgitation: apex. Radiation to the left axilla. Intensity does not change with inspiration. Occurs when the mitral valve fails to close in systole, blood regurgitates from left ventricle to the left atrium causing the murmur and increasing LV preload=LV dilation. Causes: structural, from mitral valve prolapse, infectious endocarditis, rheumatic heart disease, collagen vascular disease. Stenotic Valve (aortic stenosis)- abnormally narrowed valvular orifice that obstructs blood flow Regurgitant Murmur-a valve allows blood to leak backward into a retrograde direction Congestive Heart Failure Orthopnea: dyspnea that occurs when lying down and improves when the patient sits up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure. Maneuvers to identify Murmurs and Heart Failure -Standing position: venous return to the heart decreases, as does peripheral vascular resistance. Arterial blood pressure, stroke volume, and the volume of blood in the left ventricle all decline. Squatting position: vascular and volume changes occur in the opposite direction. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A pathologic, arising from high left ventricular filling pressures and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase of diastole. Causes include decreased myocardial contractility, heart failure, and ventricular volume overload from aortic or mitral regurgitation, and left-to-right shunts. • In most adults over age 40 years, the diastolic sounds of S3 and S4 are pathologic, and are correlated with heart failure and acute myocardial ischemia. • Orthopnea and PND occur in left ventricular heart failure and mitral stenosis and also in obstructive lung disease Peripheral Artery Disease: PAD-refers to stenotic, occlusive, and aneurysmal disease of the abdomen aorta, its mesenteric and renal branches, and the arteries of the lower extremities, exclusive of the coronary arteries. Atherosclerotic disease leading to obstruction of peripheral arteries causing exertional claudication (muscle pain relieved by rest) and atypical leg pain; may progress to ischemic pain at rest. Usually in calf but also in the buttock, hip, thigh, or foot depending on the level of obstruction; rest pain may be distal in the toes or forefoot. PAD timing: may be brief if relieved by rest; if there is rest pain, may be persistent and worse at night. PAD aggravating factors: Exercise such as walking; if rest pain, leg elevation and bedrest. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Coronary heart disease risk equivalent: peripheral arterial disease, abdominal aortic aneurysm, carotid atherosclerotic disease, and diabetes mellitus. Relief factors: Rest usually stops the pain in 1-3 min; rest pain may be relieved by walking (increases perfusion), sitting with legs dependent. Associated manifestations: local fatigue, numbness, progressing to cool dry hairless skin, trophic nails, diminished to absent pulses, pallor with elevation, ulceration, gangrene. Asymmetric BPs can be sign of: aortic dissection or coarctation/congenital narrowing of the aorta PAD risk factors: • > 50 • Smoking, Dm, Htn, Elevated Cholesterol, African American, Or CAD Symptom location suggests the site of arterial ischemia: • Buttock, hip-aortoiliac • Erectile dysfunction- iliac-pudendal • Thigh- common femoral or aortoiliac • Upper calf- superficial femoral • Lower calf- popliteal • Foot- tibial or peroneal Peripheral arterial disease warning signs: these symptoms suggest= intestinal ischemia of the celiac or superior or inferior mesenteric arteries • Fatigue, aching, numbness, or pain that limits walking or NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A exertion in the legs; if present, identify the location. Ask also about erectile dysfunction. • Any poorly healing or non-healing wounds on the legs or feet • Any pain present when at rest in the lower leg or foot and changes when standing or supine. • Abdominal pain after meals and associated “food fear” and weight loss • Any 1st degree relatives with AAA (15 %-28%) PAIN IN CALVES GREAT INDICATOR OF PVD!!!! Upper extremity DVT- central venous catheters. Ask about arm discomfort, pain, paresthesia’s, and weaknesses. Most patients are asymptomatic with thrombosis detected on routine screening. Screening tool/diagnostic for all patients with suspected DVT: WELLS CLINICAL SCORE AND THE PRIMARY CARE RULE Risk factors for lower-extremity peripheral arterial disease • > 65 year or > 50 years with a hx of dm or smoking • Leg symptoms with exertion • Non-healing wounds NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Arterial insufficiency (Rubor and ischemic ulcer) Arterial insufficiency: Intermittent claudication, progressive to pain at rest. Tissue ischemia. Decreased or absent pulses. Pale, especially on elevation; dusk and red on dependency. Cool temperature. Absent or mild edema; may develop as the patient tried to relieve rest pain by lowering the leg. Trophic skin changes; thin, shiny, atrophic skin; loss of hair over the foot or toes; nails thickened and rigid. Ulceration involves the toes or points of trauma on feet. Gangrene may develop. Buerger Test: raise both legs to about 90 % for up to 2 minutes until there is maximal pallor of the feet. Light skinned-expect to see normal color or slight pallor. Dark skin-inspect soles of feet. • normal=return to pinkness about 10 sec or less. Filling of the veins in the feet and ankles, normally take 15sec. • Abnormal= Foot still pale and the veins are just starting to fill The Allen Test: compares the patency of the ulnar artery and radial arteries 1. Ask patient to make a tight fist then compress the radial and ulnar arteries w 2. Ask the patient to open the hand into a relaxed, slightly flexed position, the palm is pale 3. Release your pressure over the ulnar artery, if the ulnar artery is patent, the palm flushes within 3 to 5 sec. When drawing an arterial blood gas in the radial artery, perform the allen test to be sure that the ulnar artery is patent. Results : negative= palmar flushing positive= palmar pallor MARKED PALLOR SUGGESTS ARTERIAL INSUFFICIENCY Chapter 10 Breast/Axillae NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Assessment The Breast pg. 434 The most significant risk factors for breast cancer: age (65 years old), BRCA status 1 and/or BRCA 2, breast density on mammogram, personal history of breast cancer, family hx of breast cancer, and reproductive factors affecting duration of uninterrupted estrogen exposure. At the age of 50, the risk of breast cancer for someone with the BRCA1 gene is 50%. A thorough examination of the breasts includes careful inspection for skin changes, symmetry, contours, and retraction in four views. The risk of a breast mass being cancerous is 10% Breast tend to swell and become more nodular before menses from increasing estrogen. Best time for exam= 5-7 days after menstruation Inspect: Arms at side: note the appearance of the skin, color, thickening of the skin, pores. • Redness suggests local infection or inflammatory carcinoma NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A • Thickening and prominent pores suggests breast cancer Inspect size and symmetry of the breasts. Some differences in the size of the breasts and areolas are common and usually normal. Contour of the breasts. Look for changes such as masses, dimpling, or flattening. Compare one side with the other. The characteristics of the nipples, including size and shape, direction in which they point, any rashes or ulceration, or any discharge. • Flattening of the normally convex breasts suggest cancer • Asymmetry • Eczematous changes with rash, scaling, or ulceration on the nipple extending to the areola occurs in Paget disease of the breast, associated with underlying ductal or lobular carcinoma • A nipple pulled inward, tethered by underlying ducts signal retraction from a possible underlying cancer. The retracted nipple may be depressed, flat, broad, or thickened. • Clear or bloody nipple discharge (esp if unilateral) is suspicious of breast cancer. Arms Over Head: Hands Pressed Against Hips; Leaning Forward. To bring out dimpling or retraction that may otherwise be invisible, ask the patient to raise her arms over her head, then press her hands against her hips to contract the pectoral muscles. Inspect the breast contours care- fully in each position. If the breasts are large or pendulous, it may be useful to have the patient stand and lean forward, supported by the back of the chair or the examiner’s hands. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Inspect: skin, rash, infection, unusual pigment. Palpate: To examine the axilla, ask the patient to relax with the arm down and warn the patient that the examination may be uncomfortable. Support the patient’s wrist or hand with your hand. Cup together the fingers of your hand and reach as high as you can toward the apex of the axilla. Place your fingers directly behind the pectoral muscles, pointing toward the mid-clavicle. Now press your fingers in toward the chest wall and slide them downward, trying to palpate the central nodes against the chest wall. Of the axillary nodes, the central nodes are most likely to be palpable. The central nodes at the apex of the axilla are most commonly involved in breast cancer If the central nodes feel large, hard, or tender, or if there is a suspicious lesion in the drainage areas for the axillary nodes, palpate for the other groups of axillary lymph nodes: NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A ■ Pectoral nodes—grasp the anterior axillary fold between your thumb and fingers, and with your fingers, palpate inside the border of the pectoral muscle. ■ Lateral nodes—from high in the axilla, feel along the upper humerus. ■ Subscapular nodes—step behind the patient and, with your fingers, feel inside the muscle of the posterior axillary fold. ■ Infraclavicular and supraclavicular nodes—Also re-examine the infraclavicular and supraclavicular nodes Normal VS. Abnormal Findings and Interpretation Palpable Masses of the Breast Breast masses show marked variation in etiology, from fibroadenomas and cysts seen in younger women, to abscess or mastitis, to primary breast cancer. All breast masses warrant careful evaluation, and definitive diagnostic measures should be pursued. Age Common Lesion Characteristics Age 15–25: Fibroadenoma Usually smooth, rubbery, round, mobile, nontender Age 25–50: Cysts Usually soft to firm, round, mobile; often tender. Fibrocystic changes: Nodular, ropelike. Cancer Irregular, firm, may be mobile or fixed to surrounding tissue Over 50: Cancer until proven otherwise. As above. Pregnancy/ lactation Lactating adenomas, cysts, mastitis, and cancer As above Paget’s disease of the nipple, galactorrhea Tenderness-infection/premenstrual NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A tenderness Nodules-cyst, fibroadenoma, cancer The Male Breast Gynecomastia-mass suspicious for cancer, fat Lymphadenopathy One third of men have breast tissue underlying their nipple Visible Signs of Breast Cancer Skin dimpling Abnormal Contours NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A ● Examine the breast in an up-and-down or “strip” pattern. Start at an imaginary straight line under the arm, moving up and down across the entire breast, from the ribs to the collarbone, until you reach the middle of the chest bone (the sternum). Remember how your breast feels from month to month. ● Repeat the examination on your left breast, using the finger pads of the right hand. ● If you find any masses, lumps, or skin changes, see your clinician right away. ● Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and makes it harder. Chapter 11 & 12 Abdominal/Peritoneal/Rectal Assessment and Modification for Age Sequence: Inspection, auscultation, percussion, palpation Auscultation: for bowel sounds, bruit, and friction rub. Possible abnormal sounds: increased or decreased motility, bruit of renal artery stenosis, liver tumor, splenic infarct. Percuss the abdomen for patterns of tympany and dullness. Possible abnormalities: Ascites, GI obstruction, pregnant uterus, ovarian tumor. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Palpate all quadrants of the abdomen for abdominal tenderness. Light palpation for guarding, rebound, and tenderness. Possible abnormalities: Firm, board like abdominal wall— suggests peritoneal inflammation. Guarding if the patient flinches, grimaces, or reports pain during palpation. Rebound tenderness from peritoneal inflammation; pain is greater when you withdraw your hand than when you press down. Press slowly on a tender area, then quickly “let go. If you feel a mass, examine with the abdominal muscles tensed, usually, abdominal wall masses can be observed, whereas intra-abdominal masses are more concerning. A left upper quadrant mass is more likely to be a kidney if there is no palpable “notch,” you can push your fingers between the mass and the costal margin, there is normal tympany over this area, and you cannot push your fingers medial and deep to the mass. Rectal assessment: Rectal assessment is a part of regular GI assessment over age of 40. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Inspection: Check for fissures, lesions, scars, inflammation, discharge, rectal prolapse, skin tags, and external hemorrhoids. Palpation: The rectal walls should feel soft and smooth, without masses, fecal impaction, or tenderness. Peritoneal assessment: Check for ascites, a large accumulation of fluid in the peritoneal cavity caused by advanced liver disease, heart failure, pancreatitis, or cancer. Do not palpate a rigid abdomen. Peritoneal inflammation may be present, in which case palpation could cause pain or rupture an inflamed organ Pancreatitis: In acute pancreatitis, epigastric tenderness and rebound tenderness are usually present, but the abdominal wall may be soft. Intrapancreatic trypsinogen activation to trypsin and other enzymes, resulting in autodigestion and inflammation of the pancreas. Epigastric, may radiate straight to the back or other areas of the abdomen; 20% with severe sequelae of organ failure Chronic pancreatitis: Usually steady. Irreversible destruction of the pancreatic parenchyma from recurrent inflammation of either large ducts or small ducts. Epigastric, radiating to the back Severe, persistent, deep. Peptic Ulcer Disease Mucosal ulcer in stomach or duodenum >5mm, covered with NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Males are affected more than females, teenagers more frequently than adults. Visceral periumbilical pain suggests early acute appendicitis from distention of an inflamed appendix. It gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum. In the elderly, signs and symptoms of appendicitis may vary greatly. Signs may be very vague and suggestive of bowel obstruction or another process; some patients may experience no symptoms until the appendix ruptures. The incidence of perforated. Appendix is higher in the elderly because many of these people do not seek health care as quickly as younger people. -In women, consider pelvic inflammatory disease, ruptured ovarian follicle, and ectopic pregnancy. Combining signs with laboratory inflammatory markers and CT scans markedly reduces misdiagnosis and unnecessary surgery. -Obturator sign: right hypogastric pain with the right hip and knee flexed and the hip internally rotated CLINICAL MANIFESTATIONS NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A -Lower right quadrant pain usually accompanied by low-grade fever, nausea, and sometimes vomiting. -At McBurney’s point (located halfway between the umbilicus and the anterior spine of the ilium), local tenderness with pressure and some rigidity of the lower portion of the right rectus muscle. - Rebound tenderness may be present; location of appendix dictates amounts of tenderness, muscle spasm, and occurrence of constipation or diarrhea. -Rovsing’s sign (elicited by palpating left lower quadrant, which paradoxically causes pain in right lower quadrant). - If appendix ruptures, pain becomes more diffuse; abdominal distention develops from paralytic ileus, and condition worsens. The major complication is perforation of the appendix, which can lead to peritonitis ASSESSMENT AND DIAGNOSTIC METHOD - Diagnosis is based on a complete physical examination and laboratory and radiologic tests. -Leukocyte count greater than 10,000/m, Neutrophil count greater than 75%; -Abdominal radiographs, ultrasound studies, and CT scans may reveal right lower quadrant density or localized distention of the bowel. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Surgery is indicated if appendicitis is diagnosed and should be performed as soon as possible to decrease risk of perforation. -Administer antibiotics and intravenous fluids until surgery is performed. -Analgesic agents can be given after diagnosis is made. Visceral periumbilical pain early signs of appendicitis. It gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum. Acute inflammation of the appendix with distention or obstruction. Quality- mild but increasing, possibly cramping, steady and more severe Timing- last 4-6 hrs., depending on intervention Aggravating factors- movement or cough Relieving factors- it if subsides temporarily suspect perforation of the appendix Associated factors- anorexia, nausea and possibly vomiting following onset of pain, low fever Twice as likely in the presence of RLQ tenderness, Rovising sign, and the psoas sign; it is three times more likely if there is McBurney point NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A chronic condition, and can include fatigue, anorexia, abdominal pain, fever, diarrhea, vomiting, jaundice, dark urine, and pale clay- colored stools. The mode of transmission, communicability, and incubation period differ greatly with the type of virus. In the United States, hepatitis A, B, and C are the most common viruses that cause hepatitis and are of great public health significance. The best strategy for preventing infection and transmission of hepatitis A and B is vaccination. Also, educate patients about how the hepatitis viruses spread and behavioral strategies to reduce the risk of infection. Screen high-risk groups for hepatitis B. Hepatitis A Transmission of hepatitis A virus (HAV) is through a fecal– oral route. Fecal shedding followed by poor hand washing contaminates water and foods, leading to infection of household and sexual contacts. Infected children are often asymptomatic, contributing to spread of infection. To reduce transmission, advise hand washing with soap and water after bathroom use or changing diapers (daycare workers), and before preparing or eating food. Diluted bleach can be used to clean environmental surfaces. HAV infection is rarely fatal—fewer than 100 deaths occur each year— and usually only in people with other liver diseases; it does not cause chronic hepatitis. The vaccine alone may be administered at any time before traveling to endemic areas. Healthy unvaccinated individuals should receive either a hepatitis A vaccine or a single dose of immune globulin (preferred for those ≥age 40 years) within 2 weeks of being exposed to HAV. These recommendations apply to close personal contacts of persons with confirmed HAV, coworkers of infected food handlers, and staff and attendees (and their NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A household members) of childcare centers where HAV has been diagnosed in children, staff, or households of attendees. Hepatitis B Hepatitis B virus (HBV) infection is a more serious threat than infection with hepatitis A. The fatality rate for acute infection can be up to 1% and HBV infection can become chronic. Approximately 95% of infections in healthy adults are self-limited, with elimination of the virus and development of immunity. Risk of chronic HBV infection is highest when the immune system is immature—chronic infection occurs in 90% of infected infants and 30% of children infected before age 5 years. About 15% to 25% of those with chronic HBV infection die from cirrhosis or liver cancer, accounting for nearly 3,000 deaths each year in the United States. Most persons with chronic infection are asymptomatic until the onset of advanced liver disease. Screening. The USPSTF recommends screening for HBV in persons at high risk for infection (grade B), including those born in countries with a high endemic prevalence of HBV infection, persons with HIV, injection drug users, men who have sex with men, and household contacts or sexual partners of HBV- infected persons. The CDC recommends screening all pregnant women, ideally in the first trimester, and universal vaccination for all infants beginning at birth. For adults, vaccine recommendations also target high-risk groups, including those in high-risk settings. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Hepatitis C -There is no vaccination for hepatitis C, so prevention targets counseling to avoid risk factors. Screening should be recommended for high-risk groups. • Hepatitis C virus (HCV), transmitted mainly by percutaneous exposures, it is the most prevalent chronic bloodborne pathogen in the United States. Anti- HCV antibody is detectable in just under 2% of the population, though prevalence is markedly increased in high- risk groups, particularly injection drug users. • Additional risk factors for HCV infection include blood transfusion or organ transplantation before 1992, transfusion with clotting factors before 1987, hemodialysis, health care workers with needle stick injury or mucosal exposure to HCV-positive blood, HIV infection, and birth from an HCV-positive mother. Sexual transmission is rare. • Hepatitis C becomes a chronic illness in over 75% of those infected and is a major risk factor for subsequent cirrhosis, hepatocellular carcinoma, and need for liver transplant for end-stage liver disease. • However, the majority of persons with chronic HCV are unaware of being infected. Response to antiviral therapy (undetectable HCV RNA 24 weeks after completing treatment) ranges from 40% to over 90% depending on the viral genotype and the combination of drugs used for treatment. Consequently, the USPSTF has concluded that screening for hepatitis C infection is of moderate benefit for persons at high risk for infection as well as those born NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A bowel syndrome. Worse in the morning; rarely at night. Crampy lower abdominal pain, abdominal distention, flatulence, nausea; urgency, pain relieved with defecation. - Altered motility or secretion from luminal and mucosal irritants that change mucosal permeability, immune activation, and colonic transit, including mal- digested carbohydrates, fats, excess bile acids, gluten intolerance, enteroendocrine signaling, and changes in microbiomes. - Currently, there is no gold standard for the diagnosis of IBS. Diagnosis is complicated by the lack of reliable, standardized biomarkers and because abnormalities cannot be detected by radiologic or endoscopic tests. - Irritable bowel syndrome will cause loose bowel movements with cramps but no systemic symptoms of fever, weight loss, or malaise. This syndrome is more likely in young women with alternating symptoms of loose stools and constipation. Stress usually makes the symptoms worse, as do certain foods. -BS diagnose guidelines recommend that providers use a symptom-based strategy based on routine physical examination and standardized criteria, such as the Rome III. The validated Bristol Stool Scale, developed in the late 1990s, is typically used to subtype IBS according to bowel habit. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A - Hypothyroidism can cause constipation Treatment Plan: • Increase dietary fiber Supplement fiber with psyllium (Metamucil or Konsyl), methylcellulose (Citrucel), wheat dextrin (Benefiber). Start at a low dose (causes gas). • -Avoid gas-producing foods: Beans, onions, cabbage, high- fructose corn syrup. If poor response, use a trial diet of lactose avoidance or gluten avoidance. • Antispasmodics for abdominal pain: Administer dicyclomine (Bentyl) or hyoscyamine as needed. IBS with constipation: Begin a trial of fiber supplements, polyethylene glycol (osmotic laxative). If severe constipation: Prescribe lubiprostone or linaclotide (contraindicated in pediatric patients younger than 6 years, has caused death from dehydration). IBS with diarrhea : Take loperamide (Imodium) before regularly scheduled meals. • Severe diarrhea–predominant IBS: Administer alosetron (warning: ischemic colitis, which can be fatal). Decrease life stress. Address anxiety/stress with patient and offer treatment strategies. Rule out: Amoebic, parasitic, or bacterial infections; inflammatory disease of the GI tract; and so forth. Check stool for ova and parasites (especially diarrheal stools) with culture Osmotic diarrhea: usually related to lactose intolerance, watery diarrhea often follows meal ingestion. Crampy abdominal pain, distension, and gas often accompany symptoms. Diarrhea is often provoked by pizza, milkshakes, yogurt, and other lactose- NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A containing foods Incontinence Urinary incontinence see p. 463 & 497 If the patient reports incontinence, ask if the patient is leaking small amounts of urine due to increased intra-abdominal pressure from coughing, sneezing, laughing, or lifting. *Stress incontinence Or following an urge to void, is there an involuntary loss of large amounts of urine? Is there a sensation of bladder fullness, frequent leakage, or voiding of small amounts but difficulty emptying the bladder? In stress incontinence, increased abdominal pressure causes bladder pressure to exceed urethral resistance—there is poor urethral sphincter tone or poor support of bladder neck. Arises from decrease intraurethral pressure. Causes: childbirth and surgery. Local conditions affecting urethral sphincter such as postmenopausal atrophy of mucosa and urethral infection; in men, stress incontinence may follow prostate surgery Symptoms: Occurs with coughing, laughing, and sneezing while in upright position. Urine loss if unrelated to conscious urge to urinate. Physical signs: Atrophic vaginitis may be evident. Bladder distention absent. In urge incontinence, urgency is followed by involuntary leakage due to uncontrolled detrusor contractions that overcome urethral resistance. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A § Incontinence secondary to medications: Sedatives, tranquilizers, anticholinergics, sympathetic blockers, and potent diuretics. The pain from a kidney stone causes dramatic, severe, colicky pain at the CVA that radiates down into the groin. Colon/Anorectal Cancer: Colorectal cancer - Very gradual (years) with vague GI symptoms. Tumor may bleed intermittently, and patient may have iron-deficiency anemia. Changes in bowel habits, stool, or bloody stool. Heme positive stool, dark tarry stools, mass on abdominal palpation. Older patients (older than 50 years of age), especially with history of multiple polyps or inflammatory bowel disease such as Crohn’s disease (CD) or ulcerative colitis (UC). - Screening for Colorectal Cancer: Screening tests include stool tests that detect occult fecal blood, such as fecal immunochemical tests, high-sensitivity guaiac-based tests, and tests that detect abnormal DNA. Endoscopic tests are also used for screening, including colonoscopy, which visualizes the entire colon and can remove polyps, and flexible sigmoidoscopy, which visualizes the distal 60 cm of the bowel. Imaging tests include double-contrast barium enema and CT colonography. Any abnormal finding on a stool test, imaging study, or flexible sigmoidoscopy warrants further evaluation with colonoscopy. - Colorectal cancer is the third most frequently diagnosed NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A cancer among both men and women (over 140,000 new cases) and the third leading cause of cancer death (nearly 50,000 deaths) each year in the United States. The lifetime risk of diagnosis with colorectal cancer is about 5%, while the lifetime risk for dying from colorectal cancer is about 2%.50 The good news is that U.S. incidence and mortality rates have been gradually but steadily declining over the past three decades. These trends are attributed to changes in risk factor prevalence, such as decreased tobacco use; increased screening, which both prevents cancers and increases detection of early-stage curable cancers; and improved treatment. - The strongest risk factors for colorectal cancer are: increasing age; personal history of colorectal cancer, adenomatous polyps, or longstanding inflammatory bowel disease; and family history of colorectal neoplasia—particularly those with affected multiple first-degree relatives, a single first-degree relative diagnosed before age 60 years, or a hereditary colorectal cancer syndrome. - Prevention. The most effective prevention strategy is to screen for and remove precancerous adenomatous polyps. Screening programs using fecal blood testing or flexible sigmoidoscopy have been shown in randomized trials to reduce the risk of developing colorectal cancer. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A - Physical activity, aspirin and nonsteroidal anti- inflammatory drugs (NSAIDs), and postmenopausal combined hormone replacement therapy (estrogen and progestin) are also associated with decreased risk of colorectal cancer. - However, the USPSTF recommends against routinely using aspirin and NSAIDs for prevention in average-risk persons because the potential harms, including GI bleeding, hemorrhagic stroke, and renal impairment, outweigh the benefits (grade D). - Hormone therapy for cancer chemoprevention is not advised; women receiving combined therapy were actually more likely to present with advanced- staged colorectal cancers and appear to have a higher risk for colorectal cancer mortality. Hormone therapy is associated with increased risk of breast cancer, cardiovascular events, and venous thromboembolism. There has been no convincing evidence that dietary changes or taking supplements can prevent colorectal cancer. - With a past history of colon cancer and recent weight loss and fatigue, a relapse of colon cancer would be expected. Colon cancer usually metastasizes to the liver, creating hard, irregular nodules, usually non-tender, which can sometimes be palpated on examination Screening Tests. Screening tests include stool tests that detect occult fecal blood, such as fecal immunochemical tests, high- sensitivity guaiac-based tests, and tests that detect abnormal NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A chancres and carcinomas. Smegma, a cheesy, whitish material, may accumulate normally under the foreskin. The glans. Look for any ulcers, scars, nodules, or signs of inflammation. The urethral meatus. Inspect the location of the urethral meatus. Compress the glans gently between your index finger above and your thumb below. This maneuver should open the urethral meatus and allow you to inspect it for discharge. Normally, there is none. If the patient has reported a discharge that you are unable to see, ask him to strip, or milk, the shaft of the penis from its base to the glans. Alternatively, do this yourself. This maneuver may expel some discharge from the urethral meatus for appropriate examination. Have a glass slide and culture materials ready. Palpation: Palpate the shaft of the penis between your thumb and first two fingers, noting any induration. (This may be omitted in a young asymptomatic male patient.) Palpate any abnormality of the penis, noting any induration or tenderness. If you retract the foreskin, replace it before proceeding on to examine the scrotum. Inspect the scrotum, including: The skin. Lift up the scrotum so that you can inspect its posterior surface. Note any lesions or scars. Inspect the pubic hair distribution. The scrotal contours. Inspect for swelling, lumps, veins, bulging masses, or asymmetry of the left and right hemiscrotum. The inguinal areas. Note any erythema, excoriation, or visible adenopathy. There may be dome-shaped white or yellow papules or nodules formed by occluded follicles filled with keratin debris of desquamated follicular epithelium. Such epidermoid cysts are common, frequently multiple, and benign. Palpation. If using a one- handed technique, palpate each testis and epididymis between NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A your NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A thumb and first two fingers. If using two hands, cradle the testis at both poles in the thumb and fingertips of both hands. Palpate the scrotal contents as you gently slide them back and forth from the fingertips of one hand to the other, without changing the position of your hands as they cup the scrotum. This technique is comfortable for the patient and allows a subtle controlled and accurate examination. The testes should be firm but not hard, descended, symmetric, nontender, and without masses. For each testis, assess size, shape, consistency, and tenderness; feel for any nodules. Pressure on the testis normally produces a deep visceral pain. Palpate the epididymis on the posterior surface of each testicle without applying excess pressure, which can cause discomfort. The epididymis feels nodular and cord-like and should not be confused with an abnormal lump. Normally, it should not be tender. Palpate each spermatic cord, including the vas deferens, between your thumb and fingers, from the epididymis to the external inguinal ring (Fig. 13-6). The vas feels slightly stiff and tubular and is distinct from the accompanying vessels of the spermatic cord. Palpate any nodules or swellings. Swelling in the scrotum apart from the testicles can be evaluated by transillumination. After darkening the room, shine the beam of a strong flashlight from behind the scrotum through the mass. Look for transmission of the light as a red glow Normal VS. Abnormal Findings and Interpretation Prostate Issues and Cancer Prostate Cancer: 2nd leading cause of cancer of cancer in the US. Risk Factors:<40, African American men, genetics, (potentially exposure to agent orange, diets high in animal fats, smoking, obesity. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A often causing infertility problems. Like most varicose veins in any area, varicoceles can cause a nonspecific aching. Although usually benign, a unilateral varicocele on the right or a varicocele which does not resolve in the supine position deserves further workup Hydrocele: Fluid-filled cyst originating within the tunica vaginalis. An examining finger can be placed over the mass into the inguinal ring. An outside light source can be placed beneath the scrotum. Hydroceles often transilluminate light, whereas solid tumors do not. Erectile Dysfunction May be a from psychogenic causes, especially if early morning erection is preserved; it may also reflect decreased testosterone, decreased blood flow in the hypogastric arterial system, impaired neural innervation, and diabetes. Erectile dysfunction, or the inability to maintain an erection, affects approximately 50% of older men. Vascular causes are the most common, from both atherosclerotic arterial occlusive disease and corpora cavernosa venous leak. Chronic diseases such as diabetes, hypertension, dyslipidemia, and smoking, as well as medication side effects, all contribute to the prevalence of erectile dysfunction Men with screen-detected cancers who undergo aggressive treatment with surgery or radiation frequently leads to complications such as erectile NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A dysfunction, urinary incontinence, and bowel problems that adversely affect the quality of life Arterial ischemia in iliac–pudendal leads to erectile dysfunction Erectile dysfunction can be due to psychogenic causes, especially if early morning erection is preserved. Decreased testosterone decreased blood flow in hypogastric arterial system, impaired neural innervation, and diabetes can also cause Erectile Dysfunction. Chapter 14- Female Genitalia and Modification for Age External Genitalia (Vulva) includes mons pubis overlying the symphysis pubis; labia majora; labia minora; prepuce and clitoris. The opening into the vagina is the introitus (in virgins may be hidden by the hyman). The perineum refers to tissue between introitus and anus. The urethral meatus opening is between the clitoris and vagina. Paraurethral (Skene) glands are just posterior and adjacent to the meatus on either side. The Bartholin glands are posteriorly on both sides but not always visible. Internal Genitalia: Locate the cervix with a gloved and water- lubricated index finger. Assess support of vaginal outlet by asking patient to strain down. Enlarge the introitus by pressing its posterior margin downward. Insert a water-lubricated speculum of suitable size. Start with speculum held obliquely, then rotate to horizontal position for full NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A insertion. Open the speculum and inspect cervix. Observe: ● Position ● Color ● Epithelial surface Any discharge or bleeding ● Any ulcers, nodules, or masses Obtain specimens for cytology (Pap smears) with: An endocervical broom or brush with scraper (except in pregnant women), to collect both squamous and columnar cells ● Or, if the woman is pregnant, use a cotton-tipped applicator moistened with water NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Weakness of the pelvic floor muscles may cause pain; urinary incontinence; fecal incontinence; and prolapse of the pelvic organs that can produce a cystocele, rectocele, or enterocele. Risk factors are advancing age; prior pelvic surgery or trauma; parity and child- birth; clinical conditions (obesity, diabetes, multiple sclerosis, Parkinson disease); medications (anticholinergics, a-adrenergic blockers); and chronically increased intra-abdominal pressure from chronic obstructive pulmonary disease (COPD), chronic constipation, or obesity.1 Loss of urethral support contributes to stress incontinence. Weakness of the perineal body from childbirth predisposes to rectoceles and enteroceles. Epidermoid Cyst A small, firm, round cystic nodule in the labia suggests an epidermoid cyst. They are yellowish in color. Look for the dark punctum marking the blocked opening of the gland Venereal Wart (Condyloma Acuminatum) Warty lesions on the labia and within the vestibule suggest condylomata acuminata from infection with human papillomavirus. Genital Herpes Shallow, small, painful ulcers on red bases suggest a herpes infection. Initial infection may be extensive, as illustrated here. Recurrent infections are usually confined to a small local patch. Syphilitic Chancre A firm, painless ulcer suggests the chancre of primary NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A syphilis. Because most chancres in women develop internally, they often go undetected Secondary Syphilis (Condyloma Latum) Slightly raised, round or oval flat-topped papules covered by a gray exudate suggest condylomata lata, a manifestation of secondary syphilis. They are contagious. Carcinoma of the Vulva An ulcerated or raised red vulvar lesion in an elderly woman may indicate vulvar carcinoma. Trichomonas vaginitis Discharge: Yellowish green, often profuse, may be malodorous Other Symptoms: Itching, vaginal soreness, dyspareunia Vulva: May be red Vagina: May be normal or red, with red spots, petechiae Laboratory Assessment: Saline wet mount for trichomonads NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Candida vaginitis Discharge White, curdy, often thick, not malodorous Other Symptoms: Itching, vaginal soreness, external dysuria, dyspareunia Vulva: Often red and swollen Vagina: Often red with white patches of discharge Laboratory Assessment: KOH preparation for branching hyphae Abnormalities of the Cervix Endocervical polyp A bright red, smooth mass that protrudes from the os suggests a polyp. It bleeds easily. Mucopurulent cervicitis A yellowish exudate emerging from the cervical os suggests infection from Chlamydia, gonorrhea (often asymptomatic), or herpes. Carcinoma of the cervix An irregular, hard mass suggests cancer. Early lesions are best detected by colposcopy following abnormal Pap smear from of high risk of HPV. Fetal exposure to diethylstilbestrol (DES) Several changes may occur: a collar of tissue around the cervix, columnar epithelium that covers the cervix or extends to the vaginal wall (then termed vaginal adenosis), and, rarely, carcinoma of the vagina. Relaxations of the Pelvic Floor NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A the risk of infertility. Chlamydial infection is a cause of urethritis, cervicitis, PID, ectopic pregnancy, infertility, and chronic pelvic pain. Risk factors include age younger than 26 years, multiple partners, and prior history of STIs. To improve detection and treatment, the CDC and the USPSTF57 strongly recommend screening for STIs, summarized below. CDC STI and HIV Screening Recommendations 2014 ● Chlamydia and gonorrhea screening annually for all sexually active women ages <25 years and older women with risk factors such as new or multiple sex partners, or a sex partner infected with an STI. ● Chlamydia, syphilis, hepatitis B, and HIV screening for all pregnant women and gonorrhea screening for at-risk pregnant women starting early in pregnancy, with repeat testing as needed to protect the health of mothers and their infants. Chlamydia, gonorrhea, and syphilis screening at least once a year for all sexually active gay, bisexual, and other MSM. MSM who have multiple or anonymous partners should be screened more frequently for STIs (i.e., at 3-to 6-month intervals). ● HIV testing at least once for all adults and adolescents from ages 13 to 64 years. ● NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A ● HIV testing at least once a year for anyone having unsafe sex or using injection drug equipment. Sexually active gay and bisexual men may benefit from testing every 3 to 6 months. Bacterial Vaginosis- Discharge: Gray or white, thin, homogeneous, scant, malodorous Other Symptoms: Fishy genital odor Vulva: Usually normal Vagina: Usually normal Laboratory Assessment: Saline wet mount for “clue cells,” “whiff test” with KOH for fishy odor Example of physical exam findings: Bilateral shotty inguinal adenopathy. External genitalia without erythema or lesions. Vaginal mucosa and cervix coated with thin white homogeneous discharge with mild fishy odor. After swabbing the cervix, no discharge visible in the cervical os. Uterus midline; no adnexal masses. Rectal vault without masses. Stool brown and negative for fecal blood. pH of vaginal discharge >4.5” These findings are consistent with bacterial vaginosis. **Menstruation Cervical Disorders and Cancer As estrogen stimulation increases during adolescence, all or part of this columnar epithelium is transformed into squamous epithelium by a process termed metaplasia. This change may block the secretions of columnar epithelium and cause retention cysts, also called Barthian cysts. This appear as translucent nodules on the cervical surface and have no pathologic NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A significance. A cervical polyp usually arises from the endocervical canal, becoming visible when it protrudes through the cervical os. It is bright red, soft, and rather fragile. When only the tip is seen, it cannot be differentiated clinically from a polyp originating in the endometrium. Polyps are benign but may bleed Mucopurulent cervicitis - produces purulent yellow drainage from the cervical os, usually from the Chlamydia trachomatis, Neisseria gonorrhoeae, or herpes infection. These infections are sexually transmitted and may occur without signs and symptoms Carcinoma of the cervix - begins in an area of metaplasia. In its earliest stages, it cannot be distinguished from a normal cervix. In later stages, an extensive, irregular, cauliflower-like growth may develop. Early frequent intercourse, multiple partners, smoking, and infection with HPV increase the risk for cervical cancer NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Significant edema of the hands and feet of a newborn girl may be suggestive of Turner syndrome. Other features such as a webbed neck would reinforce this diagnosis. Webbed neck: Dehydration is a common problem in infants. Usual causes are insufficient intake or excess loss of fluids from diarrhea. Birthmarks (Hye) Eyelid Patch: This birthmark fades, usually within the first year of life. Salmon Patch: called “stork bite,” or “angel kiss,”splotchy pink mark fades with age. Café-au-lait Spots: These light-brown pigmented lesions usually have borders and are uniform. Noted in more than 10% of black infants. If > 5 café- au-lait spots exist, consider the diagnosis of neurofibromatosis Slate Blue Patches: more common among dark-skinned babies. to note that are not mistaken for bruises. Childhood Vaccinations Pediatric Immunizations: https ://www .cd c.gov/vaccines/schedules/downloads/child/0-18yrs- child-combined- schedule.pdf Developmental Milestones p. 853-890 Early childhood (1-4 years): after infancy, physical growth slows by NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A ½; after 2 years, toddlers gain 2-3 kg and grow 5 cm/year. Gross motor skills: Walk by 15 months, run by 2 years, tricycle/jump by 4 years. Drawing/Fine motor: 18-month old scribbles, 2-year old draws lines, 4-year old makes circles; Cognitive: toddlers move from sensorimotor to symbolic thinking. 18-month old: 10-20 words, 2-year old: three-word sentences; 4-year old: complex sentences. Toddlers are impulsive with poor self-regulation= common temper tantrums. Middle Childhood (5-10 years): Physical growth: steadily and slowly, strength and coordination improve. More awareness of physical disability limitations. Cognitive: “concrete operational,” meaning capable of limited logic and more complex learning. Limited ability to understand consequences and are greatly influenced by school, family, and environment. + language complexity. Social: more independent, start activities, enjoy accomplishments (this helps with self- esteem), + self-identity evolves. + Guilt and poor self-esteem may emerge. Clear sense of “right” and “wrong.” Adolescents (11-20 years): Physical growth: pubertal transformation over several years (age 10-14 years in girls, 11-16 years in boys); Cognitive: progression from concrete to formal operational thinking, ability to reason w/ abstract thinking; NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Social: family-influence versus autotomy and peer influence. + struggle for identity, independence, intimacy, stress, health-related problems, and high-risk behaviors. Tanner Staging Females: p. 897 Stage 1: preadolescent (elevation of nipple only) Stage 2: breast bud stage (elevation of breast and nipple as a small mound; enlargement of areolar diameter Stage 3: further enlargement of elevation of breast and areola; no contour separation Stage 4: projection of areola and nipple to form a second mound above the level of the breast Stage 5: mature stage (projection of nipple only; areola has receded to general contour of the breast) Males: p. 899 Stage 1: no pubic hair, penis is the same size as in childhood, testes and scrotum the same size as childhood Stage 2: sparse hair growth at base of penis, penis has slight to no enlargement, testes and scrotum are larger Stage 3: darker, courser, spreading pubic hair, increase in penis size (primarily length); further enlargement of testes and scrotum Stage 4: adult-type pubic hair except not involving thighs, further width and length growth of penis, development of the glans, further enlargement of testes and scrotal skin darkens Stage 5: adult hair quality and quantity, adult size and shape of NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Head and Neck Face: With the patient seated, inspect the head and neck, paying particular attention to the following features: ■ Face. Irregular brownish patches around the forehead, cheeks, nose, and jaw are known as chloasma or melasma, the “mask of pregnancy,” a normal skin finding during pregnancy. ■ Hair. Hair may become dry, oily, or sparse during pregnancy; mild hirsutism on the face, abdomen, and extremities is also common. 942 Facial edema after 20 gestational weeks is suspicious for preeclampsia and should be investigated. Localized patches of hair loss should not be attributed to pregnancy (though postpartum hair loss is common). • Gestational hypertension is systolic blood pressure (SBP) >140 mm Hg or diastolic blood pressure (DBP) >90 mm Hg first documented after 20 weeks, without proteinuria or preeclampsia, that resolves by 12 weeks postpartum. • Chronic hypertension is SBP >140 or DBP >90 that predates pregnancy. Chronic hypertension affects almost 2% of U.S. births. Facial edema after 20 gestational weeks is suspicious for preeclampsia and should be investigated. Localized patches of hair loss should not be attributed to pregnancy (though postpartum hair loss is common). NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A Anemia may cause conjunctival pallor. Erosions and perforations of the nasal septum may represent use of intranasal cocaine. Dental problems are associated with poor pregnancy outcomes, so initiate prompt dental referrals for tooth and gum pain or infections. Thyroid enlargement, goiters, and nodules are abnormal and require investigation. Dyspnea accompanied by increased respiratory rate, coughing, rales, or respiratory distress point to possible infection, asthma, pulmonary embolism, or per- partum cardiomyopathy Assess dyspnea and signs of heart failure for possible peripartum cardiomyopathy, particularly in the late stages of pregnancy. Murmurs may signal anemia. Investigate any diastolic murmur. Prenatal Laboratory Screenings. The standard prenatal screening panel includes blood type and Rh, antibody screen, complete blood count—especially hematocrit and platelet count, rubella titer, syphilis test, hepatitis B surface antigen, HIV test, STI screen for gonorrhea and chlamydia, and urinalysis with culture. Scheduled screenings include an oral glucose tolerance test for gestational diabetes around 24 to 28 weeks and a rectovaginal swab for group B streptococcus between 35 and 37 weeks. Because obesity is associated with insulin resistance, the obese pregnant patient is at increased risk of both gestational diabetes and type 2 diabetes mellitus. Both ACOG and the American Diabetes Association recommend testing for glucose tolerance in the first trimester for obese pregnant patients.33 if indicated, pursue additional tests related to the mother’s risk factors, such as screening for aneuploidy, Tay–Sachs disease, or other genetic diseases, and amniocentesis Immunizations. Given the persistent increase in pertussis infection NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ DOWNLOAD TO SCORE A in the United States, the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices and ACOG recommend that T-dap be administered during each pregnancy, ideally at 27 to 36 weeks of gestation, regardless of the prior immunization history.21 Caretakers in direct contact with the infant should also receive T-dap. Inactivated influenza vaccination is indicated in any trimester during the influenza season.22 The following vaccines are safe during pregnancy: pneumococcal, meningococcal, and hepatitis B. Hepatitis A and B, meningococcal polysaccharide and conjugate, and pneumococcal polysaccharide vaccines can be given, if indicated.23 The following vaccines are not safe during pregnancy: measles/mumps/rubella, polio, and varicella. All women should have rubella titers drawn during pregnancy and be immunized after birth if found to be nonimmune. Check Rh (D) and antibody typing at the first prenatal visit, at 28 weeks, and at delivery. Anti-D immunoglobulin should be given to all Rh-negative women at 28 weeks’ gestation and again within 3 days of delivery to prevent sensitization if the infant is Rh-D positive. Chapter 20 Geriatric Assessment General Survey. As the patient enters the room, how does the patient walk to the chair? Move onto the examining table? Are there changes in posture or involuntary movements?