NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+. Download to score, Exams of Nursing

Download NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+. Download to score and more Exams Nursing in PDF only on Docsity! NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score 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 NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score • -Retrieve and process data more slowly and take longer to learn new information • -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 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 NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score Erotomanic: the belief that another person is in love with the individual 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 -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. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score be as effective as using more detailed instruments. All positive 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 • 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 NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score support instincts for self-preservation • Suicide is the second leading cause of death among 15- to 24- 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 NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score lateral to the midsternal line) . Normal diameter 1 to 2.5 cm. The left ventricle, behind the RV and to the left, forms the left margin of the heart, its tapered inferior tip is often termed the cardiac apex which produces the apical impulse, identified during palpation of the precordium as the PMI. Abnormal PMI • Situs inversus and dextrocardia->PMI located at the right side of chest • PMI>2.5cm-> left ventricular hypertrophy from HTN or aortic stenosis causing pressure overload in the left ventricle • Displacement of the PMI lateral to the midclavicular line or > 10 cm lateral to the midsternal line-> LVH and Ventricular dilatation from a MI or heart failure • COPD patients-> the PMI may be in the xiphoid or epigastric area due to right ventricular hypertrophy • Hyperkinetic high-amplitude=hyperthyroidism severe anemia, HTN, aortic stenosis, and aortic regurgitation • Sustained high amplitude- increased LVH from HTN Cardiac chambers, valves, and circulation • AV valves= Mitral and Tricuspid (based on location) • Semilunar valves= Aortic and Pulmonic (based on half-moon shape) NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score • 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. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score • Jugular venous pressure-reflect right atrial pressure which in 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 Heart Disease Heart Sounds • Waist circumference men>102cm; women >88cm • Fasting plasma glucose: >100; or being treated for high BS • HDL cholesterol: men <40 women ;<50; or being treated • Triglycerides: >150; or being treated • BP: >130/85; or being treated - Closure of the heart valves creates a pair of audible heart sounds. - The first sound, S1, arises from closure of the mitral valve. - Tricuspid valve closure may also contribute to S1. - The second sound, S2, arises from closure of the aortic valve. - Pulmonic valve closure may also contribute to S2. - Ventricular diastole occurs between S2 and the next S1. - After the mitral valve opens, there is a period of rapid ventricular filling as blood flows early in diastole from left atrium to left ventricle. - Third heart sound: S3 o In children and young adults (35-40 and last trimester of pregnancy), may arise from rapid deceleration of the column of blood against the ventricular wall. o An S3 in adults over age 40 years (an S3 gallop) is usually 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 NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score contractility, heart failure, and ventricular volume 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. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score · 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 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 o This brings the left ventricle closer to the chest wall and makes low pitched sounds more audible. Then, recheck the position of the apical impulse and place the bell lightly over that location. Is there an audible S3. Now, notice how the third heart sound disappears when the bell is placed more firmly on the chest wall. Listen again with light pressure o 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. o an S3 corresponds to an abrupt deceleration of inflow across the mitral valve, and an S4 to increased left ventricular end diastolic stiffness which decreases compliance. Murmurs Heart murmurs: distinct heart sounds distinguished by their pitch and their longer duration. They are attributed to turbulent blood flow and are usually diagnostic of VALVULAR DISEASE. Identify when the murmur occurs (systolic or diastolic) by palpating the carotid artery at the same time Chest Wall Location and Origin of Valve Sounds and Murmurs R 2nd Interspace to the apex Aortic Valve Left 2nd and 3rd interspaces close to the sternum, but also at higher or lower levels Pulmonic Valve NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score At or near the lower left sternal border Tricuspid At and around the cardiac apex Mitral Valve Midsystolic Murmurs • Innocent Murmur: Left 2nd to 4th interspace between the left sternal border and the apex. Minimal radiation. Grade 1 to 2, possibly 3. Soft to medium pitch. Variable quality. Usually decreases or disappears on sitting. Turbulent blood flow, probably generated by Ventricular ejection of blood into the aorta from the left and occasionally right ventricle. VERY COMMON IN CHILDREN AND YOUNGER ADULTS. Older adults= CVD • Physiologic Murmurs: Similar to innocent murmur. Turbulence due to temporary increase in blood flow in predisposing conditions such as anemia, pregnancy, fever, and hyperthroid Pathologic Murmurs/Midsystolic • Aortic Stenosis: Right 2nd and 3rd interspaces. Radiation, often to the carotids, down the left sternal border, even to the apex. Sometimes soft but often loud with a thrill intensity. Medium, harash; crescendo-decrescendo may be higher at the apex for pitch. Often harsh, may be more musical at apex for quality. Heard best with patient sitting and leaning forward.Significant stenosis NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score 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 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. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score Squatting position: vascular and volume changes occur in the opposite direction. o These maneuvers help (1) to identify a prolapsed mitral valve and (2) to distinguish hypertrophic cardiomyopathy from aortic stenosis. - Valsalva maneuver: Used to identify hypertrophic cardiomyopathy, heart failure, and pulmonary hypertension. o The murmur of hypertrophic cardiomyopathy is the only systolic murmur that increases during the “strain phase” of the Valsalva maneuver due to increased outflow tract obstruction. o Identify HF and Pulmonary HTN by using blood pressure cuff kept at 15 mmHg above SBP during Valsalva Maneuver. In patients with severe heart failure, blood pressure remains elevated and there are Korotkoff sounds during the phase 2 strain phase, but not during phase 4 release, termed “the square wave” response. This response is highly correlated with volume overload and elevated left ventricular end-diastolic pressure and pulmonary capillary wedge pressure, in some studies outperforming brain natriuretic peptide o In healthy patients, phase 2, the “strain” phase, is silent; Korotkoff sounds are heard after straining is released during phase 4. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score 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 NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score • Fatigue, aching, numbness, or pain that limits walking or 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 The ankle-brachial index: noninvasively diagnose PAD. The ABI is the ratio of blood pressure measurements in the foot an arm; values <0.9 are abnormal. Mild disease: ABI of 0.71 to 0.9. Moderate disease: ABI 0.7 and 0.41. Severe disease is ABI 0.4 or less. As the internal diameter of a blood vessel changes, the resistance changes as well...Resistance varies proportionally to the fourth power of the diameter Treatment for PAD: supervised exercise program, tobacco cessation, treatment of hyperlipidemia, optimal control of diabetes and htn, use of antiplatelet agents, meticulous foot care and well- fitting shoes, revascularization. -expanding hematoma from triple A= may cause symptoms by compressing the bowel, aortic branch arteries, or ureters. -Mesenteric ischemia: food fear, weight loss, or dark stool. These symptoms suggest mesenteric ischemia from arterial embolism, arterial venous thrombosis, bowel volvulus or strangulation, or hypoperfusion. Failure to detect acute symptoms can cause bowel necrosis or death. -Atherosclerotic PAD: symptomatic limb ischemia with exertion. Ask about any pain or cramping in the legs during exertion that is relieved by rest within 10 minutes, called intermittent claudication, pain in calves. -Neurogenic claudication: Pain with walking or prolonged standing, radiating from the spinal area into the buttocks, thighs, lower legs, or feet. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score Chapter 10 Breast/Axillae 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 • 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 NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score hands. Palpate: Palpation is best performed when the breast tissue is flattened. The patient should be supine. Palpate the rectangular area extending from the clavicle to the inframammary fold or bra line, and from the midsternal line to the posterior axillary line and well into the axilla to ensure that you examine the tail of the breast. A thorough examination takes at least 3 minutes for each breast. Palpate in small, concentric circles applying light, medium, and deep pressure at each examining point. Press more firmly to reach the deeper tissues of a large breast. Examine the entire breast, including the periphery, tail, and axilla. Examining the lateral portion of the breast. To examine the lateral portion of the breast, ask the patient to roll onto the opposite hip, placing her hand on her forehead but keeping the shoulders pressed against the bed or examining table. This flattens the lateral breast tissue. Begin palpation in the axilla, moving in a straight line down to the bra line, then move the fingers medially and palpate in a vertical strip up the chest to the clavicle. Continue in vertical overlapping strips until you reach the nipple, then reposition the patient to flatten the medial portion of the breast. Examining the medial portion of the breast. To examine the medial portion of the breast, ask the patient to lie with her shoulders flat against the bed or examining table, placing her hand at her neck NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score a sitting position is preferable. 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 ■ 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 NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score cancer As above Paget’s disease of the nipple, galactorrhea Tenderness-infection/premenstrual 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 enhances any breast changes.) NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score ● 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, NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score ovarian tumor. 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 Aggravated by: lying down, bending over, physical activity, diseases such as scleroderma, gastroparesis, drugs like nicotine that relaxes the lower esophageal sphincter. Relieved by: Antacids, PPI, avoiding alcohol, smoking, fatty meals, chocolate, theophylline, CCB Associated symptoms: Wheezing, chronic cough, SOA, hoariness, choking sensation, dysphagia, regurgitation, halitosis, sore throat, increases risk for Barrett esophagus and esophageal cancer. Risk factors: salivary flow which prolongs acid clearance by damping action of the bicarbonate buffer; obesity; delayed gastric emptying; selected medications; hiatal hernia. Appendicitis The appendix is a small, finger-like appendage attached to the cecum just below the ileocecal valve. Because it empties into the colon inefficiently and its lumen is small, it is prone to becoming obstructed and is vulnerable to infection (appendicitis). The obstructed appendix becomes inflamed and edematous and eventually fills with pus. It is the most common cause of acute inflammation in the right lower quadrant of the NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score abdominal cavity and the most common cause of emergency abdominal surgery. 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 -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 NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score redundant there may be suprapubic or right-sided pain. Look for localized peritoneal signs and a tender underlying mass. The clinical presentation of acute diverticulitis ranges from mild abdominal pain to peritonitis with sepsis. The diagnosis can often be made based on clinical features alone, but imaging is necessary in more severe presentations to rule out complications such as abscess and perforation. Assess for guarding, rebound, and distention of the left lower quadrant. The treatment of diverticulitis depends on the severity of the presentation, presence of complications and underlying comorbid conditions. Foods that can get stuck in a diverticula (such as popcorn, nuts, and corn) should be avoided. Hepatitis: Visceral pain in the RUQ. Liver span decreases. Jaundice- is a striking yellowish discoloration of the skin and sclera from increased levels of bilirubin, Hepatitis -Hepatitis, or inflammation of the liver, can be caused by several different viruses. Symptoms of hepatitis are universal, regardless if caused by an infectious agent or NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score 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 NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score close personal contacts of persons with confirmed HAV, coworkers of infected food handlers, and staff and attendees (and their 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 Cirrhosis: varices such as esophageal varices are common with cirrhosis and can cause black tarry stools and positive occult blood. Other symptoms such as jaundice, ascites, spider hemangiomas, and dilated veins on the abdomen can signal cirrhosis. IBS: Irritable bowel syndrome A chronic functional disorder of the colon (normal colonic tissue marked by exacerbations and remissions (spontaneous). Commonly exacerbated by excess stress. It may be classified as diarrhea predominant or constipation predominant. In some cases, it may alternate between the two. - Irritable bowel syndrome (IBS) is a chronic functional bowel disorder associated with abdominal pain or discomfort, bloating, and altered bowel habits that continue for 3 months with onset 6 months before diagnosis and occurs in the absence of any structural or biochemical abnormalities. IBS is a common disorder, although prevalence rates vary, in part because IBS remains undiagnosed in at least three-quarters of patients. IBS is more common among women and more often diagnosed in younger individuals. - Change in bowel habits with a mass lesion warns of colon cancer. Intermittent pain for 12 weeks of the preceding 12 months with relief from defecation, change in frequency of bowel movements, or change in the form of stool (loose, NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score watery, pellet-like), linked to luminal and mucosal irritants that alter motility, secretion, and pain sensitivity suggests irritable 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 NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score typically used to subtype IBS according to bowel habit. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score Bladder typically small. · Occur from decreased cortical inhibition of detrusor contractions from stroke, brain tumor, dementia, and lesions of the spinal cord above sacral level. o Symptoms: Involuntary urine loss followed by urge to urinate. Volume moderate. o Physical signs: small bladder not detectable on examination. · Also from Hyperexcitability of sensory pathways as in bladder infections, tumors, and fecal impactions. o Symptoms: urgency, frequency, nocturia with small-mod amounts. If acute inflammation is present, pain on urination. o Physical signs: decreased cortical inhibition will shows mental deficits or motor signs of central nervous system disease · Also from deconditioning of voiding reflexes such as frequent voluntary voiding at low bladder volumes. o Symptoms: possibly pseudo-stress incontinence – voiding 10- 20sec after stresses such as change in position, going up and down stairs, possibly laughing, coughing, sneezing. o Physical sign: signs of local pelvic problems or fecal impaction may be present. § In overflow incontinence, neurologic disorders or anatomic obstruction from pelvic organs or the prostate limit bladder emptying until the bladder becomes overdistended. Detrusor contractions are insufficient to overcome urethral resistance, causing urinary retention. · Mechanisms: Obstruction of the bladder outlet, as in benign prostatic hyperplasia or tumor. Weakness of the detrusor muscle associated with peripheral nerve disease at S2–4 level. Impaired bladder sensation that interrupts the reflex arc, as in diabetic NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score neuropathy. · Symptoms: When intravesicular pressure overcomes urethral resistance, continuous dripping or dribbling incontinence ensues. Decreased force of the urinary stream. Prior symptoms of partial urinary obstruction or other symptoms of peripheral nerve disease may be present. ·Physical signs: Examination often reveals an enlarged, sometimes tender, bladder. Other signs include prostatic enlargement, motor signs of peripheral nerve disease, a decrease in sensation (including perineal sensation), and diminished to absent reflexes. o Bladder control involved neuroregulatory and motor mechanism. Central and peripheral severe lesions affect S2 to S4 can affect normal voiding. Ask: does patient feel when bladder is full, when voiding: functional and mixed incontinence. § Functional incontinence arises from impaired cognition, musculoskeletal problems, or immobility. Patient functionally unable to reach the toilet in time because of impaired health or environmental conditions. ·Mechanism: problems in mobility resulting from weakness, arthritis, poor vision, or other conditions. Environmental factors such as unfamiliar setting, distant bathroom, bed rails, or physical restraints. · Symptoms: Incontinence on way to toilet or only early morning. · Physical signs: Bladder not detectable on exam; look for physical or environmental clues as the cause. § Mixed incontinence is combined stress and urge incontinence is o Pt’s functional status can affect voiding behaviors: mobile? Immobile? Alert? Medications? NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score § 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. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score 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. Ischemia pain (abdominal) does not increase with palpation. Chapter 13 Male Genitalia Assessment and Modification for Age Undescending testes: In infant, testis must often be “milked” into the scrotum from the inguinal canal Surrounding or appended to the testes are several structures. The scrotum is a loose, wrinkled pouch of skin and underlying dartos muscle. The scrotum is divided into two compartments, each containing a testis or testicle. Covering the testis, except posteriorly, is the serous membrane of the tunica vaginalis, derived from the peritoneum of the abdomen and brought down into the scrotum during testicular descent through the deep internal inguinal ring. The parietal layer of the tunica vaginalis cloaks the anterior two thirds of the testis, and the visceral layer lines the adjacent scrotum. On the posterolateral surface of each testis is the softer, comma- shaped epididymis, consisting of tightly coiled tubules emanating from the testis that become the NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score vas deferens. The epididymis is normally separated from the testis NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score by a palpable sulcus, and provides a reservoir for storage, maturation, and transport of sperm. The inguinal canal, which lies medial to and roughly parallel to the inguinal ligament, forms a tunnel for the vas deferens as it passes through the abdominal muscles. The internal opening of the canal, the internal inguinal ring, is approximately 1 cm above the midpoint of the inguinal ligament. Neither the canal nor the internal ring is palpable through the abdominal wall. The exterior opening of the tunnel, the external inguinal ring, is a triangular slit-like structure palpable just above and lateral to the pubic tubercle. When loops of bowel force their way through the inguinal canal, they produce inguinal hernias. Another route for a herniating mass is the femoral canal, below the inguinal ligament. Although this canal is not visible, you can estimate its location by placing your right index finger, from below, on the right femoral artery. Your middle finger will then overlie the femoral vein; your ring finger, the femoral canal. Femoral hernias protrude at this location. Ask about any discharge from the penis, dripping, or staining of underwear. If penile discharge is present, clarify the amount, color, and any fever, chills, rash, or associated symptoms. Note that for men born between 1940 and 1989, the median age of sexual initiation is 16.1 years and the median number of lifetime partners is 8.8, underscoring the importance of screening for STIs. Inquire about sores or growths on the penis. Ask about swelling or pain in the scrotum. Inspection: Inspect the penis, including: The skin. Inspect the skin on the ventral and dorsal surfaces and the base of the penis for excoriations or inflammation, lifting the penis when necessary. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score 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, NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score obesity. Prevention: PSA TESTING (normal levels are >4.0). False positives are caused by BPH, prostate infections, and ejaculation. Digital Rectal Exam: finds palpable nodules in the posterior and lateral areas of the prostate gland. It is unable to detect cancer in the anterior and central areas of the gland. The exam is performed by having the pt bear down and note any irregularities or nodules. Sweep your finger carefully over the prostate gland, identifying it’s lateral lobes and the groove of the median sulcus. Note shape, mobility, and consistency of the prostate. Screening: Patients with average risk should begin screening between 50-55 years of age. PSA screening should continue every 1-2 years. High risk screening: should start at 40-45 years of age STI Gonorrhea-yellow penile discharge Chlamydia-white discharge MOST COMMON STI Disseminated Gonorrhea- rash, tenosynovitis, monoarticular arthritis, even meningitis,not always urogenital symptoms NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score Herpes: BURNING pain, vesicles Genital warts: (condylomata Acuminata)- single or multiple papules or plaques of carriable shapes. Caused by HPV. Incubation-weeks to months; infected person may not have visible warts Syphilis- small red papule that becomes chancre, a painless erosion up to 2 cm in diameter. Syphilis is fairly uncommon but does occur in the highly promiscuous population, especially when coupled with illegal drug use. Base of chancre is clean, red, smooth, and glistening; borders are raised and indurated. Chancre heals within 3 to 8 weeks. Cause-treponema pallidum, a spirochete. Incubation 9-90 days after exposure. May develop inguinal lymphadenopathy within 7 days, lymph nodes are rubbery, non-tender, mobile. Patients develop secondary syphilis while chancre still present (suggests coinfection of HIV) Chancroid- red papule or pustule initially, then forms a painful deep ulcer with ragged nonindurated margins; contains necrotic exudate, has a friable base. Cause- Haemophilus ducreyi, an anaerobic bacillus. Incubation- 3 to 7 days after exposure. Painful inguinal adenopathy Testicular Disorders and Cancer Acute orchitis: The scrotum will be red and tense. Orchitis is usually unilateral and often associated with viral infections such as mumps. Varicocele: Varicoceles are varicose veins surrounding the spermatic cord, coming through the inguinal ring. These veins feel NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score speculum held obliquely, then rotate to horizontal position for full 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 Inspect the vaginal mucosa as you withdraw the speculum. Palpate, by means of a bimanual examination: ● The cervix and fornices ● The uterus ● Right and left adnexa (ovaries) Assess strength of pelvic muscles. With your vaginal fingers clear of the cervix, ask patient to tighten her muscles around your fingers as hard and long as she can. Perform a rectovaginal examination to palpate a retroverted uterus, uterosacral ligaments, cul-de-sac, and adnexa or screen for colorectal cancer in women 50 years or older. ADOLESCENT GIRLS: Assessing sexual maturity is done by rating pubic hair Stage 1- Preadolescent girls have no pubic hair but may have fine, vellus hair Stage 2- Sparse growth of long, slightly pigmented, curly or straight hair along labia Stage 3- Darker coarser hair spreading to pubic symphysis Stage 4- Coarse and curly hair as in adults; but not as much and not including thighs NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score Stage 5- Adult hair quantity and quality- spreads to medial surface of the thighs not on abdomen Considerations for Adolescent girls: first examination should be done by experienced provider. Adolescent Initial sign of puberty: hymen thickening and redundancy secondary to estrogen, widening of the hips, beginning of height spurt - these changes may be difficult to detect. The first easily detectable sign of puberty is the appearance of breast buds although pubic hair may be seen earlier. Normal VS. Abnormal Findings and Interpretation Normal : No inguinal adenopathy. External genitalia without erythema, lesions, or masses. Vaginal mucosa pink. Cervix parous, pink, and without discharge. Uterus anterior, midline, smooth, and not enlarged. No adnexal tenderness. Pap smear obtained. Rectovaginal wall intact. Rectal vault without masses. Stool brown and Hemoccult negative. Abnormal: NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score 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. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score Relaxations of the Pelvic Floor A cystocele is a bulge of the anterior wall of the upper part of the vagina, together with the urinary bladder above it. A cystourethrocele involves both the bladder and the urethra as they bulge into the anterior vaginal wall throughout most of its extent. A rectocele is a bulge of the posterior vaginal wall, together with a portion of the rectum. A prolapsed uterus has descended down the vaginal canal. There are three degrees of severity: first, still within the vagina (as illustrated); second, with the cervix at the introitus; and third, with the cervix outside the introitus. Positions of the Uterus and Uterine Myomas An anteverted uterus lies in a forward position at roughly a right angle to the vagina. This is the most common position. Anteflexion—a forward flexion of the uterine body in relation to the cervix— often coexists. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score A retroverted uterus is tilted posteriorly with its cervix facing anteriorly. A retroflexed uterus has a posterior tilt that involves the uterine body but not the cervix. A uterus that is retroflexed or retroverted may be felt only through the rectal wall; some cannot be felt at all. A myoma of the uterus is a very common benign tumor that feels firm and often irregular. There may be more than one. A myoma on the posterior surface of the uterus may be mistaken for a retro displaced uterus; one on the anterior surface may be mistaken for an anteverted uterus. STI For STIs and HIV, assess risk factors by taking a careful sexual history and counseling patients about spread of disease and ways to reduce high-risk practices. Test women younger than 26 years and pregnant women for Chlamydia; in women at increased risk and pregnant women, test for gonorrhea, syphilis, and HIV. In 2006, the CDC recommended universal screening for HIV for those ages 13 to 64 because infection occurs in many without known risk factors. For sexually transmitted infections (STIs) and diseases, identify sexual preference (male, female, or both) and the number of sexual partners in the previous month. Ask if the patient has concerns about HIV infection, desires HIV testing, or has current or past partners at risk. NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score cysts, also called Barthian cysts. This appear as translucent nodules on the cervical surface and have no pathologic 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 Fetal exposure to diethylstilbestrol (DES) - daughters of women who took DES during pregnancy are greatly increased risk for several abnormalities, including 1.) columnar epithelium that covers most or all of the cervix, 2.) vaginal adenosis, i.e. extension of the epithelium to the vaginal wall, and 3.) a circular collar or ridge of tissue, of varying shapes, between the cervix and vagina. Much less common is an otherwise rare carcinoma of the upper vagina Chapter 18 **Newborn/Infant/Pediatric Assessment and Modification for Age Normal VS. Abnormal Findings and Interpretation Newborn Skin Disorders (Hye) Ruddy (reddish purple color): newborn with polycythemia Cutis marmorata-prominent in premature infants or infants with congenital hypothyroidism and Down syndrome. If acrocyanosis does not disappear within 8 hours or with warming, cyanotic congenital heart disease should be considered. Central cyanosis in a baby or child of any age should raise suspicion of congenital heart disease. The best area to look for central cyanosis is the tongue and oral mucosa, not the nail beds, lips, or the extremities. café-au-lait spots (See below) -Pigmented light-brown lesions (<1 to 2 cm at birth) Isolated lesions have no significance, but multiple lesions with sharp borders may suggest neurofibromatosis NR 509 FINAL EXAM STUDY GUIDE LATEST UPDATE RATED A+ . Download to score Skin desquamation -normal in full-term newborns but may rarely be a sign of placental circulatory insufficiency or congenital ichthyosis. Both erythema toxicum (see above pic 18-2) and pustular melanosis may appear similar to the pathologic vesiculopustular rash of herpes simplex or Staphylococcus aureus skin infection. Midline hair tufts over the lumbosacral spine region - a possible spinal cord defect. Jaundice within the first 24 hours of birth may be from hemolytic disease of the newborn. Late-appearing jaundice or jaundice that persists beyond 2 to 3 weeks should raise suspicions of biliary obstruction or liver disease. A common source of jaundice during the first couple of weeks is breastfeeding jaundice, which resolves around 10 to 14 days of life. Persistent jaundice requires evaluation. A unilateral dark, purplish lesion, or “port wine stain” over the distribution of the ophthalmic branch of the trigeminal nerve may be a sign of Sturge–Weber syndrome, which is associated with seizures, hemiparesis, glaucoma, and mental retardation.