NUR 509 Final Study Guide 2024 Best Rated Solution. Guaranteed Success., Exams of Nursing

Download NUR 509 Final Study Guide 2024 Best Rated Solution. Guaranteed Success. and more Exams Nursing in PDF only on Docsity! NUR 509 Final Study Guide 2024 Best Rated Solution. Guaranteed Success. Behavior/Mental Health Assessment and Modification _for_ Age 1. Assessmen t: a. b. Many mental health disorders are masked by other clinical conditions; 20% of primary care outpatients have mental disorders(50-70% go undetected and untreated) c. Physical symptoms account _for_ approx. 50% of office visits d. ⅓ of physical symptoms are unexplained; in 20-25% those symptoms become chronic e. Symptoms and Behaviors: i. Sorting symptom _is_ a challenge; can be unexplained symptoms 1. Patients who have unexplained symptoms depression and anxiety exceeds 50% ii. Physical or “somatic” symptoms account _for_ 50% of U.S. office visits 1. Pain, fatigue, palpitations, GI symptoms, sexual dysfunction, dizziness or loss of balance 2. Symptoms that present as clusters are called “functional syndromes” such as IBS, fibromyalgia, chronic fatigue, TMJ disorder, and multiple chemical sensitivity 3. The presence of symptom overlap _is_ high in the common functional syndromes such as fatigue, headache, sleep disturbance, pain, GI upset iii.Patients with unexplained and somatic symptoms are often frequent users of the health care system and termed “difficult patients” iv.Patients with symptoms that last longer than 6 weeks are recognized as chronic and should be screened _for_ depression and anxiety. a. A two tiered approach _is_ recommended _for_ screening. A brief screening with questions that yield high sensitivity then a more detailed investigation when indicated V.Patient who warrant a mental health screening include: 1. medically unexplained physical symptoms 2. Multiple physical or somatic symptoms vii. A person who can write a correct sentence does NOT have aphasia e. Testing _for_ Aphasia i. Word Comprehension: Ask the patient to follow one-stage commands such as “Point to your nose” ii. Repetition: Ask the patient to repeat a phrase of one- syllable words “ No ifs, ands, or buts” iii. Naming: Ask the patient to name the parts of a watch iv. Reading Comprehension: Ask the patient to read a paragraph aloud v. Writing: Ask the patient to write a sentence · Mental Status Examination 1. Five components of the mental status examination a. Appearance and Behavior i. Note level of consciousness: _is_ the patient awake and alert, does the patient understand your questions and respond appropriately 1. If the patient does not respond then speak to the patient by name in a loud voice 2. Lethargic patients are drowsy but open their eyes and look at you, respond to questions, then fall back asleep 3. Obtunded patients open their eyes and look at you but respond slowly and are somewhat confused ii. Note posture and motor behavior:does the patient sit or lie quietly or prefer to walk around; note the pace, range, and type of movement 1. Look _for_ tense posture, restlessness, and anxious fidgeting; the crying, pacing, and hand wringing of agitated depression 2. The hopeless slumped posture and slowed movement of depression 3. The agitated and expansive movements of manic ep_is_odes iii. Note Dress, Grooming, and Personal hygiene: how _is_ the patient dressed, clean and presentable?, how _is_ grooming compared to those of similar age, compare one side to the other 1. May deteriorate in depression, schizophrenia, and dementia 2. Excessive fastidiousness may be seen OCD 3. One-sided negligence may result from a lesion in the opposite parietal cortex; usually the non-dominant side iv. Note facial expression: observe the face at rest and during conversation; are changes in expression appropriate 1. Note Expressions of anxiety, depression, apathy, anger, elation, or facial immobility in parkinson_is_m v. Manner, Affect, and Relationship to People and Things: assess the patients external expression of the inner emotional state(Affect). _is_ the affect appropriate to topics being d_is_cussed?, seem exaggerated at points, labile, blunted, or flat? 1. Paranoia= anger, hostility, suspiciousness, or evasiveness 2. Mania= elation and euphoria 3. Schizophrenia=flat affect with remoteness 4. Dementia and Anxiety or Depresion= apathy(dulled affect with detachment and indifference) 5. Hallucinations=schizophrenia, alcohol withdrawal, and systemic toxicity b. Speech and Language= SEE ABOVE in language patterns c. Mood: Ask patient to describe h_is_/her mood, including usual level and fluctuations related to life events i. Moods range from sadness and melancholy, contentment, joy, euphoria, and elation; anger and rage, anxiety and worry, to detachment and indifference ii. If you suspect depression, assess its severity and any r_is_k of suicide iii. It _is_ your responsibility as the provider to ask directly about suicidal thoughts. Th_is_ may be the only way to uncover suicidal ideation and plans that launch immediate intervention and treatment d. Thought and Perception: i. Thought Process: assess the logic, relevance, organization, and coherence of the patients thought process throughout the interview; does speech progress logically?, l_is_ten _for_ patterns of speech that suggest d_is_orders; Variations and Abnormalities include: 1. Circumstantiality: speech with unnecessary detail, indirection, and delay in reaching the point; Occurs in patients with obsessions 2. Derailment: “tangential” speech with shifting topics that are loosely connected or unrelated; seen in schizophrenia, manic ep_is_odes, and other psychotic d_is_orders 3. Flight of Ideas: a continuous flow of accelerated speech with abrupt changes from one topic to the next; most frequently seen in manic ep_is_odes 4. Neolog_is_ms: Invented or d_is_torted words, or words with new and highly idiosyncratic meanings; observed in schizophrenia, psychotic d_is_orders, and aphasia 5. Incoherence: Speech that _is_ incomprehensible and illogical, with lack of meaningful connections, abrupt changes in topic, or d_is_ordered grammar or word use. Flight of ideas, when severe, may produce incoherence. Seen in severe psychotic d_is_turbances usually schizophrenia 6. Blocking: Sudden interruption of speech in mid sentence or be_for_e the idea _is_ completed, attributed to “losing the thought.” Blocking occurs in normal people. May be striking in schizophrenia 7. Confabulation: Fabrication of facts or events in response to ques- tions, to fill in the gaps from impaired memory. Seen in Korsakoff syndrome from alchol_is_m 8. Perseveration: Pers_is_tent repetition of words or ideas Occurs in schizophrenia and other psychotic d_is_orders 9. Echolalia:Repetition of the words and phrases of others. Occurs in manic ep_is_odes and schizophrenia 10. Clanging: Speech with choice of words based on sound, rather than meaning, as in rhyming and punning. _for_ example, “Look at my eyes and nose, w_is_e eyes and rosy nose. Two to one, the ayes have it!” Seen in schizophrenia and manic ep_is_odes ii. Thought Content: to assess follow patients cues rather than asking direct questions; “Can you tell me more about that” or “What do you think about times like these?” Abnormalities in content include 1. Compulsions: Repetitive behaviors that the person feels driven to per_for_m in response to an obsession, aimed at preventing or reducing anxiety or a dreaded event or situation; these behaviors are excessive and unreal_is_tically connected to the provoking stimulus 2. Obsessions: Delusions 3. Recurrent pers_is_tent thoughts, images, or urges experienced as intrusive and unwanted that the person tries Start with simple questions, then move to more difficult questions. Note the person’s grasp of in_for_mation, complexity of the ideas, and choice of vocabulary. In_for_mation and vocabulary are rela- tively unaffected by psychiatric d_is_orders except in severe cases. Testing helps d_is_tingu_is_h adults with life-long intellectual impairment (whose in_for_- mation and vocabulary are limited) from those with mild or moderate dementia (whose in_for_mation and vocabulary are fairly well preserved). ii. Calculating Ability: Test ability to do arithmetical calculations; start with simple addition, or pose practical functionally important questions such as if something cost 78 cents and you give the clerk $1 how much change should your receive Poor per_for_mance suggests dementia or aphasia, but should be measured against the patient’s fund of knowledge and education. iii. Abstract Thinking: ask the patient about what certain proverbs mean or explain the similarity between two things such as an apple and orange. Concrete responses are common in people with intellectual d_is_ability, delirium, or dementia, but may also reflect limited education. Patients with schizophrenia may respond concretely or with personal and bizarre interpretations iv. Constructional Ability: ability to copy figures of increasing complexity onto a piece of blank unlined paper. With intact v_is_ion and motor ability, poor constructional ability suggests dementia or parietal lobe damage. Intellectual d_is_ability can also impair per_for_mance. i. Special Techniques _for_ the Mental Exam i. Mini-Mental State Examination: brief test used to screen _for_ cognitive dysfunction or dementia, and follow the patients course over time j. Recording Your Findings i. Example of normal findings:The patient _is_ alert, well- groomed, and cheerful. Speech _is_ fluent and words are clear. Thought processes are coherent, insight _is_ good.The patient _is_ oriented to person, place, and time. Serial 7s accurate; recent and remote memory intact. Calculationsintact. ii. 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 responses delayed. Clock drawing _is_ good. · Screening _for_ Depression: BECKY PECK Generalized Anxiety D_is_order: WONGEL MARKOS Depressive D_is_orders: CRYSTAL SHAGENA/Ada Ejimadu Depressive D_is_orders ( pg 156) Ada Ejimadu Depression and anxiety d_is_orders are a common cause of hospitalization in the United States, and mental illness _is_ associated with increased r_is_ks _for_ chronic medical conditions, decreased life expectancy, d_is_ability, substance abuse, and suicide. About 19million adult American or almost 7% have major depression with other co- ex_is_ting anxiety d_is_order or substance abuse. Depression _is_ as common in women as men, and the prevalence of postpartum depression _is_ about 7% to 13%. Most patients with chronic medical conditions have depression. Symptoms of depression in high-r_is_k patients may be subtle and may include; I. Low self-esteem II. Loss of pleasure in daily activities (Anhedonia) III. Sleep d_is_order, IV. Difficulty concentrating or making dec_is_ions. Look carefully _for_ symptoms of depression in vulnerable patients, especially those who are young, female, single, divorced or separated, seriously or chronically ill, bereaved, or have other psychiatric d_is_orders, including substance abuse. A personal or family h_is_tory of depression also places patients at r_is_k. Asking two simple questions about mood and anhedonia appears to 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 d_is_order _is_ associated with an 11-fold increased r_is_k _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. Suicide I. Suicide _is_ the second leading cause of death among 15- to 24-year olds. II. Suicide rates are highest among those ages 45 to 54 years, III. followed by elderly adults ≥age 85 years. IV. Men have suicide rates nearly four times higher than women, though women are three times more likely to attempt suicide. V. Men are most likely to use firearms to commit suicide, VI. while women are most likely to use po_is_on. VII. Overall, suicides in non-H_is_panic whites account _for_ about 90% of all suicides. VIII. American Indian/Alaska Native women ages 15 to 24 years have the highest suicide rates of any racial/ethnic group. Substance Use D_is_orders, Including Alcohol and Prescription Drugs. The harmful interactions between mental d_is_orders and substance use d_is_orders 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_ D_is_ease Control and Prevention reports that prescription drugs have replaced illicit drugs as a leading cause of drug-induced deaths. Every slight r_is_e in atrial pressure that accompanies atrial contraction. It occurs just prior to S1 and be_for_e the carotid upstroke. The normal upstroke _is_ br_is_k; it _is_ smooth, rapid, and follows S1 almost immediately. The timing of the carotid upstroke in relation to S1 and S2. Note that the normal carotid upstroke follows S1 and precedes S2. -Carotid Bruits- The carotid pulse provides valuable in_for_mation about cardiac function, especially aortic valve stenos_is_ and regurgitation. Press just inside the medial border of a relaxed SCM muscle. Never palpate both carotid arteries at the same time. Th_is_ may decrease blood flow to the brain and induce syncope. Auscultate both the carotid arteries to l_is_ten _for_ a bruit, a murmur- like sound ar_is_ing from turbulent arterial blood flow. Ask the patient to stop breathing _for_ ∼15 seconds, then l_is_ten with the diaphragm of the stethoscope, which generally detects the higher frequency sounds of arterial bruits better than the bell. 3.) Palpate and describe the apical impulse (PMI). -To assess the PMI and extra heart sounds such as S3 or S4, ask the patient to turn to the left side, termed the left lateral decubitus position—th_is_ brings the ventricular apex closer to the chest wall. To bring the left ventricular outflow tract closer to the chest wall and improve detection of aortic regurgitation, have the patient sit up, lean _for_ward, and exhale. -Location of PMI: Left sternal Boarder 5 th intercostal space Midclavicular line -Diameter of PMI: In the supine position it usually measures 2.5cm, about the size of a quarter. In the decubitus position it may feel larger. -Amplitude of PMI: _is_ it Br_is_k and tapping, diffuse, or sustained? Normal Findings: small/br_is_k/ tapping 4.) Auscultate S1 and S2 in 6 positions from the base to the apex. See Figure 9- 41 page 390 1.)-2 nd right interspace (Aortic) 2.)-2 nd left interspace (Pulmonic) 3.)-3 rd left interspace (Erbs Point) 4 &amp;5) -4 th &amp; 5 th left interspace (Tricuspid Valve can be heard) 6) -5 th left interspace midclavicular line (Mitral area) 5.) Recognize the effect of the P-R interval on the intensity of S1. -S1 _is_ accentuated in (1) tachycardia, rhythms with a short PR interval, and high cardiac output states (e.g., exerc_is_e, anemia, hyperthyroid_is_m) and (2) mitral stenos_is_. In these conditions, the mitral valve _is_ still open wide at the onset of ventricular systole and then closes quickly. 6.) Identify physiologic and paradoxical splitting of S2. -Physiologic Splitting: L_is_ten _for_ physiologic splitting of S2 in the 2nd or 3rd left interspace. The pulmonic component of S2 _is_ usually too faint to be heard at the apex or aortic area, where S2 _is_ a single sound derived only from aortic valve closure. Normal splitting _is_ accentuated by inspiration, which increases the interval between A2 and P2, and d_is_appears on expiration. In some patients, especially younger ones, S2 may not become single on expiration until the patient sits up. -Paradoxical Splitting: Paradoxical or reversed splitting refers to splitting that appears on expiration and d_is_appears on inspiration. Closure of the aortic valve _is_ abnormally delayed so that A2 follows P2 in expiration. Normal inspiratory delay of P2 makes the split d_is_appear. The most common cause _is_ left bundle branch block. 7.) Auscultate and recognize abnormal sounds in early diastole, including an S3and OS of mitral stenos_is_. -The opening snap (OS) _is_ a very early diastolic sound caused by abrupt deceleration during the opening of a stenotic mitral valve. It _is_ best heard just medial to the apex and along the lower left sternal border. If loud, an OS radiates to the apex and to the pulmonic area, where it may be m_is_taken _for_ the pulmonic component of a split S2. Its high pitch and snapping quality help to d_is_tingu_is_h it from an S2, but it becomes less audible as the valve leaflets become more calcified. It _is_ heard better with the diaphragm. -You will detect physiologic S3 frequently in children and young adults to the age of 35 or 40 years, and often during the last trimester of pregnancy. Occurring early in diastole during rapid ventricular filling, it _is_ later than an OS, dull and low in pitch, and heard best at the apex in the left lateral decubitus position. Diastolic murmurs are less common than systolic murmurs and more difficult to hear, requiring more meticulous examination. 10.) Evaluate and interpret a paradoxical pulse. -A paradoxical pulse may be detected by a palpable decrease in the pulse amplitude on quiet inspiration. If the sign _is_ less pronounced, a blood pressure cuff _is_ needed. Systolic pressure decreases by &gt;10–12 mm Hg during inspiration. A paradoxical pulse occurs in pericardial tamponade, exacerbations of asthma and COPD, and constrictive pericardit_is_ · Normal VS. Abnormal Findings and Interpretation CORKY HOSKINS-WINDER Cardiovascular R_is_k Factors -Smoking -Hypertension -Hyperlipidemia -Diabetes -Stroke -Coronary heart d_is_ease -Body mass index -Sedentary lifestyle -Poor Diet choices -Family h_is_tory of cardiovascular d_is_ease -Approximately 13% of U.S. adults meet five or more criteria, 5% meet six or more criteria, and virtually none meet seven criteria at ideal levels. -Women have become increasingly aware that CVD _is_ their leading cause of death. -2013 data indicate that CVD death rates remain significantly higher _for_ black women than white women, death rates _for_ CHD _is_ higher _for_ blacks than whites. Screening _for_ cardiovascular r_is_k factors -Step 1: Screen _for_ global r_is_k factors -Begin routine screening at 20 years _for_ individual r_is_k factors or “global” r_is_k of CVD and _for_ any family h_is_tory of premature heart d_is_ease (age <55 years in first- degree male relatives and age <65 years in first-degree female relatives). -R_is_k factors to screen _for_ at th_is_ level: family h_is_tory, smoking, poor diet, physical inactivity, obesity, hypertension, dyslipidemias, diabetes, pulse -Step 2: Calculate 10-year and lifetime CVD r_is_k using an online calculator -Use the CVD r_is_k calculators to establ_is_h 10 yr and lifetime r_is_k _for_ patients ages 40-79 -Step 3: Track individual r_is_k factors- hypertension, diabetes, dyslipidemias, metabolic syndrome, smoking, family h_is_tory, and obesity -almost ⅓ of U.S. adults over the age of 20 have HTN (>140/90), representing nearly 80 million people. -While prevalence of HTN _is_ similar between men and women, prevalence in blacks _is_ substantially higher than in whites. Heart D_is_ease MONICA GONZLEZ Heart Sounds S1- S1 can be best heard over the apex (bottom of heart). The first heart sound _is_ caused by turbulence created when the mitral and tricuspid valves close. Note its intensity and any apparent splitting. Normal splitting _is_ detectable along the lower left sternal border. (Note that S1 _is_ louder at more rapid heart rates, and PR intervals are shorter Accentuated with pregnancy, hyperthyroid_is_m, mitral stenos_is_) S2- The second heart sound (S2) _is_ produced by the closure of theaortic and pulmonic valves. The sound produced by the closure ofthe aortic valve _is_ termed A2, and the sound produced by theclosure of the pulmonic valve _is_ termed P2. May be split with inspiration. Note its intensity. Split S2- L_is_ten _for_ splitting of th_is_ sound in the 2nd and 3rd left interspaces. Ask the patient to breathe quietly, and then slightly more deeply than normal. Does S2 split into its two components, as it normally does? Width of split. How wide _is_ the split? It _is_ normally quite narrow. Timing of split. When in the respiratory cycle do you hear the split? It _is_ normally heard late in inspiration. Does the split d_is_appear as it should, during exhalation? If not, l_is_ten again with the patient sitting up. Intensity of A2 and P2. Compare the intensity of the two components, A2 and P2; A2 _is_ usually louder. (Expiratory splitting suggests a valvular abnormality- p. 405) Extra Sounds in Systole- Such as ejection sounds or systolic clicks Note their location, timing, intensity, and pitch, and variations with respiration (The systolic click of mitral valve prolapse _is_ the most common extra sound) The shape of a murmur _is_ determined by its intensity over time Crescendo-grows louder (mitral stenos_is_) Decrescendo-grows softer (aortic regurgitation) Crescendo-decrescendo-r_is_es then falls (aortic stenos_is_ and innocent flow murmurs) Plateau-constant intensity throughout (mitral regurgitation) Location of Maximal Intensity Determined by the site the murmur originates from-ex murmur heard in 2 nd right intercostal space usually originates from the aortic valve Radiation or transm_is_sion from PMI Reflects the site of origin, intensity of murmur, direction of blood flow and bone conduction. Ex-murmurs associated with aortic stenos_is_ radiate to the neck in the direction of atrial flow- mitral regurgitation murmur radiates to axilla. Intensity Graded on a 6 point scale-Grade 1-very faint, l_is_tener must be “tuned in”, not heard in all positions. Grade 2-quiet but heard immediately after placing stethoscope on chest. Grade 3- Moderately loud. Grade 4- Loud with palpable thrill. Grade 5- Very loud, with thrill. May be heard when stethoscope _is_ partly off chest. Grade 6- very loud with thrill. May be heard with stethoscope completely off chest. *Identical murmurs may be louder in a thin person than a muscular or obese person. Emphysema may dimin_is_h intensity of murmurs. Pitch High, medium or low Quality release, increases with standing and strain. Usually benign but can progress to syncope, _is_chemia a fib. And heart failure Pulmonic Stenos_is_-left 2 nd &amp; 3 rd interspaces. Radiates toward left shoulder and neck, soft to loud intensity, medium pitch, harsh. Congenital d_is_order valvular stenos_is_ Mitral regurgitation-location apex radiates- left axilla and left sternal boarder, soft to loud (apical thrill), pitch medium to high, harsh quality. Intensity does not change with inspiration. Increases left ventricular preload leading to left ventricular dilation (structural, mitral valve prolapse, endocardit_is_, rheumatic heart d_is_ease, ventricular dilatation). Tricuspid regurgitation-Left 3 rd , 4 th and 5 th , wide radiation, often loud with thrill, pitch high (smaller defects have higher pitch), harsh quality. Congenital abnormality-blood flows from high pressure left ventricle to low pressure right ventricle. Aortic regurgitation-left 2 nd -4 th interspaces radiates to apex if loud, Grade 1-3, High pitch, blowing decrescendo, best heard when sitting leaning _for_ward holding breath. Leads to left ventricular overload. Causes-leaflet abnormalities, aortic pathology (Marfan syndrome), subaortic stenos_is_, atrial septal defect Mitral stenos_is_-Apex, no radiation, Grade 1-4, decrescendo low- pitched rumble. Use the bell on the apical impulse with patient left lateral, heard better in exhalation. Most common cause rheumatic fever (causes fibros_is_, calcification and thickening of leaflets) Chapter 10 Breast/Axillae Assessment The Breast A thorough examination of the breasts includes careful inspection _for_ skin changes, symmetry, contours, and retraction in four views. Inspect: Arms at side: note the appearance of the skin, color, thickening of the skin, pores. Inspect size and symmetry of the breasts. Some differences in the size of the breasts and areolae 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 character_is_tics of the nipples, including size and shape, direction in which they point, any rashes or ulceration, or any d_is_charge. Arms Over Head: Hands Pressed Against Hips; Leaning _for_ward. To bring out dimpling or retraction that may otherw_is_e be inv_is_ible, ask the patient to ra_is_e 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 _for_ward, ), supported by the back of the chair or the examiner’s hands. Palpate: Palpation _is_ best per_for_med when the breast t_is_sue _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 t_is_sues 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 _for_ehead but keeping the shoulders pressed against the bed or examining table. Th_is_ flattens the lateral breast t_is_sue. 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 verti- cal 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 and lifting up her elbow until it _is_ even with her shoulder (Fig. 10-13). Palpate in a straight line down from the nipple to the bra line, then back to the clavicle, continuing in vertical over- lapping strips to the mid-sternum. Examine the breast t_is_sue carefully _for_: Cons_is_tency of the t_is_sues. Normal cons_is_tency varies widely, depending on the proportions of firmer glandular t_is_sue and soft fat. Physiologic nodularity may be present, increasing be_for_e menses. Note the firm inframammary ridge, which _is_ the transverse ridge of compressed t_is_sue along the lower margin of the breast, especially in large breasts. Th_is_ ridge _is_ sometimes m_is_taken _for_ a tumor. Tenderness that may occur prior to menses. Nodules. Palpate carefully _for_ any lump or mass that _is_ qualitatively different from or larger than the rest of the breast t_is_sue. Th_is_ _is_ sometimes called a dominant mass that may be pathologic when evaluated by mammogram, aspiration, or biopsy. Assess and describe the character_is_tics of any nodule Location—by quadrant or clock, with centimeters from the nipple Size—in centimeters Shape—round or cystic, d_is_c-like, or irregular in contour Cons_is_tency—soft, firm, or hard Delimitation—well circumscribed or not Tenderness Mobility—in relation to the skin, pectoral fascia, and chest wall. Gently move the breast near the mass and watch _for_ dimpling. The Axillae Although the axillae may be examined with the patient lying down, a sitting position _is_ preferable. Inspect: Inspect-skin, rash, infection, unusual pigment. Palpate: Palpate- To examine the axilla, ask the patient to relax with the arm down and warn the patient that the examination may be uncom_for_table. Support the patient’s wr_is_t 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 midclavicle. 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. 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: ■ Pectoral nodes—grasp the anterior axillary fold between your thumb and fingers, and with your fingers, palpate inside the border of the pectoral muscle. _for_ descriptive purposes, the abdomen _is_ often divided by imaginary lines crossing at the umbilicus, _for_ming the right upper, right lower, left upper, and left lower quadrants (Fig. 11-2). Another system divides the abdomen into nine sections. Terms _for_ three of them are commonly used: epigastric, umbilical, and hypogastric or suprapubic Examine the abdomen, moving in a clockw_is_e rotation; several organs are often palpable. Exceptions are the stomach and much of the liver and spleen which lie high in the abdominal cavity close to the diaphragm, where they are protected by the thoracic ribs beyond the reach of the palpating hand. The dome of the diaphragm lies at about the fifth anterior intercostal space. Right upper quadrant Liver, gallbladder, pylorus, duodenum, hepatic flexure of colon, and head of pancreas Left upper quadrant Spleen, splenic flexure of colon, stomach, body and tail of pancreas, and transverse colon Left lower quadrantSigmoid colon, descending colon, left ovary Right lower quadrant Cecum, appendix, ascending colon, right ovary V_is_ceral pain occurs when hollow abdominal organs such as the intestine or biliary tree contract unusually _for_cefully or are d_is_tended or stretched (Fig. 11-7). Solid organs such as the liver can also become painful when their capsules are stretched. V_is_ceral pain may be difficult to localize. It _is_ typically palpable near the midline at levels that vary according to the structure involved, as illustrated on the next page. _is_chemia also stimulates v_is_ceral pain fibers. V_is_ceral periumbilical pain suggests early acute appendicit_is_ from d_is_tention of an inflamed appendix. It gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum. _for_ pain d_is_proportionate to physical findings, suspect intestinal mesenteric _is_chemia In emergency rooms, 40% to 45% of patients have nonspecific pain, but 15% to 30% need surgery, usually _for_ appendicit_is_, intestinal obstruction, or cholecystit_is_.6 RLQ pain or pain that migrates from the periumbilical region, combined with abdominal wall rigidity on palpation, _is_ suspicious _for_ appendicit_is_. In women, consider pelvic inflammatory d_is_ease, ruptured ovarian follicle, and ectopic pregnancy. Combining signs with laboratory inflammatory markers and CT scans markedly reduces m_is_diagnos_is_ and unnecessary surgery. Parietal pain originates from inflammation of the parietal peritoneum, called peritonit_is_. It _is_ a steady, aching pain that _is_ usually more severe than v_is_ceral pain and more prec_is_ely localized over the involved structure. It _is_ typically aggravated by movement or coughing. Patients with parietal pain usually prefer to lie still · Diverticulit_is_ MORGAN ROGERS · Hepatit_is_ LYNN DUKES Viral Hepatit_is_: R_is_k Factors, Screening, and Vaccination. The best strategy _for_ preventing infection and transm_is_sion of hepatit_is_ A and B _is_ vaccination. Also, educate patients about how the hepatit_is_ viruses spread and behavioral strategies to reduce the r_is_k of infection. Screen high-r_is_k groups _for_ hepatit_is_ B. Hepatit_is_ A. Transm_is_sion of hepatit_is_ 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 transm_is_sion, adv_is_e hand washing with soap and water after bathroom use or changing diapers, and be_for_e 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 d_is_eases; it does not cause chronic hepatit_is_. CDC Recommendations _for_ Hepatit_is_ A Vaccination ● All children at age 1 year ● Individuals with chronic liver d_is_ease ● Groups at increased r_is_k of acquiring HAV: travelers to areas with high endemic rates of infection, men who have sex with men, injection and illicit drug users, individuals working with nonhuman primates, and persons who have clotting factor d_is_orders. The vaccine alone may be admin_is_tered at any time be_for_e traveling to endemic areas. Postexposure Prophylax_is_.Healthy unvaccinated individuals should receive either a hepatit_is_ 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 household members) of child care centers where HAV has been diagnosed in children, staff, or households Loss of urethral support = stress incontinence. Childbirth pred_is_poses to rectoceles and enteroceles. RCT in 2012: USPSTF found that estrogen plus progestin and estrogen alone increased r_is_k _for_ urinary incontinence. Stress incontinence = muscle weakness due to aging, vaginal deliveries, neuro conditions. Assess pelvic floor muscle _for_ strength during pelvic exam: fingers are spread against the vaginal walls-ask patient to squeeze. Snug compression of fingers 3 seconds or greater = full strength. Ask patient to cough or bear down to assess _for_ urinary leakage. Increased intraurethral pressure helps prevent incontinence. Voluntary control of bladder depends on higher centers in the brain and motor/sensory pathways connecting the brain and reflex arcs of sacral spinal cord. Ask if the patient _is_ leaking small amounts of urine due to increased intra- abdominal pressure from coughing, sneezing, laughing or lifting or following urge to void _is_ there and involuntary loss of large amounts of urine. Urge incontinence-urgency followed by involuntary leakage due to uncontrolled detrusor contractions that overcome urethral res_is_tance. Overflow incontinence- neurologic d_is_orders or anatomic obstruction from pelvic organs or prostate, decreased bladder emptying until bladder becomes over d_is_tended Functional incontinence- ar_is_es from impaired cognition, musculoskeletal problems or immobility Mixed incontinence= stress & urge incontinence combined. Colon/ Anorectal cancer: Grant Freiberg Ch11, pg. 468 Screening _for_ colorectal cancer Epidemiology: 3rd most frequently diagnosed cancer in MEN AND WOMEN and the 3rd leading cause of cancer deaths each year in the US. The lifetime r_is_k of diagnos_is_ _is_ about 5%, while the lifetime r_is_k _for_ dying of colorectal cancer _is_ about 2% Incidence rates steadily decreasing due to changes in r_is_k factors, such as decreased tobacco use and increased screenings. R_is_k factors: The strongest r_is_k factors include increased age, hx of colorectal cancer, family h_is_tory of colorectal neoplasms, long-standing inflammatory bowel d_is_ease, and adenomatous polyps. Weaker r_is_k factors include male sex, African Americans, tobacco use, excessive alcohol use, red meat consumption, and obesity **All are r_is_k factors, but the STRONGEST LINK WILL ALWAYS BE GENETIC IN NATURE** 90% of new cases and 94% of deaths occur in population over 50 years of age Prevention: The MOST EFFECTIVE prevention strategy _is_ to screen _for_ and remove pre- cancerous adenomatous polyps. Physical activity, ASA and NSAIDs, and postmenopausal combined hormone replacement therapy are associated with decreased r_is_k of colorectal cancer. ** -The USPSTF recommends against ASA and NSAIDS _for_ prevention in average-r_is_k populations because of potential GI _is_sues, hemorrhagic CVA, and renal impairment. - Also, increased hormonal replacement therapy _is_ associated with an increased r_is_k of developing breast cancer, CV events (like MI), and thromboembol_is_m. ** there has been NO CONVINCING EVIDENCE that dietary changes or supplements can prevent colorectal cancer** Screening tests: - Stool tests that detect occult fecal blood- test include immunochemical tests, high-sensitivity guaiac-based tests, and tests that detect abnormal DNA - Endoscopic tests are also used _for_ screening oColonoscopy- v_is_ualizes the entire colon and can remove polyps that are d_is_covered GOLD STANDARD oFlexible sigmoidoscopy- v_is_ualizes the d_is_tal aspect of the bowel. -Imaging tests used _for_ screening Barium enema and CT colonography ** ANY abnormal findings on a stool test, imaging study, or flexible sigmoidoscopy warrants further evaluation via colonoscopy** Guidelines: (page 469) Screening recommendations include: Ages 50-75 years High sensitivity fecal occult blood test (FBOT) annually Sigmoidoscopy every 5 years Screening colonoscopy every 10 years Ages 76-85 years Do not screen routinely Benefits small when compared to r_is_ks associated with colonoscopy Use individual dec_is_ion making if initial · STI ANNE KAMAU To assess _for_ ST_is_, ask about any d_is_charge from the pen_is_, dripping or staining of the underwear. If the d_is_charge _is_ present, clarify the amount, color and any fever, chills rash or associated symptoms. Gonorrhea- yellow penile d_is_charge Chlamydia- white d_is_charge. Genital warts-single or multiple papules or plaques of variable shapes. May be ra_is_ed, flat or cauliflower like caused by HPV and can take weeks to months _for_ incubation and the infected contact may not have v_is_ible warts. Can r_is_e on pen_is_, scrotum, groin, thighs, and anus, usually asymptomatic, occasionally cause itching and pain and may d_is_appear without treatment. Genital herpes simplex- small scattered or grouped vesicles, 1 to 3mm in size on glans or shaft of pen_is_. Appears as erosions if vesicular membrane breaks. It _is_ usually caused by herpes simplex virus and incubation takes 2 to 7 days. Primary ep_is_ode may be asymptomatic, recurrence _is_ usually less painful of shorter duration. It _is_ associated with fever, mala_is_e, headache, arthralgia, local pain and edema, and lymphadenopathy. Primary syphil_is_- small red papule that becomes a chancre, a painless erosion up to 2cm in diameter. Base of chancre _is_ clean, smooth and gl_is_tening; borders are ra_is_ed and indurated. Chancre heals between 3 to 8 weeks. Incubation: 9-90 days and _is_ caused by Treponema pallidium. May develop inguinal lymphadenopathy within 7 days; lymph nodes are rubbery, nontender and mobile. 20-30% of patients may develop secondary syphil_is_ while chancre still present suggesting coinfection with HIV. Chancroid- red papule or pustule initially, then _for_ms a painful deep ulcer with raged nonindurated margins; contains necrotic exudate, has a friable base. It _is_ caused by haemophilus ducreyi with incubation of 3-7 days after exposure. Painful inguinal adenopathy with suppurative buboes in 25% of the patients · Testicular D_is_orders and Cancer JAMIE KERN · Erectile Dysfunction JEANETTE CARPENTER ● 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 d_is_ease and corpora cavernosa venous leak. Chronic d_is_eases 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 dysfunction, urinary incontinence, and bowel problems that adversely affect the quality of life ● Arterial _is_chemia 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 APRIL BAUGHMAN · Normal VS. Abnormal Findings and Interpretation DUSTIN SKILES · STI TREY RESSEGER · Bacterial Vaginos_is_ JULIE WARD MONDAY · Menstruation JAMIE CHAMBERLIN · Cervical D_is_orders and Cancer SHEILA RAMAS Abnormalities of the cervix: p.599-600 As estrogen stimulation increases during adolescence, all or part of th_is_ columnar epithelium _is_ trans_for_med into squamous epithelium by a process termed metaplasia. Th_is_ change may block the secretions of columnar epithelium and cause retention cysts, also called nabothian cysts. Th_is_ appear as translucent nodules on the cervical surface and have no pathologic significance. A cervical polyp usually ar_is_es from the endocervical canal, becoming v_is_ible 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 cervicit_is_ - produces purulent yellow drainage from the cervical os, usually from the Chlamydia trachomat_is_, Ne_is_seria gonorrhoeae, or herpes Meningit_is_ Pertuss_is_ Cervical Cancer Approximately 90%-95% of recipients of a single dose of certain live vaccines admin_is_tered by injection at the recommended age (i.e., measles, rubella, and yellow fever vaccines) develop protective antibodies, generally within 14 days of the dose. _for_ varicella and mumps vaccines, 80%-85% of vaccines are protected after a single dose. However, because a limited proportion (5%-20%) of measles, mumps, and rubella (MMR) or varicella vaccines fail to respond to 1 dose, a second dose _is_ recommended to provide another opportunity to develop immunity. Of those who do not respond to the first dose of the measles component of MMR or varicella vaccine, 97%-99% respond to a second dose -immunocomprom_is_ed patients should not receive a live vaccine. -patients with an acute moderate to severe illnesses (with or without a fever) should not receive any vaccines. (Table 4-1 - link to cdc) Clinicians or other health-care providers might m_is_perceive certain conditions or circumstances as valid contraindications or precautions to vaccination when they actually do not preclude vaccination (Table 4-2). These m_is_perceptions result in m_is_sed opportunities to admin_is_ter recommended vaccines. *CDC Routine physical examinations and procedures (e.g., measuring temperatures) are not prerequ_is_ites _for_ vaccinating persons who appear to be healthy. The provider should ask the parent or guardian if the child _is_ ill. If the child has a moderate or severe illness, the vaccination should be postponed. * CDC -a personal or family h_is_tory of seizures _is_ a precaution _for_ MMRV vaccine. Recommended _for_ all children, unless patient can not safely receive the vaccine. Recommended _for_ children with certain health or lifestyle conditions that put them at greater r_is_k _for_ serious d_is_ease. Vaccine should be given if a child _is_ catching up on m_is_sed vaccines Children not at an increased r_is_k may get the vaccine after speaking with provider. · Developmental Milestones JENNIFER WASHINGTON · Tanner Staging MEGHAN HENRY Tanner Staging- also known as Sexual Maturity Rating (SMR), _is_ an objective classification system that providers use to document and track the development and sequence of secondary sex character_is_tics of children during puberty. Sexual Maturity Ratings in Girls: Breasts Generally, over a four year period, the breasts progress through five stages, called Tanner stages or Tanner sex maturity rating stages. The stages are described below: Sexual Maturity Rating in Boys -increase in thyroid-binding globulin due to r_is_ing estrogen levels and stimulation of TSH receptors by HCG = slight increase in serum free T3 ,T4 and decrease in TSH levels (transient hyperthyroid_is_m – considered physiologic) · Relaxin - secreted by corpus luteum and placenta - involved in remodeling of reproductive tract connective t_is_sue to facilitate delivery - increases renal hemodynamics - increases serum osmolality - does not affect peripheral joint laxity during pregnancy *Weight gain and shifts in center of gravity contribute to lumbar lordos_is_ and musculoskeletal strain. · Erythropoietin - Levels increase during pregnancy - Ra_is_es erythrocyte mass - Plasma volume increases which causes hemodilution and physiologic anemia – protects against blood loss during birth - Cardiac output increases, systemic vascular res_is_tance decreases = results in net fall in BP (more prominent in 2nd trimester, returns to normal in 3rd trimester) · Basal metabolic rate - Increased 15-20% during pregnancy - Daily energy demand _is_ increased, requiring additional kcal/day o 1st trimester = additional 85 kcal/day o 2nd trimester = additional 285 kcal/day o 3rd trimester = additional 475 kcal/day Anatomic Changes: · Breasts - Moderately enlarged due to hormonal changes – increased vascularity and glandular hyperplasia, more tender during exam - 3rd month of gestation – breasts become more nodular - Nipples become larger and more erectile, areolae darkens and Montgomery glands (bumps on areola) are more pronounced - Breast veins more v_is_ible - Colostrum secretion may occur in 2nd and 3rd trimester - thick, yellow, nutrient rich, precursor to breastmilk · Uterus - Weight of uterus increases from ~ 70g to almost 1,100g @ delivery - Growth related to muscle cell hypertrophy, increase in fibrous and elastic t_is_sue, and development of blood vessels and lymphatic vessels - Externally palpable by 12-14 weeks - In 2nd trimester, size of fetus pushes uterus into anteverted position – puts pressure on bladder causes frequent voiding - Round ligament pain (felt in lower quadrants) - caused by uterus stretching its own supporting ligaments · Vagina - Increased vascularity causes vagina to look blu_is_h – known as Chadwick sign - Normal secretions may become thick, white and more profuse – known as leukorrhea of pregnancy - Increased glycogen stores causes proliferation of lactobacillus acidophilus = lowers vaginal pH – contributes to higher rates of yeast infections (vaginal candidias_is_) · Cervi x - Softens ~ 1 month after conception – turns blu_is_h in color. - Hegar sign = palpable softening of the cervical _is_thmus (portion of uterus that narrows into the cervix) - Mucous plug _for_ms from cervical secretions – protects u t e r i n e e n v i r o n m e n t f r o m o u t s i d e p a t h o g e n s , e x p e l l ed as “bloody show” at delivery. o Mental health d_is_orders (i.e postpartum depression) o HIV o ST_is_ o Abnormal pap smears o Exposure to diethylstilbestrol (DES) (synthetic estrogen) in utero · Past OB H_is_tory – Ask: - How many prior pregnancies? - Term deliveries? - Preterm deliveries? - Spontaneous and terminated pregnancies? - How many live births? - Any complications from diabetes, hypertension, preeclampsia, intrauterine growth restriction (IUGR), preterm labor? - Delivery complications? i.e. fetal macrosomia (large baby), fetal d_is_tress, emergency interventions - Vaginal delivery, ass_is_ted delivery (_for_ceps, vacuum) or C-section? · R_is_k Factors _for_ Maternal and Fetal Health – Ask: - Tobacco, alcohol or illicit drug use? - Medications, OTC drugs, herbal preparations? - Any toxic exposures at work, home or other settings? - Adequate nutrition? Obese? - Good social support? Adequate income? - Unusual sources of stress at home or work? - H_is_tory of physical abuse or domestic violence? · Family H_is_tory – Ask: - Genetic and family h_is_tory of patient and father of baby (FOB)? - Ethic background of patient and FOB? - Family hx of genetic d_is_eases? (i.e. sickle cell, cystic fibros_is_, muscular dystrophy, etc.) - Previous children born with congenital problems? · Plans _for_ Breastfeeding - Educate patient about benefits of breastfeeding o Protects baby from infectious/noninfectious conditions o Protects mother against breast cancer and other conditions *Encouragement from provider and education during pregnancy increases rate and duration of breastfeeding. · Plans _for_ Postpartum Contraception - Initiate d_is_cussion early - Postpartum contraception reduces r_is_k of unintended pregnancy and shortened interpregnancy intervals – linked to increased adverse pregnancy outcomes - Plan _for_ contraception depends on: o Patient preference o Clinical h_is_tory o Dec_is_ion about breastfeeding Determining Gestational Age and Expected Date of Delivery (EDD): · Accurate dating _is_ best done early: - Helps manage pregnancy appropriately - Establ_is_hes time frame _for_ normal progress - Establ_is_hes paternity - Timing of screening tests - Track fetal growth - Triaging preterm and postdated (late gestation) labor · To establ_is_h gestational age: - Count # of weeks and days from the first day of the LMP - Average length of pregnancy = 40 weeks - If actual date of conception _is_ known (i.e. IVF), a conception age can be used (2 weeks less than menstrual age) - EDD = 40 weeks from LMP o Naegele rule – LMP + 7 days – 3 months + 1 year · Tools _for_ Calculation: - Pregnancy wheel - Online calculators (more reliable) · Limitations on pregnancy dating - Patient recall highly variable - LMP affected by hormonal contraceptives, menstrual irregularities, variations in ovulation/atypical cycle lengths *LMP dating should be checked against physical exam markers (i.e. fundal height) -D_is_crepancies should be clarified by ultrasound. *At end of initial v_is_it: review findings, d_is_cuss any tests or screenings that are needed, and rein_for_ce need _for_ regular prenatal care/timing of future v_is_its. Prenatal V_is_it Schedule: ❖ Monthly appts. until 28 weeks gestation ❖ Biweekly until 36 weeks ❖ Weekly until delivery Physical exam findings at every v_is_it: ❖ Vital signs (especially BP and weight) ❖ Fundal height ❖ Verification of fetal heart rate (FHR) ❖ Determination of fetal position and activity ❖ Urinalys_is_ to assess _for_ infection and proteinuria o DVT - May reduce length of labor and complications during delivery - Excessive activity during pregnancy may cause low birth weight. - After 1st trimester, avoid exerc_is_e in supine position (causes compression of inferior vena cava, dizziness and decreased placental blood flow) - 3rd trimester- avoid sports that could cause loss of balance (due to center of gravity shift) - No contact sports throughout pregnancy *Caution on overheating, dehydration, and any exertion that causes marked fatigue/d_is_com_for_t. Substance Abuse ***Abstinence _is_ a TOP PRIORITY during pregnancy! · Tobacco : - causes low birth weight, placenta previa, placental abruption and preterm labor. - Increased r_is_k of spontaneous abortion, fetal death, and fetal digit anomalies - Cessation _is_ goal but any decrease in use _is_ favorable. · Alcohol: - Causes fetal alcohol syndrome – leading cause of preventable mental retardation in the US - No safe dose establ_is_hed - ACOG strongly recommends women abstain throughout pregnancy · Illicit drugs: - Cause significant detrimental effects on fetal development - Pregnant women with addiction should be referred _for_ treatment immediately and screened _for_ HIV, Hep C. · Prescription drug abuse: - Ask patient about use of narcotics, stimulates, benzos, and other prescription drugs · Herbal and unregulated supplements - Poor studies, limited data - May contain toxins that could harm fetus Intimate Partner Violence: - Increased r_is_k during pregnancy -Pre-ex_is_ting patterns of abuse may intensify -1 in 5 women experience some _for_m of abuse during pregnancy -Associated with delayed prenatal care, low infant birth weight, or even murder of mother and fetus *Watch _for_ nonverbal clues of abuse: -frequent last-minute appt. changes - unusual behavior during v_is_its - partners who refuse to leave the patient during the v_is_it - bru_is_es/other injuries *If patient acknowledges abuse, ask how you can help. -Accept her dec_is_ion about how to handle the situation safely. Prenatal Lab Screenings · Standard prenatal screening: - Blood type and Rh - Antibody screen - CBC - Rubella titer - Syphil_is_ test - Hep B surface antigen - HIV test - STI screen _for_ gonorrhea and chlamydia - UA w/ culture · Scheduled screenings: - Oral glucose tolerance test (GTT) _for_ gestational diabetes @ 24-28 weeks *Obese patients should be screened in 1st trimester - Rectovaginal swab _for_ group B strep @ 35-37 weeks · Normal VS. Abnormal Findings and Interpretation MEL_IS_SA TRENT · Gestational _is_sues and D_is_orders SARAH HURD · Vaccinations and Laboratory Testing Recommended vaccine _is_ TDAP at 27 to 36 weeks of gestation, regardless of prior vaccine h_is_tory. Caretakers in direct contact with the infant should also receive Tdap. Inactivated influenza vaccination _is_ indicated in any trimester of pregnancy. Safe Vaccines during pregnancy: Pneumococcal, meningococcal, hep B, Hep A, meningococcal polysaccharide and conjugate, and pneumococcal polysaccharide NOT SAFE during pregnancy: Measle/mumps/rubella, polio, and varicella All pregnant 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 v_is_it, 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.