NURS 6512 Final Compiled Exam Review Document (week 7-11) 100% correct, Exams of Nursing

Download NURS 6512 Final Compiled Exam Review Document (week 7-11) 100% correct and more Exams Nursing in PDF only on Docsity! NURS 6512 Final Compiled Exam Document NURS 6512 Final Exam Review (Week 7-11) Heart, Lungs, and Peripheral Vascular • Examination techniques of the Heart, Lungs, and PV systems 1. Examination techniques of the Heart: • Inspection - use tangential lighting; stand to the patient’s right, patient should sit erect and lean forward, lye supine, and left lateral recumbent position; apical pulse midclavicular line 5th left intercostal space; check the skin for cyanosis, venous distention, nail bed for cyanosis and capillary refill time • Palpation - patient supine, palpate the precordium, use proximal halves of the 4 fingers or whole hand; being at apex, move inferior to left sternal border, then up the sternum to the base and down the right sternal border in the epigastrium or axillae; apical pulse seen at point of maximal impulse; feel for a thrill – fine, palpable, rushing, vibration, a palpable murmur, over the base of the heart; locate each sensation in terms of its intercostal space and relationship to the midsternal, midclavicular, or axillary lines; when palpating the precordium, use your other hand to palpate the carotid artery • Percussion - limited value by defining the borders of the heart or determining its size because the shape of the chest is rigid; a chest radiograph useful in defining the heart border; begin tapping at the anterior axillary line, moving medially along the intercostal spaces toward the sternal border; resonant to dull marks the border; • Auscultation - listen to all 5 of the cardiac areas using the diaphragm first then the bell; use firm pressure with the diaphragm and light pressure with the bell; 5 cardiac areas – aortic valve, pulmonic valve, second pulmonic, tricuspid, mitral; assess rate and rhythm, have patient breath normally then hold the breath in expiration, listen for S1 while palpating the carotid pulse; have the patient inhale deeply, listen closely for S2 during inspiration; basic heart sounds pitch, intensity, duration, and timing in the cardiac cycle; 4 basic heart sounds S1, S2, S3, S4 1. Examination techniques of the lungs: • Chest/Lungs – Inspect the chest, front, back, noting thoracic landmarks of and shape of anteroposterior (AP) diameter compared with the lateral diameter, symmetry, color, superficial venous patterns, prominence of ribs Inspection; patient sit upright, unclothed, using tangential light NURS 6512 Final Compiled Exam Document • Retractions and deformity e.g. minimal pectus excavatum are difficult to detect; pigeon chest, funnel chest, barrel chest seen with chronic condition • AP diameter less than lateral diameter; if they equal each other, chronic condition present – e.g. barrel chest related to chronic asthma, emphysema • Evaluate respirations for rate and rhythm – respiratory rate is 12-20 per minute; respirations to heartbeats is a 1:4 ratio; • Rhythm – breathe easily, regularly, with no apparent distress; variations – to shallow or to deep; tachypnea – rapid breathing, Kussmal – deep and rapid, Cheyene-Stokes – regular periods of breathing with intervals of apnea followed by a crescendo/decrescendo sequence of respiration • Inspect chest movement with breathing for symmetry and use of accessory muscles; retractions are seen when the chest wall seems to cave in at the sternum • Palpate the chest for thoracic expansion, sensations such as crepitus (palpated and heard) - gently bubbling feeling, grating vibrations, • Tactile fremitus (palpable vibration of the chest wall that occurs from speech), best felt posteriorly, use phrase “99” or “Mickey Mouse”, palpate both sides simultaneously and symmetrically; increased fremitus fluid or solid mass is present, decreased is excess air in the lungs • Thoracic expansion evaluation – stand behind patient, place thumbs along spinal process of the tenth rib with palms lightly in contact with posterolateral surfaces, thumbs will diverge during quiet and deep breathing • Palpate for pulsations, tenderness, bulges, depressions, masses, and unusual movement • Pleural friction rub – grating, coarse vibration, on inspiration, e.g. leather rubbing on leather • Perform direct or indirect percussion of the chest, comparing both sides for diaphragmatic excursion, percussion tone intensity, pitch, duration, and quality - tap sharply and consistently from the wrist; examine back of patient while sitting with the head bent forward and arms folded in front, then have patient raise arms overhead while percussing the later and anterior chest • Resonance heard over all areas of the lungs, hyperreasonance heard with hyperinflation (emphysema, asthma), dullness or flatness suggests pneumonia or atelectasis NURS 6512 Final Compiled Exam Document * Platypnea: Dyspnea increases in the upright position * Tachypnea: Faster than 20 breaths per min. Rapid breathing with no change in depth, and can be caused by hypoxia, pain, fever, or anxiety. Consider PE, foreign body aspiration, anaphylaxis, pneumothorax, heart failure, asthma, or pneumonia * Bradypnea: Slower than 20 breaths per minutes • Symptoms associated with intrathoracic infection Symptoms associated with intrathoracic infection * Dyspnea * tachypnea * Pleuritic chest pain * Fever * Cough with green/rusty sputum * Chills * Anorexia * Malaise * Altered mental status • Percussion techniques when examining the lungs Percussion techniques when examining the lungs NURS 6512 Final Compiled Exam Document * Tap sharply and consistently from the wrist without excessive force * Compare all areas bilaterally using one side as a control for the other * Move systematically through posterior thorax, right lateral thorax, left lateral thorax, and anterior thorax * Have the patient sitting with head bent forward and arms folded. This moves scapulae laterally, exposing more of the lung * Have patient raise arms overhead to percuss the lateral and anterior chest. * For all positions percuss at 4-5 cm intervals over the intercostal spaces, moving systematically from superior to inferior and medial to lateral • Examination findings when percussing the lungs Part 3 1. Examination of findings when percussing the lungs a. Tone type: i. Resonant 1. Intensity-Loud 2. Pitch- Low 3. Duration-Long 4. Quality- Hollow ii. Flat 1. Intensity- Soft 2. Pitch-High 3. Duration-Short NURS 6512 Final Compiled Exam Document 4. Quality-Very dull iii. Dull 1. Intensity-Medium 2. Pitch-Medium to high 3. Duration- Medium 4. Quality-Dull thud iv. Tympanic 1. Intensity-loud 2. Pitch- High 3. Duration- Medium 4. Quality-Drumlike v. Hyperresonant 1. Intensity-Very loud 2. Pitch-Very low 3. Duration-Longer 4. Quality- Booming • Cardiac examination findings for a patient with rheumatic fever a. May result in serious cardiac valvular involvement of mitral or aortic valve, then valves become stenotic and regurgitation. Children ages 5-15 are commonly affected. Patient may present with chest pain, palpitations, and shortness of breath. Objective findings upon examination include: Murmurs of mitral regurgitation and aortic NURS 6512 Final Compiled Exam Document * S1 results from the closure of the mitral and tricuspid valves and indicates the beginning of systole. It is best heard towards the apex of the heart where it is louder than S2. * S2 results from the closure of the aortic and pulmonic valves and indicates the end of systole and is best heard at the aortic and pulmonic area. It is of a higher pitch and shorter duration than the S1. S2 is louder than S1 at the base of the heart and softer than S1 at the apex of the heart. * S3 and S4 heart sounds should be quiet and difficult to hear. A loud S 4 always indicates pathology and deserves additional evaluation. • Varicosity findings in pregnant women • Varicosity findings in pregnant women. • *Women are 4 times more likely than men to have varicose veins. • *In pregnancy increased hormonal levels weaken the walls of the vein and result in failure of the valves. • Examination of peripheral arteries • The pulses are best palpated over arteries that are close to the surface of the body and lie over bones. These include carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial arteries. • Lack of symmetry (in pulse contour or strength) between the left and right extremities suggests impaired circulation. • Auscultate over an artery for a bruit. • The carotid pulses are most easily accessible and closest to the cardiac source, making them most useful in evaluating heart function. (never palpate both sides simultaneously) • The Allen Test assesses the patency of the ulnar artery. • Grading of pulses • Grading of pulses: • The Amplitude of the pulse is described on a scale of 0 to 4: • 4. Bounding, aneurysmal NURS 6512 Final Compiled Exam Document • 3. Full, increased • 2. Expected • 1. Diminished, barely palpable • 0. Absent, not palpable • Examination findings of a child with Kawasaki disease Examination findings of a child with Kawasaki disease (Dains et al, 2016, p. 2015) (Ball et al, 2016, p. 349) (an acute small vessel vasculitis illness of uncertain cause affecting young males more often that females; the critical concern is cardiac involvement in which coronary artery aneurysms may develop) • High spiking remittent, persist fevers – 100.4 to 104 ℉ (38 to 40 °C) despite use of empirical antibiotic and antipyretic treatment o Fever lasts 5 to 25 days, mean 10 days o Patients develop rash, which resembles scarlet fever • Seizures may be present • Initial Diagnosis requires for fever to last 5 days with at least 4 of the following present, in absence of an infection o Bilateral conjunctival hyperemia o Mouth lesions: dry fissured lips and injected pharynx or strawberry tongue o Change in peripheral extremities, edema, erythema, desquamation of skin at 10 to 14 days o Nonvesicular erythematous rash o Cervical lymphadenopathy • Long term complications of CAD, coronary occlusion or MI (Dains et al, 2016) • Subjective Data o (systemic vasculitis) Weight loss, fatigue, myalgias as well as arthritis • Objective findings o Fever, conjunctival injection, strawberry tongue, edema of the lands and feet, lymphadenopathy and polymorphous nonvesicular rashes o Examination findings of a patient with peripheral edema NURS 6512 Final Compiled Exam Document Examination findings of a patient with peripheral edema (Dains et al, 2016, p. 166) (Ball et al, 2015, p.344) • Edema of the lower extremities can be a sign of increased right heart filling pressure caused by primary lung disease or left ventricular failure o 1+ slight pitting, no visible distortion, disappears rapidly o 2+ a somewhat deeper pit than 1+, but again no readily detectable distortion, disappears in 10 to 15 seconds o 3+ noticeably deep pit that may last more than a minute dependent extremity looks fuller and swollen o 4+very deep pit that lasts as long as 2 to 5 minutes ; dependent extremity is grossly distorted • Thickening and ulceration of the skin is frequently associated with deep venous obstruction or venous valvular incompetence o Have patient with varicose veins stand on toes 10 times in succession, palpate the legs to feel for venous distention. If distention of the veins is visible for more than a few seconds venous insufficiency is suspected • In children the location of peripheral edema is age dependent o Young infant’s edema occurs as hepatomegaly and periorbital or flank edema • Angioedema with generalized or local urticaria can be evidence of anaphylaxis • Check skin perfusion- capillary refill o Color return to the skin in 2 seconds – normal findings • Feel the skin for diaphoresis- due to respiratory muscles working at maximum level to overcome increased resistive and elastic forces o Examination of ammonia in breath odor Examination of ammonia in breath odor (Ball et al, 2015, p. 274 & 409) • Ammonia breath odor can be a sign of uremia • Uremia can be a sign of kidney insufficiency • Acute renal failure: sudden impairment of renal function over hours to days, resulting in acute uremic episode o a common clinical laboratory definition is an absolute rise in serum creatine concentration of 0.5 to 1.0 mg/dL o Urine output may be normal, decreased or absent (anuria) • Prerenal ARF -vomiting, diarrhea, decreased intake or diuretic use may have resulted in dehydration and decreased kidney perfusion; patients also may have symptoms of intravascular volume depletions i.e. SOB, peripheral edema with CHF • Post AFR - patients may have had symptoms from urinary tract obstruction i.e. anuria • Intrinsic AFR- symptoms related to the underlying cause of their renal failure • Objective findings o Examinations nonspecific o May display fluid overload (JVD, peripheral edema) or volume deficit (hypotension orthostatic pulse and BP changes and dry mucous membranes) NURS 6512 Final Compiled Exam Document § Arthritis of hands and joints for more than 6 weeks § Symmetrical arthritis of same joint § Rheumatoid nodules § Positive serum rheumatoid factor § Radiographic changes showing erosions or bony decalcification • Orthopedic screening evaluation techniques Orthopedic Screening Evaluations and Techniques 1.Inspect the skeleton and extremities · Alignment · Contour and symmetry · Size · Gross deformity 2. Inspect the skin and subcutaneous tissues over muscles and joints · Color · Number of skinfolds · Swelling · Masses 3. Inspect muscle and compare sides for size, symmetry, and fasciculations or spasms. 4.Palpate all bones joints, and surrounding muscles for · Muscle tone · Heat · Tenderness NURS 6512 Final Compiled Exam Document · Swelling · Crepitus 5.Test each major joint for active and passive ROM while comparing sides. 6.Test major muscle groups for strength and compare sides. Assessing Muscle Strength · Grade 0- no evidence of movement · Grade 1- trace movement · Grade 2- full ROM but not against gravity · Grade 3- full ROM against gravity but not resistance · Grade 4- full ROM against gravity and some resistance but weak · Grade 5-full ROM against gravity and against resistance All Joints- inspect, palpate, test ROM, test strength Hand and Wrist Assessment · Katz hand diagram- median nerve integrity (page 525 in Ball et al., 2015) · Thumb abduction test- median nerve integrity; palm up and raise the thumb perpendicular to it. Apply downward pressure on thumb to test muscle strength. Weakness is associated with carpal tunnel. · Tinel sign- median nerve integrity; strike wrist with index or middle finger- a tingling sensation radiating from the wrist to hand is positive Tinel’s and is indicative of carpal tunnel · Phalen test- median nerve integrity; have patient hold wrists in a fully palmer flexed position with dorsal surfaces pressed together for 1 minute- numbness is a sign of carpal tunnel Elbows · Carrying angle is 5 to 15 degrees · Use a goniometer to measure joint ROM and limitations NURS 6512 Final Compiled Exam Document Shoulders · Neer test- shoulder rotator cuff impingement or tear; forward flex the patient’s arm up to 150 degrees while depressing the scapula; increased shoulder pain is indicative of inflammation or tear · Hawkins test- shoulder rotator cuff impingement or tear; abduct the shoulder to 90 degrees, flexing the elbow to 90 degrees, and then internally rotate the arm to the limit-pain is indicative of inflammation or tear Temporomandibular joint · Mandible should move 1 to 2 cm laterally. · Open and close mouth and expect a space of 3 to 6 cm when jaw is open. · Clench teeth and palpate contracted muscles to assess strength of temporalis and masseter muscles (Cranial nerve V). Cervical Spine Thoracic and Lumbar Spine · Straight Leg raising test- L4, L5, S1 nerve root irritation; have patient lie supine with neck slightly flexed then raise the leg while keeping knee extended. Radicular pain below knee is disk herniation. Cross over pain is indicative of sciatic nerve impingement. · Femoral stretch test-L1, L2, L3, L4 nerve root irritation; lie prone and extend the hip-pain is a positive sign. Hips · Thomas test- flexion contracture of hip; lie supine while fully extending one knee and flexing the other to the chest-lifting extended leg off table indicates a hip flexion contracture · Trendelenburg test- weak hip abductor muscles; stand and balance on one foot then the other; observe from behind facing their back; when the iliac crest drops on one side then the hip abductor muscle is weak. Legs and knees · Ballottement -effusion of the knee; extend the knee and apply downward pressure on the suprapatellar pouch with thumb and forefinger and push the patella down against the femur with a finger from your other hand. A tapping or clicking will be sensed. When you let go, the patella will float out as if a wave is pushing it if an effusion is present. · Bulge sign-effusion of the knee; extend the knee and milk the medial aspect of the knee upward then on the lateral side. There will be a bulge of fluid as it returns indicating fluid. NURS 6512 Final Compiled Exam Document Assessment of Cognition and the Neurologic System • Significance of the Denver II tool Significance of the Denver II tool: The purpose of the tests is to identify young children with developmental problems so that they can be referred for help. The tests address four domains of child development: personal-social (for example, waves bye-bye), fine motor and adaptive (puts block in cup), language (combines words), and gross motor (hops). • Examination of the mental status Exam of the mental status: Mental status is the total expression of a person’s emotional responses, mood, cognitive functioning, and personality. Assessment includes Physical appearance and behavior: hygiene, is pt cooperative and friendly, do they make eye contact and have good posture. State of Consciousness: Oriented to person, place, and time. Cognitive Abilities: Give the pt 3 words, ask the pt to draw a clock with the time, then ask the pt to repeat the 3 words previously given. Signs of impairment would be memory loss, confusion, or disorientation. Analogies: Ask the pt to describe simple analogies, then more complex IE. What is similar about peaches and lemons? Abstract Reasoning: Ask the pt to tell you the meaning of a fable or metaphor IE A stitch in time saves nine. Arithmetic Calculation: Ask them to do simple math problems without paper and pencil. Writing Ability: Ask pt to write their name and address. Execution of motor skills: Ask pt to unbutton shirt or comb hair. Memory: ask pt to listen, then repeat a sentence. Attention span: Ask pt to follow simple set of commands Judgement: Determine their judgement and reasoning skills by asking things such as What are your plans for the future? NURS 6512 Final Compiled Exam Document Speech and Language: Voice quality, articulation, comprehension, coherence. Emotional stabitlity: Mood and feelings, thought process and content, any hallucinations. Questions: What is the Mini-Mental State Examination? Answer: Screening tool for dementia: The Mini-Mental State Examination is a screening tool used to determine if the patient has problems consistent with dementia. It is not a tool to screen for autism or suicide risk or a tool to evaluate aphasia. How does the nurse test for recent memory in an adult? Answer: Ask the pt to repeat a series of numbers just told to them: Recent memory is tested by giving the patient objects to remember and then testing recall 10 minutes later. Asking about past facts is testing remote memory. Asking the patient to recall facts just presented is immediate recall or new learning. What is the initial step in performing a mental status examination: Answer: Observe the ability to maintain eye contact: The nurse first observes the patient’s appearance and behavior as a baseline. Comparison continues throughout the evaluation. • Examination findings associated with Attention Deficit Hyperactivity Disorder (ADHD) 1. Examination findings associated with Attention Deficit Hyperactivity Disorder (ADHD) Subjective Data: * Short attention span, easily distracted, fails to complete school assignments of follow instructions * Fidgets and squirms, often moving, running, climbing * Disruptive behavior, talks excessively, temper outbursts, labile moods, poor impulse control NURS 6512 Final Compiled Exam Document Objective Data: * Onset before 7 years of age * Increased motor activity * Difficulty organizing tasks * Difficulty sustaining attention * Poor school performance * Low self-esteem * Has problems in more than one setting • Behavior patterns of a patient with Schizophrena, Depression, Anxiety, and Mania 2. Behavior patterns of a patient with: Schizophrenia: a severe, persistent, psychotic syndrome with impaired reality that relapses throughout life. A genetic disorder that involves many genes on different chromosomes in patients who are vulnerable due to factors such as intrauterine infection, maternal nutritional deficiencies, perinatal complications, and neonatal hypoxia. Structural brain abnormalities exist such as enlarged lateral and third ventricles, reduced size of the temporal lobe and thalamus, and progressive loss of cortical gray matter. Subjective Data: * Hears voices * Unpleasant tastes or odors * Sees images * Paranoid thoughts NURS 6512 Final Compiled Exam Document Objective data: * OCD: Ritualized acts performed compulsively (washing, cleaning, hoarding, organizing, counting) Subjective data: * PTSD: recurrent intrusive flashbacks (e.g., images, odors, sounds, and negative emotions), dreams, thoughts; avoidance behavior; sleeping difficulty; hypervigilance; poor concentration Objective data * PTSD: anger or rage reactions, impulsive behavior, hyperarousal, emotional numbing, detachment from others Mania: A persistently elevated, expansive, euphoric, or irritable and agitated mood lasting longer than a week; one phase of the bipolar psychiatric disorder. Associated with abnormally elevated levels of neurotransmitters, norepinephrine, serotonin, dopamine, and glutamate, along with lower levels of gamma-aminobutyric (GABA); may also be associated with dysregulation of cellular mechanisms that mediate neurotransmission Subjective data: * Hyperactivity * Overconfidence, exaggerated view of own abilities * Impaired occupational, social, and interpersonal functioning * Excessive involvement in pleasurable activities with high potential for serious or painful consequences * Decreased need for sleep * Racing thoughts * Lack of impulse control Objective data: * Grandiose or persecutory delusions, euphoria NURS 6512 Final Compiled Exam Document * Increased talkativeness or pressure to keep talking, may involve excessive rhyming or puns; flight of ideas * Impaired attention, easily distracted * Impaired judgment * Hypersexual behavior • Examination findings of a patient with Diabetic Peripheral Neuropathy 3. Examination findings of a patient with Diabetic Peripheral Neuropathy A disorder of the peripheral nervous system that results in motor and sensory loss in the distribution of one or more nerves. Common causes are diabetes mellitus or alcohol abuse. Other causes include nerve compression (compartment syndrome), HIV infection, nutritional disorders, and neurotoxic chemotherapy. Inflammatory processes from biochemical exposures (hyperglycemia, lipoproteins, neurotoxins) damage axons and nerve fibers may lead to sensory deficits. Present in 8% of population by 55 years of age, but present in up to 66% of patients with diabetes. Subjective data: * Gradual onset of numbness, tingling, burning, and cramping, most commonly in the hands and feet * Night pain in one or both feet * Early signs may be unusual sensations of walking on cotton, floors feeling strange, or inability to distinguish between coins by feel. * Sensation of burning accompanied by hyperalgesia and allodynia (all sensation is painful) NURS 6512 Final Compiled Exam Document Objective data: * Reduced sensation in the foot with the monofilament; reduced sensation of pain or touch sensation * Distal pulses may be present or diminished * Diminished or absent ankle and knee reflexes * Decreased or no vibratory sensation below the knees; temperature sensation may be less impaired * Distal muscle weakness, inability to stand on toes or heels * Skin ulceration or injuries to extremities the patient does not feel • Examination findings of all Cranial Nerves • Examination techniques of all Cranial Nerves Cranial Nerves CN – I – Olfactory * Test ability to identify familiar aromatic odors, one naris at a time with eyes closed * Anosmia – loss of sense of smell or an inability to discriminate odors CN – II – Optic: * Test distant and near vision * Perform ophthalmoscopic examination of fundi CN– III – Oculomotor, CN – IV – Trochlear and CN VI - Abducens: * Test visual fields by confrontation and extinction of vision * Inspect eyelids for dropping * Inspect pupils’ size for equality and their direct and consensual responses to light and accommodation * Test extraocular eye movements * The sixth cranial never is commonly one of the first to lose functioning the presence of increased intracranial pressure CN – V – Trigeminal: * Inspect face for muscle atrophy and tremors NURS 6512 Final Compiled Exam Document knee. The presence of this sign may indicate meningeal irritation. (Seidels Guide, page 566 for picture ) Assessing the Genitalia and Rectum Case Study • Significance of Montgomery tubercles Significance of Montgomery tubercles (pg 351-352) Tiny sebaceous glands may be apparent on the areola surface (Montgomery tubercles). What are Montgomery’s tubercles? (INFORMATION FOUND AT https://www.healthline.com/health/montgomerys-tubercles) THE ANSWER WAS NOT EASY TO FIND IN THE BOOK. SO ALL YOU NEED TO KNOW ABOUT MONTGOMERY TUBERCLES. Montgomery’s tubercles are sebaceous (oil) glands that appear as small bumps around the dark area of the nipple. Studies have found between 30 and 50 percent of pregnant women notice Montgomery’s tubercles. Their primary function is lubricating and keeping germs away from the breasts. If you’re breastfeeding, secretion of these glands may keep your breast milk from becoming contaminated before being ingested by your baby. You can identify Montgomery’s tubercles by looking for small, raised bumps on the areola. The areola is the dark area surrounding the nipple. They can also appear on the nipple itself. They usually look like goosebumps. The size and number of tubercles varies for each person. Pregnant women may notice between two and 28 tubercles per nipple, or more. Causes Changes in hormones are often the cause for Montgomery’s tubercles to enlarge around the nipple, especially: * during pregnancy * around puberty NURS 6512 Final Compiled Exam Document * around a woman’s menstrual cycle Other common causes include: * stress * hormonal imbalances * breast cancer * physical body changes, such as weight gain or loss * medications * stimulation of the nipple * tight fitting clothes or bras In pregnancy Breast changes are often an early pregnancy symptom. Montgomery’s tubercles around your nipples may be one of the first symptoms of pregnancy. They may be noticeable even before you’ve missed your period. Not every woman who experiences Montgomery’s tubercles is pregnant. If you notice these bumps and have other pregnancy symptoms, you should take a home pregnancy test. If the test is positive, your doctor’s office can confirm your pregnancy. Later in pregnancy, you may notice increasing tubercles on your nipples as your body prepares for breastfeeding. Your nipples may become darker and larger as your pregnancy progresses. This is completely normal and not cause for concern. In breastfeeding Montgomery’s tubercles allow for smooth, lubricated breastfeeding. These glands secrete an antibacterial oil. This oil serves an important purpose to moisten and protect the nipples during breastfeeding. For this reason, it’s important for breastfeeding moms not to wash their nipples off with soap. Also avoid any disinfectants or other substances that could dry or damage the area around your nipples. Instead, just rinse your breasts with water during your daily shower. If you notice any drying or cracking, apply a few drops of healing lanolin. Avoid non- breathable plastic lining in bra pads or in your nursing bra. Signs of infection Montgomery’s tubercles can become blocked, inflamed, or infected. Look out for redness or painful swelling around the nipple area. See your doctor if you notice these or any other unusual changes. NURS 6512 Final Compiled Exam Document Let your doctor know if you experience any itching or a rash, as they may be symptoms of a yeast infection. If you experience discharge and you aren’t breastfeeding, make an appointment with your doctor. See your doctor right away if you notice any blood or pus. Removal Montgomery’s tubercles are usually normal and mean your breasts are functioning as they should. The tubercles will usually shrink or disappear completely on their own following pregnancy and breastfeeding. If you aren’t pregnant or breastfeeding and want the tubercles removed, your doctor may recommend surgery. This is a cosmetic option and may be recommended if they are causing pain or inflammation. Surgical removal of Montgomery’s tubercles involves your doctor making an excision (removal of the bumps) around your areola. This is an outpatient procedure that takes around 30 minutes. Hospitalization is not usually required. You will likely notice scarring after the procedure. Work with your doctor to determine if this is the best option for you. • Examination findings of breast changes during menopausal Examination findings of breast changes during menopause After menopause, glandular tissue atrophies gradually and is replaced by fat. The inframammary ridge at the lower edge of the breast thickens. The breasts tend to hang more loosely from the chest wall as a result of the tissue changes and relaxation of the suspensory ligaments. The nipples become smaller and flatter and lose some erectile ability. (Seidel’s Guide, Page 353) The breasts in postmenopausal women may appear flattened, elongated, and suspended more loosely from the chest wall as the result of glandular tissue atrophy and relaxation of the suspensory ligaments. A finger granular feel on palpation replaces the lobular feel of glandular tissue. The inframammary ridge thickens and can be felt more easily. The nipples become smaller and flatter. (Seidel’s Guide, Page 365). NURS 6512 Final Compiled Exam Document * Peau D’Orange (orange skin)-edema of breast due to blocked lymph drainage o Skin will appear thickened o Often seen first in the areola * Unilateral venous patterns-due to dilated superficial veins (may be due to increased blood flow to the malignancy) * Unilateral inversion of nipple that was previously everted * Retraction seen as flattening or pulling back of the nipple and areola * One nipple pointing in different direction for the other nipple * Unilateral discharge from a single duct of the nipple * Hard, stone-like mass felt that is unilateral, irregular, oar stellate in shape * Breast may have dimpling, retraction, or prominent vasculature • Proper technique for using a speculum during the vaginal exam • 1. Select right size of speculum • 2. You may lubricate the speculum with water or a water-soluble lubricant • a. Warm water may be utilized as this will also assist with warming a cold speculum • b. Gel lubricants should not be utilized as it is questionable if they interfere with specimen analysis and interpretation • 3. Hold speculum with index finger over the top of the proximal end of the anterior blade with other fingers around the handle • 4. Insert finger of opposite hand just inside the vaginal introitus and apply downward pressure NURS 6512 Final Compiled Exam Document • 5. Ask the female patient to breath slowly and try to relax her muscles or muscles of the buttocks • 6. When you feel relaxation, use fingers to separate labia minora to allow visual of the vaginal opening • 7. Slowly insert speculum following the path of least resistance (often downward) • 8. Insert the speculum the full length of the vaginal canal • 9. While maintaining downward pressure with the speculum, open the speculum by pressing on the thumb piece • 10. Sweep the speculum slowly upward until you can visualize the cervix • 11. When the cervix is visualized, manipulate the speculum so the cervix is fully exposed between the anterior and posterior blades • 12. Lock the speculum blades in place to stabilize the distal spread of the blades and adjust the proximal spread if needed • 13. When complete with exam, unlock the speculum and remove slowly and carefully while inspecting the vaginal walls • a. Be careful not to pinch the cervix and vaginal walls • b. Maintain downward pressure of the speculum to avoid trauma to the urethra • c. Hook your index finger around the anterior blade as speculum is removed with one thump on the handle lever to control the closing of the speculum • Proper technique for the bimanual examination *Inform patient regarding the examination * To palpate the vagina and cervix in order to identify the cervix; noting cervical position, shape, consistency, regularity, mobility, and tenderness NURS 6512 Final Compiled Exam Document o Insert middle and index fingers into the vaginal opening pressing downward; waiting for the muscles to relax (gloves and lubrication utilized) o When muscles are relaxed, insert fingers the full length of the vagina o Abduct the thump and flex the ring and little fingers into the palm (if the thumb touches the clitoris it could cause discomfort) o Palpate the vaginal wall while inserting fingers o Grasp cervix and gently move it from side to size (should move 1-2cm in each direction with minimal to no discomfort) * To palpate the uterus in order to feel the uterus and identify the size, position, consistency, mobility, and tenderness o Place palmar surface of other hand midway between the umbilicus and the symphysis pubis and press downward toward the pelvic hand o Place intravaginal fingers in the anterior fornix o Slide abdominal hand slowly toward the pubis, press downward and forward with the flat surface of fingers while pushing inward and upward with the fingertips of the intravaginal hand while pushing downward on the cervix with the backs of your fingers * If uterus is anteverted or anteflexed, the fundus will be felt between fingers of two hands at the level of the pubis * If it is not felt as described above, place intravaginal fingers together in the posterior fornix, with the abdominal hand immediately above the symphysis pubis * Press firmly downward with the abdominal hand while pressing against the cervix inward with the other hand. A retroverted or retroflexed uterus will be felt utilizing this maneuver * If not felt as described above, move intravaginal fingers to each side of the cervix pressing inward and feeling as far as you can. * Slide fingers so that one is on top of the cervix and one is underneath. When uterus is in mid-position, the fundus will not be felt with the abdominal hand o Utilizing the palmar surface of fingers, palpate the uterine fundus while gently pushing the cervix anteriorly with the pelvic hand * To palpate the ovaries in order to note size, shape, mobility, and tenderness o Slide vaginal fingers gently into the lateral vaginal fornix, pushing inferiorly with the abdominal hand o Entrap the adnexa between the abdominal and vaginal hand o Complete both right and left sides * To palpate adnexa o Complete following palpitation of ovaries NURS 6512 Final Compiled Exam Document • more tympathy than adults on percussion due to swallowing of air with feeding and crying. • Palpation of spleen tip at let costal margin • Soft abdomin with palpation • Bladder percussed and palpated in suprapubic area • Slight protude of the abdomin (potbellied) when child is sitting, standing, or supine • Abnormal • Tenderness or pain with palpation • Hard, rigid, resistant to pressure = peritoneal irritation • Masses • Intussusception (sausage shaped mass in LUQ or RUQ in ill looking newborn) • Hirschsprung disease (midline suprapubic mass) • Constipation (mass in LLQ) • Liver >3cm below right costal margin = hepatomegaly • Bruits and venous hums in abdomin • Renal bruits = renal artery stenosis sometimes with renal arteriovenous fistula • Visualization of peristaltic waves = intestinal obstruction like pyloric stenosis • Unbilical hernia • Spider nevi = liver disease • Risk factors for colorectal cancer NURS 6512 Final Compiled Exam Document The majority of CRC occcurances are sporadic rather than familial but risk factors (RF) can be divided into two categories: those who confer a suficeintly high risk to alter recommendations for CRC screenings and those that do not alter screening recommendations. RF that alter screening recommnedations • • Family members with • hereditary CRC syndromes • o o Familial adenomatous o polyposis (FAP) o o o Lynch Syndrome (hereditary o nonpolyposis colorectal cancer {HNPCC}) o o o MUTYH-Associated o polyposis (MAP) o o o Hereditary breast o and ovarian cancer syndrome o o o Personal or family o history of sporadic CRCs or adenomatous polyps o NURS 6512 Final Compiled Exam Document o o IBS/UC/Chron disease o history o o o Cystic fibrosis o o o African-Americans o have the highest CRC rates of all ethnic groups in the US and it occurs at a younger age. o o o Men have a higher o mortality rate than women o o o Renal transplant o o o Acromegaly o • • Risk factors that • do not alter screening recommendations • NURS 6512 Final Compiled Exam Document • Examination findings consistent with Prostate Cancer Examination findings consistent with Prostate CA • • Elevated PSA in men, • likelihood of prostate CA, increases with a more elevated PSA value. • • • Abnormality found • on digital rectal exam • • • Positive prostate • biopsy • • • Prostate CA is typically • asymptomatic • Examination position when assessing anal sphincter tone NURS 6512 Final Compiled Exam Document Examination position when assessing anal sphincter tone Rectal exams can be performed in any of the following positions: Knee-chest Lithotomy Left lateral with hips and knees flexed Standing with the hips flexed and the upper body supported by the exam table Women - preferred position is lithotomy as the exam is usually performed as part of the rectovaginal examination Men – preferred positions (below) because they provide better visualization of the perianal and sacrococcygeal areas 1. Left lateral with hips and knees flexed 2. Standing with the hips flexed and the upper body supported by the exam table * Source :Seidel text - pg. 489 • Characteristics of menopausal disorder Characteristics of Menopausal Disorder Frequency of monthly ovulation becomes irregular after 40 – causes intermittent symptoms of menopause Perimenopausal or climacteric phase – this when the onset of irregularity starts until complete cessation of menstruation. Can last 10yrs. Genetically determined – similar from mother & grandmother Unrelated to age of menarche, pregnancies, or contraceptives used Menopausal symptoms: Hot flashes NURS 6512 Final Compiled Exam Document Disturbed sleep patterns, insomnia, fatigue Vaginal dryness, dyspareunia, atrophic vaginitis (from vaginal atrophy) *Menopause prior to age 40 is considered premature ovarian failure Source: Dains, Baumann & Scheibel, 2016 pg 422-423) • Characteristics of Pelvic Inflammatory Disease Characteristics of Pelvic Inflammatory Disorder Early stages many women are asymptomatic Most commonly caused by Chlamydia trachomatis and N. gonorrhoeae Causes bleeding, abdominal pain, fever, vaginal discharge Increased amount of discharge and bleeding after sexual intercourse Infection begins intravaginally and then spreads upward to cause salpingitis (inflammation of the fallopian tubes) Ectopic pregnancy is greater with women with PID – pregnancy test should be performed to rule out ectopic pregnancy Gonorrhea source – patients may have inflammation of Skene glands, Bartholin glands, and/or urethra – causes pain and dysuria Examination you will find: Abdominal tenderness Cervical motion tenderness Adnexal tenderness (usually near ovaries or fallopian tubes) Patient may have guarding and rebound tenderness Labs NURS 6512 Final Compiled Exam Document • N/V • • • Irritative voiding symptoms (frequency, urgency, pain) • Characteristics of Epispadias • congenital defect in which the urinary meatus is located • on the UPPER SURFACE of the penis • Characteristics of Hypospadius • congenital abnormality in which the male urethral opening • is on the UNDER SURFACE of the penis, instead of at its tip The Ethics Behind Assessment • Ethical considerations when completing adolescent sports physicals with no injuries vs adolescents with previous injuries • Diagnostics tests used to evaluate sports injuries NURS 6512 Final Compiled Exam Document • Examination of children with heart murmurs when conducting a sports physical • * Examination of children with heart murmurs when conducting a sports physical • -Important to note the location, grade, and radiation with murmurs • -incompetent heart valves produce murmurs and can lead to heart failure • -in children, a loud murmur is best heard at the upper right sternal border, or upper left sternal border with a thrill can indicate congenital heart defect • -structural heart disease likely if the murmur is: holosystolic, diastolic, grade 3 or higher, associated with a systolic click, increased in intensity with standing, of a harsh quality • -children’s chest yield more to cardiac enlargement • -children’s hearts are more horizontal until age 7 so the apex is usually located around the 4th left intercostal • -many murmurs in young athletes are “Still Murmurs” or innocent murmurs and are the result of vigorous myocardial contration causing a strong blood flow in early/mid systole • -thin chests make these murmurs easier to hear • -generally, grade I or II, without radiation, medium itch, blowing, brief, and split S2 NURS 6512 Final Compiled Exam Document • -located 2nd left intercostal space/left sternal border • -murmur may disappear with sitting or standing • -innocent murmurs differ from benign murmurs • -benign murmurs caused by a structure change that is not causing any issues clinically • -auscultation should be performed in both supine and standing positions, or with Valsalva maneuver, to identify murmurs of dynamic left ventricular outflow of obstruction, assess the heart rate and rhythm to assess for arrhythmias • Ethical considerations to be made as Advanced Practice Registered Nurse * Ethical considerations to be made as Advanced Practice Registered Nurse -negligence and moral obligation -consent and patient autonomy -responsibility, liability, scarce resources -clinical governance -research