NURS 6512 NURS 6512 Final Exam Review (Week 7-11)Compiled LATEST UPDATE 2021/2022 STUDY G, Exams of Nursing

Download NURS 6512 NURS 6512 Final Exam Review (Week 7-11)Compiled LATEST UPDATE 2021/2022 STUDY G and more Exams Nursing in PDF only on Docsity! 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 5" 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 $1 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, $3, 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 Diaphragmatic excursion - the movement of the thoracic diaphragm during inhalation and exhalation; pg. 274 Dains - pt. Take breath, hold it, percuss scapular line locating lower border, mark the point where resonance changes to dullness, mark with a marking pen, allow the patient to breathe, then repeat the procedure on the other side, have the patient take several breaths to exhale as much as possible and then to hold; percuss up from the marked point and make a mark at the change from dullness to resonance, have the patient start to breathe and then repeat on the other side; measure and record the distance in cm between the marks on each side, distance is usually 3-5 cm Auscultate the chest with the stethoscope diaphragm, from apex to base, comparing both sides for intensity, pitch, duration, quality of breath sounds, unexpected breath sounds (crackles, rhonchi, wheezes, friction rubs) and vocal resonance; have pt. Sit up and breathe slowly and deeply through the mouth; have the patient sit the same way as for percussion; also have the patient sit erect with shoulder back for auscultation of the anterior chest Breath sounds - vesicular, bronchovesicular and bronchial pg. 276; adventitious breath sounds - crackles (formerly rales), rhonchi, wheezes, friction rub Vocal resonance - spoken voice transmits through the lung fields that may be heard with the stethoscope, have patient recited numbers, names and other words Examination techniques of the peripheral vascular system: Peripheral Arteries - palpation occurs best over the arteries, close to the surface, that lie over bones; when palpating the carotid, never palpate both sides simultaneously; palpate at least one pulse point in each extremity, usually at the most distal point; perform the Allen test (pg. 340) to ensure ulnar artery patency prior to radial artery puncture; the thumb can be used to fix the brachial or femoral pulse; palpate the arterial pulses to assess heart rate, rhythm, pulse controu, amplitude, symmetry, and occasiuonally sometimes obstructions to blood flow Carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial arteries Observe for signs of cyanosis, lip pursing, finger clubbing, alae nasi for flaring - any signs of this suggest cardiac or respiratory difficulty ¢ Alae nasi flaring - sign of air hunger ¢ Clubbing - enlargement of the terminal phalanges of the fingers/and or toes; seen with emphysema, lung cancer, cystic fibrosis, congenital heart disease ¢ Auscultation - use the bell of the stethoscope over the artery, auscultate for a bruit over the carotid, subclavian, abdominal aorta, renal, iliac, and femoral arteries; when listening to the carotid, have the patient suspend their breathing for a few seconds; assess the degree of peripheral artery degree - patient lie supine, elevate extremity, note degree of blanching, have patient sit on edge of bed to lower the extremity, note time for return of color to extremity; assess capillary refill; jugular venous pressure - pg.342. Assess Homan sign, edema, and varicose veins ¢ Examination findings of arterial blood flow in infants Examination findings of the heart and lungs in a patient with illegal drug use ¢ Description of types of shortness of breath (orthopnea, platypnea. ¢ Percussion techniques when examining the lungs Percussion techniques when examining the lungs * 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 insufficiency, cardiomegaly, friction rub of pericarditis, signs of congestive heart failure, and prolonged PR interval on ECG. ¢ Grading of heart murmurs 3. Grading of heart murmurs a. Grade I-Barely audible in a loud room b. Grade II-Quiet but not clearly audible c. Grade III-Moderately loud d. Grade IV-Loud, Associated with thrill e. Grade V-Very loud, thrill easily palpable f. Grade V1-Very loud, audible with stethoscope not in contact with chest, thrill palpable and visible ¢ Evaluation of ECG tracings Evaluation of ECG tracings (Seidel’s guide to physical examination 8th edition, p. 298) * ECG is a graphic record of electrical activity during a cardiac cycle. * ECG records depolarization ( spread of stimulus through the heart muscle) and repolarization ( return of stimulated heart muscle to a resting state. * Electrical activity is recorded in the ECG as specific waves; * P Wave : First upward movement of ECG tracing. It is the spread of stimulus through the atria( atrial depolarization). It indicates that the atria are contracting and pumping blood into ventricles * PR interval: it is the time from the initial stimulus of the atria to the initial stimulation of the ventricles, usually 0.12 to 0.20 * QRS complex: It is the spread of stimulus through the ventricles (ventricular depolarization) less that 0.10 seconds. * ST segment and T wave: the return of stimulated ventricular muscle to resting state ( ventricular repolarization. * U wave : small deflection seen just after the T wave ; thought to be related to the repolarization of the purkinje fibers. * QT interval the time elapsed from the onset of ventricular depolarization until the completion of ventricular repolarization. ¢ Examination technique for the apical pulse Examination techniques for the apical pulse ( p. 305) * The apical pulse is visible at the midclavicular line in the fifth left intercostal space (in most adults) * In some patients it may be visible in the 4th left intercostal space. * In order to palpate the apical pulse, feel for the apical impulse by identifying its location by the intercostal space and the distance from the midsternal line. * The point at which the apical pulse is readily seen or heard should be described as the point of maximum impulse ( PMI). * PMI is noted at left 5th intercostal space midclavicular line in adults and Ath intercostal space medial to the nipple in children. ¢ Examining technique for different cardiac sounds and their names ¢ Grading of pulses * Grading of pulses: ¢ The Amplitude of the pulse is described on a scale of 0 to 4: ¢ 4, Bounding, aneurysmal ¢ 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 °F (38 to 40 °C) despite use of empirical antibiotic and antipyretic treatment 0. Fever lasts 5 to 25 days, mean 10 days 0 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 0 Bilateral conjunctival hyperemia © 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 0 Nonvesicular erythematous rash 0 Cervical lymphadenopathy . Long term complications of CAD, coronary occlusion or MI (Dains et al, 2016) . Subjective Data 0 (systemic vasculitis) Weight loss, fatigue, myalgias as well as arthritis . Objective findings 0 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 °O Post ARF with complete obstruction may have abdominal distention and suprapubic tenderness to palpation Assessing Musculoskeletal Pain ¢ Diagnostic tests for patients with carpal tunnel DIAGNOSTIC TESTS FOR PATIENTS WITH CARPAL TUNNEL 1. The thumb abduction test isolates the strength of the abductor pollicis brevis muscle. Pl ace hand palm up and raise the thumb perpendicular to it. Apply downward pressure on t humb to test muscle strength. Weakness is associated with carpal tunnel syndrome. 2. Phalen test done by holding both wrists in full palmar-flexed position with dorsal surface s pressed together for one minute. Numbness and paresthesia in median nerve may sugge st carpal tunnel. © = Tinel sign done by striking patient’s wrist with your finger where median nerve passes under the flexor retinaculum and volar carpal ligament. Tingling is a positive sign. Examination techniques used for muscle and joint pain 1. Observe gait and posture; look for asymmetry 2. Look for discoloration, swelling, masses 3. Look for gross deformity, bony enlargement, alignment contour, symmetry Palpate inflamed joints last Note heat, tenderrness, swelling, crepitus, Spinal deformities noted during examination 1. Lordosis...obesity or pregnancy 2. Kyphosis...over curvature of the thoracic vertebrae 3. Scoliosis...curved from side to side ¢ Characteristic examination findings for Rheumatoid Arthritis Rheumatoid Arthritis A chronic inflammatory disorder of the synovial tissue surrounding the joints. Found in younger adults; anorexia and weight loss Morning stiffness of small joints of the hands and feet, swelling, for at least one hour before improvement; pain not relieved with rest. progressive fatigue with onset 4 to 5 hours after rising Symmetrical arthritis of same joint Fever, rheumatoid nodules, deviation of wrists Spindle-shaped fingers caused by painful swelling of the proximal interphalangeal joints In the elbow: subcutaneous nodules along pressure points of the ulnar surface (or may be indicative of gouty tophi) Medium to fine crepitus noted Involved joints include hands, wrists, feet, ankles, hips, knees, and cervical spine. Synovitis with soft tissue swelling and effusions are present on physical exam Diagnostics: ESR: increased CBC: normochromic, normocytic anemia rheumatoid factor: positive radiograph: bony erosion at the ioint margins and joint deformities spasms. 4.Palpate all bones joints, and surrounding muscles for Muscle tone Heat Tenderness 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 McMurray test- torn meniscus in the knee; lie supine and flex one knee then rotate the foot and knee outward (laterally); any palpable or audible click, grinding, pain, or limited extension is a sign of a torn meniscus. Anterior and posterior drawer tests- anterior and posterior cruciate ligament integrity (page 528 Ball et al., 2015) Lachman test- anterior cruciate ligament; (page 528 Ball et al., 2015) Varus and valgus stress test- medial or lateral collateral ligament instability in knee; lie supine and extend the knee; stabilize the femur and ankle then apply varus force against the ankle. Laxity in the joint indicates injury. (page 528 Ball et al., 2015) Feet and ankles Pes varus (in-toeing) and pes valgus (out-toeing) are common foot alignments Pes planus- a foot that remains flat despite weight bearing Pes cavus- a high instep © Characteristic examination findings consistent with Osteoarthritis Osteoarthritis A deterioration of articular cartilage covering the ends of bones in synovial joints (bone rubbing against bone). Onset in adults 40 years and older, obesity, and repetitive joint trauma (such as occupational or sports overuse), or with a family history of osteoarthritis Asymmetrical ioint pain and stiffness that improves throughout the day (usually only lasts minutes and is localized). Involves pain in hands, feet, hips, knees, and cervical or lumbar spine that is relieved with rest. Heberden nodes- bony overgrowths felt as hard nontender nodules usually 2 to 3mm in diameter or larger located along the distal interphalangeal (DIP) joints Bouchard nodes- bony overgrowths felt as hard nontender nodules usually 2 to 3mm in diameter or larger located at the proximal interphalangeal (PIP) joints Limited, painful cervical spine ROM and felt coarse to medium crepitus over joint Diagnostics: radiograph: osteophytes and loss of joint space ESR: elevated © Characteristic examination findings consistent with Gout Musculoskeletal Characteristics exam findings consistent with gout- Subjective data: joints swollen, hot, pain, limited range of motion. Affects men older than 40 and postmenopausal women. Most common in the proximal phalanx of the great toe, but can occur in wrist, hands, ankles, and knees. Objective data: Skin over the joint may be shiny and red or purple. Tophi will be present under the skin due to uric acid crystals. Question: A patient states that he has severe foot pain that started hours earlier. The area of pain is the metatarsophalangeal joint of the first toe. The skin over the joint is red, warm, and swollen. This is consistent with what condition? Answer: Gout is a metabolic disorder in which uric acid is elevated. Acute episodes of gout cause severe inflammation of a joint, often the great toe. Tophi are small 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? 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 * Unable to experience emotions, blunted affect, apathy, detached from environment * Poor personal hygiene Objective Data: * Incoherent speech loose associations, illogical answers to questions * Hallucinations (tactile, auditory, visual, somatic, gustatory, or olfactory) * Delusions * Repetitive or aimless behavior * Inappropriate affect in response to a situation Depression: A mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for an extended period (weeks or longer). Associated with a neurochemical imbalance, a decreased level of monoamines, or increased plasma cortisol. Genetic predisposition and family environmental influences. Associated with stressful life event, grief, or change in lifestyle. Subjective data: * Feels sad, hopeless, worthless; guilt * No interest or pleasure in what was previously of interest or pleasurable * Fatigue or loss of energy * Insomnia or excessive sleeping * Increased or decreased appetite; weight gain or loss (>5% ina month). Objective data: * Poor concentration * Slowed thought processes and speech * Agitation, irritability, or restlessness Anxiety: A group of disorders with such marked anxiety or fear that it causes significant interference with personal, social, and occupational functioning. Abnormalities in the norepinephrine and serotonin systems; may have genetic predisposition; increased sensitivity of brain pH chemosensors in sites that modulate fear and arousal, such as the prefrontal cortex and amygdala Specific disorders include the following: * Panic attacks * Generalized anxiety disorder * Specific phobias * Obsessive-compulsive disorder (OCD) * Posttraumatic stress disorder (PTSD) Subjective data: * Panic attacks: palpitations, sweating, shaking, dizziness, faintness, chest pain, nausea, abdominal distress, chills or hot flashes, chronic social avoidance fear of losing control and dying Objective data: * Panic attacks: tachycardia, diaphoresis, tremors Subjective data: * Generalized anxiety disorder: chronic worry, restless, irritable, tense, fatigue, poor concentration, sleep disturbance Objective data: * Generalized anxiety disorder: impaired attention, motor tension, tremors, restlessness * Lack of impulse control Objective data: * Grandiose or persecutory delusions, euphoria * 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) * Palpate jaw muscles for tone and strength when patient clenches teeth * Test superficial pan and touch sensation in each branch (test temperature sensation if there are unexpected findings to pain or touch) * Test corneal reflex CN — VII — Facial: * Inspect symmetry of facial features with various expressions (e.g. smile, frown, puffed cheeks, wrinkled forehead) * Test ability to identify sweet and salty tastes on each side of tongue CN — VIII — Acoustic: * Test sense of hearing with whisper screening tests or by audiometry * Compare bone and air conduction of sound * Test for lateralization of sound CN — IX —Glossopharyngeal and CN — X — Vagus: * Test ability to identify sour and bitter taste on each side of the tongue * Test gag reflex and ability to swallow * Inspect palate and uvula for symmetry with speech sounds and gag reflex * Observe for swallowing difficulty * Evaluate quality of guttural speech sounds (presence of nasal or hoarse quality to voice) CN — XI - Spinal Accessory: * Test trapezium muscle strength (shrug shoulders against resistance) * Test sternocleidomastoid muscle strength (turn head to each side against resistance) CN — XII — Hypoglossal: * Inspect tongue in mouth and while protruded for symmetry, tremors and atrophy * Inspect tongue movement toward nose and chin * Test tongue strength wit index finger when tongue is presses again cheek * Evaluate quality of lingua speech sounds (1, t, d, n) Unexpected findings indicate trauma or a lesion I the cerebral hemisphere or local injury to the nerve. ¢ Deep Tendon Reflex evaluation ¢ Bicep reflex, Brachioradial reflex, Triceps reflex, Patellar Reflex, Achilles reflex, Clonus ¢ Scoring for reflexes: * 0 —no response ¢ 1+- sluggish ¢ 2+- active ¢ 3+-more brisk than expected ¢ 4+ - brisk, hyperactive ¢ Test each reflex and compare sides ¢ Absent reflexes may indicate neuropathy or lower motor neuron disorder. ¢ Hyperactive reflexes suggest an upper motor neuron disorder. ¢ Examination technique and findings for nuchal rigidity Examination technique and findings for nuchal rigidity (Seidel’s Guide, page 565- A stiff neck, or nuchal rigidity, is a sign that may be associated with meningitis and intracranial hemorrhage. With the patient supine, slip your hand under the head and raise it, flexing the neck. Try to make the patient’s chin touch the sternum, but do not force it. Placing your hand under the shoulders when the patient is supine and raising the shoulders slightly will help relax the neck, making the determination of true stiffness more accurate. PATIENTS GENERALLY DO NOT RESIST OR COMPLAIN OF PAIN. Pain and a resistance to neck motion are associated with nuchal rigidity. (Occasionally painful swollen lymph nodes in the neck and superficial trauma may also cause pain and resistance to neck motion.) The Brudzinski sign may also be present when neck stiffness is assessed. Involuntary flexion of the hips.and knees when flexing the neck is a positive Changes in hormones are often the cause for Montgomery’s tubercles to enlarge around the nipple, especially: * during pregnancy * around puberty * 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. The following information was obtained from https://www.healthline.com/health/aging-changes-in-the-breast Breast changes As you age, the tissue and structure of your breasts begin to change. This is due to differences in your reproductive hormone levels caused by the natural process of aging. As a result of these changes, your breasts begin to lose their firmness and fullness. Also with age comes an increased risk of developing growths in the breast such as fibroids, cysts, and cancer. Keep in mind that women of any age can develop these conditions, however. Causes Natural decline of estrogen One of the main causes of aging changes in the breasts is a natural decline of the female reproductive hormone estrogen. This reduced amount of estrogen causes the skin and connective tissue of the breast to become less hydrated, making it less elastic. With less elasticity, the breasts lose firmness and fullness and can develop a stretched and looser appearance. It’s not uncommon for an older woman to have a change in her cup size. Dense breast tissue is replaced by fatty tissue as the aging process continues. Menopause Most changes in the breast due to age occur around the time of menopause. Menopause is a natural process during which a woman ceases ovulation and menstruation, and after which she can no longer have children. This transition normally occurs between the ages of 45 and 55. A woman is officially in menopause once she has not had a period for 12 consecutive months. Other causes Women who have had their ovaries surgically removed can have changes in their breasts at any time due to the loss of hormones. Common breast changes Common changes that occur in the breast due to age include: * stretch marks * downward pointing nipples * an elongated, stretched, or flattened appearance * wider space between the breasts * Jumpiness, which may be due to benign fibrocystic changes in the breast or serious conditions such as breast cancer Aging changes in the breasts are visible upon physical examination. Puckering, redness, or thickening of breast skin, a pulled in nipple, nipple discharge, breast pain, or hard lumps are not considered normal aging changes. See your doctor if you notice any of these conditions, or if one breast looks significantly different than the other. Prevention There’s no sure way to prevent your breasts from being affected by changes due to natural aging. Not smoking or quitting smoking is important for good skin and tissue health, however. Being as kind to your body as possible, throughout your life, is important too. By getting adequate and regular sleep, eating a healthy diet, and participating in regular exercise, you can do your best to promote a gentle aging process. Quizlet information below when asked changes of breast during menopause normal physiological changes of menopause breast - loss of glandular breast tissue, replacement with fat tissue vulvovagina -atrophy, vaginal shortening and loss of elastic tone uterus - atrophy and reduction in size, fibroids may shrink, may be development of prolapse due to decrease in muscle tone of pelvic floor ¢ 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 ¢ 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 o If unable to feel anything in adnexal areas with palpitation, no abnormality is presence (unless clinical symptoms exist) ¢ Proper technique for examining the male genitalia, including the prostate Proper technique for examining the male genitalia, including the prostate Check for hernia by having patient bare down and inspect the inguinal canal and fossa ovalis. Should be no bulges Insert finger into lower part of scrotum and up into vas deferens into inguinal canal where external oval ring can be felt. Have patient cough while finger is still inserted to assess for hernia which will bump against finger with coughing. Inspect penis for lesions, or sores. If uncircumcised retract foreskin for inspection and replace once done with inspection. (Smegma may be present over glands in uncircumcised male). Palpate testes using thumb and 1st 2 fingers to assess for lumps, nodules, or tenderness Should be smooth, and rubbery with no tenderness Palpate the epididymis on upper section of testes bilaterally (should be smooth and not lumpy or tender) Palpate vas deferens (Should be smooth, discrete, not lumpy or painful) PROSTATE-warn patient he may feel the urge to pee but he wont actually pee! Pg 491 To palpate prostate lube up index finger and touch the anus with tip of finger. Gently insert index finger in about 1 cm into the rectum to feel the posterior surface of the prostate through the anterior wall of the rectum. Prostate should be about the size of a pencil eraser, firm, smooth, and slightly moveable. Note size, contour, consistency, & mobility. © Risk factors for testicular cancer ¢ Risk factors for testicular cancer pg 470 ¢ Cryptorchidism (when the testes fail to descend down from abdomen into scrotum) * Age 20-54 ¢ White males are 5 times more likely than blacks and 3 times more likely than Asians and native American men ¢ Family history of testicular cancer ¢ Muscle building supplements ¢ History of testicular cancer ¢ Klinefelter syndrome ¢ HIV infection ¢ Normal vs abnormal bowel findings in newborns ¢ Normal vs abnormal bowel findings in newborns pg 394-397 ¢ Normal ¢ Abdomin and chest should move in sync ¢ Spider nevi = liver disease © Risk factors for colorectal cancer 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 Familial adenomatous o polyposis (FAP) o Lynch Syndrome (hereditary o nonpolyposis colorectal cancer { HNPCC}) o MUTYH-Associated o polyposis (MAP) o Hereditary breast o and ovarian cancer syndrome ° Personal or family o history of sporadic CRCs or adenomatous polyps o Obesity o Diabetes mellitus o and insulin resistance o Long-term consumption o of red meat or processed meats o Tobacco and alcohol o use o Use of androgen deprivation o therapy o cholecystectomy ¢ Examination findings consistent with Benign Prostate Hypertrophy + ectal exam to check + for the presence of asymmetry or nodules which suggests malignancy and to assess. Tender prostate gland may reflect the prescence of prostatitis. While estimates of prostate size are unreliable, most clinicans are able to recognize a very large prostate (>50 * grams). * Typical presentation « — Approximately 50 percent of men at age 50 and up to 80 percent of men at age 80 have lower urinary tract symptoms (LUTS) attributable to BPH [2,3]. * Common manifestations include: o Storage o symptoms - Increased daytime frequency, nocturia, urgency, and urinary incontinence o Voiding o symptoms - Slow urinary stream, splitting or spraying of the urinary stream, intermittent urinary stream, hesitancy, straining to void, and terminal dribbling ° « The nature of symptoms * reported vary over time and tend to progress gradually over a period of years. The severity of symptoms may not correlate well with prostate size on digital rectal exam in some men with BPH because differential enlargement of the transitional zone, which the * urethra transverses, cannot be detected on palpation. Patients with BPH may have microscopic or gross hematuria. However, the ¢ Examination position when assessing anal sphincter tone 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 WBC’s and ESR elevated Cultures, gram staining & DNA testing will assist with diagnosis HIV testing should also be conducted ¢ Characteristics of Hydrocele, Epididymitis, Epispadias, and Hypospadias Characteristics of Hydrocele * Scrotal tenderness and swelling * Sensation of heaviness in the scrotum ¢ Inguinal hernia * Soft, nontender fullness within the hemiscrotum * Transillumination of the scrotum revealing a homogenous ¢ glow without internal shadows Characteristics of Epididymitis ¢ Inflammation of the epididymis ¢ Fast onset ¢ Urethral discharge preceding the onset (in some) * One side * Severe swelling of scrotum ¢ Exquisite pain