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Health Assessment Test 3
Complex Nurs Adults (NURS 403)
Clemson University
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Health Assessment Unit 3
This test was pretty similar to the others so far in this class! Definitely pay attention to what is located in each quadrant (I missed which side of the body the sigmoid colon was on lol). But yeah nothing too new or unexected on this one, y’all will do great!
I. Two ways of anatomical mapping a. Four Quadrants and what is located within each quadrant: RUQ LUQ Liver Gallbladder Duodenum Head of pancreas Right kidney and adrenal Hepatic flexure of colon Part of ascending and transverse colon
Stomach Spleen Left lobe of liver Body of pancreas Left kidney and adrenal Splenic flexure of colon Part of transverse and descending colon RLQ LLQ Cecum Appendix Right Ovary and Tube Right Ureter Right spermatic cord
Part of descending colon Sigmoid colon Left ovary and tube Left ureter Left spermatic cord MIDLINE Aorta Uterus if enlarged Bladder if distended b. Nine Sections i. Abdomen extends from diaphragm to the symphysis pubis ii. Contains multiple organs related to various systems iii. Divided into 4 quadrants or 9 regions (of which we use 3)
- epigastric is above the stomach
- suberpubic above the pubic bone
- umbilical above the belly button
II. Pertinent history concerning the GI system III. Health history IV. A. Current health V. B. Past health/family history VI. C. Abdominal pain a. Pain-related Questions: i. Onset
ii. Characteristics 1. Quality and intensity 2. Location 3. Temporal Character 4. Duration/ pattern 5. Aggravating Factors 6. Relieving Factors 7. Relation to meals, BM's, stress iii. Associated Symptoms
- Nausea/vomiting
- Indigestion/distention
- Change in bowel function, color a. Black – bleeding high in GI tract (stomach/small intestine) i. Dark tarry stools.. to skin b. Red – bleeding low in GI tract (sigmoid or rectum area or tumor or hemorrhoid) c. Grey (or clay-colored) – Gall bladder disease d. Green – diarrhea/gastroenteritis or diet *Some medications may also change stool color: Example: Anything with bismuth in it (Pepto-Bismol) causes black stools
VII. Identify assessment order when performing abdominal assessment Assessment of the Abdomen Preparation Empty bladder Warm room Supine, knees bent (relaxes abdominal muscles) Order of Assessment: Least intrusive to most Inspection Auscultation Percussion Palpation
VIII. Identify observations to note for inspection Contour: scaphoid, flat, rounded, protuberant Umbilicus: (belly button) mid-line, inverted; if everted – increased intra-abdominal pressure (mass, ascites.. in the fluid of abdomen) Skin: lesions, striae, scars Vascular pattern: faint and symmetrical if visible Pulsations or movements: abdominal aortic pulse visible, peristalsis not normally visible Hernias: umbilical, incisional, epigastric Caused by a weakness in the abdominal wall and the intestines stick through it Reducible Incarcerated—the intestine is trapped and you cant push it back in, but it has adequate blood flow. Doesn’t cause pain nausea or vomiting. Strangulated—non treated incarcerated and abdomen cuts off blood supply when swelling happens. the abdominal wall is cutting it off they get nausea and vomiting and pain Abdominal Contours
ii. Left and right renal arteries—occlusion could cause high BP iii. Left and right iliacs iv. Femoral arteries b. Use Bell
XI. Describe friction rubs and state their significance a. Peritoneal friction rub i. Grating sound of friction created by inflammation of organ in contact with peritoneal lining: Rare See p. 562 (or 593)
XII. Explain purpose of percussion. Demonstrate method for scanning the abdomen. Percussion a. General: sound of tympany b. Liver span: Dullness at the top of the liver c. Spleenic Dullness: Spleen percussion sign (Gastric Air Bubble) Purpose: identify organs, masses
XIII. Demonstrate method to determine liver span Liver Span a. Percuss for liver span: 6 – 12 cms from about the 5th ICS to the costal margin b. Descends 2-3 cms with inspiration c. Test: Scratch test for liver border i. Scratch noise will change when you’re not over the liver anymore
XIV. Describe method to ascertain splenic measurement Assessing for Splenic Dullness: this is to determine the size of the spleen a. Spleen is located 9th to 11th ICS behind LMAL b. If unable to detect, have patient breath out, percuss last ICS at LAAL. Should be tympanic. Have take deep breath. Should remain tympanic. If it does not remain tympanic it could indicate that the spleen is enlarged. Fist percussion c. Kidney at costovertebral angle d. Liver/gallbladder at right costal margin
XV. Describe methods to assess ascites (p. 543-544) Assessing for Fluid (Ascites)
look at how the water moves depending on her positioning Fluid Wave o Like a water balloon. The water will move to another side if you push on it Palpating aorta: Normally 2 to 4 cm wide o If it is wider than that you would worry that they are at risk for aneurism and you would leave this alone (and seek medical care)
XVI. Demonstrate the correct technique for abdominal palpation Palpation: Visualize underlying structures a. Palpate for tenderness, muscle tone, surface characteristics b. Have patient supine, knees bent c. Light palpation – 1-2 cm: detect superficial masses, large masses, tenderness, rigidity d. Deep palpation – 5-8 cm: bimanual if needed. Note location, size, consistency, mobility of any masses; enlargement of organs, tenderness Rebound Tenderness: Blumberg’s sing
Slowly and deeply press away from painful area; release suddenly. (don’t push directly on the right side where the appendix is) Can test for apendicitis with this. Normally palpable structures e. Sigmoid colon: LLQ firm narrow f. Cecum: RLQ soft, wide g. Liver: Not always palpable: RUQ @ costal margin h. Lower portion of rt. Kidney: RUQ deep i. Aorta: pulsations un upper abdomen j. Distended bladder/ pregnant uterus k. Sacral vertebral prominence: kids/ very slender adults l. Normally not palpable: most of liver, gall bladder, spleen, duodenum, pancreas
Description of Abdominal Masses m. Location – by landmarks n. Size o. Contour p. Consistency—hard is worse that soft q. Tenderness—cancerous its bad if its not tender because early on it might be painful r. Mobility
These are supposed to lubricate Mammary ridge or milk line: Site of supernummerary nipples
Breast Quadrants: Upper outer most common site of cancer
Locations of breast cancer and common sites for metastasis
Breast Lymphatic System o Central Axillary nodes o Pectoral nodes o Subscapular nodes o Lateral nodes o Supraclavicular o Subclavicular Lymphatic drainage of the breast.
Breast Lymphatic System: Note subdiaphragmatic nodes pathway to liver and cross mammary to other breast. These contribute to metastasis to liver and other breast.
Breast Development o Tanner’s Stages Scale for stages of sexual development in puberty Scales for males and females o Thelarche = breast development in females Begins during preadolescent phase Precedes onset of menarche by about 2 years
k. Obesity adipose tissue makes estrogen
XX. Name 3 components of breast health Three components of breast health a. Self breast exam: start at 18 b. Clinical breast exam: start at 20 - every 3 years; after 40 – annually i. The clinical breast exam consists of two main components 1. Inspection of breasts and axillae 2. Palpation of breasts and axillae c. Annual mammogram: usually start at 40 High riskstart at 30
XXI. Demonstrate the breast exam a. (Inspection) i. Inspect Breasts and Axilla: 1. With woman sitting upright and disrobed 2. to the waist a. Inspect the Breasts i. General appearance and symmetry ii. Skin iii. Lymphatic drainage areas iv. Nipple v. Screen for retraction: See 4 positions next slide b. Inspect the axillae i. Rashes/inflammation ii. Masses ii. Inspect Breasts in 4 Positions:
- Inspect in 4 positions to bring out signs of retraction (Dimpling, peau d’orange, nipple retraction) a. Upright with arms at side b. Arms over head c. Hands on hips pressing down d. Bending over from waist iii. Nipple Retraction
- Ask if it has always been this way. If it’s changing to this, they might have cancer. iv. Left, Orange peel;
- Enlarged pores due to edema of breast b. (Palpation) 1. Woman should be in supine position with arm on side being palpated above head 2. Use the pads of the first 3 fingers 3. Three patterns for palpation a. Vertical strip method: preferred method b. Wedge method – Like spokes on a bike wheel c. Circular method: concentric circles in/out Strip Method: Preferred Method
Palpating a pendulous (large) breast
Lymphatic drainage of the breast.
Masses of the breast and their characteristics (p. 432)
learn this!!!
q. Benign (Fibrocystic) breast disease most common breast disorder in women
r. Fibroadenoma (benign) benign neoplasm
s. Intraductal papilloma: Usually benign
t. Cancer: Note loss of margins malignant neoplasm
Self Breast Examination u. Breast self exam every month after age 18 v. 4th to 7th day after the beginning of the menstrual period w. Encourage post-menopausal patients to do the same time every month Mammogram: Annually after 40, 30 if high risk Infants and Children
Health Assessment Test 3
Course: Complex Nurs Adults (NURS 403)
University: Clemson University
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