Exam 1 Review Check

EXAM 1 REVIEW OF KNOWLEDGE PVS and Lymphatic System 1. Describe and demonstrate the correct techniques used to assess the peripheral artery. o During a complete physical examination, examine arms at very beginning when you are checking vital signs and person is sitting o Examine legs directly after abdominal examination while person is still supine; then stand person up to evaluate leg veins o Examination of arms and legs includes peripheral vascular characteristics o Room temperature should be about 22°C and free of drafts to prevent vasodilation or vasoconstriction o Use inspection and palpation o Compare your findings with opposite extremity 2. Discuss the expected findings related to the peripheral vascular assessment for the aging adult. o DP and PT pulses may become more difficult to find o Trophic changes associated with arterial insufficiency may be seen  Thin, shiny skin  Thick, ridged nails  Loss of hair on lower legs o Peripheral blood vessels grow more rigid with age, resulting in a condition called arteriosclerosis o Care for myocardial infarction (MI) now includes early mobilization and lowdose anticoagulant medication, which reduce risk of pulmonary embolism o Loss of lymphatic tissue leads to fewer numbers of lymph nodes in older people and to decrease in size of remaining nodes 3. Identify subjective data to be collected during the peripheral vascular assessment and provide a sample question for each category. o Leg pain or cramps o Skin changes on arms or legs o Swelling o Lymph node enlargement o Medications o Smoking history 4. Identify objective data to be collected during the peripheral vascular assessment. o During a complete physical examination, examine arms at very beginning when you are checking vital signs and person is sitting o Examine legs directly after abdominal examination while person is still supine; then stand person up to evaluate leg veins o Examination of arms and legs includes peripheral vascular characteristics o Room temperature should be about 22°C and free of drafts to prevent vasodilation or vasoconstriction o Use inspection and palpation o Compare your findings with opposite extremity 5. Differentiate between the following four types of abnormal peripheral vascular diseases and identify subjective/objective findings (Raynaud Phenomenon, Lymphedema, Varicose Veins, and Deep Vein Thrombosis). o Raynaud Phenomenon – Episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress: (1) white (pallor) in top figure from arteriospasm and resulting deficit in supply; (2) blue (cyanosis) in lower figure from slight relaxation of the spasm that allows a slow trickle of blood through the capillaries and increased oxygen extraction of hemoglobin; (3) finally red (rubor) in heel of hand caused by return of blood into the dilated capillary bed or reactive hyperemia. May have cold, numbness, or pain along with pallor or cyanosis stage; then burning, throbbing pain, swelling along with rubor. Lasts minutes to hours; occurs bilaterally. Several drugs predispose to the episodes, and smoking increases the symptoms. o Lymphedema – Lymphedema is high-protein swelling of the limb, most commonly caused by breast cancer treatment. Surgical removal of lymph nodes or damage to lymph nodes and vessels with radiation therapy impedes drainage of lymph. Protein-rich lymph builds up in the interstitial spaces, which further raises local colloid oncotic pressure and promotes more fluid leakage. Stagnant lymphatic fluid increases risk for infection, delayed wound healing, chronic inflammation, and fibrosis of surrounding tissue. Lymphedema after breast cancer is common but usually mild. Obesity increases risk. Early symptoms include self-reported sensations of a tired, thick, heavy arm; jewelry too tight; swelling; or tingling. Objective data include a unilateral swelling, nonpitting brawny edema, with overlying skin indurated. Early recognition is important because evidence supports complete decongestive physiotherapy, exercise, nonelastic wrapping, compression garments, and skin care.13 Without treatment, lymphedema is chronic and progressive, which is psychologically demoralizing as a threat to body image and constant reminder of the cancer. o Varicose veins – Normal leg veins have dilated as a result of chronic increased venous pressure (obesity, multiple pregnancies) and incompetent valves that permit reflux of blood back toward leg instead of forward toward heart. Varicose veins are 3 times more common in women than men. Older age increases risk as a result of thinning of elastic lamina of veins and degeneration of vascular smooth muscle. Size ranges from 1 mm to 1 cm in diameter; color ranges from red to blue or purple.  S: Aching, heaviness in calf, easy fatigability, restless legs, burning, throbbing, cramping.  O: Dilated, tortuous veins. New varicosities sit on surface of muscle or bone; older ones are deep and feel spongy. o Deep vein thrombosis - A deep vein is occluded by a thrombus, causing inflammation, blocked venous return, cyanosis, and edema. Virchow triad is the classic 3 factors that promote thrombogenesis: stasis, hypercoagulability, and endothelial dysfunction.7Cause may be prolonged bed rest, history of varicose veins, trauma, infection, cancer, obesity, immobility, heart failure, or the use of estrogen hormones. Requires emergency referral because of risk for pulmonary embolism. Note that upper-extremity DVT is increasingly common as a result of frequent use of invasive lines such as central venous catheters. 8a  S:Suddenonsetofi nt e ns e , s har p, dee pmus c l epai n. r veus uals hoes i z ea si nabovephot o) ;  O:Increasedwarmth;swel l i ng( t oc ompar es we l l i ng, obs e r e dne s s ;de pe nde ntc y anos i si smi l dorma ybea bs e nt ; t e nde rt opa l pa t i on; appl yWe l l sc r i t e r i a asonp.5 26. 6. Differentiate between arterial ischemic ulcer and venous stasis ulcer subjective/objective finings and what occurs? o Venous stasis ulcer – IRREGULAR borders o Arterial ischemic ulcer – ROUND, DEFINED borders 7. 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The y s houl dfitt he i rs hoe st ot hel ar ge rf oot . o Se l ec ts hoest ha tar es hape dl i keone' sf e e t .Theba l loft hef oot ot hewi de s tpar toft hes hoe . Toe ss houl d s houl dfitc omf or t abl yi nt notbec r o wde d. o Forwome n, l owhe e l e ds hoe sar es a f e randl e s sdama gi ngt han hi ghhe e l eds hoe s . Kee pi ngs ki ns of tands moot h. o o o Us emi l ds oap. t Bec ar e f ulaboutaddi ngoi l st oba t hwa t e r . The yc anmakeyourf e e andt heba t ht ubbot hve r ys l i ppe r y . At hi nc oa tofs ki nl ot i onove rt het opsandbot t omsofone ' sf e e t moot h. he l pst oke e ps ki ns of tands 8. Medication: o Coumadin (warfarin) is an anticoagulant (blood thinner), used to treat or prevent blood clots in veins or arteries, which can reduce the risk of stroke, heart attack, or other serious conditions. o Atorvastatin is used to lower cholesterol in people who have been diagnosed with high cholesterol. 9. Explain how does smoking affect peripheral arteries? o Smoking is the strongest risk factor associated with PAD o Tobacco constricts arteries, increases coagulability, injures endothelium, and promotes inflammation. 10. Identify the staging of edema (1-4) o If pitting edema is present, grade it on following scale: o 1+ Mild pitting, slight indentation, no perceptible swelling o 2+ Moderate pitting, indentation subsides rapidly o 3+ Deep pitting, indentation remains, leg looks swollen o 4+ Very deep pitting, indentation lasts long time, leg very swollen 11. Identify what occurs when there is not lymphatic drainage and lymphatic obstruction? Pg 502 and 513 o Without lymphatic drainage, fluid would build up in the interstitial spaces and produce edema. o Edema of upper extremities occurs when lymphatic drainage is obstructed after breast surgery or radiation. 12. Identify DVTs signs and symptoms and Risk Factors. o Signs and symptoms:  Pain  Swelling  Warmth     Redness Leg cramps, often starting in the calf Leg pain that worsens when bending the foot Bluish or whitish skin discoloration  Pain Unilateral edema Warm skin Calf Tenderness + Homan's sign SVC: upper extremity edema IVC: lower extremity edema o Risk factors:  Due to thromphelbitis of larger deeper vein, 3 factors include venous stasis, endothelial damage & hypercoagulability of the blood o Wells score used to categorize low, moderate, or high probability of DVT Chapter 21 Abdomen 1. Identify assessment techniques to assess the abdomen. 2. Differentiate between the following three assessment techniques and explain their significance (Blumberg sign, Murphy sign, and Iliopsoas muscle test). Pg 551 o Blumberg sign (Rebound Tenderness) – Assess rebound tenderness when the person reports abdominal pain or when you elicit tenderness during palpation. Choose a site away from the painful area. Hold your hand 90 degrees, or perpendicular, to the abdomen. Push down slowly and deeply then lift up quickly kes structures that are indented by palpation rebound suddenly. A normal, or negative, response is no pain on release of pressure. Perform this test at the end of the examination because it can cause severe pain and muscle rigidity. o Murphy sign (Inspiratory Arrest) – Normally palpating the liver causes no pain. In a person with inflammation of the gallbladder (cholecystitis), pain occurs. Hold your fingers under the liver border. Ask the person to take a deep breath. A normal response is to complete the deep breath without pain. (NOTE: This sign is less accurate in patients older than 60 years; evidence shows that 25% of them do not have any abdominal tenderness. ) o Iliopsoas muscle test – Perform the iliopsoas muscle test when the acute abdominal pain of appendicitis is suspected. With the person supine, lift the right leg straight up, flexing at the hip then push down over the lower part of the right thigh as the person tries to hold the leg up. When the test is negative, the person feels no change. 3. Discuss the expected findings related to the abdominal assessment for the aging adult. o Aging alters appearance of abdominal wall o Changes of the GI system occur with aging, but most do not significantly affect function as long as no disease is present o Salivation decreases, leading to a dry mouth and decreased sense of taste o Esophageal emptying and gastric acid secretion are delayed o Incidence of gallstones increases with age o Although liver size decreases, most liver functions remain normal; however, drug metabolism is impaired o Aging adults frequently report constipation 4. Identify subjective data to be collected during the abdominal assessment and provide a sample question for each category. o Appetite o Dysphagia o Food intolerance o Abdominal pain o Nausea and vomiting o Bowel habits o Past abdominal history o Medications o Nutritional assessment 5. Identify objective data to be collected during the abdominal assessment. o Inspection  Contour, symmetry, umbilicus, skin, pulsation or movement, hair distribution, and demeanor o Auscultation  Bowel sounds; note any vascular sounds o Percussion  All four quadrants and borders of liver and spleen o Palpation  Light and deep palpation in all four quadrants, and palpate for liver and spleen 6. Medication: o Ondansetron (Zofran) – prevents nausea and vomiting o Protonix – It can treat gastroesophageal reflux disease (GERD) and a damaged esophagus. It can also treat high levels of stomach acid caused by tumors. 7. Review cultural and genetic considerations: o Lactose intolerance  Lactase is digestive enzyme necessary for absorption of carbohydrate lactose (milk sugar)  In some racial groups, lactase activity is high at birth but declines to low levels by adulthood  These people are lactose intolerant and have abdominal pain, bloating, and flatulence when milk products are consumed  Estimated incidence of lactose intolerance is  15% of Whites, 50% of Mexican Americans, and 80% of Blacks o Obesity  Obesity is caused by a complex interaction of genetics, dietary consumption, physical activity leading to an obesogenic environment  Globally and within the U.S., the incidence of obesity has increased significantly  NHANES data show significant differences in obesity among racial groups  Obesity presentation across the life cycle leads to development of significant comorbidities  Recommendations: healthy food patterns, decreased consumption of sweetened/processed foods, and increased physical activity 8. Differentiate between expected bowel sounds, hyperactive sounds, hypoactive sounds and borborygmus sounds. And how long to auscultate? o Normal bowel sounds are high pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute; do not bother to count them o Hypoactive – Diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. Occurs also with pneumonia. o Hyperactive – Loud, gurgling sounds, “borborygmi,” signal increased motility. They occur with early mechanical bowel obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus. o Borborygmus is the sound of hyper peristalsis ; “stomach growling”