APGAR Scoring for Newborns

APGAR Scoring for Newborns Week 9Cardiovascular & Peripheral Vascular With Lymphatics Red Flags: cardio LOC Chest Pain Shortness of breath Fluid Volume Overload Expected Findings- Cardiovascular Without JVD, hepatojugular reflux (512) negative. Carotid pulses 2+ bilaterally/ 4 without bruits. PMI observed and palpated in 5th ICL, MCL. No thrills, heaves, lifts. Heart rate and rhythm regular.. Without gallops, murmurs, opening snaps, clicks, or rubs. S1 and S2 single sounds. Red Flags: Peripheral vascular & lymphatics Deep vein thrombosis (DVT) ◦Pain, edema, warmth ◦Risk of Pulmonary Embolism (PE) ◦Acute dyspnea, chest pain, tachycardia, diaphoresis, anxiety Compartment Syndrome Facial enclosed compartments of: ◦blood vessels ◦nerves ◦muscles Usually caused by bleeding or swelling after injury into closed compartment. Pain and paresthesia. >6 hours = permanent damage! Expected findings: Peripheral vascular & lymphatics Skin dry & pink throughout, equal and even hair distribution to extremities, capillary refill brisk throughout, no edema, peripheral pulses palpable (give specifics) Gidden’s 2017 Concept- Homeostasis and Regulation (perfusion) Cardiac Output Significance CO= HR x SV Does it meet physiologic demands? Is there enough output for what you body needs? Is there efficiency? Is the output being efficiently distributed? This is what we’re testing, to make sure enough blood and oxygen is being sent through the body. Signs and Symptoms of decreased perfusion: ◦Skin ◦Dizziness ◦Fatigue ◦Exercise intolerance ◦End organ issues…. ◦Pooling of fluid ◦Edema ◦Pulmonary edema (S&S eg. SOB, cough, < O2 sat.) ◦Venous overload (S&S eg. jugular venous distention) Heart Location- Anatomy Review Mostly Left 2nd – 5th intercostal spaces (ICS) In mediastinal space Between lungs & diaphragm Superior border = base (broad) Inferior border = apex (apical pulse at 5th ICS) Great Vessels aorta, carotid arteries, pulmonary arteries; pulmonary veins (O2 blood from lungs), superior vena cava (plus subclavian & jugular veins), inferior vena cava Blood Flow Upper chambers = atria ◦Right: Blood from body via Superior and Inferior Vena Cava ◦Left: Blood returning to heart from Pulmonary Veins Lower chambers = ventricles ◦Right: Blood to Lungs via Pulmonary Arteries ◦Left: Blood to body via Aorta Heart Diagram Electrical activity (ECG) ECG (electrocardiogram) ◦P = atrial depolarization (atrial contraction) ◦PR interval = SA-BB conduction ◦QRS = ventricular systole (hidden is atrial diastole) ◦T = ventricular diastole Cardiac Cycle Blood enters atria from vena cavas Atria fill passively }Mitral & tricuspid valves open to allow ventricular filling SA node fires Atrial contraction begins (atrial systole = atrial kick) Ventricles fill-up (increased pressure) BB impulse spreads Ventricular contraction begins ◦Closure of tricuspid & mitral valves = S1 ‘lub’ ◦Systole =full ventricular contraction ◦Pulmonic & aortic valves open = blood flow to pulmonary & systemic circulation ◦Pulse! ◦Perfusion Diastole (ventricular relaxation) ◦Closure of aortic & pulmonic valves = S2 ‘dub’ ◦Twice the length of systole , Afterload, Stroke Volume Preload (textbook correction) = end-diastolic volume in ventricles ◦Contractility = increased stretch increases contractility Afterload = pressure in great vessels against which the heart will pump Stroke volume (SV) = blood ejected per heart beat ◦Average = 80mL/beat ◦Cardiac output (CO) = HR x SV ◦Average CO = 6-8 L/min Anatomy and Physiology: Peripheral Vascular Arteries ◦Elastic ◦Largest is the AORTA ◦ Veins ◦Low pressure system ◦Valves (higher number in distal veins) for flow ◦Upper extremities, upper torso, head & neck = superior vena cava Capillaries ◦Exchange of nutrients, gases, metabolites Lymphatics Lymphatic system ◦Lymph nodes & vessels ↳ Valves for flow ◦Maintains fluid balance & immune function ◦Parallel to arteries & veins ◦Drains into Thoracic duct & Right Lymphatic duct ◦ ↓ subclavian veins ◦ ↓ superior vena cava ◦ ↓ right atrium Arteries/veins/lymphatics diagrams Cardiovascular Health History/ General Survey Carotid Artery and Jugular Vein Diagram Carotid Artery Assessment Iap 1. Inspect ◦Visualize 2. Auscultate for bruits (stethoscope: bell) ◦Have patient hold breath ◦https://en.wikipedia.org/wiki/Carotid_bruit ◦ (most carotid bruits are innocent – but must be further evaluated by us or imaging) 3. Palpate ◦One at a time!!!!- Putting pressure on both baroreceptors of the carotid sinuses may precipitate reflex bradycardia ◦medial to sternocleidomastoid, inferior to carotid sinus ◦Compare bilaterally Normal: rate, rhythm, quality, no adventitious sounds Jugular Veins: inspection (511) -Subtle, making their inspection difficult. Instead of identifying waveforms, nurses observe the pattern and rhythm instead. -Position patient with the head of the bed at 30-45 degrees to promote visibility of the pulsation. Raising the head slightly on a pillow relaxes the sternomastoid muscles for your inspection. The right side of the patient is always easiest to see- have the patient turn the head to the left. Use an oblique (indirect) lighting at a 45 degree angle to help emphasize shadows of the pulsation. -external veins cross diagonally over the sternomastoid muscles and the pulsations are best observed in the roove near the middle of the clavicle. -Internal vein is not visible, but the pulsations transmitted to soft tissue are usually most prominent in the suprasternal notch, the supraclavicular fossa, or just below the ear lobe. If the pulsation is not visible, it may be necessary to lower the head of the bed. *there are usually two pulsations with two descents, compared to the carotid pulse, which has one pulsation (prominent ascent with systole) Jugular Vein Distention/ JVD: Jugular vein distention or JVD is when the increased pressure of the superior vena cava causes the jugular vein to bulge, making it most visible on the right side of a person's neck. Jugular Venous Pressure (JVP) Assessment (511) ● Locate Sternal Angle ● Landmark JV location (head turned slightly to left), ● Observe for distention in Right External Jugular Vein ● Measure distention distance After locating the internal jugular vein in the sternal notch, identify the top height of the pulsation. If the internal vein is difficult to visualize, use the more prominent external vein. Locate the sternal angle (bony ridge where the manubrium joins the body of the sternum). Use a line parallel to the horizon, from the sternal angle estimate the difference between the parallel line and the top of the pulsation, in the external jugular vein. Because of the wide differences in chest shape and location of the sternal angle, exact measurements varies widely among patients Expected findings are up to 3 cm above sternal angle, which is equivalent to 8 mm Hg central venous pressure. . JVD is associated with fluid volume overload, right sided congestive heart failure, constrictive pericarditis, tricuspid stenosis, and superior vena cava obstruction. Relationship of Pulses to the ECG/Heart Sounds Heart Assessment IPPA 1. Inspection 514 ◦HOB 30 degrees, tangentially using penlight ◦Look for heaves/lifts ◦Jugular Venous Pressure Assessment Inspect the anterior chest for any lesions, masses, heaves, or lifts that appear as forceful thrusting on the chest. Observe for the point of maximal impulse (PMI) in the apex at the 5th ICS medial to the left midclavicular line (MCL). It is easier to observe in children, men and people with a thin chest wall. Impulses should be absent or located in the 5th ICS medical to the MCL with no lifts or heaves. 2. Palpation 514 ◦Use finger pads & hand ◦ Intercostal Spaces ◦2nd R&L ◦L 3rd 4th 5th & Apex ◦Point of maximal impulse location ◦Feel for heaves/lifts & ‘thrills’ (vibrations) Palpate the anterior chest for any masses, lesions or tender areas. WHen palpating for sensations related to the heart, use the PALMAR surface of the hand. Beginning at the apex (5th ICL MCL) of the heart, feel for the pulse in the location which you inspected. To locate the impulse, it may be useful to use the finger pads and depress in. If present the PMI is usually felt as a light tap that lasts from S1 to halfway through the systole and is <1 cm to 2 cm. It may or may not be palpable in adults. Also palpate with finger pads in the right and left 2nd ICS, left 3rd ICS, left 4th ICS and left 5th ICS. Ask the patient to exhale and hold his or her breath each time. In the epigastric area, point your index finger up under the costal margin and ask the patient to inhale and hold the breath. The PMI is in the 5th left ICS medical to the MCL when present. No pulsations in other areas palpated. 3. Percussion ◦Used to assess heart enlargement or fluid in pericardium ◦Mostly replaced by x-rays – but there are still arguments for its use by experts Beginning at the anterior axillary line in the 4th ICS, percuss medially toward the sternum. Note the point at which the note changes from resonant (lung) to dull (cardiac) repeat the procedure in the 5th and 6th ICS. The left border of the heart is percussed from the apex in the 4th to 5th ICS medial to the MCL. 4. Auscultation ◦Diaphragm for S1 & S2 Bell – low pitch sounds detection (eg. Stenosis) Auscultate in these areas, in this order: APETM -aortic, pulmonic, erb's point, tricuspid, mitral Aortic: 2nd ICL, right sternal border Pulmonic: 2nd ICL, left sternal border Erb’s Point: 3rd ICL, left sternal border Tricuspid: 4th & 5th ICL, left sternal border Mitral: 5th ICL, midclavicular line. When listening to heart sounds, begin by hearing the rhythm of the beat and the characteristic lub dub. Each lub-dub is one pulse. Auscultate the heart rate and rhythm in each area. Listen for a regular versus irregular rhythm. Count the heart rate for 60 seconds at the apical area. Listen to each of the 6 auscultatory areas, proceeding systematically. In all areas: 1. Isolate the lub-dub rhythm, listening for a regular rhythmic cadence 2. Listen first to S1 and then listen to S2 for a single sound or split sound. Identify if S1 or S2 is louder, depending on the area being auscultated. 3. Listen for extra heart sounds, then identify it ‘s heard before or after S1 or S2. 4. Listen for murmurs, and then identify if it’s systole or diastole. Characteristics of heart sounds (516) Visual representation Intensity and Pitch Quality Duration Location S1 Louder at apex lub Correlates with carotid pulse mitral / tricuspid S2 Louder at base dub Correlates with beginning of diastole Aortic/ pulmonic Murmurs (517) May result from intrinsic cardiovascular disease or circulatory disturbances (anemia, pregnancy). Some murmurs have no underlying pathology (innocent). Fitting the clinical situation with the murmur is necessary to better determine if the murmur is insignificant or not. Splitting of S2 (Physiological/pathological) S3 : “Lub du bub” ◦May be normal in people <40. Congestive Heart Failure. S4: “Be Lub Dub” ◦Hypertension, aortic stenosis, cardiomyopathy… Systolic Murmurs ◦Aortic or pulmonic valve stenosis ◦Mitral or tricuspid regurgitation ◦Ventricular septal defect Diastolic Murmurs ◦Aortic or pulmonic valve regurgitation Peripheral Vascular & Lymphatics Assessment Common peripheral vascular & lymphatics signs and symptoms: ● ● ● ● ● ● ● ● Pain in arms, hands, legs or feet Numbness or tingling sensations in hands, legs, feet or toes Change in temp in hands or feet Colour changes in fingertips or toes, especially in cold weather Pale hands or feet Edema of arms, hands, calves, legs or feet Edema with redness and/or tenderness Hair loss Inspect ◦Extremities Bilaterally ◦Skin, Hair and Nails! Palpate ◦Distal to proximal ◦Skin Texture = smooth? Dry? Wet? ◦Turgor (skin tent test) = intact ◦Capillary refill <3 seconds ◦Edema (grade it) ◦Pulses (grade each pulse site, compare for symmetry) -Temp Check for 6 P’s of Limb Ischemia! Pain quality & quantity ◦Rest pain usually worse distally (may be relieved by dependency) Pallor (pale, mottled skin) ◦Compare to opposite limb (white rather than blue) ◦Chronic may appear pink due to compensatory vasodilation ◦Buerger’s test: Pallor on elevation and erythema on dependency Pulselessness ◦Use a Doppler Polar sensation/Poikilothermia ◦cold to palpation compared to other limb Paresthesia (burning, tingling, numbness) ◦Earlier sign as small sensory nerves fibres are sensitive to ischemia Paralysis ◦Late sign Edema Grading Chart Description Depression depth Time for pitting to disappear Grade Slight pitting 2 mm Rapidly 1+ Deeper pitting 4 mm 10-15s 2+ Visible swelling of extremity 6 mm >1 min 3+ Grossly swollen extremity 8 mm Up to 2-3 mins 4+ Where to Take Peripheral Pulses Lymphatics Epitrochlear Nodes ◦Support forearm with elbow flexed ◦Finger pads between biceps and triceps (3cm above medial epicondyle) ◦Usually not palpable: note size, consistency, mobility & tenderness. Inguinal Nodes •Horizontal – medial (symphysis pubis) to lateral •Vertical – proximal upper/medial thigh May be palpable: <2cm, mobile and non tender Week 10- Abdominal, Genitoury, Nutritional Abdomen: expected findings: 630 “Abdomen is flat (rounded) with active bowel sounds, soft, non-tender; no masses or hepatosplenomegaly. Liver span is 6cm (6-12 cm) in the MCL.” Abdomen Red Flags: Acute Abdomen Rebound tenderness = more pain when palpation withdrawn Appendicitis ◦Pain at umbilicus – toward RLQ (McBurney’s Point) ◦Rovsing sign: Deep palpation in LLQ, quick withdraw of this stimuli, elicits rebound tenderness in RLQ https://www.youtube.com/watch?v=ja9EBQ2N9FY Peritonitis ◦Abdominal Surgery ◦Ectopic Pregnancy ◦Perforation ◦Trauma ◦Ulcer ◦Appendix ◦Diverticulum What other findings Genitourinary Expected findings Male: (769) Penis: Skin is clear, intact and smooth. No masses or lesions noted. Foreskin intact. No Phimosis or paraphimosis. Penis size is appropriate to age and smooth without lesions or pain. No discharge, edema, or redness. Rectum: Full closure around the finger is palpable. It feels smooth without any nodules, masses or irregularities. The lateral and posterior rectal walls feel smooth and uninterrupted. Internal hemorrhoids are not felt. Prostate: Posterior surface of the prostate gland can be felt. The prostate gland has the consistency of a rubber ball. It is non tender, firm, smooth and slightly movable. The diameter is approx. 4 cm, <1 cm protrudes into rectum. Female: External Genitalia: Mons pubis: skin colour consistent, labia majora and minora symmetrical. NO ecchymosis, excoriation, rashes, swelling or inflammation. Even hair distribution in shape of inverted triangle. No nits or lice. No tenderness elicited on light and deep palpation. Clitoris is not enlarged. Urethral opening is slit like, midline and not prolapse. No discharge or odour. Internal Genitalia: Cervix is midline, smooth and evenly pink. Projects 3 cm into vagina. Nutritional (ch.8) Primary Nutrients: - Carbs - Should be 45% -65 % of calories - Lipids - Should be 20 - 35% of calories - Triglycerides - Cholesterol - Phospholipids - Proteins - Should be 10% - 35% of calories - Vitamins & Minerals - Vitamins: A,Bs,C,D,E,K - Folate (Vitamin B9) is the natural form and is needed for metabolism & cell synthesis. - Folic Acid (more stable form added to foods and multi vitamins) - Minerals: *Iron, Zinc, & Calcium - Supplements - Herbs beginning with letter “g” are most common involved in herbdrug interaction - Fluid & Electrolytes - ~1500ml fluids/day - Electrolyte: - Potassium - Adequate Intake per day is 4.7 g/day. - (Lab Value: Narrow range of 3.5 to 5.2 mmol/L to prevent heart dysrhythmias) - Sodium - 9-50yo: 1500mg - 50-70yo: 1300mg - >70yo: 1200mg - Max: 2300mg Food Serving & Sizes (pg.156-157) General Survey and Health History ○ ○ ○ ○ ○ ○ ○ ○ ○ Illness Dental Issues Challenges with food purchasing and preparation Using 3 or more prescription drugs daily Use of over the counter medications Weight gain/loss Changes in eating habits Changes in hair, nail, & skin Lethargy Food Records: Includes amounts & times food, fluids, supplements were consumed. 24-Hour Recall ● Everything the person ate or drank on a particular day. (Useful to do a week day and a weekend day). Food Frequency Questionnaires ● Used to assess intake of specific food/day, week, or month. Can be used with 24 Hour Recall. ● Examples: calcium and folate/folic acid intake during pregnancy; salt intake with hypertension. Three-Day Food Diary ● Ask the client to immediately record everything he/she eats and drinks for 3 days. Include a weekend day. Physical Assessment Inspection: - Body Type: observe body build - General Appearance - Cachexia: high catabolic state w/ accelerated muscle loss & chronic inflammation - Swallowing - Elimination: stool, unine, & emesis BMI: - “Ideal weight for height” - BMI = weight (kg) / height (m)2 Weight Calculation - % of ideal body weight - (current weight / ideal weight) x 100 Recent Weight change ((usual weight - present weight) / usual weight) x 100 Waist Circumstance / Waist-to-Hip Ratio - W-H ratio = waist circumference / hip circumference Skinfold Thickness: measure to indicate subcutaneous fat reserve Laboratory / Diagnostic Testing ➔ Serum Proteins: Albumin, Prealbumin, Creatinine (reflects renal function). ➔ Total proteins – protein stores ➔ Lipid Measurements: includes total cholesterol, high density lipoprotein, low density lipoprotein, and triglyceride levels. Findings are associated with the risk for atherosclerosis, heart attack, and stroke. ➔ Hemoglobin & Hematocrit: Low levels may indicate poor iron intake or absorption. Bleeding, fluid excess, low intake of vitamin B12 and folate may decrease these values. ➔ Total Lymphocyte (white blood cells) Count is an indicator of ability to mount an immune response. ➔ Other laboratory tests: anemias are associated with iron, vitamin B12, and folate deficiencies. Sodium, potassium, and phosphate are serum electrolytes associated with nutritional status. Signs of Malnutrition: ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ Weight – underweight or overweight Balance and Coordination – unsteady when walking Decreased Energy Skin – turgor decreased, edema, rough, lesions, bruising, slow healing of lesions. Hair – dull, brittle, dry, falls out easily. Nails – spoon-shaped, ridged, brittle Lips – edematous, cracks, bleeding, lesions in corners of mouth. Tongue – smooth, edematous papillae Teeth – caries, dentures don’t fit, gums are spongy, bleed easily, and have receded. Thyroid – enlarged ❖ ❖ ❖ ❖ ❖ Skeleton – stooped, bending of ribs, bowed legs, knock kneed. Muscles – flaccid, poor tone, wasted, underdeveloped Extremities – weak, tender, edematous Abdomen – scaphoid or protruding; enlarged liver and/or spleen. Nervous System – decreased or absent ankle and knee reflexes; or hyper reflexes. Abdomen (22) Abdominal assessment spans many systems ◦Neuro ◦GI ◦ From the oral cavity (outside of the abdominal cavity) down to stomach & intestines ◦Accessory organs (e.g.. Liver, pancreas) ◦Endocrine ◦ Pancreas, adrenal glands ◦Hematopoietic/Lymphatic ◦ Spleen ◦Cardiovascular ◦ Major vessels & Kidneys ◦Urinary ◦ Kidneys, ureters & bladder ◦ Kidneys regulate blood pressure = cardiovascular system ◦Reproductive ◦ Spermatic cord, testes; uterus & ovaries Abdomen Health History Pain Nausea & vomiting Dysphagia Diet patterns Regurgitation, GERD, peptic ulcer disease, indigestion, belching Change in bowel habits: diarrhea, constipation, flatulence, melena Hemorrhoids Colonoscopy Jaundice, pruritus Family history (e.g.. Colon cancer, GERD, IBD, celiac disease?) Travel Abdominal Findings: Pain Where to Find Appendix - Mcburney’s Point ASIS ⅔ of the way Landmarking: Quadrants and Regions Major Arteries Abdominal Physical Assessment: IAPP -inspection -auscultation -percussion -palpation Positioning ◦Supine ◦Pregnant females not supine; roll under right side (left lateral recumbent position about 30 degrees). ◦Expose entire abdomen and drape accordingly ◦Explain what you are going to do ◦And explain what you are doing while assessing -ask to empty bowels and urinary!! Inspection: Skin ◦Color/visible veins, moisture, temperature, texture, scars Overall impression ◦Size, shape/contour, symmetry, bulges/inflammation/masses Umbilicus Deep inhale ◦Assess: movement, symmetry, masses Urinary: urine is clear & light yellow BM (stool): soft, shape of intestines, & light brown No emesis (vomiting) (619) Inspect the abdomen. Look at the condition of the skin and umbilicus. Look at the abdomen for contour, peristaltic waves and pulsations. Bend down or sit to look at the abdomen tangentially and horizontally. Tangential lighting may help with visualization. Inspect for size, shape, symmetry. Are there visible organs or masses? Note whether the umbilicus is inverted or everted and it’s position. Observe for inflammation or bulges suggesting a hernia. Inspect from different angles to evaluate colour, surface characteristics, contour, and surface movements. Note visible veins. Have the patient take a deep breath and bear down to determine any hernias or organomegaly. Assess for distention. If present, determine if it is generalized or only in one area. Ask the patient if the abdomen looks or feels different from normal. Inspect for any visible aortic pulsations, peristalsis and resp. Pattern. Urine: clear and light yellow Stool: soft and light brown. Jaundice Ascites >500 mL of extravascular peritoneal fluid; confirm with ‘shifting dullness’ percussion assessment technique Fluid wave – not specific Auscultation: bowel sounds Diaphragm of stethoscope Indicates bowel motility ◦“All four quadrants” ◦RLQ & proceed clockwise ◦Use stethoscope diaphragm ◦Clicks, gurgles and occasional borborygmi Normal: ◦Peristalsis sounds ◦5-30 sounds/minute ◦RLQ most active – ileocecal area No sounds ◦Do 5 minute auscultation in one place. Bowel sounds are WIDELY transmitted! Auscultation: vascular sounds Bell of stethoscope Bruits ◦Hypertension pts./narrowing of arteries from atherosclerosis ◦Aorta (midline) https://www.youtube.com/watch?v=PrlTdsJ7lWg ◦Renal arteries (RUQ & LUQ) ◦Iliac arteries (RLQ & LLQ) ◦Systole, extend into diastole, or continuous FYI: Venous hum: continuous sound, may also lightly palpate if found Hepatic Friction Rub: movement of liver during respiration Splenic Friction Rub: Movement of spleen during respiration Percussion Percuss to assess organ size & tenderness: ◦Liver (anterior percussion) ◦Spleen (anterior percussion) ◦ ◦Kidneys (posterior percussion) ◦Ascites presence Liver Percussion 1. Percuss from: ◦RMCL, 3rd ICS & move down ◦Note when dullness begins 2. Percuss from: ◦RMCL, at umbilicus & move up ◦Note when dullness begins Mean Liver Size by Percussion ◦7 cm women ◦10.5 cm men Normal finding: dullness (liver) btw 5-7th ICS Liver span is 6 - 12 cm, if the liver span in the MCL is > 12 cm, measure it in the midsternal line. Expected Midternal liver span is 4 - 8 cm. (623) Splenic Percussion Supine position & Elevate left arm Expected size: 8-10 cm, Location: left axillary, 9-11th rib Castell’s Method: ◦Find last intercostal space, left anterior axillary line ◦1) Percuss on expiration – 2) Have client inhale and hold – 3)Percuss ◦Expiration = Resonant or tympany ◦Inspiration = Positive if Dull; expected is resonant or tympany (no change) ◦Sensitivity 82%, specificity 83% Bladder percussion Generally the bladder cannot be assessed unless it is distended superior to the symphysis pubis. An empty bladder does not rise above the symphysis pubis. Percuss from Umbilicus to Pelvic Brim FYI Bladder Scanner Used to Assess Residual ◦post-op decreased urinary output ◦an enlarged prostate. ◦ a urethral stricture. This can impair the patient's ability to fully empty the bladder because the urethral pathway, through which urine exits, is narrowed. ◦neurogenic bladder. The patient's inability to void may be due to damaged neural pathways to or from the bladder. ◦spinal cord injuries. These conditions can cause urinary retention because of edema resulting from the injury. ◦stroke. A stroke patient may experience an impaired ability to void because of neurologic injuries, such as paralysis or cerebral edema. ◦impaired cognitive ability. This may prevent the patient from correlating the sensation of needing to void with the physical act of voiding. ◦urinary incontinence. This can result in incomplete emptying of the bladder due to infection, neurologic conditions, or anomalies of the renal structures. A bladder scan can assist the nurse in noting the frequency and volume of retained urine to tailor an individualized bladder retraining program for the patient. Kidney Percussion There is slight or no pain with fist percussion. Abdominal Palpation Light palpation: ◦1-2 cm depression ◦Use finger pads & dipping motion ◦RLQ & proceed clockwise ◦All 4 quadrants ◦Note: ◦Guarding ◦Masses ◦character, location ◦Tenderness (grimacing) Deep Palpation (beyond this course!) ◦Murphy’s sign (RUQ) – gallbladder disease ◦Liver (RUQ) ◦Spleen - should not be palpable Tenderness may be noted in an adult near the xiphoid process, over the cecum or over the sigmoid colon. Palpation Tips If tensing muscles ◦Bend knees ◦Palpate on expiration Ticklish – hand over yours If you note a mass in the suprapubic region ◦Note: distended bladder is palpable in this region – make sure patient has voided prior to abdominal assessment! Splenomegaly - Dullness at the midaxillary (MAL) line is suggestive of splenomegaly. (624) Palpation: Inguinal Nodes Gloves Horizontal Nodes ◦Inferior & parallel to the inguinal ligament. ◦Palpate from symphysis pubis to ASIS Vertical Nodes ◦Medial to femoral canal from superior ramus to 5 cm distally Expected Findings ◦Non-tender and slightly palpable ◦Up to 1.5cm Rectum and Stool Inspection ◦Anus (fissures, fistulas, hemorrhoids, tumors, warts) ◦Stool Palpation ◦Sphincter, walls (tonus, stenosis, blood, mucus, polyps, masses), stool ◦Prostate (see GU) Bristol stool chart: Genitourinary GI/GU Link Shared autonomic and somatic (S2-S4) innervation Bowels affect bladder Common signs and symptoms ◦Nausea and vomiting ◦Diarrhea ◦Abdominal discomfort/distention ◦Difficult to diagnose, especially in children and elderly Pain: Kidney – costovertebral angle Bladder - Suprapubic Ureteral – Costovertebral angle, flank, lower abdominal, testis or labium Prostatic – Perineum and rectum Urethral – Along penis to meatus or urethra to meatus Health History Obtaining a GU health history requires excellent communication skills and a safe comfortable environment. Promote patient comfort Urinary Tract ◦Frequency (polyuria), blood (hematuria), changes? ◦Hesitancy, nocturnal urination (nocturia), incontinence? ◦Burning? pain? (dysuria), back pain? Genitalia - female ◦Menstruation (duration, flow, regularity, frequency), LMP__, ◦Contraceptives ◦Vaginal changes/discharge ◦Pregnancy (OB in Nursing 405!) Genitalia – male ◦Pain, discharge, trauma ◦Changes in function ◦Testicular discomfort ◦PSA/Prostate Exam Sexual History ◦Changes in libido ◦Sexual life Medications, family history, immunizations, risk factors Tanner stages of female puberty Tanner stages of male puberty Urinary terminology Frequency: >3 hours. Urgency: Strong desire to void. Dysuria: Painful or difficulty voiding Hesitancy: Delay, difficulty initiating Nocturia: Excessive urination at night Incontinence: Involuntary loss of urine. Urge vs stress. Enuresis: Involuntary voiding during sleep Polyuria: Increased volume of urine Oliguria: <400ml/day Anuria: <50 ml/day Hematuria: RBCs in urine Proteinuria: Protein in urine Physical Assessment Inspection & Palpation ◦External Genitalia & Perineum (inflammation, tumours, protrusions, lesions, discharge) ◦Inguinal nodes, hernias ◦Bimanual vaginal palpation for cervix, uterus, ovaries, fallopian tubes and uterine ligaments ◦Rectovaginal examination ◦Rectal Examination for Prostate Percussion (Kidneys) Rectum Inspection -hemorrhoids -masses Palpation -anal reflex -nerves? Idfk. DRE (digital rectal exam) - lots of lubrication - smooth walls - any masses, pain, bleeding - examining finger ◦Stool characteristics, blood Testicular Exam & Prostate Health assessment questions: ◦Pain? ◦Analysis of a symptom ◦Urination – difficulty, frequent, incontinence, incomplete emptying ◦Penile – lesions, discharge, erectile dysfunction, pain ◦Scrotal – swelling, masses, pain, heaviness Testicular cancer has a high incidence ages 15-29 BUT can occur any age Self-exam monthly recommended Risk Factors include ◦Family History ◦Undescended testicle ◦HIV infection ◦Caucasian High cure rate Myths: Trauma & physical activity no relationship! Prostate Cancer Male annual check-up >40yrs of age includes DRE (digital rectal exam) & PSA screening Prostate cancer incidence: 1 in 7 Canadian men Q: are you able to palpate the entire prostate? no Ovarian Cancer ◦abnormal vaginal bleeding ◦a lump that can be felt (palpable) in the pelvic or abdominal area ◦need to urinate often (frequency) ◦intense need to urinate (urgency) ◦constipation ◦changes to digestion (such as difficulty eating, feeling full after a small meal, heartburn, gas , indigestion or nausea) ◦feeling of pressure in the pelvic or abdominal area ◦fatigue ◦pain in the legs, lower back, pelvis or abdomen bloating (swelling of the abdomen) -painful intercourse ◦buildup of fluid in the abdomen (ascites) ◦buildup of fluid around the lungs (pleural effusion) ◦weight loss ◦bowel obstruction ◦buildup of lymph fluid (lymphedema) in the legs Cervical Cancer Screening via Pap test starting at age 25 or 3 years after becoming sexually active – whichever is later. ◦Sexually active is not limited to intercourse. Continue every three years until at least 69 years old. Week 11: Musculoskeletal Connective Tissue: Type Function Cartilage Reduce friction between bones, prevents damage, & absorbs shocks Tendons Connects muscles to bones Ligaments Bone to bone, stabilize joints and limit movement Bursae Fluid-filled sacs to reduce friction & cushion bones & ligaments Meniscus Cartilage discs between bones Fascia Flat sheets that line and protect muscle fibers,attach muscle to bone, & provide structure for neves blood vessels and lymphatics Joints: - Fibrous: immovable - Cartilaginous: slightly movable - Synovial: freely movable: Neck Shoulder Elbow Flexion X X X X X X X X Dorsiflexion X Extension X X X X X X X X Plantar Flexion X Hyperextension X X X X X X Rotation X X X Movements Circumduction Abduction Wrist Fingers Spine X X Hip X Adduction X X Internal Rotation X X External Rotation X X Supination, pronation of forearm Changes with Aging: - Decreased bone density - Increased bony prominence - Cartilage disintegration - Joint stiffness & laxity - Muscle atrophy Spinal Ankle Toes X X X Other Knee Fingerthumb opposition X X X X Inversion eversion of foot ❖ ❖ ❖ ❖ Swelling ❖ Lack of balance & coordination ❖ Bruising Common Signs & Symptoms: Pain (mono/polyarticular myalgia/ arthralgia) Weakness/discomfort Deformity PHYSICAL EXAM: “CSMT” Circulation Sensation Movement Temperature Inspection: ➢ Posture ➢ Gait & Mobility ➢ Balance ➢ Coordination ➢ Inspection of Extremities ○ Size and shape ○ Measurements Palpation: Joints for contour & size, Muscles for tone. Any bumps, nodules, deformity, & tenderness. Joint ROM: Assess symmetry, ROM (chart above), if they can’t, support their limb and perform passive ROM, for limited ROM use a goniometer to measure angle of maximum flexion and extension; healthy joints move quietly. Muscle Tone and Strength: Assess tone before strength, move patients arm in a snaking motion, compare sides and repeat with legs. - Muscle Strength is done bilaterally and compare sides. Muscle Strength Test: Muscle Test Neck Hand on side of face, observe opposite sternomastoid contraction & force Deltoid Hand on patient's upper arm and try to push arm down Biceps Elbow bent. Hand on the flexor surface and try to straighten the patient's arm. Triceps Elbow bent, Hand on extensor surface, and try to flex the patient's arm further. Wrist Flex patient’s fist downwards and try to push patients fist up against resistance. Vice versa, and bilaterally. Fingers - Cross your 1st & 2nd fingers and ask the patient to squeeze it. - Use 2 index fingers to bring together outspread fingers - Use thumb to pull patients thumb against resistance Hip - Supine, push the thigh down as they try to raise it. Put hand underneath and test extensor strength Place 2 fists inside thigh to test adductor strength Place fists on lateral sides of knee to test abductor strength Quadriceps Supine, knees bent, place you hand on patient’s shin and try flex against resistance Hamstring Supine, knees bent, place your hand on patient’s calf and try to straighten against resistance Ankle - Push against sole of foot (plantar flexion strength) - Pull against dorsum of foot (dorsiflexion strength) Advanced MSK Tests pg. 676-677 Terms for Muscle Tone: ➔ Atony: Lack or residual tension ➔ Hypotonicity: diminished tone (skeletal) ➔ Splastisty: Hypertonic; stiff and awkward movement ➔ Spasm: sudden violent muscle contraction ➔ Fasciculation: involuntary twitching ➔ Tremors: involuntary contraction Muscle Strength Scale 5/5 (100%) Full ROM against full resistance 4/5 Full ROM against moderate resistance 3/5 Full ROM against gravity 2/5 Full ROM with support, no ROM against gravity 1/5 Contraction visible, but no joint movement 0/5 No visible muscle contraction Expected Findings: Area of Assessment Expected Findings Spine Intact cervical, thoracic, & lumbar curvatures. Full, smooth ROM in cervical & lumbar spine. Upper and lower extremities are symmetrical. Posture Head erect & midline, patient sits upright in chair Gait Smooth, even gait, arms swinging in opposition Joints Fool ROM in all joint, no swelling/deformity Muscle Strength Strength 5/5, active motion against resistance for all muscles. Morse Fall Scale (pg. 682) MSK Unexpected Findings (pg. 690-696) Week 12: Older Adults Anatomy and Physiology: Changes in Older Adults (926-928) Skin, Hair Nails: -Epidermis thins -epithelium renews every 30, instead of 20 days -50% reduction rate in healing -degeneration of elastic fibers -loss of collagen -loss of subcutaneous fat 0sweat and sebaceous glands reduced -vascularity and capillary strength of skin layer diminished -nails more rigid, thick, brittle Photoaging: not expected, but very common difference between expected aging, and aging due to exposure to the sun. -coarse wrinkling -solar lentigines (age, or liver spots) -dispigmentation areas -actinic keratoses -smoking also reduces dermal elastic fibers Head and Neck: -Facial subcutaneous fat decreases, making skeleton more pronounced -skin may sag and wrinkle across forehead, tip of nose, cheeks -skin lesions more likely -thyroid function and thyroid hormones do not change during aging. Eyes and Vision -less orbital fat -laxity of orbital muscles -decreased lid elasticity -fewer goblet cells to provide mucin, less lubrication for eyes -tear production decreases, which leads to dry eyes -corneal sensitivity diminish -increased lipid deposits may be found at the periphery of the cornea around the iris -ciliary body secretes less aqueous humor, and the ciliary muscle may atrophy, compromising the ability to focus the lens -lens becomes more elastic, larger and denser with age and can become progressively yellowed and opaque. -Iris loses some pigment and pupil becomes progressively smaller - slowed pupillary responses, may lead to difficulty accommodating to changes in light, night driving, issues with glare Ears and Hearing -Widening and lengthening of the auricle -course, wirey hair growth in external ears -narrowing of auditory canal, dry cerumen in canal -tympanic membrane becomes dull, less flexible, retracted, grey -Organ of Corti atrophies, causing sensory hearing loss, cochlear neurons lost, causing neural hearing loss -changes in inner ear can reduce the older adult’s ability to discriminate sounds, especially in noisy conditions. Nose, Mouth, Throat -loss of olfactory receptor neurons: diminished sense of smell, 3rd or 4th decade -chronic medical conditions can also alter smell, such as alzheimers or parkinsons. -Teeth surfaces become worn, increases risk of dental carries -Collagen and elasticity affect oral issues, mucosal thinning and smoothing of tongue -Taste buds are replaced every 10 -100 days. -change in taste happens around 60 -loss of taste more likely because of medications, diseases, long term smoking damage, or malnutrition. Thorax And Lungs -changes to connective tissue evident throughout the respiratory system. -chest wall less elastic, -rigidity or lack of compliance limits chest expansion. -Decreased resp. Muscle strength creates a less effective cough -loss of alveolar elastic recoil produces a 20 percent decrease in lung capacity -loss of alveolar surface are creates less area available for oxygen exchange and difficulties responding to hypoxic or hypercapneic episodes - residual volume increases with age -forced expiratory volume in 1 s declines about 0.2 percent after 40 years. -Major changes in resp. Function are usually due to deconditioning and disease or damage from long-term smoking rather than the aging process itself. Heart and Neck Vessels -changes in connective and smooth muscle tissue affect the peripheral vessels and heart. -arterial walls are less elastic and stiffen -subsequent decreased compliance affects blood pressure (BP) by increasing the afterload on the left ventricle. -Systolic BP increases, -left ventricle wall hypertrophies or thickens, and there is an increased dependence on atrial contraction. -Coronary artery blood flow decreases by about 1/3 . -loss of atrial pace maker cells and bundle of His fibers may result in decreased heart rate -intrinsic cardiac contractile function diminishes, reducing cardiac output, stroke volume and cardiac reserves. -responsiveness to beta-adrenergic receptor stimulation and reactivity of baroreceptors and chemoreceptors decrease, while circulating catecholamines increase. -jugular venous pulsations increase with fluid volume excess and decrease with fluid volume deficit. Peripheral Vascular and Lymphatics -calcification of arteries (arteriosclerosis) causes them to become more rigid. -Less arterial compliance results in increased systolic BP -often compounded by coexistence of atherosclerotic disease in the arteries supplying the brain, heart, other vital organs. -incidence of peripheral arterial disease (PAD) increases dramatically in 7th and 8th decade -patients with venous congestion may also develop edema from poor lymphatic drainage Breast and Lymphatics: 927-928 Abdomen, Metabolism, Elimination -slowed peristalsis, delayed emptying of stomach, delayed movement of food through GI system. -Absorption of vitamin D, calcium, zinc in small intestine reduced -number and size of hepatocytes decrease, hepatic blood flow decreased -Metabolism of medications on first pass through the liver decreases, leaving older adults at risk for higher circulating medication levels. -secretion of bicarbonate and enzymes in the pancreas decreases, and pancreatic duct becomes more dilated. -Colonic transit rate is slower -size and function of kidneys decreases with age -nephrons in cortex of kidneys are fewer, while unexpected changes may occur in glomeruli -body responds to sclerotic changes in glomeruli by increasing the size of remaining healthy glomeruli. -Older adults develop diverticular changes in the distal renal tubules. -for older patients with vascular conditions, the decrease in blood flow to glomerular units leads to a decrease in glomerular filtration rate. -changes are also reflected in a decrease in creatinine clearance and loss of ability to conserve sodium -general reduction in peak bladder capacity and weakening of bladder muscles, which can lead to incomplete emptying of bladder. Musculoskeletal -lose height, gradual compression of spinal column is related to narrowing of intervertebral disks -at 30 years of age, bone absorption starts to exceed bone formation. -In women, bone loss accelerates in the decade immediately following menopause -decrease in lean body mass also occurs with aging -loss of type II muscle (fast twitch) as compared with type I muscle fibers which leads to muscle wasting -regeneration of muscle tissues slows with age, but studies show that exercise can increase lean muscle mass, even in frail older adults. Neurological -number of neurons and glial cells gradually decline, show structural changes -studies do not support the notion of extensive brain atrophy with healthy aging. -atrophy is common with those that have degenerative neurological diseases. -overall number of neuronal synapses decrease -lipofuscin granules in nerve cells accumulate -there is an increased production and accumulation of oxyradicals in all body systems -neurological changes are worsened in people who have changes to vessels that supply the nervous system. (diabetes mellitus, smokers) -efficiency of the autonomic functions of the central nervous system decreases, so that recovery from stress becomes more difficult. -healthy older adults maintain cognitive function, but retrieval speed decreases -psychomotor performance slows -reaction times are slower, but are affected by other changes such as vision and musculoskeletal. -postural control, decreased vibratory sense, and decreased righting reflex ability may affect balance. Male and female genitourinary: 928 Endocrien: 928-930. (Elderly) Older Adults Expected findings: (pg.948 - 949) DETERMINE Checklist (pg.932) Disease Eating Poorly Tooth loss/ mouth pain Economic hardship Reduced social contact Multiple medication Involuntary weight flux Need assistance in self-care Elder Age >80 - Heal slower (slower growth of new cells) - Hearing Impaired: - Check hearing aid - Sit in front at visual level (don't talk down) - - - Make sure to have patients attention and are close enough to hear you - Don't cover you face to allow for visual cues - Speak normally or slightly louder, low pitch, calm voice - Avoid constantly repeating, use visual cues (pictures, body language, gestures) Visually Impaired - Identify yourself and address your intention, address them to let them know ur talking to them - Repeat & Reflect throughout the interaction - Make sure glasses are clean Mobility impairment, falls, polypharmacy, pressure ulcers Common symptoms/signs: urinary incontinence, sleep difficulty, pain, mobility changes, cognitive changes, depression, bruising/injuries Often skin wrinkled, less elastic, dryer, thinner dry/ red eyes, and slower pupillary reaction Less elastic chest wall, decreased resp muscle strength, loss of alveolar recoil, and increased residual volume. Atrial walls are less elastic and stiffer ^ systolic BP, v coronary blood flow & cardiac output. ^ circulating catecholamines Arrhythmias especially atrial fibrillation, common but unexpected Slower peristalsis, reduced hepatic flow, and slower metabolism of drugs. Decreased upward gaze, slow coordination, gait, reflexes, decreased strength, and impaired sensation Lose height and lean body mass v kidney functions, v glomerular filtration rate, v creatinine clearance, and can’t conserve sodium v growth hormone, adrenal hormones and immune system, ^ glucose intolerance ^ risk of falls & impaired mobility Comprehensive physical assessment: 939-947