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2nd week assessment
Nurse health assessment
| Question | Answer |
|---|---|
| RUQ - RIght upper quadrant contains | *Liver, *Gallbladder, Duodenum, Head of pancreas, Rt kidney & adrenal, part of ascending & transvere colon |
| What is Viscera? | Solid organs |
| What is Viscera pain? | Organ pain |
| What is Cutaneous pain? | Pain on the surface of the skin |
| Three systems of the abdomen? | 1. Hepatic (liver) 2. GI Tract 3. GU Genito Urinary |
| LUQ - Left upper quadrant contains | left lobe of liver, spleen, stomach, Body of pancreas, left adrenal gland, portion of left kidney, splenic flexure of colon, part of transverse & descending colon |
| RLQ - right lower quadrant contains | Cecum, appendix, portion of ascending colon, right ovary & tube, right ureter, right spermatic cord |
| LLQ - left lower quadrant contains | part of descending colon, sigmoid colon, left ovary & tube, left uretur, left spermatic cord |
| Midline contains | Abdominal Aorta - you can see the pulse on thin people Uterus - enlarged when pregnant or fibroid tumors Bladder - Distended = full bladder |
| Abdominal Aneurysm | Sac formed in the artery bcuz of athersclerosis Athersclerosis - hardening of the arteries More common in men over 55 Feeling "seering/tearing back pain" |
| Subjective data - Things to ask in an abdominal assessment | * APPETITE; anorexia; weight; gain/loss? (Thyroid - controls metabolism); lactose, allergies, GERD (reflux disease) *PAIN * Dysphagia - difficulty swallowing * Food Intolerances- lactose, allergies |
| Hypothyroidism - Hypo (below) underworked | 1. weight gain 2. constipated 3. fatigue |
| Hyperthyroidism - Hyper (above) overworked | 1. loss of weight 2. Insomnia 3. diahrrea 4. energized |
| ABD Pain | N & V (nausea & vomiting) What does it look like? 1. Coffee ground - old blood (ulcer) 2. Hematemesis - blood in vomit |
| What do Bowel Movement (BM) look like? Frequency? | Color, consistency, black/tarry, melana-microscopic blood in stool; |
| ETOH (Alcohol)/Smoking | can cause ulcers/GIB (gastrointestinal bleeding) |
| Hemoccult | test to see if there is blood in the feces/stool |
| Peristalsis | the involuntary constriction & relaxation of the intestines that pushes contents (food) forward |
| Ascites | accumulation of serous fluid in the abdomen |
| Serous fluid | thin fluid/straw color-pale yellow |
| Sangumous | thick like blood |
| Ascites is commonly found with? | heart failure, cirhossis of liver, cancer (liver, colon) |
| Cranial Nerves | |
| CN I. | Olfactory - Smell. |
| CN II. | Optic - Vision. |
| CN III. | Oculomotor - Extra-ocular movement, pupillary constriction, upper eyelid elevation, lens shape change |
| CN IV. | Trochlear - downward & inward eye movement |
| CN V. | Trigeminal - chewing, corneal reflex, face & scalp sensations |
| CN VI. | Abducen - lateral eye movement |
| CN VI. | Facial - Expressions in forehead, eye & mouth; taste |
| CN VII. | Acoustic - Hearing & Balance |
| CN VIII. | Glossopharyngeal - swallowing, salivating & taste |
| CN IX. | Vagus - swallowing & gag reflex, talking; sensations of throat |
| CN XI. | Accessory/Spinal - shoulder movement & headrotation |
| CN XII. | Hypoglossal - tongue movement |
| Subjective interview q's for patient: | Trauma/Injuries? Dizziness/Vertigo? Neck Pain? |
| What nurse's are objectively assessing when looking at size & shape of head | Normocephalo -Normal head size; Macrocephalic-enlarged; Microcephalic-very small. ROM, Trachea is midline. & lymph nodes are palpable |
| Subjective question to ask patient is: | Change or frequency of headaches? Where? Feels like? sharp/stabbing, dull/throbbing |
| Aura | a subjective sensation or motor phenomenon of a migraine or seizure coming. |
| photophobia | sensitive to light |
| Nucchal rigidity | can't touch their chin to their chest |
| what is the sensory organ of vision? | eyes |
| Name lymph nodes of head & neck | Prearicular, Postaricular, Occipital, Submental, Submandibular, Cervical- multiple chains of cervical lymph nodes |
| Palpating lymph nodes should feel: | Size, shape, mobility, consistency (hard or spongy), discreet (individual) or clumped, tenderness |
| Normal lymph nodes are: | moveable, soft, not tender, & discreet |
| Cancerous lymph nodes | hard, uni-lateral, non-tender & fixed |
| lymph | filters infection |
| perrla | pupil, equal, round, reactive to light & accommodation |
| pupil size determined by | autonomic nervous system ANS |
| lymphadenopathy (acute infection - strep throat) | > 1 cm. Bilateral, warm, tender & moveable - Acute infection |
| lymphadema | chronic swelling. common with women who have breast cancer |
| what dilates pupil | sympathetic |
| what constricts pupil | Parasympathetic |
| what to look for in an eye assessment | blurring, blind spot, night vision, decreases acuity |
| diplopia | double vision |
| strabismuss | cross eyes |
| the snellen tests for | visual acuity 20/20 is normal 20/60 nearsighted. the larger the bottom the poorer the vision |
| myopia/myopic | nearsighted |
| presbyopia | change in vsion related to age |
| hyperopia | farsighted |
| conjunctivitus | pink eye; viral infection, very contagious, purulent discharge |
| corneal abrasion | a lash in the eye, it still feels like its there |
| subconjunctival hemorrhage | white of eye is red |
| cataracts | opaque/grey- difficult to see rxn w/ the pupillary light reflex |
| ear anatomy - tragus & pinna | tragus - ant, front, little cartilage tab pinna, or auricle - the whole external ear |
| assess for | earache, infections, discharge, hearing loss, environmental noise exposure, tinnitus, cerumen, CSF (be worried if this comes out of ear), vertigo |
| tinnitus | ringing in the ears, 25% pop. has ideopathic ringing (no known cause) |
| ototoxic | drugs that can cause permanent hearing loss |
| Rhinorrhea |
Created by:
sairahjane
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