Lab Test 1: Assessment PDF

# LAB TEST 1: ASSESSMENT ## Positions for Examination: 1. **Dorsal Recumbent:** laying on the back, knees pulled in and hips externally rotated 2. **Supine:** laying on the back with legs extended 3. **Sitting** 4. **Lithotomy:** laying on the back with feet supported in stirrups 5. **Sims:** layi...

# LAB TEST 1: ASSESSMENT ## Positions for Examination: 1. **Dorsal Recumbent:** laying on the back, knees pulled in and hips externally rotated 2. **Supine:** laying on the back with legs extended 3. **Sitting** 4. **Lithotomy:** laying on the back with feet supported in stirrups 5. **Sims:** laying on the side with lower-most arm behind the body, upper arm and leg flexed 6. **Prone:** laying on the stomach with head turned to the side ## Skin Color Variations * **Cyanosis:** blue; inadequate oxygen and poor circulation * **Jaundice:** yellow-orange; too much bilirubin delivered to the liver and in the blood * **Pallor:** pale color of the skin due to reduced amount of oxyhaemoglobin (mostly in face and palms, but sometimes on skin and mucus membranes, eyes) * **Erythema:** reddening of the skin, usually in patches (capillaries are dilated) (sometimes in joints) ## Primary Skin Lesions: * **Macule:** FLAT, smaller than 1 cm have a circular border, anything bigger than 1cm has an irregular border. Example: freckles, measles and petechiae. * **Papule:** RAISED elevated, solid palpable mass with circular border. Smaller than .5 cm. Example: warts, plaques * **Nodule:** UNDER AND DEEPER OF THE SKIN, elevated/raised, solid, hard mass extending deeper than a papule. May have Irregular borders. Example: tumors. * **Vesicle:** elevated, fluid filled round or oval shaped, palpable mass with thin translucent walls. Example: herpes, early chicken pox, poison ivy and small burn blisters, contact dermatitis. * **Bula:** same as vesicle, but bigger like from a burn and filled with blood or serous fluid EX. Large burn * **Wheal:** elevated, reddish area with irregular border caused by diffuse fluid in tissues. Example: insect bites and hives. * **Pustule:** Elevated, pus filled vesicle or bulla. Example: acne, large boils. * **Cyst:** Elevated, encapsulated, fluid filled or semisolid mass originating in the dermis. Example: sebaceous cysts and epidermoid cysts. ## Clubbing of Nails: Occurs with chronic cardiovascular or respiratory disease. ## Capillary Refill: Monitors dehydration and the amount of blood flow to that tissue, as well as oxygenation and perfusion. Less than 3 seconds is ideal. ## VISUAL: * **Presbyopia:** trouble seeing close (aging) * **Myopia:** trouble seeing far away * **Cataracts:** affects close and distance vision. Interferes with light transmission through the lens. Patient complains of seeing a glare due to light rays being scattered. Impaired color discrimination. Pupil appears cloudy gray or white. * **Strabismus:** cross eyed. Due to poor neuromuscular control of eye muscles * **Nystagmus:** involuntary eye movement (usually seen in clients with strokes) * **Visual fields:** entire area in which a person can see while fixed in one position * **6 directions of gaze:** up right, up left, left, right, down left, down right * **PERRLA:** pupils equal, round, reactive to light and accommodation * **Red reflex:** red-orange flash of color observed when light reflects off the retina (testes on infants) ## LYMPH NODES * **Normal lymph nodes:** mobile, soft, moves with circular motion, and drains eventually * **Inflamed lymph nodes:** swollen, puffy, enlarged, painful or tender * **Malignant lymph nodes:** hard, immobile ## CHEST/THORAX LANDMARKS: * **Suprasternal notch:** notch at lower neck directly above collar bones and sternum * **Manubrium:** bone directly below clavicle, first part of sternum * **Sternal Angle:** the angle of the manubrium and sternal body * **2nd Rib** * **2nd intercostal space** * **Midclavicular:** middle of the clavicle marks the line down the chest * **Midscapular:** middle of the scapula * **Midaxillary:** middle of the armpit down the side of the body * **Costal angle:** the space between the ribs at the end of the xyphoid process ## CARDIAC * **Aortic, Pulmonic, Erb's point/Second pulmonic, Tricuspid, Mitral Valves (Left to Right)** * **PMI:** point of maximal impulse (mitral area, which is the apex of the heart) *this is where the cardiac impulse can be felt* * **Murmur:** abnormal changes to the valve, swishing sound of blood moving when heart is turbulent/abnormal (S3) * **Thrill:** vibratory sensation felt on the skin overlying an area of turbulence, indicating a loud heart murmur * **Bruit:** abnormal blowing or swishing sound of murmur heard with a stethoscope **Pathway of bloodflow through the heart:** * Superior Vena Cava * Right atrium * Right Ventricle * Pulmonary Valve * Pulmonary Artery * LUNGS * Pulmonary veins * Left atrium * Left ventricle * Aorta * REST OF THE BODY ## SELF BREAST EXAM * Palpation of both breasts a few times a month * Breasts should feel smooth, firm and elastic * Sometimes it's normal for some women to have lumpiness or tiny nodules due to hormone changes or cystic fibrosis ## SELF TESTICULAR EXAM * Check for bulging (could mean a hernia) * Nonerect penis should be soft and flaccid without any lesions * No redness or discharge on external urinary meatus *To allow yourself to catch problems early* ## MUSCULOSKELETAL ### Postural Abnormalities * **Lordosis**- exaggerated lumbar curve * **Kyphosis**- hunchback * **Scoliosis**- crooked spine * **Hypertonicity**- over flexion of muscles; clenched fists, pronated wrist * **Hypotonicity**- less than normal muscle tension, flaccid or limp. ### ROM Positions * **Flexion:** tensing the muscle * **Extension:** extending away from the body * **Dorsi flexion:** foot pulls towards the body, toes come towards the head * **Plantar flexion:** planting the foot, pointing the toes * **Hyperextension:** moving body part beyond normal resting extension * **Pronation:** body part faces downward (palm faces to the ground * **Supination:** palm faces upwards * **Abduction:** moving extremity away from the body * **Adduction:** moving extremity towards the body * **Internal rotation:** rotation of extremity inward * **External rotation:** rotating of extremity outwards ## NEURO ### Level of Consciousness: * **Full consciousness:** alert&oriented to time, place and person; comprehends spoken and written words * **4:** walkie talkie * **3:** stupors, appropriate response to stimuli * **2:** drowsy and disoriented, neurological deficit * **1:** coma * **Confusion:** unable to think rapidly and clearly, poor memory, short attention span, impaired judgment * **Disorientation:** not aware of time, place or person * **Obtundation:** lethargic, responsive to stimuli but quickly falls back asleep * **Stupor:** unresponsive, except sometimes aroused to repeated or painful simuli, may shrink away or grab at source of stimuli * **Coma:** unarousable, may exhibit slight movement of stimuli but makes no attempt to withdraw * **Aphasia:** difficulty speaking * **Deep coma:** completely unarousable and unresponsive ## Cranial Nerves: Misplaced pain; for example, the hand may indicate a nerve problem from the brain since the nerves extend through the whole body. * Eye test, symmetry, shrugging shoulders, tongue in cheek, raising eyebrows. ## 5 Ps: * Pain * Pallor * Pulse * Paresthesias (weird sensations) * Paralysis ## Glascow Coma Scale: AVPU; 3-15 (less than 8 is bad) (alert, verbal response, pain response, unresponsive) * **Delirium:** not an expected variation with aging, short term and can be due to poor 02, meds, infections * **Dementia:** long term, irreversible ## 3 Phases of Memory: 1. Immediate (what day is it) 2. Recent (howd you end up in the hospital) 3. Remote (childhood memories) ## Leukoplakia: White stuff on someone's tongue (can be due to lack of sleep) ## Hypoactive bowel sounds: Quiet, slow ## Hyperactive bowel sounds: Loud, consistent ## Absent bowel sounds: No sound at all, must listen for 5 minutes in each quadrant ## Inspiration & Expiration: Equal in lungs * **Expiration:** louder in trachea (TRACHEAL/BRONCHIAL SOUNDS) * **Elsewhere:** VESICULAR (soft sounds) inspiration is louder than expiration ## Normal breath sounds: * **Vesicular:** everywhere else (loud inspiration) * **Bronchovesicular:** chest area (over heart vesicles) (equal sounds) * **Bronchial:** Trachea (loud expiration) ## Petechiae: Red dots that don't go away with palpation ## Pulse 0-4 scale: * **0:** absent * **1:** diminished, barely palpable * **2:** expected, normal (radial) * **3:** full pulse, increased * **4:** bounding ## Edema scale: * **1+:** 2mm * **2+:** 4mm * **3+:** 6mm * **4+:** 8mm If there is no return of the skin when you push down, it is called a pitting edema and it's over 4+ ## R Upper Quadrant: * Liver * R kidney ## L Upper Quadrant: * Stomach * Transverse colon * L kidney ## R Lower quadrant: * Ascending colon * Small intestines ## L Lower Quadrant: * Small intestines ## Descending colon ## Midline: * Bladder ## Assessment PATIENTS: * **Pneumonia:** check lung sounds, do double hand expansion on the back, say "there are no crackles or abnormal sounds in the lungs" * **Erythema:** check the leg, verify there is no more redness or tenderness, do sharp and dull pain check on that leg as well * **Acute Appendicitis:** palpate and listen around the wound, don't press on the wound and be gentle when coming in contact with the gauze. Ask about tenderness; verify there is not redness or abnormalities * **Osteoarthritis, hip replacement:** don't ask him to roll on the side where his hip hurts, check surgical wound, verify there isn't any redness, swelling, bleeding. * **Atrial fibrillation and hyperthyroidism (heart racing with dizziness and shortness of breath):** check more heart sounds, emphasize the spirometer for expanding the lungs, verify that heart beat is regular and at a normal rate. Verify breath sounds are normal and there is no wheezing sounds in the lungs. Do a neuro assessment. ***ALWAYS MENTION SPIROMETER***